GERM CELL TUMOURS OF THE OVARY IN CHILDREN AND ADOLESCENTS: A CLINICAL STUDY OF 109 PATIENTS IN A SPECIALIZED CANCER CENTRE

Objective: Paediatric ovarian germ cell tumours (GCTs) are rare tumours withmalignant tumours extremely rare.Methods: All the paediatric patients who received treatment for histology proven ovarian GCT at Shaukat Khanum Memorial Cancer Hospital from January 2006 to December 2014 were retrospectively reviewed. Patients over the age of 18 years were excluded from the study. A total of 109 patients were included in the study. A set of parameters were identified to record initial clinical presentation and examination, imaging and laboratory investigations including tumour marker levels. Decisions of multidisciplinary team meetings, surgical treatment, neo adjuvant, adjuvant chemotherapy and radiation data retrieved. Data analysiscarried out using SPSS 20.Results: In total 109 girls presented to our hospital during the study period, most of them above the age of 5 years, with dysgerminoma being the most common followed by yolk sac tumour. Most of the patients received treatment outside our hospital and were referred here for chemoradiotherapy. Fertility preserving surgery was the most commonly performed surgical procedure with a mean follow-up of 50.4 months and >75% overall 5-year survival.Conclusion: Regardless of histologic types, the outcomes of GCT can be improved with a multidisciplinary approach.Key words: Dysgerminomas, germ cell tumours, ovarian tumour

Reported Male Circumcision Practices in a Muslim-Majority Setting

Introduction. Male circumcision is a recommended practice in Muslim tradition. It is important to ensure that this procedure is performed as safely as possible in these communities. Methods. Five hundred adult men and women with at least one male child less than 18 years were interviewed in Karachi, Pakistan, regarding details of their child’s circumcision. The survey focused on actual and perceived delays in circumcision and perceptions about appropriate age and reasons and benefits and complications of the procedure. Circumcisions done after two months of age were defined as delayed. Results. Religious requirement was the primary reason for circumcision in 92.6% of children. However, 89.6% of respondents were of the opinion that circumcision had medical benefits as well. Half of the children (54.1%) had delayed circumcision (range 2.5 months to 13 years), even though 81.2% of parents were of the opinion that circumcisions should be done within 60 days of birth. Facility-delivered babies had less delay in circumcisions (49.1%) as compared to home-delivered babies (60.5%). Conclusion. Understanding the perceptions and practices around male circumcision can help guide national strategies for designing and implementing safe circumcision programs in Muslim-majority settings, with the potential to benefit an annual birth cohort of 20–25 million boys worldwide

Migration of an intrauterine device to the left inguinal region, the first reported case

Introduction: A large number of complications are reported with the use of IUD. Migration to inguinal region has not been mentioned in literature. We report a rare case of migrated IUD to inguinal canal. Case report: A 25-year-old lady presented with a painfull mass in the left inguinal region. Diagnostic work up showed migrated IUD to inguinal region. Operation was done and the impacted IUD with surrounding granuloma was retrieved. Discussion: When the string of the IUD is no longer visible at the external os of the cervix, radiological scan must be performed, this should begin with a sonographic examination and plain abdominal radiography may be used to localize the IUD. Conclusion: IUD Migration may occur to unusual area and perforation can be misdiagnosed as non-witnessed expulsion

PENILE CANCER AND OUR EXPERIENCE AT TERTIARY CARE HOSPITAL

Purpose: Penile cancer is a rare malignancy which accounts for <1% of adult male cancers. Phimosis, poor hygiene, smoking and human papillomavirus infection (type 16 and 18) are major risk factors for penile cancer. This analysis is to know the mode of presentation and treatment outcome of penile cancer in our setting.Materials and Methods: We reviewed case notes of all patients who had histologically proven penile cancer from January 2005 to December 2014. Patient’s demographics, predisposing factors, symptoms, type of tumour, treatment and its outcome were analysed using the Statistical Package for the Social sciences 19.Results: A total number of 19 patients who had histologically proven penile cancer were included in the study. Circumcision was done in 16 (84.2%), while 3 (15.8%) were uncircumcised. Most of the patients presented with a lesion 16 (84.2%) and the rest 3 (15.8%) with pain. Patients having delayed presentation by 1 year were 15 (78.9%), 3 (15.8%) after 2 years and one patient (5.3%) after 5 years. Partial and total penectomy were performed in 4 (40%) patients each while wide local excision in 2 (20%) of the patients (n = 10). 4 (30.7%) patients had complication of treatment. The overall 5-year survival was 69.2%.Conclusion: Penile cancer is an aggressive malignancy with generally poor outcome. There is a need of awareness amongst the masses of this cancer to detect the disease at an early stage. There is further need for specialised oncological centre to improve survival rates and outcome.Key words: Circumcision, penectomy, penile cancer, phimosi

Case report of laparoscopic anterior resection presented with portal vein and superior mesenteric vein thrombosis

OBJECTIVE: This case report describes a case of superior mesenteric and portal vein thrombosis (PVT) following laparoscopic-assisted anterior resection for a sigmoid colon carcinoma without liver metastases. METHODS: A retrospective case review was performed. RESULTS: A 43-year-old female, presented with altered bowel habits, bleeding per rectal, and loss of weight for the last 10 months. CT scan performed which showed a mass in the sigmoid colon which was confirmed as adenocarcinoma of the sigmoid colon on endoscopic biopsy. Laparoscopic-assisted anterior resection was performed. Following smooth recovery, she was discharged on the 5th post-operative day. Post-operative day 9th, she presented in the emergency room with abdominal pain, then CT scan was performed which showed thrombus involving superior mesenteric vein and portal vein. She was managed conservatively with anticoagulation. CONCLUSION: There is scarcity in the published literature regarding this complication (portal vein and superior mesenteric vein thrombosis) associated with laparoscopic colonic resections. As the world is moving towards more minimally invasive procedures, medical professionals will encounter unknown complications

Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study

Background: Gastrointestinal perforation is the most serious complication of typhoid fever, with a high disease burden in low-income countries. Reliable, prospective, contemporary surgical outcome data are scarce in these settings. This study aimed to investigate surgical outcomes following surgery for intestinal typhoid. Methods: Two multicentre, international prospective cohort studies of consecutive patients undergoing surgery for gastrointestinal typhoid perforation were conducted. Outcomes were measured at 30 days and included mortality, surgical site infection, organ space infection and reintervention rate. Multilevel logistic regression models were used to adjust for clinically plausible explanatory variables. Effect estimates are expressed as odds ratios (ORs) alongside their corresponding 95% confidence intervals. Results: A total of 88 patients across the GlobalSurg 1 and GlobalSurg 2 studies were included, from 11 countries. Children comprised 38.6% (34/88) of included patients. Most patients (87/88) had intestinal perforation. The 30-day mortality rate was 9.1% (8/88), which was higher in children (14.7 vs. 5.6%). Surgical site infection was common, at 67.0% (59/88). Organ site infection was common, with 10.2% of patients affected. An ASA grade of III and above was a strong predictor of 30-day post-operative mortality, at the univariable level and following adjustment for explanatory variables (OR 15.82, 95% CI 1.53–163.57, p = 0.021). Conclusions: With high mortality and complication rates, outcomes from surgery for intestinal typhoid remain poor. Future studies in this area should focus on sustainable interventions which can reduce perioperative morbidity. At a policy level, improving these outcomes will require both surgical and public health system advances

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially