ARTERY FIRST TECHNIQUE FOR MANAGEMENT OF ABERRANT HEPATIC ARTERIAL ANATOMY DURING PANCREATICODUODENECTOMY-EXPERIENCE FROM A SPECIALIZED HEPATO-PANCREATO-BILIARY UNIT

Purpose: Aberrant hepatic arterial anatomy poses a challenge for surgeon during pancreaticoduodenectomy (PD). These anomalies are best picked up on pre-operative imaging to avoid inadvertent injury to the aberrant vasculature resulting in liver ischaemia or biliary-enteric anastomotic failure. We present our experience of dealing with aberrant hepatic vessels during PD. Methods: Patients with aberrant hepatic vasculature who underwent PD between September 2014 and August 2015 were included in the study. We used artery rst technique for dissection in cases identified on pre operative imaging. Aberrations were classed according to Hiatt classi cation. Results: A total of 23 PD were performed with aberrant arterial anatomy in 10 (43%) cases. These vessels were recognised and preserved in nine cases. In one patient, the replaced right hepatic artery (RRHA) arising from superior mesenteric artery (SMA) was coursing through pancreatic parenchyma needing resection and reconstruction with uneventful post-operative recovery. We also identified one RRHA arising from SMA coursing lateral to common bile duct and entering liver parenchyma in gallbladder fossa. Conclusion: Aberrant hepatic arterial anomalies are common and should ideally be picked up by pre-operative imaging. It is possible to preserve these vessels in most cases with careful surgical dissection using artery first technique. Surgeons performing PD should be well versed with the aberrant vascular anatomy to minimise any inadvertent damage. Key words: Aberrant hepatic artery, artery first technique, pancreaticoduodenectomy

Mucinous carcinoma of breast: A rare tumour with favorable prognosis - 10 years experience from a single center

Purpose: The purpose of this study was to describe the biological behaviour of mucinous breast carcinoma (MBC) regarding their clinical presentations, pathological features, prognosis and survival.Methodology: We conducted this retrospective study from 2006 to 2015 (10-year duration) and included all the patients who presented with mucinous carcinoma of the breast at any age. We excluded all the patients who presented with invasive ductal carcinoma or other rare breast tumours. Each patient with mucinous carcinoma breast was categorised in terms of diagnosis, surgery, chemotherapy and outcome. For categorical variables, Chi-square test was used. Kaplan–Meier curves were used to determine estimated overall survival. Data analysis was carried out using the SPSS 20.Results: In total, 8841 patients with breast carcinoma presented during the study period. Of these, 74 patients were diagnosed as cases of MBC, constituting <1%. Family history of breast carcinoma was positive in 20% of patients. Most of the women were postmenopausal (66.2%) falling in BIRADS Category 4 and 5 (32.4% each). Considering laterality tumours had almost equal distribution between the right and left side. Breast-conserving surgery was performed in 47.3% of women as compare to modified radicle mastectomy in 52.7% of women. Most of the patients had pathological T2 (51.4%), N0 (81.1%) and moderately differentiated (69%) mucinous carcinoma. ER was positive in 85% of patients, PR in 80% and H2N in 74.6% of patients. Neoadjuvant chemotherapy was given to 20 patients (27%) and adjuvant chemoradiotherapy was given to 51 patients (69%). Metastasis occurred in 12 (16.2%) of our patients while 62 (83.8%) were metastasis free on long-term follow-up, with bones being the most common site of metastasis, occurring in 6 patients (8.1%) followed by lungs, occurring in 4 patients (5.4%). A total of 32 (43.2%) patients are alive, and on regular follow-up, 3 (4.1%) died during the course of follow-up and 39 (52.7%) are lost to follow-up with a median survival of 60 months and an overall 5-year survival rate of >95%.Conclusion: Mucinous carcinoma is a rare breast carcinoma with a good prognosis.Key words: Breast cancer, mucinous carcinoma, prognosi

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

HEAD AND NECK CANCER IN A DEVELOPING COUNTRY- A HOSPITAL BASED RETROSPECTIVE STUDY ACROSS 10 YEARS FROM PAKISTAN

Purpose: Head and neck cancers (HNC) are among the most common cancers in developing countries, especially in the Southeast Asia. Oral cavity is the most commonly affected site. The risk factors are tobacco, betel nut and alcohol. The dimensions of the disease are quite different in developing countries than the western world. Poor socioeconomic status, poverty, lack of healthcare facilities and illiteracy are the factors that pose a major challenge to the management of the disease. The aim of this study is to analyse the database that has been collected over a period of 10 years showing the trends of the disease and the management outcome of these individuals. Methods: Men and women diagnosed with HNC from 2004 to 2014 from Cancer Registry Database of Shaukat Khanum Memorial Cancer Hospital and Research Centre have been retrospectively analysed. Results: In the 10 year period a total of 5027 patients presented to the head and neck clinic at our institution with a mean age + standard deviation of patients of 58.33 + 20.54. Oral cavity (42.6%) and larynx (13%) were the two most common sites followed by the less frequent ones. Squamous cell carcinoma ranked as the most common histological type presented to our institute (69.2%), followed by basal cell carcinoma (6.6%), mucoepidermoid carcinoma (4%), adenoid cystic carcinoma (3.6%) and 1.9% adenocarcinoma. Conclusions: Being a third world country, the burden of the disease on the healthcare system is enormous. With limited resources and funding, there is a need to train people in the speciality and develop the National Cancer Control Program (NCCP) for better monitoring and disease control. Key words: Developing country, head and neck cancer, health infrastructur

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