Risk factors of pancreatic fistula in distal pancreatectomy patients.

INTRODUCTION: Benign and malignant lesions of the pancreas located at the body and tail of the pancreas are managed by the standard procedure of distal pancreatectomy (DP). The mortality associated with this procedure is reported as less than 5% in high-volume centers. The major proportion of morbidity is comprised of pancreatic fistula with a reported incidence of 5% to 60%. The most considered risk factors associated with pancreatic fistula formation are soft pancreatic texture, diameter of the pancreatic duct \u3c3 mm, intraoperative blood loss \u3e1000 ml and surgical techniques. Among all these factors, the modifiable factor is the surgical technique. Several surgical techniques have been developed and modified for closure of the pancreatic remnant in the recent past in order to minimize the risk of pancreatic fistula and other complications. The main objective of the study is to analyze the factors associated with formation of pancreatic fistula after distal pancreatectomy. PATIENTS AND METHODS: We performed a single-center retrospective study at Aga Khan University Hospital from January 2004 till December 2015. The perioperative and postoperative data of 131 patients who underwent pancreatic resection were recorded by using ICD 9 coding. 45 patients underwent distal pancreatectomy, out of which 38 were included in the study based on inclusion criteria. Variables were grouped into demographics, indications, operative details, and postoperative course. Statistical analysis software (SPSS) was used for analysis. Quantitative variables were presented as mean with standard deviation or median with interquartile range depending on the distribution of data. Study endpoints for the risk factor analysis were surgical morbidity and development of pancreatic fistula. Univariate logistic regressions were performed associated with study endpoints. P value less than 0.05 was considered significant. RESULTS: Postoperative pancreatic fistula was the most common perioperative morbidity. The significant associated risk factor for pancreatic fistula was multivisceral resection as compared to spleen-preserving distal pancreatectomy (P value 0.039). However, the technique of stump closure when opted for suture techniques was seen to be associated with a higher occurrence of postoperative pancreatic fistula. The mortality rate was 2.6%. CONCLUSION: Postoperative pancreatic fistula is the most common complication seen after distal pancreatectomy in our series. Multivisceral resection is associated with a high incidence of pancreatic fistula and is a statistical significant predictor of pancreatic fistula

Diagnostic accuracy of CT scan in staging resectable esophageal cancer

Abstract INTRODUCTION: CT scan is an important tool in staging of esophageal cancer. Survival can be improved by providing neoadjuvant treatment which depends on stage of esophageal cancer. So it is very important to stage the disease accurately. METHODS: The objective of this study is to determine diagnostic accuracy of CT scan to stage esophageal cancer. Ct scans of 62 patients included in the study were reviewed by a Consultant radiologist who was blinded to the final stage of tumour. Diagnosticaccuracy measured by comparing with histopathological staging. RESULTS: Accuracy, sensitivity and specificity of CT for T2 and T3 are 66%, 61%, 68% and 63%, 67%, 56% respectively. Accuracy, sensitivity and specificity of CT for presence of nodal disease are 65%, 59% and 75%. CONCLUSIONS: Ct scan alone has low diagnostic accuracy for staging Esophageal Cancer

Pancreaticogastrostomy - an alternate for dealing with pancreatic remnant after pancreaticoduodenectomy - experience from a tertiary care center of Pakistan

Whipple\u27s pancreaticoduodenectomy has been refined over the years to be a safe operation though the morbidity rate still remains high (30-50%). Pancreatic fistula is the most important cause of mortality following pancreaticoduodenectomy. To prevent it, surgeons have used two anastomotic techniques: pancreaticojejunostomy and pancreaticogastrostomy. Recent studies found that pancreaticogastrostomy is associated with fewer overall complications than pancreaticojejunostomy. This is a retrospective review of patients who underwent Whipple\u27s at Aga Khan University Hospital and had pancreaticogastrostomy as a preferred anastomosis for pancreatic stump. Forty four patients met the inclusion criteria, 27 were male. No patient developed post-operative pancreatic fistula, 13 (31%) patients had morbidities including delayed gastric emptying 4(9.1%), wound infection 3(6.8%), and haemorrhage 6(13.6%). Mortality is reported to be 5 (11.9%). Pancreaticogastrostomy seems to be a safe alternative and easier anastomosis to perform with less post-operative morbidity and mortality. Further data should become available with greater numbers in the future.

Telesurgery prospects in delivering healthcare in remote areas

Feasibility and safety of performing remote surgery was first established by performing surgeries on pigs in later part of the 20th century. The first tele-robotic remote surgical system was set up in Canada in 2003 between two hospitals 400 kilometres away. The current review was planned to have a look at the current state of robotic surgery and its use in telesurgery. Literature search was conducted for articles related to Robotic Surgery and Tele-Surgery . Our search included articles published in English literature, including case studies and review articles. We searched Google Scholar and PubMed to search relevant articles. Introduction of haptic feedback technology added significantly to safety robotic surgery. Tele-surgery, also called tele-robotics, combines the advantages of robotic surgery, including magnified view, augmented reality and improved ergonomics and dexterity, and provision of surgical care in remote areas and difficult-to-reach locations like spacecrafts and ships. Challenges, like cost, availability and legislations, remain to be addressed

Recurrent acute pancreatitis due to a santorinicele in a young patient

A cystic dilatation of the terminal portion of the minor pancreatic duct (duct of Santorini) is referred to as a santorinicele. It is usually associated with pancreas divisum and has been suggested to be a cause of relative stenosis of the minor papilla, often leading to recurrent pancreatitis. While this anomaly has been reported in the paediatric population, it is more commonly found in the elderly. We present a 27-year-old woman with recurrent acute pancreatitis attributed to a santorinicele with a dorsal duct-exclusive pancreatic drainage

Surgical management of inflammatory bowel disease: A low prevalence, developing country perspective

OBJECTIVE: To determine the outcomes of surgical management of inflammatory bowel disease. METHODS: The retrospective case series was conducted at Aga Khan University Hospital, Karachi, and comprised medical record of adult patients operated between January 1986 and December 2010 for inflammatory bowel disease. Outcomes consisted of complications till last follow-up and 30-day mortality (disease or procedure related). Functional status of patients with ileal pouch was determined via telephone. SPSS 16 was used to analyse data. RESULTS: Of the 36 patients whose records were reviewed, 21(58%) were males, and body mass index was less than 23 in 34(91%). A total of 27(75%) patients underwent elective surgery for their condition. Ileal pouch was formed in 9(25%). Overall mortality was 14(38.8%). Overall incidence of complications was 26(72%), with wound infection being the most common early morbidity in 11(30.5%). Late morbidity included pouchitisin 4/9 (44.9%) and strictures 2/36 (5.5%).On telephonic follow-up, 6 of the remaining 7patients (85%) with ileal pouch were satisfied with the functional results of the procedure. CONCLUSIONS: The retrospective case series represents results from a developing country with low prevalence of inflammatory boweldisease and hence limited experience

30-day readmission rate and its causes in general surgical patients

Objective: To find out the 30-day readmission rate for different surgical procedures and determine the causes for readmissions. Study Design: An audit report. Place and duration of study: Department of Surgery, The Aga Khan University Hospital, Karachi, in the calendar year 2014. Methodology: Records were retrospectively reviewed for 30-day readmission rate and their cause in general surgical patients who underwent a general surgical procedure at The Aga Khan University Hospital, Karachi, in the year 2014. Results: Out of 217 (6.4%) readmissions in 3,387 patients, more than 50% unplanned readmissions were avoidable. The highest readmission rate was after placement of feeding tubes (28.5%). Conclusion: More than half of the readmissions could have been prevented by proper patient/attendant education, good communication and provision of nursing services to these patients beyond the hospital

Congenital morgagni hernia presenting as complete small bowel obstruction in the adult - A case report

Introduction: Congenital Diaphragmatic hernia (CDH) is a condition in which there is a defect in the diaphragm present at the time of birth. Morgagni hernia is one of the two most common types of CDH which constitutes 2%-4% of diaphragmatic hernias. They mostly remain silent or discovered as an incidental finding on radiological studies. Symptomatic adult Morgagni hernias are extremely rare.Presentation of case: Elderly woman presented with a 1-day history of abdominal pain, vomiting, and acute onset of respiratory distress. There was no history of trauma to the chest or abdomen. After initial resuscitation, a Chest x-ray was performed which showed bowel shadow under the right hemidiaphragm. She then underwent computed tomography (CT), which showed a defect in the right hemidiaphragm and segment of herniated small bowel loop with fecalization into the thoracic cavity. After initial resuscitation, she underwent laparotomy, reduction of bowel loops, and primary repair of the hernia defect. Postoperatively she remained well and was discharged on 4th post-operative day.Discussion: Congenital diaphragmatic hernia occurs in 1 out of every 4000-5000 live births. A majority of the patients will be diagnosed either antenatally or will present with respiratory distress in the neonatal period. Presentation in adults is extremely rare and mostly characterized by abdominal pain, vomiting, intestinal obstruction with some acute respiratory distress, at the background of insignificant past medical history. Surgical management is the mainstay of treatment in symptomatic cases.Conclusion: CDH of Morgagni type can present uncommonly in adults with symptoms. A good history and clinical examination along with aid of chest x-ray and CT scan should establish the diagnosis. Early surgical intervention is key to prevent ischemia and later gangrene of intestinal content

Short term outcome and predictors of response to neoadjuvant treatment in rectal cancer

Abstract OBJECTIVE: To evaluate response to neoadjuvant chemoradiation in the treatment of rectal cancer and to see if it can be predicted whether a particular patient will benefit from such treatment. METHODS: The retrospective case series was done at the Aga Khan University Hospital, Karachi, and comprised data related to period from January 2005 to December 2014 of patients with rectal cancer who had received neoadjuvant treatment. They were divided into responders and non-responders on the basis of imaging. Pre-treatment factors were compared to identify differences in the two groups. SPSS 19 was used for statistical analysis. RESULTS: The median age of 35 patients whose records were studied was 44 years (interquartile range: 33-54). Response to neoadjuvant treatment was seen in 13(37%) patients with complete pathological response in 8(22.9%). There was no statistically significant difference in age, gender, pre-treatment tumour stage, tumour biology and distance from anal verge among the responders and the non-responders (p\u3e0.05 each)