PNEUMATOSIS INTESTINALIS - A RARE CLINICAL FINDING REQUIRING MULTIMODALITY TREATMENT

This is a case report of Pneumatosis intestinalis (PI), which has traditionally been associated with immediate operative intervention and a high mortality rate. We present a case of ulcerative colitis that developed Pneumatosis intestinalis and was managed at our hospital. A 29 year old male with known history of ulcerative colitis presented with an acute exacerbation. A week into his treatment, PI developed. Emergency total colectomy with end ileostomy was performed. Postoperatively, he remained critically ill and expired during same hospitalization after 45 days.Key words: Pneumatosis intestinalis, Ulcerative Colitis, Adalumima

Follicular Lymphoma of Breast: a Case Report from Pakistan

Introduction: Breast Lymphoma (BL) is a rare breast tumor and accounts for less than 1% of all breast malignancies. It is further categorized into primary breast lymphoma and secondary breast lymphoma. This manuscript presents a case report of a patient diagnosed with secondary breast lymphoma. Case description: A 51-year-old female presented in the one-stop breast clinic with six months history of having a static, painless left breast lump. Mass was firm, non-tender, and 2 cm in size. It was not adherent to skin or muscle, and it was present in the upper outer quadrant of the left breast. Mammo-sonography revealed a circumscribed mass of 17 mm in the outer quadrant of the left breast. There were enlarged ipsilateral lymph nodes. Core biopsy suggested atypical lymphoid infiltrates. She underwent wide local excision of breast and axillary nodal mass. The definitive histological diagnosis revealed a follicular lymphoma (FL) grade 2/3, non-Hodgkin's lymphoma. Staging computed tomography scan features were suggestive of cervical lymphadenopathy. Hence, staging workup proved this to be a case of secondary breast lymphoma. Practical implication: The early diagnosis of breast lymphoma is highly relevant. Its diagnosis is challenging due to non-specific clinical presentation and imaging features. Commonly FL is diagnosed on excisional biopsy or after wide local breast mass excision. Primary and secondary lymphomas, though rare, should be considered in the differential diagnosis of breast malignancies

Morbidity analysis in minimally invasive esophagectomy for oesophageal cancer versus conventional over the last 10 years, a single institution experience

Background: There has been an increasing inclination towards minimally invasive esophagectomies (MIEs) at our institute recently for resectable oesophageal cancer. Objectives: The purpose of the present study is to report peri-operative and long-term procedure specific outcomes of the two groups and analyse their changing pattern at our institute. Methods: All adult patients with a diagnosis of oesophageal cancer managed at our institute from 2005 to 2015 were included in this retrospective study. Patients' demographic and clinical characteristics were recorded through our hospital information system. The cohort of esophagectomies was allocated into two groups, conventional open esophagectomy (OE) or total laparoscopic MIE; hybrid esophagectomies were taken as a separate group. The short-term outcome measures are an operative time in minutes, length of hospital and Intensive Care Unit (ICU) stay in days, post-operative complications and 30 days in-hospital mortality. Complications are graded according to the Clavien-Dindo classification system. Long-term outcomes are long-term procedure related complications over a minimum follow-up of 1 year. Trends were analysed by visually inspecting the graphic plots for mean number of events in each group each year. Results: Our results showed no difference in mortality, length of hospital and ICU stays and incidence of major complications between three groups on uni- and multi-variate analysis (P > 0.05). The operative time was significantly longer in MIE group (odds ratio [OR]: 1.66, confidence interval [CI]: 2.4–11.5). The incidence of long-term complication was low for MIE (OR: 1.0, CI: 133–1.017). However, all post-operative surgical outcomes trended to improve in both groups over the course of this study and stayed better for MIE group except for the operative time. Conclusion: MIE has overall comparable surgical outcomes to its conventional counterpart. Furthermore, the peri-operative outcomes tend to improve in our centre with the maturation of program and experience

USE OF PEG SITE FOR SPECIMEN RETRIEVAL AND EXTRACORPOREAL GASTRIC CONDUIT FORMATION, IN MINIMALLY INVASIVE ESOPHAGECTOMY

Purpose: Purpose of the present study is to report our technique of the use of percutaneous endoscopic gastrostomy (PEG) site excision biopsy wound, for specimen retrieval and gastric conduit formation, in minimally invasive oesophagectomy for oesophageal cancer. Methods: It is a retrospective comparative study where we present data of our 100 resectable oesophageal cancer patients who underwent postneoadjuvant minimally invasive oesophagectomy from January 2012 to September 2015. All of the patients had an initial staging endoscopic ultrasound with PEG placement. The prestudy (conventional) approach, i.e., laparoscopic gastric conduit formation along with specimen pull up from the cervical/thoracic wound is compared to the present (Study) group. Results: The two groups were similar for basic demographic variables, tumour stage, morphology and nutritional status. The primary endpoints were an operative time in minutes and any additional procedure-speci c complications. The rate of procedure speci c complications (Abdominal excision wound complications or conduit failure) was low 11%. PEG site excision biopsy was positive in two cases; one adenocarcinoma and one squamous carcinoma, both were mid to lower oesophageal tumours not involving gastroesophageal junction. Conclusions: Bene ts of the approach are ease of gastric conduit formation along with an additional second layer with less operative time through the small wound, avoidance of tumour specimen removal all the way through mediastinum from the cervical incision, and excision of a potential site of oesophageal cancer metastasis, without any added morbidity. Key words: Extracorporeal gastric conduit, minimally invasive oesophagectomy, percutaneous endoscopic gastrostom

Impact of SSO-ASTRO margin guidelines on re-excision rate in breast-conserving surgery: A single-center experience

Introduction: Breast-conserving surgery (BCS) has been historically linked with a high rate of re-excision. To address this issue, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) developed consensus guidelines in 2014 to standardise practices and improve clinical outcomes for BCS patients. In our tertiary cancer care hospital, we assessed the impact of these guidelines on the re-excision rate following BCS. Materials and Methods: We conducted a retrospective study on breast cancer patients who underwent BCS at the Shaukat Khanum Memorial Cancer Hospital and Research Centre in Lahore, Pakistan. The study compared the re-excision rate before the implementation of the SSO-ASTRO consensus guidelines (November 2015 to July 2017) and after the implementation (January 2018 to August 2019). Margins were considered positive if "ink on tumour" was present and negative if "no ink on tumour" was present. Fisher's exact test or chi-square test was used to compare the re-excision rates between the pre- and post-guideline periods. Results: A total of 919 patients were identified, with 533 from the pre-guideline period and 386 from the post-guideline period. Of the 919 patients, 31 with ductal carcinoma in situ (DCIS) were excluded from the re-excision analysis because the guidelines were not implemented on the DCIS. Furthermore, the overall rate of re-excision in our data was 4.3%. The re-excision rate decreased from 71.1% to 28.9% (P ≤0.05) following the adoption of the guidelines. We observed a statistically significant decrease in the re-excision rate after implementing the SSO-ASTRO guidelines. Conclusion: Implementation of the SSO-ASTRO margin guidelines led to a notable decrease in the overall re-excision rate in our data set. These findings suggest that continued adherence to the guidelines may lead to a further reduction in the re-excision rate in the future