Sensitivity and specificity of bi-rads scoring system in carcinoma of breast

To find out the sensitivity and specificity of mammogram according to BI-RADS scoring, in correlation with pathological findings so as to develop protocol for biopsy in patients presenting with clinically palpable breast lump or nipple discharge. Cross sectional study. Jinnah Postgraduate Medical Centre, Surgical unit 1 [Ward 3] Karachi, from July 2007 to June 2008. Female patients who presented with clinically palpable breast lumps or nipple discharge in general surgical OPD were examined and referred for mammography. Ultrasound examination was also done where considered necessary. The final diagnosis regarding the lump or nipple discharge as shown in the mammography was made and patients sent for biopsy [FNAC/ Trucut/ excision biopsy]. The mammographic diagnosis was compared with the histopathological report. Fifty patients were examined of whom 47 clinically suspected patients had confirmation of diagnosis on biopsy while 3 were found negative. Forty one suspected cases on BI-RADS mammogram were true positive that revealed 87.2% sensitivity of BI-RADS mammogram while 6 cases were false negative. All three cases of negative on biopsy were true negative that revealed hundred percent specificity. In this way positive predictive value was also hundred percent with negative predictive value of 33.3%. Overall diagnostic accuracy of mammogram was 88% when compared with histopathological diagnosis. Mammography can be used as an important diagnostic tool for the diagnosis of breast diseases and where there is doubt, diagnosis should be made by means of triple assessment i.e. clinical examination, mammography, and histopathology

Late presentation of a patient with an anorectal malformation [ARM]

Vestibular fistula represents the most common type of anorectal defect seen In girls with anorectal malformation. Adult presentation of this malformation is rare. The following is a case of adult presentation of anorectal malformation with a vestibular fistula in a 23 years old female, who came because of cosmetic and fertility concerns before her marraige. The patient complained of having an anorectal malformation since birth and passage of fecal matter through the fistula. The patient was continent for feces, but had leakage of flatus. She had no other associated anomaly. The patient subsequently underwent a surgical procedure where anal transpositioning was done with an intact skin bridge. Post-operatively, these developed an anal stenosis which was successfully treated through anoplasty, and the patient is now continent both for feces and flatus for the last 6 months

Cardiac surgery in octogenarians

In Europe and North America, cardiac surgery can be done successfully on octogenarians, but differences in patient selection, surgical and bypass techniques prevent us from concluding similarly in Pakistan. This study investigated the short and long-term outcomes of cardiac surgery in octogenarians operated over a 5 years period at The Aga Khan University Hospital, from January 2001 to December 2006. Seventeen octogenarians, [mean age 81.7 +/- 2.3] underwent coronary artery bypass graft [CABG]. Thirty-days hospital mortality was reported in only 1 patient. Surgical complication of any kind was reported in 13 [76.5%] patients with pleural effusion being the commonest in hospital complication seen in 11 [64.7%] patients. About 13 [92.9%] patients were satisfied with the results of the surgery and reported post-surgery improvement in quality of their life. Cardiac surgery has an important role in the management of elderly patients with medically refractory cardiac symptoms, but the implications of widespread cardiac surgery in the elderly need to be addressed

Value of total leucocyte count and C-reactive proteins in the diagnosis of acute appendicitis

To find out the predictive value of total leucocytes count and C-reactive proteins [CRP] in the diagnosis of acute appendicitis. Cross sectional study. Surgical unit 1, Department of Surgery, Jinnah Postgraduate Medical Center Karachi, from November 2006 to April 2007. A total of 50 patients attending emergency department with provisional diagnosis of acute appendicitis were included. All patients were evaluated by clinical features and their total leucocytes count and C-reactive protein levels were checked and compared with histopathological report which is gold standard for the diagnosis of acute appendicitis. Positive predictive value of total leucocyte count was 90.6% and negative predictive value was 44.4% with accuracy of diagnosis of 74%. Positive predictive value of C-reactive protein was 97.1% and negative predictive value was 62.5% with accuracy of diagnosis of 86%. The diagnosis of acute appendicitis can be made confidently with excellent history and proper examination. Total leucocyte count and C-reactive protein levels estimation can be helpful in the diagnosis of doubtful cases of right iliac fossa pain. When measured together it increases their diagnostic value

[Genetic variation of Echinococcus granulosus isolates from Indian buffalo and Iranian sheep, cattle and camel]

India and Iran are an important endemic focus of cystic hydatid disease [CHD], where several species of intermediate host are commonly infected with Echinococcus granulosus. Strain characterization of E. granulosus is significant for the development of an effective control programme and to asses the infectivity. In present study, genetic variations in tapeworms causing cystic echinococcosis in the North of India and Iran were investigated and compared. Isolates of E. granulosus were collected from buffalo [India] and sheep, cattle, and camel isolates from Iran. PCR linked RFLP approach of ITS1 region of rDNA. Repeat was used in the present study to characterize buffalo isolates from sheep, cattle and camel. 17 pooled samples of protoscoleces from various animals were used for DNA extraction and PCR-RFLP analysis respectively. The PCR products of each isolates were digested separately with 5 restrictive endonucleases enzymes [AluI, HhaI, MspI, TaqI and EcoRI]. Based on the PCR-ITS1 method, the buffalo [liver and lungs] isolates have shown different genotypes and the sheep, cattle and camel isolates appeared to have the same genotype. The RFLP patterns of buffalo lung isolates differed from liver isolates with Taq1 and Hha1, however, showed a similarity with Msp1, EcoR1 and Alu1. Furthermore, differences in numbers and sizes of bands were also observed between buffalo, sheep and camel isolates with Taq1 and Msp1. The sheep and camel isolates differ in the number and sizes of fragments with Msp1 and Taq1. The buffalo lung isolate were quite different from other isolates, with the liver isolate showing a similarity with the sheep isolate. RFLP pattern of isolates from sheep and camel origin was identical, along with the same patterns. Moreover, the existence of buffalo strains [G1 and G3] and sheep strain [G1] were confirmed and our results support the previous studies in Northern India and Iran. These results are relevant for the possibility of transmission of G1 and G3 genotype, between livestock, animals and humans. It can be speculated that buffalo lung isolates represent G3 genotype and liver isolate as G1 genotype. Further, the existence of sheep [G1] strain was also confirmed in Iran by this study. However, more molecular studies, particularly, mitochondrial gene and amino acid sequencing are required, which can provide valuable data for a better understanding of the differences between different cysts localization

Early experience of sentinel lymph node biopsy in breast cancer

To assess the results of sentinel lymph node biopsy in breast cancer. Case Series. Surgical Ward 3, Jinnah Postgraduate Medical Centre Karachi, from April 2007 to March 2009. In this study patients with biopsy proven carcinoma breast and clinically negative lymph nodes in the axilla were included. Patients with history of previous breast surgery, clinically palpable lymph nodes, Stage IV disease, bleeding disorders, chronic liver disease or history of allergic reaction to the dye were excluded. The study patients underwent sentinel lymph node mapping and dissection. One ml of gentian violet or methylene blue dye injected into the peritumoral area followed by one minute massage. Simple mastectomy or wide excision with axillary clearance was done after 30 minutes of injection. This study was conducted on 35 patients with the age range from 28 years to 68 years. In all the patients diagnosis was infiltrating ductal carcinoma. Wide local excision with axillary clearance was possible in only two patients with clinically stage 1 disease. In rest of the patients simple mastectomy with axillary clearance was done. According to the tumor size; T1 was observed in 15 patients, 72 in nine, T3 in six and T4 in five patients. In all patients [n 15] with T1 tumor, stained lymph node was positive in eight patients while tumor metastasis in the remaining lymph nodes removed by axillary clearance showed involvement in six patients. In patients with T2 masses, tumor involvement was seen in both groups of lymph nodes in six patients. In three patients with T4 tumor, sentinel lymph nodes were negative for tumor metastasis however in rest of the lymph nodes tumor involvement was seen in four patients. In patients with T3 masses, three showed involvement of the entire axillary lymph node group and sentinel lymmph node as well. If sentinel lymphnode is involved by the tumor, axillary clearance should be done irrespective of the tumor size. Sentinal node biopsy should be avoided in patients with T4 lesions

Unusual presentation of choriocarcinoma

Choriocarcinoma is a rare malignant genital tract tumor, arising in the uterus or in the testis. These tumors in women usually follows a pregnancy. It is more common after a molar pregnancy. A 35 years old married woman was admitted with two weeks history of bleeding per rectum. Patient was explored via a midline incision. A 2x2 cm polypoidal lesion was found in terminal ileum and a haemorrhagic cystic mass seen in upper pole of right kidney. Uterus was bulky. Heal lesion was resected and anastomosis done. Excision Biopsy was taken from the renal mass, conserving the kidney. Resected Heal tissue and kidney mass were reported as Choriocarcinoma

Outcome of stapled haemorrhoidectomy versus Milligan Morgan's haemorrhoidectomy

To compare the postoperative outcome of stapled haemorrhoidectomy and conventional Milligan Morgan's open haemorrhoidectomy. Comparative study. Surgical Unit 1, Ward-3, Department of Surgery, Jinnah Postgraduate Medical Centre, Karachi, from March to September 2006. Sixty patients of late 2nd, 3rd and 4th degree haemorrhoids were selected for admission from the outpatient department after taking informed consent. Patients with concomitant anal disease [e.g. fissure, abscess, fistula, ano-rectal cancer etc.] were excluded. Two groups of thirty each were made, one for Milligan-Morgan open haemorrhoidectomy and another for stapled haemorrhoidectomy, in which excision of a ring of mucosa proximal to the haemorrhoid[s] was done thus, interrupting the blood supply but maintaining continuity of the rectal mucosa. The operative time was measured in minutes. Postoperative pain was assessed through VAS. Bleeding was measured as no, mild, profuse. Other post-operative complications during hospital stay like urinary retention, anal stenosis etc. were noted. Student t-test, chi-square test and repeated measured analysis of variance were applied to compare the variables. The mean age was 40.7 +/- 11.6 years. A majority [53.3%] of patients [combined% in both groups] had third degree haemorrhoid. The mean length of operative time was found statistically insignificant between open and stapled groups [19.6 +/- 5.9 vs. 22.4 +/- 7.2 minutes, p=0.974]. However, the mean length of postoperative hospital stay was significantly less in the stapled than open haemorrhoidectomy group [3.37 +/- 2.2 vs. 2.03 +/- 0.81 days, p=0.003. Mean postoperative pain [observed by VAS] in the stapled group was significantly less than the open haemorrhoidectomy group [4.43 +/- 1.25 vs. 7.37 +/- 0.72]. The proportion of postoperative bleeding, infection, anal tag, urinary retention, tenderness on digital rectal examination and wound discharge was higher in open than stapled haemorrhoidectomy group, but statistically insignificant [p < 0.05]. There was a significant difference between Milligan Morgan's and stapled haemorrhoidectomy for postoperative pain and hospital stay. However the mean length of operative time was insignificantly different

case of pseudotumorous form of ascaris

A 35-year-old woman presented with lower abdominal pain and amenorrhoea. CT showed a thick walled lobulated mass with Ascaris adjacent to caecum along with the presence of a left ovarian mass. The peroperative findings were a tubular mass with central tunneling containing an Ascaris lumbricoides. Left ovary showed a haemorrhagic cyst. Biopsy of the mass showed acute on chronic granulomatous inflammation and the worm was found to be female. This was a rare case of Ascaris lumbricoides presenting as a pseudotumorous mass

Tubercular fistula-in-ano

To determine the frequency of tuberculosis in recurrent fistula-in-ano. Case series. This study was conducted in Surgical Ward-3, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, from 1998 to 2007. The study included 100 cases of recurrent fistula-in-ano not responding to conventional surgery. Patients with other co-morbidities such as diabetes mellitus, bleeding disorders or with the evidence of pulmonary, abdominal or intestinal tuberculosis were excluded from this study. Fistulogram was performed in all patients. All the patients were subjected to fistulectomy followed by histopathology of the resected specimen. Thereafter, confirmation of the disease, anti-tuberculous treatment was immediately started and response to treatment was observed after 6 months. Out of the 100 studied patients, 11 cases had biopsy proven tuberculosis in the fistula. All the patients were male. The fistulae were low type, single and usually located posteriorly [n=9] with everted margins. Ten were located within 3 cm of anus. Fistulogram revealed single internal opening. Comparative statistics of tuberculous fistula-in-ano with fistulas due to specific inflammation revealed no major differences. The diagnosed patients of tubercular fistulae-in-ano were observed for at least 6 months after starting anti-tuberculous treatment. They all responded well to anti-tubercular treatment and the fistulae healed without any complication such as recurrence or anal stenosis within 6 months. Tuberculosis should be suspected in case of recurrent fistulae-in-ano, so as to avoid unusual delay in the treatment and miseries to the patient. Appropriate anti-tuberculous therapy leads to healing within 6 months

Frequency of infection in cholelithiasis

To determine the frequency of infection in cholelithiasis and find common infecting organisms with their antibiotic sensitivity. A descriptive study. This study was conducted in Surgical Unit - I, Jinnah Postgraduate Medical Centre [JPMC], Karachi, Pakistan, from April 2001 to March 2002. First 100 cases of cholelithiasis, selected and operated by open or laparoscopic cholecystectomy were included in this study. Patients with acute cholecystitis, history of jaundice, stones and / or dilated common bile duct were excluded from the study. Ultrasound was the main tool for pre-operative diagnosis. During cholecystectomy, bile was aspirated and specimens were sent to laboratory for microbiological examination. The results were recorded on a proforma. Out of 100, 36 patients had positive bile culture. The most common organism was E. coli [17 patients] followed by Klebsiella [9], Pseudomonas [6], Staphylococcus aureus [2], Salmonella [1] and Bacteroids fragalis [1] patient. In this study, most of the biliary organisms were highly sensitive to the 2nd generation cephalosporins and quinolones. From the bacteriological assessment, it seems that both endogenous and exogenous contamination were the causes of wound sepsis. It was also found that the infection of bile did not increase the risk of postoperative wound infection when prophylactic perioperative antibiotics were used

Complications of laparoscopic cholecystectomy: a learning curve

The objective of the study was to find out the rate of complications of laparoscopic cholecystectomy being performed by trainees under supervision. Case Series. Place and Duration: Study was conducted in Surgical unit-1 [ward-3] of JPMC Karachi from November 2001 to November 2005. All the patients above twelve years of age of both sexes were admitted for laparoscopic cholecystectomy after evaluation in the outpatients department who were diagnosed as cases of chronic cholecystitis with cholelithiasis. A total of 620 patients were included in the study. Biliary complications were 0.16% and non biliary 0.8%. Vascular injury, diaphragmatic injury and pneumothorax did not occur in our study. Complications of laparoscopic cholecystectomy in the hands of trainees can be minimized by adhering to the principles of good laparoscopic surgery

Tuberculous mastitis

To find out the different clinical presentations of breast tuberculosis and its treatment outcome. Design: An observational study. Surgical ward 3 of Jinnah Postgraduate Medical Centre, Karachi from June 2001 to November 2003. Fifty consecutive female patients above 13 years presenting with breast lump, multiple sinuses, axillary lymphadenopathy, and cold abscess were included in the study. Medical records of the patients presented were reviewed and analyzed. Data was collected regarding the patient's name, age and marital and lactational status. Clinical Examinations and investigations were carried out by triple assessment i.e. clinical, radiological and histological / cytological evaluation. The commonest presentation was a solitary breast lump in 30 [60%] patients, breast lump with axillary lymphadenopathy in 13 [26%]. Four [8%] patients presented with generalized breast swelling [edema] with ipsilateral axillary lymphadenopathy. Two [4%] presented with breast abscess and axillary lymphadenopathy and one [2%] with axillary sinus and breast lump. Upper outer quadrant was most frequently involved in 29 [58%] of patients. Thirty two [64%] cases were secondary to tuberculosis in other sites, mostly [40%] from tuberculous axillary lymphadenitis. Forty eight [96%] patients responded well to one year antituberculous treatment with complete disappearance of the lumps except 2 patients who had shrinkage of lump size only, underwent excision of lump. Solitary lump and enlarged lymph nodes are the commonest presentation of mammary tuberculosis. Early diagnosis and treatment is necessary to prevent disfigurement of breast. Antituberculous therapy is the treatment of choice. Surgery should be reserved for unresponsive lumps

Dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans is a rare, locally aggressive, rarely metastatic skin tumor which tends to recur. A 45-year-old female presented with dermatofibrosarcoma protuberans on her breast as a recurrent nodule after excision. Lump was re-excised with wide margins and irradiated. Follow-up was done monthly for two years, with no recurrence

Causes of intestinal obstruction: a study of 257 patients

To find out the common causes of intestinal obstruction in our practice. Design: Descriptive study. Place and Duration: The study was conducted in Surgical Unit-I, Ward-3 of Jinnah Postgraduate Medical Centre, Karachi, Pakistan between February, 2000 to January, 2004. Patient And In this study we included only those patients of intestinal obstruction who underwent exploratory laparotomy. Total of 257 patients of intestinal obstruction were diagnosed on the basis of clinical history, examination, radiological findings and investigations. After resuscitation exploratory laparotomy was performed to confirm the diagnosis and relieve the obstruction. The most common cause of intestinal obstruction was tuberculosis, 38.13% followed by obstructed/strangulated hernia 26.84%, post-operative adhesions 17.12%, large gut malignancy 10.09%, volvulus 6.22% and small gut malignancy 0.77%. The causes of intestinal obstruction are variable in different parts of world. Tuberculosis is one of the leading cause of intestinal obstruction in Pakistan

Presentation, management and outcome of mastalgia

To find out the causes of mastalgia in females of various age groups, its management and outcome. Descriptive study. The study was carried out in the breast clinic of Surgical Unit-I, Ward-3 of Jinnah Postgraduate Medical Centre, Karachi. From January 2001 to December 2001. The study included 100 consecutive patients diagnosed as a case of mastalgia on the basis of history and clinical examination. Out of 100 patients, 56 presented with cyclical mastalgia, 28 non-cyclical mastalgia, 13 associated withfibroadenoma and 3 had carcinoma. Cyclical mastalgia is commonest in pre-menopausal women whereas noncyclical mastalgia is common in post-menopausal women. Reassurance and good analgesia can cure more than 50% of patients presenting with mastalgia. Almost all patients of cyclical mastalgia were cured by evening primrose oil. Some of the cases may have other associated lesions which must be excluded carefully

Treatment of breast abscess with ultrasound guided percutaneous needle drainage

A study was conducted from August 2003 to July 2004 on 22 consecutive females with uncomplicated breast abscess in the breast clinical of ward-03 JPMC. Percutaneous aspiration of the abscesses was done under ultrasound control instead of more traditional incision and drainage. The highest number of patients had abscess in the lower outer quadrant. Minimum age was 14 and maximum 44 years. Out of 22 patients I 1 were cured on first aspiration, 7 responded on re- aspiration and 4 had incision drainage and tissue biopsy to exclude malignancy. Ultrasound guided needle aspiration is a good method to treat small breast abscess with no skin changes

Comparison of trucut biopsy with fine needle aspiration cytology in diagnosis of palpable breast lesions

A comparative study was conducted on 25 consecutive female patients with clinically palpable breast lumps from July 2003 to April 2004 in the barest clinical of Surgery ward-03 JPMC. All the patients underwent fine needle aspiration cytology and trucut biopsy simultaneously. Mean age was 45.28 years with minimum age of 32 and maximum 66 years. Most frequent site involved was upper outer quadrant [32%]. The most common lesion diagnosed on FNAC was malignancy in 60% of cases, whereas on trucut 64% of the lumps were diagnosed as malignant. Trucut biopsy defined the type of lesions more accurately than FNAC. The sensitivity of FNAC and trucut was 88% and 96%. Trucut biopsy is a valuable tool for breast lumps diagnosis and provides better characterization of benign and malignant lesions

Tuberculosis of the breast

A study was conducted to find out the frequency of breast tuberculosis and its treatment outcome, at the breast clinic of surgical unit 1 ward 3 JPMC Karachi. The study comprised of 152 patients of breast lumps between March 2000 and September 2001, out of which 35 showed positive FNAC for tuberculosis [23%]. They responded very well to antituberculosis chemotherapy and the lump totally disappeared within 12 months of therapy. Hence early diagnosis, before sinuses develop is important in preventing disfigurenment

Clinical presentation of liver abscess

Liver abscesses is a common problem in developing countries especially with poor hygiene and water supply. A retrospective study was conducted to review the records of cases of liver abscesses treated at Jinnah postgraduate medical centre Karachi from September 1996 to July 2001. The objective being to see the most common clinical presentation of liver abscess. A total of 158 cases 136 male and 22 female were admitted and treated. The most common clinical features were fever, pain right upper abdomen and hepatomagally. Ultrasound diagnosed 96.8% of cases. 56 patients were treated with antibiotics, 79 had aspiration and 17 had exploratory laparatomy. There was no mortality in our study