Pancreas divisum

Objective: To evaluate the complications, technical success, diagnostic evaluation and various endoscopic management options in patients with pancreas divisum

Study Design: Descriptive study

Place and Duration of Study: Endoscopy Suite, Surgical Unit 4, Civil Hospital, Karachi, from January 2007 to December 2013

Methodology: All Endoscopic Retrograde Cholangio-pancreatography [ERCPs] procedure performed in patients with pancreas divisum were analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy for the condition

Results: During the study period, 3600 patients underwent 4500 ERCP procedures. Pancreas divisum was found in 17 patients [0.47%]; 7 ERCPs [41.2%] were performed for diagnostic and 10 [58.8%] for therapeutic purposes. Sixteen [94.1%] had complete PD and one [5.9%] had incomplete PD. Male and Female ratio was 1:1.83 with a mean age of 26.3 years and median symptom duration of 11 months. A total of 23 procedures were performed in 17 patients; 2 had ERCP done thrice, 2 underwent the procedure twice, while the rest had single procedure done. Six [35.3%] patients had chronic pancreatitis, 7 [41.2%] had acute recurrent pancreatitis and 4 [23.5%] had acute pancreatitis. Endoscopic minor papillotomy was performed. There was no procedure-related mortality. ERCP affected management in 88.2% [15/17 procedures]

Conclusion: ERCP is a safe and feasible procedure for pancreas divisum patients

Pneumatic balloon dilation of Achalasia Cardia

Objective: To find out frequency of improvement of symptoms and complications rate following endoscopic esophageal balloon dilation in patients with achalasia cardia

Study design: Case series

Place and duration of study: Department of Surgery Dow University of Health Sciences and Civil Hospital Karachi, from January 2006 to September 2013

Methodology: Patients in whom diagnosis of esophageal achalasia was made on investigations [barium swallow and / or manometry] were included. These patients were subjected to balloon dilation. The procedure was performed using Olympus achalasia balloon dilators. All patients were followed up and their responses were noted. Excellent response was defined as improvement of dysphagia for both solids and liquids. In good response category those patients were included who had improvement of dysphagia for both solids and liquids but problems with food intake persisted. In poor response category patients there was no improvement following balloon dilation. Time to recurrence of symptoms and complications were also noted

Results: A total of sixty patients were included. There were 31males [51.7%] and 29 [48.3%] females. Male to female ratio was 1.07:1. The age of the patients ranged from 13 to 65 year. The mean age was 35.48 +/- 13.36 year. Seventy five dilations were performed [mean 1.25 +/- 0.54]. In 35 [58.33%] patients excellent response was obtained while 19 [31.67%] patients had good response. In 6 [10%] patients no improvement was seen. These were put into poor response category. In one [1.7%] patient esophageal perforation occurred. In six patients [10%] surgery was advised as no improvement following multiple sessions of balloon dilation occurred

Conclusion: Achalasia cardia can be managed effectively with balloon dilation under fluoroscopy

Early breast cancer in females presenting with palpable breast lumps

To determine the frequency of early breast cancer in women presenting with palpable breast lumps. Prospective cohort study. Surgical Unit - IV Civil Hospital Karachi, from December 2011 to June 2012. All female patients 13 year and above with palpable breast lumps were recruited in this study after seeking their consent. Triple assessment was carried out and core biopsies taken. Histopathology reports were recorded. Two hundred and eighty two females between 15 to 80 year [mean= 36.5 year] presented with breast lumps. Of the total 72% [n=199] lumps were benign on histopathology while 29% [n=83] showed malignancy. There were 19 [7%] cases of breast abscess. The frequency of breast cancer was 29% in present group of patients presenting with breast lumps

Laparoscopic cholecystectomy with and without prior ERCP

To find out operative difficulties in patients undergoing laparoscopic cholecystectomy after ERCP in comparison with those without prior ERCP. Comparative study. Surgical Unit IV Civil Hospital Karachi, from June 2011 to June 2013. Patients were divided into 2 groups. Group 1 consisted of 40 patients with choledocholithiasis, who underwent ERCP followed by laparoscopic cholecystectomy while in Group 2 there were 40 patients with uncomplicated gallstones who had no intervention prior to laparoscopic cholecystectomy. A total of 80 patients underwent laparoscpic cholecystectomy. Male: female ratio was 8:32 and 5:35 and mean age was 40.20 +/- 11.27 year and 39.58 +/- 11.29 year in Groups 1 and 2 respectively. Statistically significant difficulties were encountered during operation between the groups. Such difficulties were found in 29 [72.5%] and 3 [7.5%] patients in Group 1 and 2 respectively [p<0.0001]. The laparoscopic procedure was converted to open in eight [20%] patients in Group 1 and 1 [2.5%] patient in Group 2 [p=0.01]. Patients with difficult laparoscopic cholecystectomy had a mean ERCP frequency of 1.34 +/- 0.74 while those with no difficulty encountered had a mean ERCP frequency of 1.15 +/- 0.38 [p=0.05]. Statistically significant difference was found when comparing the operative difficulties encountered in patients who underwent ERCP and surgery in the same settings and in those where surgery was delayed after ERCP [p<0.001]. Laparoscopic cholecystectomy after ERCP was difficult and challenging. To minimize the complications and conversion, these patients should be operated in same sitting as for ERCP

Frequency and risk factors in the post-ERCP pancreatitis in a tertiary care centre

To evaluate the frequency and associated factors in the post-endoscopic retrograde cholangiopancreatography [ERCP] pancreatitis. Cross-sectional analytical study. Endoscopy Suite of Surgical Unit IV, Civil Hospital, Karachi, from December 2009 to November 2010. Patients undergoing ERCP were included. Patients who had presented with pancreatitis or raised amylase levels before procedure or patients who had previous history of surgery on the biliary or pancreatic systems were excluded from the study. Pearson chi-square and Fisher's exact test were used for qualitative data and t-test for quantitative data. Significance was taken as p

Flexible sigmoidoscopic findings in patients with fresh rectal bleeding

Flexible sigmoidoscopy can diagnose majority of pathologies in patients with rectal bleeding and is less demanding than colonoscopy. Frequency of different findings in patients with rectal bleeding on flexible sigmoidoscopy was considered. Out of a total of 215 patients, 133 [61.9%] were males and 82 [38.1%] were females. The most common findings were hemorrhoids in 49 patients [22.8%] and polyps in 37 [17.2%] patients. The mean duration of bleeding was 57.4 +51.8 months. Seventeen [7.1%] were found to have malignancy on sigmoidoscopic biopsy. Flexible sigmoidoscopy was able to determine the cause of bleeding in majority of patients with rectal bleeding

Role of pre cut sphincterotomy in difficult biliary cannulation

To assess the success rate and complications of pre cut sphincterotomy [PBS] in achieving deep common bile duct [CBD] cannulation where standard techniques of biliary cannulation failed. Descriptive study Surgical Unit 4, Civil Hospital Karachi from 14 October, 2006 to 18th December, 2007. Thirty five patients, in whom needle knife was done due to difficulty in achieving cannulation by standard means, in a 14 months period were included in the study .The data was entered into the ERCP database, locally developed at the time of ERCP and follow up was done at 24 hours and 15 days. Data was collected prospectively. No randomization was done. The main outcome measures were success and complications of precut sphincterotomy. Success of the PS was defined as the ability to deeply cannulate the CBD. Statistical data was extracted from the SPSS version 11. Variables were compared using Chi-square or t-tests as appropriate. A total of 327 ERCP's were performed during the study period out of which 35 [10.70%] precut sphincterotomies were done. The average age in the PBS group was 44.83 years [range 26- 80 years], and 71.4% [n=25] were females. Biliary cannulation was successful in 60% of the patients in the first attempt and 66.66% at a subsequent attempt. The cumulative success rate was 92.5%. Complication rate was 25.9%. Of seven PBS related complications pancreatitis occurred in four [11.4%], infection in two [5.7%] and bleeding in one patient [2.9%]. Difficulty in PBS should be anticipated in post surgical patients with altered anatomy and collapsed biliary system like CBD leakage and long distal strictures. Complication rate increases with subsequent attempts at cannulation. Overall, in experienced hands, PBS is safe and effective procedure in achieving selective cannulation

Aspiration combined with seton insertion for treatment of wrist ganglions

To evaluate the results of Aspiration combined with Seton insertion in the treatment of wrist Ganglions. Prospective, quasi experimental study from Jan. 2004 to Dec. 2006. Surgical Unit V, Civil Hospital, Karachi. Fifty five patients who presented with wrist Ganglia. All patients were assessed in detail clinically, and treated by aspiration with 14 gauge IV cannula and 10cc syringe followed b Seton [Silk No. 1 on straight needle] insertion through the cavity. Seton was removed on the 12th day. The average follow-up time was one year. Out of 55 patients, 51 [92.7%] had a Dorsal Carpal Ganglion and 4 [7.3%] a Volar Ganglion. Twenty nine [52.7%] cases were males and 26 [47.3%] females, with an age range from 17-35 years. All patients complained of a localized swelling, while 12 [21%] had pain during activity. Fifty two [95%] cases had a smooth recovery, while two had residual swellings requiring re-aspiration and on developed signs of inflammation which subsided on conservative management. No recurrence of the ganglion occurred in any case. Aspiration combined with seton insertion for treating Ganglions of wrist is a simple, economic, cosmetic, uncomplicated procedure which can be done in the out-patient department. It is a reliable and safe alternative to open resection for successful eradication of the wrist Ganglion

Biliary leakage following cholecystectomy and its outcome

To find out the causes and outcome of management in cases of bile leakage following cholecystectomy. Prospective descriptive study from April 2005 to December 2006. Surgical Unit five of Civil Hospital, Karachi. A total of 140 patients who were operated for symptomatic gall stones. Detailed information regarding the patients was collected. Initially due to non-availability of ERCP as well as high cost in the private sector, all patients with biliary leakage underwent open surgery. Later on all patients underwent ERCP due to its availability in the unit; operative intervention was only undertaken when the ERCP was not therapeutic or failed. Ultrasound studies were done in patients who were suspected to have bile collections but no discharge from the drains or the operative wounds. Out of 140 patients, two patients were noticed to have biliary leakage during surgery and 10 post-operatively. The former cases underwent repair on the spot, while in the latter group five underwent re-exploration and four ERCP; one patient expired without intervention and another from the re-exploration group. In three patients ERCP was successful and sphincterotomy with stenting was done while in one patient there was failure of cannulation, resulting in open exploration

Ultrasound drainage of pseudocyst of pancreas

This study was conducted at three medical centers of Karachi from October 1998 to October 1999. Total 18 patients underwent ultrasound guided drainage of pseudocyst of pancreas. The objective of this study was to see the advantages of ultrasound guided aspiration of pseudocysts compared with computerized tomographic [CT] guidance. Pseudocysts of any etiology but greater than 4 cm size and located on left side of abdomen were drained by either Paediatric chest tube [10-14 FR] or peritoneal drainage tube [10 FR]. Drainage was done under complete asepsis after screening for Hb%, PT and APTT. The etiology of pseudocyst was trauma, biliary tract pathology, impacted ascaris and alcohol abuse. Contents of the pseudocyst were found to be infected, hemorrhagic or clear. Complete recovery took 3-8 weeks. It was concluded that ultrasound is a primary means to localize the pathology and later on to have percutaneous drainage. It is safe and convenient with unmatched success rate