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

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

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

Prediction of difficult laparoscopic cholecystectomy on the basis of gallbladder wall thickness

To identify if gallbladder wall thickness is associated with technical difficulty during laparoscopic surgery and whether conversion to open cholecystectomy is more frequent in such patients. This prospective, non-randomized and descriptive study was conducted in Department of Surgery, Unit IV of Civil Hospital Karachi from December, 2010 to November 2012. Sixty four patients who underwent laparoscopic cholecystectomy were included. A fresh ultrasound was performed one day prior to surgery and gall bladder wall thickness of 3 mm was taken as predictor for difficult surgery. Various intraoperative parameters were recorded including total time taken, time taken to clear calots triangle and conversion to open cholecystectomy. Out of 64 patients, 4 [6.3%] were males and 60 [93.8%] were females. Age ranged from 22-65 years with a mean of 40.45 +/- 12.43 years. Gall bladder wall thickness ranged from 1-4.2 mm with a mean of 1.78 +/- 0.80 mm. Difficult laparoscopic cholecystectomy was encountered in 13 [20.3%]. In patients with difficult laparoscopic cholecystectomy the mean gallbladder wall thickness was 2.40 +/- 0.87 mm [p=0.001]. The mean age of patients with difficult surgery was 40.54 +/- 13.80 years. Mean operating time in patients with difficult laparoscopic cholecystectomy was 90.77 +/- 30.81 minutes as compared to 57.02 +/- 20.63 minutes in normal laparoscopic cholecystectomy [p<0.001] This study identifies and corroborates with the international literature that gallbladder wall thickness of 3 mm is associated with difficult cholecystectomy and higher rate of conversion to open cholecystectomy

Anatomical Variations Of Cystic Artery: Telescopic Facts

The introduction of laparoscopic cholecystectomy has stimulated a renewed interest in the anatomy of Calot’s triangle 1. This triangle is a focal area of anatomical importance in cholecystectomy and a good knowledge of its anatomy is essential for both open and laparoscopic cholecystectomy 2, 3. This triangle was described by Calot in 1891 as bounded by the cystic duct, the right hepatic duct and lower edge of liver 4. In its present interpretation the upper border is formed by the inferior surface of the liver with the other two boundaries being the cystic duct and the common hepatic duct 2,5. Its contents usually include the right hepatic artery (RHA), the cystic artery, the cystic lymph node (of Lund), connective tissue and lymphatics 5,6. The cystic artery is a branch of the RHA and is usually given off in Calot’s triangle 7. Anatomic variations in Calot’s triangle are common. Variations in cystic artery anatomy, based on its origin, position and number are well described 3, 8 because of its importance in avoiding inadvertent bleeding and its consequences. The reported incidence of these variations is from 25 to 50 % in various studies 3,9 with the magnified laparoscopic view having increased the frequency of recognition of these variations. The methods of retraction used in the laparoscopic procedure gives a different view of the area, thus introducing the term ‘laparoscopic anatomy’7. Accurate knowledge of cystic artery anatomy and its variations can reduce the likelihood of uncontrolled intraoperative bleeding, an important cause of iatrogenic extra hepatic biliary injury and conversion to open cholecystectomy 3, 7, 8. The incidence of conversion to open surgery due to vascular injury is reported to be 0-1.9% and its mortality 0.02% 3, hence these variations should stay in surgical conscience to prevent procedure related morbidity. We aim to present the variations in cystic artery seen in laparoscopic cholecystectomy in our patient population.

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

An experience of capsule endoscopy from a tertiary care hospital in Pakistan

To evaluate the effectiveness of capsule endoscopy in the management of patients with obscure gastrointestinal bleeding. A prospective descriptive study was conducted at surgical unit IV, Civil Hospital Karachi over a period of 2 years from December 2007 to November 2009. Twenty eight consecutive patients presenting with obscure gastrointestinal bleeding were included in the study. Patients having history of acute intestinal obstruction were excluded. Study was approved by the hospital ethical committee. Informed and written consent was taken from all the patients included in the study. The procedure was performed as day case. Patients were asked to swallow a capsule with a glass of water after an overnight fast and bowel preparation. Endocapsule [Olympus MAJ-1469] was used in the study. Examination was termed as complete when the capsule reached the caecum or incomplete if capsule failed to enter the caecum or the battery life was exhausted. Computer recordings were read by two examiners and finally results were interpreted. Follow up was done on telephone every 24 hours till the passage of capsule and then monthly for 4 months. In case of failure to pass the capsule after 14 days or adverse effects like vomiting, abdominal pain, an abdominal radiograph was obtained and decision regarding surgical intervention was made. A total of twenty eight patients were included in this study, 15 [53.6%] males and 13 [46.4%] females. Age of the patients ranged from 15-85 years [mean 56.25 +/- 19.6 years]. There were 8[28.6%] diabetics, 8[28.6%] hypertensives and 5[17.9%] hepatitis C positive patients. The indication for the capsule endoscopy was malena in 9 [32.1%], occult bleed in 18 [64.3%] and non specific abdominal pain in 1[3.6%]. Examination was completed in 22/28 [78.6%] patients while 6 [21.4%] patients had incomplete examination. In 2/28 [7.1%] patients endoscopic assistance was required to push the capsule through the pylorus. There was history of abdominal surgery in 3/28 [10.7%] patients prior to capsule endoscopy. Capsule entrapment occurred in 2/28 [7.1%] patients who were subjected to surgery. The results of capsule endoscopy showed ulceration and bleeding in distal ileum in 7 patients followed by Arterio Venous Malformation in 6 patients. The management and follow up was done accordingly. The diagnostic yield of CE in this study was 64.28% [18/28 patients].In a total of 28 patients referred for capsule endoscopy, bleeding was resolved in 13 patients [46.42%]. Capsule endoscopy is a well tolerated and safe examination of the small bowel with a diagnostic yield superior to radiological investigations

Endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones

To evaluate the effectiveness of endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones. A prospective non-randomized descriptive study was conducted at the Endoscopic Service of Surgical Unit 4, Civil Hospital Karachi over a period of 2 years from February 2007 to January 2009. A total of 84 patients where the biliary calculus was either greater than 15mm or difficult to remove with standard techniques underwent ERCP with endoscopic sphincterotomy and balloon sphincteroplasty. Patients with diagnosis of cholangitis or "pancreatitis were excluded from the study. Endoscopic balloon dilatation was performed after standard sphincterotomy by using standard 15-18mm Controlled Radial Expansion [CRE] balloons. All procedures were done as day case under conscious sedation. There were 18 [21.4%] male and 66 [78.6%] females. Age of the study population ranged from 16-85 years with a mean of 48.38 +/- 17.07 years. The size of the stone ranged from 10-32mm with a mean of 14.7 +/- 0.44mm. Stones were removed with sphincteroplasty in first session in 52/84 [61.9%] patients, 11/17 [64.4%] patients in the second session and 4/4 [100%] in the third session. Patients who were lost to follow up were 14[16.7%]. Surgery was advised for 2 [2.4%] patients because of failure to remove stones by sphincteroplasty. Overall success of endoscopic sphincterotomy and large balloon dilatation in our study was 79.76%. Complications were seen in seven patients [8.3%] while one [1.2%] died. Bleeding was encountered in 3 [3.6%] patients which was controlled by adrenaline injection in 2 patients while one patient died due to severe haemorrhage before any surgical intervention could be undertaken. Moderate pancreatitis necessitating admission was seen in 3 patients [3.6%]. None of the patients had severe pancreatitis or perforation secondary to the procedure. Large balloon dilatation along with endoscopic sphincterotomy is a simple, safe and effective technique in removing large bile duct stones, in patients with distal common bile duct narrowing or in whom the size of stone is greater than the size of common bile duct with a complication rate if not less equal to that of endoscopic sphincterotomy alone

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

Triple hepatitis: frequency and treatment outcome of co/super-infection of hepatitis C and D among patients of hepatitis B

To determine the frequency of hepatitis C and D in patients of chronic hepatitis B and the treatment response of hepatitis B in such patients. Case series. Civil Hospital and Lyari General Hospital, Dow University of Health Sciences, from July 2003 to June 2005. All patients of hepatitis B presenting during the study period were screened for triple infection by carrying out anti-HBc [IgG], anti-HCV and anti-HDV. Patients who were positive to all three were included in the study. Complete Blood Count [CBC]; HBsAg; HBeAg; anti-HBc IgM; anti-HDV; anti-HCV; HBV DNA PCR; HCV RNA PCR; serum albumin; SGPT; serum bilirubin and ultrasound abdomen were acquired in all patients. All patients received pegylated interferon-alpha 2a 180 mcg sc weekly x 48 weeks. Patients who were also positive for HCV RNA also received ribavirin 1000-1200 mg/d po x 24 weeks for genotype 3 and 48 weeks for genotype 1. Descriptive statistics were used for describing the data. Out of the 246 patients of HBV, 29 [11.8%] patients were also positive for anti-HBc IgG, anti-HDV and anti-HCV. After 48 weeks of therapy, the respective viral undetection by PCR was 4 [13.8%] in patients having only HBV DNA, 3 [10.3%] in patients with only HCV RNA and in patients who had both HBV DNA and HCV RNA positive, simultaneously HCV was cleared in 2 [6.9%] while HBV was not cleared in any case. In patients coming with one hepatic infection, other infections should be sought as they share a common mode of spread and may affect the overall response to treatment

Pattern of malignant tumours in general surgical practice

To study the pattern of malignant tumours in relation to various variables like age, sex, histology, anatomical involvement, etc. A retrospective study from June 2001 to May 2007. Surgical Unit V of Civil Hospital, Karachi. All patients who presented with malignant tumours were included. The data of all the patients was collected from case sheets and analyzed. A total of 217 patients, 96 males and 121 females were included in this study. The most common tumour was carcinoma of the oespophagus [23 males, 32 females], followed by carcinoma of the breast in 42 females. There were no case of male breast cancer. Malignant tumours are commonly seen in surgical units. It is important to increase public awareness about them so that patients can present at an early stage for a better outcome

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

Five years experience of carcinoma breast

To evaluate the presentation, staging and histology of carcinoma breast patients admitted over a period of five years A retrospective analytical study was conducted at surgical unit two, Civil Hospital Karachi over a period of five years from October 2001 to October 2006. Eighty five female patients with biopsy proven carcinoma breast admitted and operated, were included in the study. 43.5% patients were under the age of 45 years. 4.7%had family history, 49.4%were premenopausal, none had history of oral contraceptive intake. 84.7% had breast fed their siblings, 12% were nulliparous. 29.4% had skin involvement at presentation; nipple retraction was seen in 23.5%. 90.5% had infiltrating ductal carcinoma with 58.8% having histological involvement of axillary lymph nodes. 50% had stage 3 and 41% stage 2 cancers. The risk / predisposing factors for carcinoma breast were not significantly present in our study population. Most of the patients at presentation had stage two and three carcinoma, with the predominant cancer type being infiltrating ductal carcinoma

Treatment outcome in patients of hepatitis B with hepatitis D: experience of 4 years at a tertiary care centre in Pakistan

To determine HBV suppression in patients with dual HBV and HDV infection after 48 weeks with 10.0 MID of interferon-a 2b. Quasi experimental study. Civil Hospital, Karachi and Lyari General Hospital, Karachi, from July 2003 to June 2005. All HBsAg positive patients were screened for anti-HDV, all positives were included. Baseline investigations, liver chemistries and HBsAg; HBeAg; anti-HBcore IgM; HBV DMA quantitative PCR were done. Patients with hepatocellular carcinoma and decompensated cirrhosis were excluded. Patients were treated with Interferon-a 10.0 MID sc t.i.w. for 48 weeks. HBeAg and quantitative HBV DNA was done at week 0, 24 and 48 while CBC and SGPT were done monthly. HBV suppression was defined as levels <400 copies/ml. Fifty-two patients were selected for intervention, including 34 males and 18 females. At the end of therapy after 48 weeks, HBV DNA suppression was achieved in 51.9% and HBeAg became undetectable in 53.8% of patients. Twenty -one patients with HBV suppression still had raised SGPT. HDV should be screened in all patients eligible for HBV treatment

Efficacy of needle aspiration as primary treatment of amoebic liver abscess

To describe the efficacy of needle aspiration of amoebic liver abscess and to assess its morbidity and mortality rates. A descriptive case series is designed. This study was conducted on 46 patients admitted to surgical ward 5 of Civil Hospital Karachi during a period of 2 years from December 2004 to November 2006. The success rate of percutaneous needle aspiraion was found to be 98%. Only one case came with recurrence. Four cases did not respond and were treated through laparotomic drainage. Reason of failure was found to be the more posterior location of the abscess. Treatment of amoebic liver abscess by aspiration with a wide bore needle is a very satisfactory method. It is accompanied by very low morbidity and mortality. In developing countries like Pakistan needle aspiration should be recommended as a standard procedure to treat amoebic liver abscess

Frequency and comparative analysis of hepatitis in patients seeking treatment for hepatitis B

To find the frequency of hepatitis 'D' in patients of hepatitis 'B' seeking treatment and to compare clinical and biochemical features in patients harboring HDV with those who are not. Cross-sectional study. Medical Unit-IV, Civil Hospital Karachi, Medical Unit-VI and Surgical Unit-VII, Lyari General Hospital, Dow University of Health Sciences, Karachi; from July 2003 to June 2005. HBsAg positive patients seeking treatment were enrolled in the study. Anti-HDV was done in all. Patients were split into two groups according to their anti-HDV status into HDV positive and HDV negative groups. Liver biochemistries and viral profile for HCV, anti-HBc IgM and HBeAg were done and compared between the two groups. A total of 246 patients were selected. HDV was positive in 66 [26.8%] patients. No significant difference was observed in the frequency and stages of cirrhosis between the two groups while significant differences were observed in the mean SGPT [95% CI: -381.09 to -110.74; P = 0.001] and albumin levels [95% CI: 1.87 to 7.73; P = 0.007] and in the frequency of HBeAg [P = 0.001], anti- HBc IgM [P = 0.02] and HBV DNA [P < 0.001]. HDV infection was common in patients with HBV in this cohort of patients. All patients of HBV should be screened for HDV before treatment decision for the former is taken

Idiopathic gastroparesis

This case report describes a young female with idiopathic gastroparesis, who presented with persistent vomiting and weight loss. Treatment with erythromycin and tegaserod led to the recovery from symptoms and weight gain