Ivor Lowis esophagectomy: experience at Jinnah hospital, Lahore

Although different approaches have been used for surgical resection of esophageal cancer, the Ivor Lewis approach is the standard technique at most centers for resection of the diseased middle and lower third esophagus. This procedure has historically been associated with significant morbidity and mortality. However, modern literature suggests that Ivor Lewis esophagectomy can be performed with an acceptable complication rate and mortality. Patients and methods: We conducted a case series of thirteen consecutive patients who underwent an Ivor Lewis esophagectomy at Jinnah Hospital Lahore from January, 2001 to December, 2002. The objective was to examine the morbidity, mortality and short-term outcome of this surgical procedure. The mean age of the patients was 45.9 years +/- 18.3 years [median: 44.5 years; range: 22 to 78 years]. 7 patients were men and 6 patients were women. 6 patients [46.2%] were operated for benign corrosive esophageal strictures whereas seven patients [63.8%] had esophageal cancer. The median age of the patients with benign strictures was 28 years [range: 20 - 35 years]. The median age of the cancer patients was 58 years [range: 54-70 years]. Of these patients, one had Stage I cancer [9.29%], two had Stage II a [28.57%], two had Stage II b [28.57%], and two had Stage III disease [28.57%]. Five patients [71.42%] had adenocarcinoma and two [28.57%] had squamous cell carcinoma. Seven patients [53.8%] had one or more co-morbid conditions, including diabetes, hypertension, cardiovascular disease and chronic obstructive pulmonary disease. Four patients [30.77%] had history of smoking. The mean operative time was 270 minutes +/- 31 minutes. The mean operative blood loss was 1500 ml +/- 102 ml. The median ICU stay was one day [range: I to 7 days]. The median hospital stay was 19 days [range: 15 to 38 days]. Eight patients [61.54%] developed post-operative complications. Most of these complications were medical [60%] rather than surgical [40%]. Respiratory complications were the commonest [30.77%]. Of the surgical complications, the most common was the development of an anastomotic leak [23.08%]. All of these were managed conservatively and none proved fatal. There were two mortalities on post operative days 7 and 8, due to ARDS and multi-organ failure respectively. The operative mortality was 15.39%.Ivor Lewis esophagectomy represents a major physiological and surgical insult. However, careful patient selection, perioperative monitoring and early aggressive treatment of complications can significantly reduce morbidity and mortality

Is breast cancer in younger women a more aggressive variant? a comparative study

Breast cancer is the commonest malignancy in women in the world. About 5% of all breast cancer patients are 35 years old or younger. Current literature suggests that breast cancer in these younger women may be different in etiology, clinical features and outcome from the disease seen in older women. We included all breast cancer patients who underwent surgical treatment at Surgical Unit IV, Jinnah hospital, Lahore from December, 1998 to December, 2003. All patients who left against medical advice or were lost to follow up before completing treatment at our hospital wee excluded. The patients were divided into two groups by age. Those who were 35 years old or younger were placed in group 1 [88 patients] and those older than 35 years were placed in group 11[54 patients], which served as the control group. We compared the clinical presentation, the risk factor profile, and the grade and the stage of the tumor at presentation in younger women and their older controls. The mean age in group I was 29.38 years +/- 3.68 years. While the mean age in group II was 44.41 years +/- 7.64 years. The commonest mode of presentation in both groups was a painless lump. [93.2% in group I and 66.67% in group II; p value < 0.001]. The distribution of classical risk factors was similar in the two groups. These included family history [12.5% in group I and 11.1% in group II], nulliparity [7.95% in group I and 7.4% in group II], and oral contraceptives use[14.77% in group I and 12.96% in group II]. Younger patients presented with a greater number of poorly differentiated [Grade III] tumors compared to the older patients. [73.76% vs.24.07%; p value <0.001]. They also presented more frequently with hormone insensitive tumors [79.55% in group I vs. 24.52% in group II; p value < 0.001]. Mammography was positive more often in older women compared to the younger ones [97.44% vs.41.38%; p value < 0.001]. Ultrasound was done in 67.05% of the younger women and 27.78% in the older women. It was suggestive of malignancy in 89.83% of the younger women and 86.67% of the older ones. Modified radical mastectomy was done in 75% of the younger patients [Group I] and 61.11% of the older patients [Group II]. Radical mastectomy was done in 19.32% of group I patients and 27.78% of group II patients. Older women underwent breast conservation treatment more often than the younger women [11.11% vs. 5.68%; p value < 0.05] Adjuvant chemotherapy was given more often to younger women [73.86% in group I vs. 9.26% in group II; p value < 0.0001]. On the other hand, older patients received hormonal therapy more often that the younger ones [74.07% vs. 20.45%; p value < 0.001]. Younger patients also received adjuvant radiotherapy more frequently than their older counterparts [84.32% vs. 49.26; p value <0.05]. We conclude that women with breast cancer who are 35 years old or younger have more aggressive tumors than the older patients i.e. they present at a higher stage with poorly differentiated tumors that are frequently hormone insensitive

Experience of spontaneous small bowel perforations at the Mayo Hospital

Hospital record of 84 consecutive cases of spontaneous small bowel perforation managed by one surgical unit of mayo hospital over a period of two years was examined. Fifty eight male and 26 female cases were dealt with. Age ranged from 15-70 years. Perforations were caused by enteric fever in 50% cases tuberculosis 31%, adhesive bowel disease and non-specific in 9%. Eighty one percent cases had only one, 12% cases had two and 7% cases more than 2 perforations. Primary repair of perforation was done in 60% cases, resection and anastomosis in another 23% and in 13% cases the perforation was exteriorized. In 2% cases simple tube drainage of the coelomic cavity was done. Twenty One cases had postoperative complications out of these 5 patients expired

Experience of laparoscopic cholecystectomy in acute cholecystitis

A prospective evaluation of laparoscopic cholecystectomy in cases of acute cholecystitis is presented. Consecutive 55 histologically confirmed cases of acute cholecystitis in all age groups were included in the study. The criteria for exclusion were choledocholithiasis and inability to withstand general anaesthesia. In 12.73% cases conversion to open cholecystectomy was resorted. There was no delayed re-operation. Female to male ratio was 2.93:1 and age ranged from 23 to 80 years with a mean of 47.27 years. Largest number of patients were in their fifth decade, however 16.34% patients were over sixty years of age. Sensitivity of ultrasonography, clinical features and laparoscopy in accurate diagnosis of acute cholecystitis was 80%, 90.91% and 96.36% respectively. Empyema was found in 30.91% pericholecystic abscess [9.09%] and patchy gangrene in 7.27% cases. Operating time ranged from 35 minutes to 120 minutes with an average of 85 minutes. Average postoperative stay in patients with laparoscopic cholecystectomy was 43.5 hours as compared to 68.57 hours when converted to open procedure. After laparoscopic cholecystectomy 4 patients [8.3%] developed 5 complications including prolonged biliary leakage in one patient. However, there was no biliary injury or mortality in the series. Laparoscopic cholecystectomy appears safe option in acute cholecystitis provided a low threshold of conversion to open cholecystectomy is maintained

Acquired arteriovenous fistulas and associated aneurysms: Our experience of 20 cases

A series of 20 cases of acquired arteriovenous fistulas and associated aneurysms of the lower extremity is presented. Ninety percent of them were following the penetrating injuries, nine cases [45%] had quadruple ligation and excision of the fistula done with no incidence of arterial insufficiency during follow up of at least 3 years. Two out of 7 vascular grafts [30.3%] got infected and six patients [30%] had post operative wound infection in spite of adequate antibiotic coverage, this was probably due to the presence of metallic splinters near the vessels from the time of original injury

Management of hepatic trauma

A review of 32 consecutive patients with liver trauma admitted in two surgical units of Mayo Hospital, Lahore in the year 1994 is presented. Majority of patients were young [mean age 26.5 years] male [90.6%]. Penetrating injuries [81%] were far more common than blunt trauma. Firearm injury was later confirmed at laparotomy except in two stable patients where diagnosis was confirmed on ultrasonography. These patients were managed conservatively. Right lobe [59.4%] was primarily involved in trauma. According to Moore's classification of liver trauma, twenty two patients had Grade-1 and II injuries 9 had Grade III and IV and one had Grade V injury. Eighty percent of patients had associated injuries to other organs. Hepatorrhaphy [64.3%] was the commonest amongst the procedures carried out, others were Hepatoomentorrhaphy, [10.7%] resectional debridement with selective ligation of the vessels [14.3%] perihepatic packing [7.1%] and hepatic lobar resection [3.6%]. Morbidity in this series was 59.5% and mortality 12.5%

Ureteral injuries: a complication of hysterectomy

Ureteric injury is an important complication following hysterecotomy which a General surgeon or Urologist is called upon to deal with. A prospective study of nine such patients referred to the authors for management is presented. The mean age of patients was 36 years. Commonest [66.7%] presentation was postoperative anuria, the rest [33.3%] presented with urinary fistulae. All these injuries followed either elective abdominal or caesarian hysterectomies. Majority [89%] of these were operated by relatively junior gynaecologists. All these patients were operated upon. In five patients who had suture entrapment of both ureters, delegation with or without stenting was done. In four patient ureteroneocystostomy was done for ureteric transection. All patients were cured and discharged from the hospital with a mean stay of 11 days

Penetrating abdominal trauma

Audit of 73 consecutive patients with penetrating abdominal trauma managed from June 94 to June 95 is presented. Victims were predominantly young males. Age ranged from 14-85 years. Mode of injury was firearm in 58 cases [79.4%] and stab in 15 [20.5%], twenty six [35.6%] cases had associated extra-abdominal injuries. In this series 70 cases underwent exploratory laparotomy, of which 63 [90%] were therapeutic and in 7 cases [10%] non- therapeutic. Twenty seven [37%] patients had postoperative complications and 15 [20%] patients expired during this study period, including 3 [4%] intraoperative deaths. Suggestions to reduce such a high rate of morbidity and mortality include, a strict control on firearms, enforcement of ban on their display and development of fully equipped regional centers for managements of such patients

Changing pattern of abdominal tuberculosis

Abdominal Tuberculosis continues to give rise to diagnostic and therapeutic challenges. The population at risk, the pattern of presentation and epidemiology is changing with time. A review of all [46] cases of abdominal tuberculosis admitted in two surgical units of Mayo Hospital Lahore [MHL] in a single year [1994] is presented. The majority of patients were female, in their second or third decade of life, admitted through emergency with acute presentation. Only 41.3% were elective cases with subacute clinical features. Active pulmonary lesion was present in 19.6% cases. Diagnosis was established at laparotomy in 95.65% patients. Only in two patients diagnosis was made through less invasive means. Intestines were the most commonly involved organ in the disease process, resection of diseased segment with end to end anastomosis was the most commonly performed procedure [47.8%]. Other surgical procedures were mesenteric lymph node / omental biopsy, closure of perforation with or without proximal bypass, adhenolysis, transverse colectomy and salpingo oopherectomy. Morbidity in this series was 18% and mortality 6.5% with mean hospital stay of 9 days

Experience of selective conservatism in splenic trauma

A review of all patients with splenic trauma managed at a teaching hospital in the year 1995 is presented. Out of a total of 38 patients, thirty four [89.5%] were male. Most of the victims were young [mean age 28 years]. Eighteen patients [47.7%] had firearm injury, 11 [28.9%] had stab wound and 9 [23.7%] had blunt abdominal trauma. The average interval between the injury and presentation was four hours. The severity of injury was classified according to revised splenic injury scale. Six [15.8%] patients had grade I, 5 [13%] had grade II, 8 [21%] had grade III, 12 [31.6%] had grade IV and 4 [10.5%] had grade V injuries. Thirty one [81.6%] patients had associated injuries to other organs. Thirty five [92%] patients were operated. Splenectomy was performed in 22 [58%] patients, 6 cases had splenorrhaphy, and 5 [13.2%] had partial Splenectomy. Three [8%] otherwise stable patients where diagnosis was confirmed on ultrasonography were treated conservatively. There was no incidence of delayed Splenectomy. The overall mortality rate was 15.5%. However, there was no mortality in those treated conservatively. Mean hospital stay was 8 days