Esophageal cancer patient survival: A retrospective study from a tertiary care hospital in Pakistan.

Objective: To determine the pattern, tumor characteristics of esophageal cancer (EC) and survival of esophageal carcinoma patients presenting to upper GI Unit at Dr. Ruth K.M. Pfau Civil Hospital Karachi. Methods: We conducted a retrospective analysis of histologically confirmed EC patients from 2016 to 2021 at Upper GI Unit - Dr. Ruth K.M. Pfau Civil Hospital, Karachi. Data were collected using a filled Proforma, medical records, pathology reports and surgical notes, and patients or their family members were contacted for informed consent. Statistical analyses were performed using STATA version 16.0. Time to event was measured from the date of diagnosis to the date of the last follow-up or recorded death. Descriptive statistics and survival analyses, including Kaplan-Meier method and log-rank test, were employed. Univariate and multivariate Cox regression analyses were conducted to assess independent predictors of survival. Results: Total 152 patients with a median age of 45 (range 80-15) years were enrolled in this study. Clinical stages-III, IV-A and IV-B were identified in 35.5% (n = 54), 23.7% (n = 36) and 34.2% (n = 52), respectively. Total of 62% (n=94) had died at median follow up of 9.56 months and three years overall survival rate was 10.0%. Univariate survival analysis revealed that patients with clinical stage-II (p-value 0.002) and patients treated with combined surgery plus chemo-radiotherapy (p-value 0.040) was significantly associated with lower risk of mortality among other stages and treatment modality groups. Conversely, patients having metastasis (p value <0.001) and those with vascular involvement >90 degrees (p value <0.001) showed worse survival outcomes. Conclusion: Our study reveals a three years survival rate of 10.0%, emphasizing the formidable challenge of advanced-stage malignancies. Clinical stage, vascular involvement, and metastasis emerged as significant predictors of mortality. Moreover, integrating surgery with chemo-radiotherapy significantly improved three years survival (36.8% vs. 14.2%). Despite single-center limitations, our findings provide crucial regional insights into esophageal carcinoma outcomes.

Three-staged minimally invasive esophagectomy with end-to-end esophago-gastric anastomosis for thoracic esophageal cancers: An experience from a low middle-income country.

BACKGROUND: Esophageal cancer is on a steady rise and carries significant mortality and morbidity. Depending upon the clinical stage at presentation, either chemotherapy, radiotherapy with or without surgical resection is the treatments in practice. Traditionally, open esophagectomy was performed but over time, the importance of minimally invasive esophagectomy has been established. In this study, we aimed to report our data of totally minimally invasive esophagectomies performed for thoracic esophageal cancers in last four years. METHODOLOGY: A prospective cross-sectional study was conducted at the Department of Upper GI Surgery, Dow University of Health Sciences, Karachi. All diagnosed cases of esophageal carcinoma undergoing minimally invasive esophagectomy, from 2019 to 2022 were included in this study. Outcomes measured were operative time, intra operative complications, conversion rate to open, postoperative complications, number of lymph nodes harvested, margin clearance, in-hospital mortality and 90-days mortality. RESULTS: A total of 53 cases were included in the study, the most prevalent histological type was squamous cell carcinoma 42(79.2%) as compared to adenocarcinoma 8(15.1%). Most common tumor site was lower thoracic esophagus (30-38 cm) in 20 (56.6%) cases. Neo-adjuvant chemotherapy was given in all 53(100%) cases, whereas neo-adjuvant radiation therapy was offered to 49(92.5%) patients. There was a significant and favorable patient response to the neo-adjuvant treatment in 37(69.8%) cases, leading to a decrease in tumor size. Laparoscopic McKeown Esophagectomies were performed in 44 (83.0%) and 9(17.0%) were Robot-assisted Minimally Invasive esophagectomy (RAMIE). Intraoperative injuries (i.e., lung parenchymal injury and bleeding) were reported in only 2(3.8%) patients. Post-operative complications were recorded in 12(22.6%) patients. Margin clearance was observed in 53 (100%) of the patients. The 90-day mortality rate was 3(5.7%), one due to bleeding and other two mortalities were due to COVID related respiratory complications. CONCLUSION: Minimally invasive esophagectomy was found to be safe and feasible technique with encouraging results in terms of decreased intraoperative and post operative complications as well as achieving the standard oncological surgery with acceptable lymph node yield and margin clearance and in hospital and 90 days mortality.

Atypical Presentation of Hydatid Cyst in the Thigh.

To emphasise that hydatid cyst disease can present as a soft tissue mass even in an unusual site like the thigh, we report the case of a 21-year male patient who presented to Surgical Unit IV, Civil Hospital, Karachi, with a slow growing cystic swelling on the medial aspect of the left thigh. Based on serology and imaging, a diagnosis of solitary subcutaneous hydatid cyst thigh was made and cystopericystectomy was performed. Histopathology confirmed the diagnosis. Up to three months postoperatively, there was no recurrence. In the absence of visceral organ involvement, this is the first reported case of primary subcutaneous hydatid disease of the thigh in Pakistan.

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 ERCPprocedures. 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. Atotal 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. ERCPaffected management in 88.2% (15/17 procedures). CONCLUSION: ERCPis a safe and feasible procedure for pancreas divisum patients.

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

OBJECTIVE: To evaluate the frequency and associated factors in the post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. STUDY DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Endoscopy Suite of Surgical Unit IV, Civil Hospital, Karachi, from December 2009 to November 2010. METHODOLOGY: 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 ² 0.05. Odds ratio was calculated for the qualitative data using 95% confidence interval. RESULTS: Age of the study population ranged from 9 to 90 years (mean age 46.5 ± 14.94 years, median 45 years). Male to female ratio was 1:1.87. Pancreatitis was seen in 18 patients (3.6%), mild in 15 (3%), moderate in one (0.2%) and severe in 2 (0.4%). Mean amylase level at 4 hours and 24 hours was 280.93 ± 539.13 and 168.83 ± 338.34 respectively. Pancreatitis was seen in 15/326 (4.6%) females and 3/174 (1.72%) males. Statistically significant increased risk for pancreatitis was seen in difficult cannulation (9.8%, p = 0.006), prolonged cannulation time (7.6 minute, p = 0.002), pancreatic duct cannulation (13.7%, p = 0.001) and pancreatic duct contrast injection (13.4%, p < 0.001). CONCLUSION: The frequency of post-ERCP pancreatitis was 3.6%. Difficult cannulation, pancreatic duct cannulation, pancreatic duct contrast injection and balloon sphincteroplasty were associated with higher frequency of post-ERCP pancreatitis. Reuse of ERCP accessories poses no additional risk to the frequency of pancreatitis.

Endoscopic management of post operative bile duct injuries.

OBJECTIVE: To evaluate the pattern of post-operative bile duct injuries and their subsequent endoscopic management. METHODS: The prospective, non-randomised, cross-sectional study was conducted at the endoscopic suite of Surgical Unit-IV of the Civil Hospital, Karachi, over a period of three years. A total of 97 patients were included in the study. Post-procedure patients were followed up for resolution of symptoms and cessation of the bile leak. Patients with complete biliary cutoff or transection on Endoscopic Retrograde Cholaugio-Paucreatography (ERCP) were advised Magnetic Resonance Cholaugio-Papereatography (MRCP). Average followup of patients in our study was for 3 months. Mann Whitney U test was applied for non-parameteric data. RESULTS: Out of 97 patients in the study, 82 (84.5%) presented with post-operative bile leakage and 15 (15.5%) with obstructive jaundice. The age of the study population ranged between 20-70 years with a mean age of 40.80 +/- 13.45 years. Male-to-female ratio was 1:3. ERCP findings in our study included 41 (42.26%) patients with bile leakage out of which 27 (27.8%) had high-grade leak and 5 (5.1%) had low-grade leak, while 9 (9.3%) patients had Common Bile Duct (CBD) stones. Among the patients, 39 (40.2%) had complete cutoff of CBD. There were 15 patients with strictures and 6 with normal ERCP. As for the bile leads, 36/41 (87.8%) patients were managed successfully by endoscopic stenting, stone removal or simple sphincterotomy. Of the 41 patients, 5 (12.2%) with bile leak developed biliary stricture on subsequent ERCP. Nine of the 15 patients (60%) with complete cutoff on initial endoscopy were successfully stented on subsequent ERCP after demonstration of biliary continuity on MRCP. Six (40%) patients were referred for surgery. CONCLUSION: Patients with postoperative biliary leaks fare much better than those with complete cutoff or strictures. MRCP should be done in all patients where ERCP shows loss of biliary continuity. Re-exploration should be deferred till all other non-invasive modalities have been tried.

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.