Demographic characteristics and short-term outcomes of laparoscopic colon cancer surgeries at a newly developed cancer center in Peshawar, Pakistan.

Objective: In Pakistan, colon cancer ranks fourth in incidence, exhibiting survival rates of 90% to 14%, contingent on TNM staging and early detection. This research focuses on the demographic involvement and short-term outcomes of elective colon cancer resections at a newly established tertiary care cancer center utilizing laparoscopic procedures. Method: A retrospective analysis of elective laparoscopic colorectal resections at Shaukat Khanum Memorial Cancer Institute and Research Centre, Peshawar, from April 2021 to February 2022 was conducted. Out of 157 cases, 79 had colon cancer. Criteria included patients >18 years old with positive biopsies; consent non-providers were excluded. Statistical analysis employed descriptive statistics and cross-tabulations using SPSS-22. Results: The study encompassed biopsy-confirmed colon cancers in patients >18 years. 157 colorectal cases were performed, including 79 colon cancers. The sample comprised 61 males (77.2%) and 18 females (22.7%), mean age 42 years. Most patients (33%) were in the 36-45 age group. Majority were from KPK (69.6%), followed by Afghanistan (24%). Tumors were predominantly in the ascending colon (30.3%). Most were moderately differentiated (70.8%). Mean lymph node yield was 19.0, with 1.2% requiring open laparotomy. Post-discharge, one readmission occurred within 30 days. Mortality within 90 days was 2%, attributed to aspiration pneumonia and chemotherapy-related effects. Conclusions: Elective laparoscopic colonic surgery exhibits safety and efficacy in treating colon cancer. The study provides evidence of minimal morbidity and mortality, low readmission rates, and absence of anastomotic leaks. Hence, elective laparoscopic colonic surgery should be favored due to fewer post-operative complications and superior short-term outcomes. Larger studies on colon cancer are imperative for enhanced healthcare delivery.

Laparoscopic extralevator abdominoperineal resection for low rectal cancer: The myth of reinventing the wheel.

Background & Objective: To review oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer.In locally advanced low rectal cancer, ELAPE which is en-bloc resection of levator muscles along with the tumor in a prone position has significantly decreased the rate of having either positive circumferential resection margin (CRM) or tumor perforation. The aim of the study was to determine the oncological outcomes of laparoscopic extralevator abdominoperineal excision (LAP-ELAPE) for low rectal cancer. Methods: This retrospective study was performed at Shaukat Khanum Cancer Hospital and Research Centre Lahore. Patients who underwent ELAPE for low rectal and anal cancer from January 2014 to December 2019 were selected. Data was collected using an electronic database through a hospital information system. Results: A total of 82 patients were included in the study having a median age of 39 years. Clinically preoperative tumor sizes were T2:2, T3:65, T4:15. Neo-adjuvant chemo radiotherapy was administered to 79 (96.3%) patients. Pathologically tumor sizes were T0:12, T2:15, T3:50, T4:5 with 79.2% (n=65) R0 resections. The mean operative time was 340.36±64.51 minutes and the mean blood loss was 99 milliliters. The mean postoperative hospital stay was 6.58±4.64 days. Seventeen (20.7%) cases had pathological circumferential resection margins positive (pCRM<1mm). However, tumor perforation was found in 8(9.8%) patients. Ninety days mortality was none while 36 patients experienced recurrence (local: 23, distant: 30, local + distant 17). The median survival time was 53.00±2.69 months. Conclusion: For locally advanced low rectal cancer, ELAPE has evolved as a safe oncological procedure with acceptable outcomes.

Spotlight on laparoscopy in the surgical resection of locally advanced rectal cancer: multicenter propensity score match study.

PURPOSE: This study was aimed to assess the feasibility of laparoscopic rectal surgery, comparing quality of surgical specimen, morbidity, and mortality. METHODS: Prospectively acquired data from consecutive patients undergoing laparoscopic surgery for rectal cancer, at 2 minimally invasive colorectal units, operated by the same team was included. Locally advanced rectal tumors were identified as T3B or T4 with preoperative magnetic resonance imaging scans. All the patients were operated on by the same team. The 1:1 propensity score matching was performed to create a perfect match in terms of tumor height. RESULTS: Total of 418 laparoscopic resections were performed, out of which 109 patients had locally advanced rectal cancer (LARC) and were propensity score matched with non-LARC (NLARC) patients. Median operation time was higher for the LARC group (270 minutes vs. 250 minutes, P=0.011). However, conversion to open surgery was done in 5 vs. 2 patients (P=0.445), reoperation in 8 vs. 7 (P=0.789), clinical anastomotic leak was found in 3 vs. 2 (P=0.670), and 30-day mortality rates was 2 vs. 1 (P>0.999) between LARC and NLARC, respectively. Readmission rate was higher in the NLARC group (33 patients vs. 19 patients, P=0.026), due to stoma-related issues. There was no statistically significant difference in the R0 resection between the 2 groups (99 patients in LARC vs. 104 patients in NLARC, P=0.284). CONCLUSION: This study demonstrates that standardized approach to laparoscopy is safe and feasible in LARC. Comparable postoperative short-term clinical and pathological outcomes were seen between LARC and NLARC groups.

Laparoscopy offers better clinical outcomes and long-term survival in patients with right colon cancer: experience from national cancer center.

PURPOSE: Laparoscopic approach to colonic tumor requires skill set and resources to be established as routine standard of care in most centers around the world. It presents particular challenge in country like Pakistan due to economic constrain and lack of teaching and training opportunities available for surgeons to be trained to deliver such service. The aim of this study is to look into changing practice of our institution from conventional approach of open to laparoscopic surgery for right colon cancer. METHODS: Consecutive patients between January 2010 to December 2018 who presented to Shaukat Khanum Memorial Cancer Hospital and Research Centre with diagnosis of right colon (cecum, ascending and transverse colon) adenocarcinoma and underwent surgical resections were included in this study. RESULTS: A total of 230 patients with adenocarcinoma of the right colon underwent curative resections during the study period. Of these, 141 patients (61.3%) underwent laparoscopic surgery while open resection was performed in 89 patients (38.7%). Five-year disease-free survival (DFS) of patients with American Joint Committee on Cancer (AJCC) stage III (80.9% vs. 54.8%, P = 0.021) was significantly better if these patients underwent laparoscopic surgery while a trend toward better DFS (96.7% vs. 84.1%, P = 0.111) was also observed in AJCC stage II patients, although this difference was not significant. CONCLUSION: This study demonstrates the adoption of a laparoscopic approach for right colon cancer over 10 years. With a standardized approach and using the principle of oncological surgery, we incorporated this in our minimally invasive surgery practice at our institution.

Robotic Surgery for Colorectal Cancer.

Master-slave manipulators (otherwise known as telemanipulators) were introduced into minimally invasive surgery in the 1990s to overcome the limitations of laparoscopic surgery. This led to the development of the first robotic surgical systems which, over the last 10 years, have rapidly gained acceptance among colorectal surgeons. Advantages of robotic surgical systems such as superior instrumentation and field of vision enable precise dissection in confined spaces such as the pelvis, which make it a particularly attractive tool for rectal surgery. The feasibility and safety of robotic rectal surgery is now well established and there is increasing evidence that it might offer superior peri- and postoperative outcomes when compared to laparoscopic rectal surgery. Robotic rectal surgery is easier to learn than laparoscopic surgery and the creation of a structured training program for robotic rectal surgery in Europe has facilitated the learning of this technique in an environment that promotes patient safety and improved patient outcomes through equipment fidelity and operator skill. It is foreseeable that in the near future robotic systems will become part of routine surgical practice in colorectal surgery.

Surgical Outcome of Pancreaticoduodenectomy in Pancreatic and Periampullary Neoplasms.

OBJECTIVE: To report the results in the surgical treatment of pancreatic and periampullary neoplasms with emphasis on surgical technique, short-term postoperative outcome and the lessons learnt. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: This study was carried out at Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, from October 2014 to May 2016. METHODOLOGY: Patients undergoing surgical treatment of pancreatic and periampullary neoplasms were selected. Patients' characteristics including demographics, surgical technique, and 30-day morbidity and mortality were recorded. International Study Group of Pancreatic Fistula (ISGPF) classification was used to define postoperative pancreatic fistula and Clavien-Dindo classification to grade complications. RESULTS: Atotal number of 65 patients underwent the trial of dissection; 50 had pancreaticoduodenectomy and 15 patients underwent palliative bypass and were excluded from analysis. Sixty-four percent were males and 36% were females. The most common tumor was periampullary (n=29, 58%) followed by pancreatic head (14, 28%) and duodenal tumors (n=07, 14%). Mean age was 52.92 ±13.27 years; mean operating time was 470 ±358.28 minutes and median blood loss was 400 (287-500) ml. Pancreaticogastrostomy (PG) was the preferred reconstruction technique in 37 (74%) verses pancreaticojejunostomy (PJ) in 13 (26%) patients. Four (08%) patients needed portal vein reconstruction and two (04%) replaced right hepatic artery resection and reconstruction due to tumor involvement. There were seven Grade A, and one Grade B and C pancreatic fistulae each. Three patients (06%) needed endoscopic therapy for gastrointestinal hemorrhage from pancreatic stump. There was one death in postoperative period. CONCLUSION: Pancreaticoduodenectomy is a safe procedure with excellent postoperative outcome, if carried out in a specialized hepato-pancreato-biliary unit. APG reconstruction can be a safer alternative to PJ.

Effect of intra-abdominal pressure on post-laparoscopic cholecystectomy shoulder tip pain: A randomized control trial.

OBJECTIVE: To compare the effect of intra-abdominal pressure on postoperative shoulder-tip pain in laparoscopic cholecystectomy. METHODS: This was a randomized control study, conducted at Lady Reading Hospital Peshawar from January to August 2013 on160 patients, randomized to two groups i.e. the low pressure (LPLC) and the standard pressure group (SPLC) where the intra abdominal pressures were kept 10mmHg and above 10mmHg during surgery respectively. The age, gender, weight, duration of surgery, postoperative pain and frequency of analgesic administration in first 24 hours recorded and analyzed using Statistical Package for Social Sciences v20.0. Frequency and percentages were calculated for categorical while mean ± SD was calculated for continuous variables. P-value of <0.05 was considered significant. RESULTS: The mean operative times in group A and B were 27.84±6.078 vs. 28.51±7.45 minutes (p-value=0.625) respectively. Overall, the shoulder tip pain was reported in 25 (15%) patients. The frequencies in group A and B were 6 (7.5%) vs. 19 (23.8%) respectively (p-value = 0.005). The mean intensity of pain on VAS was 0.28±0.90 vs. 1.31±2.38 in the two groups respectively (p-value of 0.001). The mean number of analgesic administration in the first 24 hours was 2.24±0.48 in Group A vs.2.41±0.52 in Group B (p-value = 0.02) respectively. CONCLUSIONS: Our study shows that low intra-abdominal pressure results in reduced frequency of post-operative shoulder tip pain without any prolongation of duration of surgery.

Clinical profile, treatment and survival outcomes of peadiatric germ cell tumours: A Pakistani perspective.

Germ Cell Tumours (GCTs) are rare tumours. Generally 80% are benign and 20% malignant with a bimodal age distribution. The retrospective study was conducted at Shaukat Khanum Cancer Hospital, Lahore, Pakistan, and comprised all paediatric patients below 18 years of age who received treatment for histology-proven GCT from 2006 to 2014. Of the 207 patients, 98(42.3%) were males and 109(52.7%) were females. The most common GCT was yolk sac tumour in 90(43.5%) children followed by mixed GCT in 40(19.3%) and dysgerminoma in 34(16.4%). Gonads were most commonly involved in 165(79.7%) patients with metastasis in 24(11.6%) at presentation and recurrence in 26(12.5%) patients. Overall, 133(64.3%) patients are well and followed up at regular intervals and 55(26.5%) have been lost to follow-up with an expected overall 5-year median survival of 45%. Despite the distinct clinical profile of paediatric GCT, survival can be improved by early diagnosis, regimented treatment according to set guidelines, protocols and by improving follow-up.

Trainees' feedback on the prevailing teaching methods in postgraduate medical institute, Lady Reading Hospital, Peshawar, Pakistan.

OBJECTIVE: To determine the feedback of postgraduate (PG) trainees on their current teaching methods and their level of satisfaction with those at a tertiary care hospital in Pakistan. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Department of Surgery, Lady Reading Hospital, Peshawar, from January to May 2010. METHODOLOGY: A semi-structured proforma was filled by the trainees regarding teaching methods and preferences. Level of satisfaction was measured by five points Likert scale. Results were processed through SPSS 17.0 for descriptive statistics. RESULTS: The response rate was 260 out of the total 268 trainees. Lecture / tutorials were reported as the major method of teaching by 239 (91.9%), bedside teaching by 229 (88.1%), journal club by 217 (83.5%), e-learning by 157 (60.4%), audit meetings by 152 (58.5%), interactive sessions by 144 (55.4%), radiology meeting by 101 (38.8%) and TOACS by 39 (15%) trainees. Out of 28 units, TOACS were practised as a teaching method in 3 units. It was noted that 47 trainees (18.1%) graded the current training to be unsatisfactory, 127 as fair (48.8%), 77 as good (29.6%), 9 as very good (3.5%) while none considered it to be excellent. TOACS was the most preferred method of teaching, reported by 239 PGs (91.9%). Excessive work load as a cause for the dissatisfaction was reported by 229 trainees (88.1%), inadequate teaching by 157 (60.4%), lack of motivation 124 (47.7%), inappropriate teaching 122 (46.9%) and personal problems by 118 (45.4%). CONCLUSION: Lecture is the most commonly used method of teaching in the Lady Reading Hospital, Peshawar, while TOACS is the most preferred method amongst trainees, but it is the least practiced.