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Background: Esophageal cancer (EC) is a significant health concern in South Asia, yet data on prognostic factors, such as lymph node ratio (LNR), in this region is limited. This study aims to assess the prognostic significance of LNR in esophageal squamous cell carcinoma (ESCC) patients undergoing concurrent neoadjuvant therapy followed by minimally invasive esophagectomy (MIE)., Methods: This retrospective study analyzed the clinical data of ESCC patients who underwent concurrent neoadjuvant therapy followed by MIE at Dr. Ruth K. M. Pfau Civil Hospital from 2019 to 2023. Lymph node ratios were derived and patients were categorized into three groups: LNR 0, LNR low (≤ 0.1), and LNR high (>0.1). Patient characteristics were compared along with lymph node groups, and survival outcomes were analyzed using the Kruskal Wallis and Chi-square/Fisher exact test, Pearson correlation, Kaplan-Meier (KM) estimates, and Cox regression models., Results: Among the 47 patients, 15 (31.9%) deaths were observed. Patients with a high LNR had a higher mortality rate (70%) compared to those with a low LNR (41.7%) and 0 LNR (12%) (p = 0.002). Additionally, patients with a high LNR (>0.1) were associated with poorer overall survival (OS) (30.0% vs. 58.3% vs. 88.0%, p < 0.001). A significant correlation was also observed between LNR and the number of metastatic lymph nodes (correlation coefficient = 0.928, p < 0.001)., Conclusion: Our findings demonstrate that high LNR emerged as an independent prognostic factor in ESCC patients undergoing concurrent neoadjuvant therapy followed by MIE., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Qureshi, Abbasi, Jalil, Mughal and Quraishy.)

Background : Barrett's esophagus (BE), with metaplastic columnar epithelium in the lower esophagus, predisposes patients to esophageal adenocarcinoma (EAC). Despite extensive research, mechanisms underlying BE progression to EAC remain unclear, and no validated biomarkers are available for clinical use. Progastricsin/Pepsinogen-C (PGC), an aspartic proteinase linked to maintaining normal epithelial morphology, is often absent in advanced gastrointestinal malignancies. This study comprehensively investigates PGC expression across cancers, particularly in esophageal cancer (ESCA), to clarify its role in BE progression to EAC. Methods : We utilized multiple bioinformatic platforms (TIMER, UALCAN, cBioPortal, GEPIA, STRING, Metascape, and GEO database) to assess PGC expression, genomic alterations, and correlations with clinicopathological features, survival, and immune infiltration. Additionally, using the GEO dataset, we compared non-dysplastic Barrett's esophagus (NDBE) patients with those who progressed to malignancy, identifying differentially expressed genes (DEGs), their interactions, and potential roles in progression. Results : PGC was notably upregulated in various cancers, especially in adjacent normal tissues of ESCA. Genomic amplifications of PGC were linked to improved survival in EAC patients, particularly those with high PGC expression, suggesting a protective role. Moreover, PGC expression positively correlated with favorable immune infiltration, notably B cells and CD8+ T cells. Enrichment analysis of downregulated DEGs revealed significant involvement in key biological processes, specifically in extracellular matrix organization. Among the downregulated DEGs, we identified PGC among the top 10 hub genes, underscoring its role in tissue homeostasis. Conclusions : These findings suggest that PGC could serve as a promising biomarker for predicting the high-risk transformation from BE to EAC, offering new insights into EAC progression and future therapeutic targets.

Introduction: The relative efficacy and safety of insulin neutral protamine Hagedorn (NPH) and detemir (IDet), in the management of diabetes in pregnancy remains unclear. We sought to conduct an updated systematic review and meta-analysis to study the effect of NPH versus IDet during pregnancy on clinically relevant maternal and fetal outcomes., Evidence Acquisition: MEDLINE and Google Scholar were queried from inception till September 2022 for original studies comparing NPH with IDet for management of diabetes during pregnancy. Data was pooled using a random-effects model, to generate risk ratios (RR) for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes, along with 95% confidence intervals (CIs). I 2 test was used to assess the magnitude of heterogeneity. Sensitivity analysis was conducted to explore the potential source of heterogeneity. As less than ten studies were included in our analysis, funnel plots were not made to evaluate publication bias. A P value of ≤0.05 was considered significant in all cases., Evidence Synthesis: Our search of the literature yielded 1087 articles initially, of which seven articles comprising 1396 patients, were included in our analysis. All included articles were of reasonably high methodological quality. Our pooled analysis demonstrates no statistically significant difference between the efficacy of insulin Detemir and insulin NPH as assessed by the HbA1c values from baseline. For safety outcomes, insulin detemir was significantly associated with a greater gestational age at delivery (WMD=0.39, 95%CI: 0.07 to 0.71, P=0.02) and lower incidence of hypoglycemic events (RR=0.64, 95%CI: 0.48 to 0.86, P=0.003) in-contrast to insulin NPH., Conclusions: Our findings demonstrate that both, insulin IDet and insulin NPH have a similar efficacy in reducing HbA1c from baseline. However, insulin detemir was associated with lesser incidence of maternal hypoglycemic events and greater gestational age at delivery, compared to NPH.

Background: Esophageal cancer (EC) remains a significant health challenge in South Asia, with poor prognosis despite advancements in diagnostics and treatment. Identifying and validating prognostic factors is essential for improving patient outcomes. Methods: A prospective study was conducted with 146 biopsy-confirmed EC patients at the Dr. Ruth K.M. Pfau Civil Hospital, Karachi, Pakistan. Clinical and laboratory data were collected and analyzed using descriptive statistics, receiver operating characteristic (ROC) analysis, and the Chi-square test. Survival outcomes were assessed using Kaplan-Meier curves, log-rank tests, and Cox proportional hazard models for univariate and multivariate regression analyses, with statistical significance set at p ≤ 0.05. Results: Bivariate analysis showed significant associations of the neutrophil lymphocyte ratio (NLR) ( p = 0.017), C-reactive protein to albumin ratio (CAR) ( p = 0.033), red cell distribution width to platelet ratio (RPR) ( p = 0.020), and systemic immune-Inflammation index (SII) ( p = 0.009) with patient survival. Univariate analysis identified tumor length >10 cm ( p = 0.016), T4 stage ( p = 0.015), metastasis ( p < 0.001), surgery not performed ( p < 0.001), and SII ( p = 0.022) as significant factors for survival, with higher SII linked to poorer overall survival ( p = 0.020). Interestingly, in the multivariate model, only metastasis ( p < 0.001) and surgery not performed ( p = 0.011) remained significant. Conclusions: Immuno-inflammatory markers may be less pertinent prognostic factors for EC in the South Asian population.

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., Competing Interests: Conflict of Interest: None., (Copyright: © Pakistan Journal of Medical Sciences.)

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., Competing Interests: Declaration of competing interest No Conflict of interest., (Copyright © 2023 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Objective:  To collect and analyse epidemiologic data of all malignancies by age group and gender for the Karachi population to estimate the cancer incidence of 5-years (2017-2021) and identify major risk factors for setting priorities towards cancer control programs., Study Design: Observational study. Place and Duration of the Study: Karachi Cancer Registry (KCR) Secretariat, Pakistan Health Research Council (PHRC), JPMC, Karachi, from 2017-2021., Methodology: Cancer data of seven tertiary care hospitals of Karachi submitted to KCR during the study period were analysed including age, gender, date of first contact, primary site and ICD coding. All the data was cleaned, merged, and analysed. All patients 0-14 years were classified as 'children', all aged 15-19 years were classified as 'adolescents', and those age 20-years and above as 'adults'. Age standardised incidence rates (ASIR) were determined for both genders., Results: During the last five years (2017-2021), a total of 65,886 malignant cases were received. The distributions seen amongst males and females were 33,510 (51%) and 32,376 (49%), respectively with 60,145 (91.3%) tumours found in adults (≥20 years), 4844 (7.3%) in children, and 897 (1.4%) in adolescents. The three most common tumour sites were oral, liver, and colorectal in males; breast, oral and ovary in females; bone, brain and connective tissue in adolescents; and leukaemia, brain and bone in children. The overall ASIR (%) in males was 89.20 for adults, 9.19 for children, and 1.61 for adolescents. The overall ASIR (%) in females was 93.44 for adults, 5.45 for children, and 1.11 for adolescents., Conclusion: Oral cancer, a largely preventable cancer is the leading cancer in males while breast cancer is the leading cancer in females followed by oral cancer. In adolescents and children, the incidence closely matches most of the world., Key Words: Karachi, Cancer registry, Oral cancer, Breast cancer, Age-standerdised ratio.

Objective: To determine the frequency of nonalcoholic fatty pancreatic disease in patients with carcinoma pancreas presenting for upper abdominal endoscopic ultrasound., Methods: The prospective cross-sectional study was conducted in the Endoscopy Suite of Surgical Unit 4, Civil Hospital, Karachi, from October 2019 to September 2020, and comprised patients presenting for endoscopic ultrasound. Patients were divided into Group A comprising carcinoma pancreas patients, and Group B having non-carcinoma pancreas patients. Fatty pancreas was identified by hyperechogenicity on endoscopic ultrasound. Data was analysed using SPSS 19., Results: Of the 68 patients, 44(64.7%) were male and 24(35.3%) were females. The overall mean age was 49.9±13.82 years (range: 16-80 years). There were 35(51.5%) patients in Group A and 33(48.5%) in Group B. The frequency of nonalcoholic fatty pancreatic disease was 18(26.5%) and 15(83.3%) of them were male subjects (p=0.04). Group A had 12(34.28%) subjects with nonalcoholic fatty pancreatic disease compared to 6(18%) in Group B (p=0.11)., Conclusions: Nonalcoholic fatty pancreatic disease was frequently seen in carcinoma pancreas patients undergoing endoscopic ultrasound compared to non-carcinoma pancreas patients. Most of the patients affected were males.

Objective: To compare improvement in symptoms following Heller's myotomy with Dor fundoplication and endoscopic pneumatic dilatation for the treatment of achalasia cardia., Methods: The prospective comparative study was conducted at the Department of Upper Gastroenterology and Minimally Invasive Surgery, Civil Hospital, Karachi, from February 2016 to January 2019, and comprised patients diagnosed with achalasia cardia on oesophageal manometry. The subjects were randomised into endoscopic pneumatic dilatation group A and laparoscopic Heller's myotomy with Dor fundoplication group B. Eckardt scores were compared between the groups at one-year follow-up. Data was analysed using SPSS 22., Results: Of the 42 patients, 21(50%) were in each of the two groups. The mean age of patients in group A was 37±12.87 years compared to 34±8.59 years in group B. Treatment success in group A was 11(52%) compared to 21(76%) in group B. Eckardt scores between the groups were significant (p<0.001). Patient satisfaction was significantly more in group B (p<0.05)., Conclusions: The efficacy of Heller's myotomy with Dor fundoplication was found to be greater than endoscopic pneumatic dilatation for improvement in dysphagia and overall patient satisfaction at one-year follow-up.

Objective: To evaluate whether or not prior laparoscopic training improves performance during robotic surgery utilising DaVinci robotic skills simulator., Methods: The cross-sectional study was conducted at the Civil Hospital, Karachi, from May 4 to November 11, 2018, and comprised first year residents in Group A with no laparoscopic skills and fourth year residents doing laparoscopic cholecystectomy independently and surgical faculty members in Group B who had laparoscopic skills. Both the groups had no previous exposure to robotic surgery and skills simulator. There were 4 exercises which were repeated three times by each participant. Scoring was done using the DaVinci robotic skills simulator software. Data was analysed using SPSS 22., Results: Of the 30 surgeons, there were 15(50%) in Group A with a mean age of 26±0.56 years, and 15(50%) in Group B with a mean age of 32 ± 9.16 Years (p<0.001). The overall mean age was 32±9.16 years (range: 25-52 years). There were 19(63.3) females in the sample compared to 11(36.6%) males. Mean scores of Ring walk 2, Peg board 2, and Suture sponge 3 were better in Group A, while mean score of Matchboard 2 was better in Group although B (p>0.05). Group B fared better in the individual scoring of Suture sponge 2 (p>0.05)., Conclusions: Laparoscopic skills apparently did not confer any benefit while performing exercises on the DaVinci skills simulator.

Objective: To compare the recurrence rate and chronic pain in hernia patients undergoing laparoscopic or robotic transabdominal preperitoneal fixation with and without mesh., Methods: The prospective comparative study was conducted at Surgical Units 4 and 5 of the Civil Hospital, Karachi, from August 1, 2017, to July 1, 2018, and comprised hernia patients undergoing laparoscopic or robotic transabdominal preperitoneal fixation who were randomised into fixation Group A and non-fixation Group B. Postoperative visual analogue scale score was calculated at the time of discharge. At 1-year follow-up, recurrence rate and chronic pain were assessed. Data was analysed using SPSS 23., Results: Of the 98 patients, there were 49(50%) in each of the two groups. Of the total, there were 97(99%) males. The overall mean age was 44.52±14.51 years. The differences in visual analogue scale scores at the time of discharge and the mean discharge from the hospital in terms of days were statistically significant (p<0.005). At 1-year follow-up, there was recurrence in 1(1.02%) case and that was in Group A (p>0.05). Chronic pain between the groups was not significant (p>0.05)., Conclusion: There was no significant difference in terms of recurrence and chronic pain between mesh and non-mesh fixation.

Objectives: To present 2010-2019 cancer data from the Dow Cancer Registry representing all districts of Karachi (~17.4 million)., Methods: The study was conducted at the Dow University of Health Sciences. After ethical approval, the Dow Cancer Registry was established at the largest government-run diagnostic and reference center of Karachi (Dow Labs). All cancers registered during 2010-2019 were analyzed. Patients >18years of age were labeled as adults while those with ages ≤18years were classified as children/young adults., Results: During 2010-2019, a total of 22,858 cancers were registered. Of these, 9,112(39.9%) cancers were diagnosed in males while 13,746(60.1%) in females. Incidence rates for all cancers (all ages) were 108/1,00,000 for males and 188.6/1,00,000 for females. In adult males, cancer of lip and oral cavity was the most frequently diagnosed cancer (33.6%), followed by non-melanoma -skin-cancer (NMSC) (7.2%), oesophagus (6.8%), colorectum (6.7%) and stomach (4.9%). In adult females, breast cancer was the most frequently recorded malignancy (53.2%), followed by cancers of lip and oral cavity (10.4%), oesophagus (5.3%), colorectum (3.3%) and NMSC (3%). In children, most common malignancy was that of brain and nervous system (15.3%), followed by Hodgkin's lymphoma (14.2%), colorectum (8.1%), endocrine-&-related organs (8%) and non-Hodgkin's lymphoma (7.8%)., Conclusion: Cancers of lip and oral cavity and breast cancer were the most common malignancies in males and females respectively. In paediatric group, cancers of brain and nervous system were most common. Alarmingly, Karachi males have highest ASR of cancers of lip and oral cavity compared to any other city of Pakistan., Competing Interests: Conflict of Interest: None declared., (Copyright: © Pakistan Journal of Medical Sciences.)

Objectives: To estimate the cancer incidence by age group and gender for the population of Karachi Division by analyzing the Karachi Cancer Registry data of 2017-19., Settings: The population of Karachi division is 16.1 million according to national census 2017. 'Karachi Cancer Registry' which is a part of 'National Cancer Registry' is collecting data from eight major hospitals in Karachi since 2017. For outcome measures, cancer counts and the age standardized incidence rates (ASIR) per 100,000 population were computed for age groups (0-14, 15-19 and ≥20 years), in both genders and all cancer site/type., Methods: The population denominators were based on the population of Karachi division estimated at 16.1 million in the population census, 2017. Counts and age-standardized incidence rates (ASIR) were calculated for each of the three age categories., Results: From Jan 2017 till Dec 2019 a total of 33,309 malignant cases were recorded in KCR database comprising 17,490 (52.5%) females and 15,819 (47.5%) males. ASIRs in age groups 0-14, 15-19 and ≥ 20 years, among female were 11.5, 2.4 and 223.6 and in males were 17.6, 3.2 and 216.7 respectively. The commonest diagnosis in children, adolescent and adults were (1) among females: children; bone (3.12),  leukemia (2.09) brain/CNS (1.26); in adolescents: bone (0.78), brain/CNS (0.27), connective and soft tissue (0.11), in adults: breast cancer (76.07), oral cancer (16.68) and ovary (10.89) respectively, and (2) among males: children; bone (4.56),  leukemia (2.79) and brain/CNS (1.88); in adolescent; bone (1.19), brain/CNS (0.31) and leukemia (0.21) and in adults: oral cancer (42.83), liver (16.10) and bone (13.37) respectively., Conclusion: Oral Cancer, a largely preventable cancer is the leading cancer in Karachi adult males while in female adults Breast Cancer is the leading cancer followed by Oral Cancer. In children and adolescents Bone, Leukemia and Brain/CNS malignancies are most common., .

Objective: To evaluate the entire spectrum of endoscopic retrograde cholangiopancreatography procedure including site of stent migration, techniques of stent retrieval, success and complications., Methods: The retrospective study was conducted at Dr Ruth Pfau Civil Hospital Karachi, and comprised data from January 2010 to January 2017of patients who underwent endoscopic retrograde cholangiopancreatography for the retrieval of stent migrated in the common bile duct, pancreatic duct or pancreatic pseudocyst or were found to have migrated stent during either stent removal or exchange and where attempts were made to remove the stent. A team of expert endoscopists had performed all the procedures. SPSS 17 was used for statistical analysis., Results: There were 5700 procedures performed on 4800 patients. Pancreato-biliary stenting was done in 1229(21.56%) patients; 745(60.61%) with benign conditions and 484(39.38%) with malignant. Stent migration was found in 51(4.14%) patients; 30(58.8%) males and 21(41.2%) females. In terms of clinical presentation, right upper quadrant pain was the most common 9(17.6%). Technical success was achieved in all (100%) cases, with firstprocedure success in 45(88.2%). There was no complication or procedure-related mortality., Conclusions: In patients with stent migration, endoscopic retrograde cholangiopancreatography was found to be a safe and effective modality for stent retrieval.

Objective: South Asia has the highest mortality rate from burns in the world. Application of quality improvement methods to burn care can help identify health system gaps. Our overall aim is to introduce a sustainable hospital-based burn registry for resource-constrained settings to assess health outcomes of burn injury patients presenting to dedicated burn injury centers in South Asia., Results: The South Asia Burn Registry (SABR) is implemented through collaborative approach in selected burn centers in Bangladesh and Pakistan. Th registry collects data on burn injury events, the care provided, and the functional status of patients at discharge from burn centers. It covers the entire spectrum of care provision for burn injury patients from the actual event through their discharge from the healthcare system. SABR investigates locally relevant contextual factors associated with burn injury and health-system requirements for burn patients receiving emergency and inpatient care in resource-constrained settings. It also explores factors associated with burn injury and care provision. SABR will inform better prevention and management efforts in South Asia and help to address healthcare needs of burn injury patients.

Objective: To assess the clinical feasibility of robotic platform and to calculate cost for sustaining it.., Methods: The study was conducted at Sindh Government Qatar Hospital and Civil Hospital Karachi from October 11, 2011, to August 30, 2017. Feasibility was assessed in terms of clinical outcome i.e. surgical complications, duration of stay and readmissions. The cost of doing an individual procedure was calculated along with the projected cost for 150, 200 and 250 cases per year. SPSS 23 was used for data analysis.., Results: Of the 119 patients, 45(37.8%) were males and 74(62.2%) were females. Overall mean age was 42.10}13.40 years (range: 21-80 years. Mean hospital stay was 3.59}3 (range: 1-19 days). Complications occurred in 17(14.3%) patients ranging from wound infection 7(5.9%), bleeding 5(4.2%), intra-abdominal abscess 3(2.5%) and recurrence 2(1.7%). The total cost of robotic platform was Rs320 million with an annual maintenance contract of 10% of the total cost. The mean cost of performing a robotic procedure was Rs.389,263.05}39,249.63 (range: Rs252,823.09- Rs456,842.79).., Conclusions: Robotic surgery was found to be a feasible and viable option. The major hindrance was the cost involved in setting up the system and recurring costs in terms of disposables.

Objective: To compare clinically relevant pancreatic fistula rates in patients with stented versus non-stented pancreatico-jejunostomies., Methods: The randomised comparative clinical trial was conducted at Civil Hospital, Karachi, from September 2009 to August 2015, and comprised patients presenting to the Surgical Unit 4 with a diagnosis of resectable periampullary carcinoma, carcinoma of head of pancreas, duodenal carcinoma involving the second part, and distal cholangiocarcinomas. Pancreatic fistula or leakage was defined as amylase-rich fluid lasting over 5 days, collected from the peripancreatic drains on day 1, 3 and 7 postoperatively, and the rate of clinically relevant fistulas was taken as primary study endpoint., Results: There were 102 patients with a male to female ratio of 2.4:1. The overall mean age was 53.16±12.11 years (range: 30-80 years). Of the total, 53(51.9%) patients had pancreatic duct stent and 49(48%) did not. Clinically relevant pancreatic leak was seen in 13(12.7%) patients of whom 8(61.5%) were stented (p=0.46), 9(69.2%) patients had soft pancreatic texture (p=0.54) and 7(53.8%) had pancreatic duct <3mm (p=0.11)., Conclusions: Pancreatic fistula rates between stented and non-stented anastomosis did not show any significant difference.

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.

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.

Gastroesophageal reflux disease (GERD) is the most common acid-related disorder encountered during clinical practice in Pakistan and is associated with significant impairment of health-related quality of life. A number of guidelines and recommendations for the diagnosis and management of GERD have been published in different countries, but a Pakistani accepted directive by the standards of evidence-based medicine is still lacking. Our aim was to create an understanding of the natural history and presentations of reflux disease; evaluating possible treatment options available for the patients with complex and uncomplicated reflux ailments with the development of current and up to date evidence based endorsement, relevant to the needs of Pakistani health care providers in order to treat oesophageal manifestations of GERD. In order to make such guidelines, a comprehensive literature search was conducted with pertinent evidence reviewed, and quality of relevant data assessed. The resultant conclusions were based on the best available evidence and expert opinion of the authors of technical review panel.

Objective: To assess the oncologic and cosmetic outcomes for breast cancer patients who underwent breast conservation therapy using Level II oncoplasty techniques., Methods: The prospective, non-randomised and descriptive study was conducted at the Department of Surgery, Unit IV of Civil Hospital, Karachi, from December 2009 to November 2011 in which 21 consecutive women with breast carcinoma who underwent wide local excision with remodeling mammoplasty were enrolled. All patients were reviewed by the surgeon and medical oncologist every 3 months for the first year. A grading system of 5-1 (excellent to poor) was employed and those with 3 or more were considered to have acceptable results., Results: The mean patient age was 45.38 +/- 10.09 years (range: 26-70); 11 (52.3%) were premenopausal and 10 (47.7%) were postmenopausal; and 5 (27.8%) had family history of breast cancer. The mean size of the tumour determined by histology was 59.9 +/- 3.18 mm (range: 25-150). Eight (30%) patients received preoperative chemotherapy to downsize the tumour. Three (14.2%) patients received preoperative radiotherapy. Mean operative time was 1.59 +/- 0.52 hours (range: 1-2.5 hours). Mean volume of breast tissue excised from the breast containing the tumour was 545.27 +/- 412.06 cm3 (range: 43.70-1456). Assessment of excision margins showed no tumour at the margins of 19 (90.4%) patients. Two (9.5%) patients had close but negative margins. The mean hospital stay was 7.10 +/- 3.30 days (range: 4-15). There were early complications in 4 (19%) patients. One (4.76%) patient had late complications. Two (9.5%) patients developed tumour recurrence; both had an ipsilateral tumour recurrence. None of the patients developed metastases and one died of cardiac problem. Twenty (95.2%) patients had an acceptable post-surgical cosmetic result., Conclusion: Level II oncoplasty was a safe option in breast conservation allowing large-sized and difficult-location tumour excision with good cosmetic outcome in the study group. There is a need to increase the awareness and acceptance of this new technique not only amongst patients but also doctors.

Objective: To determine the outcome of duodenal stenting in palliation of patients with malignant pyloric and duodenal obstruction., Methods: The non-randomised prospective descriptive study was conducted at the Endoscopy Suite, Surgical Unit-IV, Civil Hospital, Karachi, from December 2007 to November 2010. All patients presenting with inoperable ampullary, pancreatic or biliary cancers causing duodenal obstruction and patients with resectable malignancy but unfit for surgery were included. The procedure was carried out by a single expert endoscopist under local or general anaesthaesia as required. Boston Scientific stents of variable sizes were used. Follow-up was done at 1 week, 1 month and 6 months. Data analysis was done using SPSS 15., Results: Over the study period, 159 (60%) males and 6 (40%) females were included in the study. The male-to-female ratio was 2:3. The overall age ranged from 25-80 years with a mean of 52.67 +/- 15.07 years. Primary diagnosis was pyloric carcinoma in 7(46.6%), carcinoma Gallbladder in 4(26.6%), Duodenal carcinoma in 3(20%) and carcinoma head of pancreas in 1(6.6%). Relief of symptoms were seen in 11 (73.3%), while complications were seen in 2 (13.3%). Stents were inserted with technical success in 14 (93%) patients. Clinical success was seen in 11 (73%), with a mean survival of 74.27 +/- 40.7 days (range: 15-180 days). No statistical significance was found when comparing the survival time with age, gender and diagnosis., Conclusion: Use of self-expandable metallic stents for gastroduodenal malignancies appears to be a feasible, safe and effective method, especially in those patients with limited life expectancy.

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.

Introduction: The etiological association of Helicobacter pylori with gastric ulcer (GU), gastric cancer (GC), and duodenal ulcer (DU) is well-known. Understanding the epidemiology of H. pylori facilitates the estimation of disease burden in a certain population. This study presents the diversity of H. pylori genotypes and their association with different clinical outcomes among dyspeptic patients in Pakistan over a period of four years., Methodology: Gastric biopsy samples from a total of 450 dyspeptic individualswere subjected to PCR, genotypingand histology., Results: A total of 201 (45%) cases were found positive for H. pylori. The detection rate was high in GU (91%), DU (86%) and GC (83%) cases compared with those cases who had intact gastric mucosa (18%). Histology revealed the presence of infection in 68% of cases of mild/chronic nonspecific gastritis with others belonging to the GU sequel. cagA gene carriage was observed in 104 (51%) cases or mostly from DU, GU and GC groups, of which 97 were Western type strains while 3 were East-Asian type strains that are rarely observed in South Asia. vacA allelic variant s1am1 was most commonly observed, followed by s1am2, and s1bm1, with direct correlation in diseased cases (gastritis, GU, DU and GC). Prevalent genotypic combinations were s1am1/cagA- in gastritis and s1am1/cagA+ in DU, GU, and GC., Conclusions: Our study indicates the predominant circulation of Western type cagA and vacAs1am1 type H. pylori strains in Pakistan.

Aim: To determine antibiotic resistance of Helicobacter pylori (H. pylori) in Pakistan and its correlation with host and pathogen associated factors., Methods: A total of 178 strains of H. pylori were isolated from gastric biopsies of dyspeptic patients. Susceptibility patterns against first and second-line antibiotics were determined and trends of resistance were analyzed in relation to the sampling period, gastric conditions and cagA gene carriage. The effect of cagA gene on the acquisition of resistance was investigated by mutant selection assay., Results: The observations showed that monoresistant strains were prevalent with rates of 89% for metronidazole, 36% for clarithromycin, 37% for amoxicillin, 18.5% for ofloxacin and 12% for tetracycline. Furthermore, clarithromycin resistance was on the rise from 2005 to 2008 (32% vs 38%, P = 0.004) and it is significantly observed in non ulcerative dyspeptic patients compared to gastritis, gastric ulcer and duodenal ulcer cases (53% vs 20%, 18% and 19%, P = 0.000). On the contrary, metronidazole and ofloxacin resistance were more common in gastritis and gastric ulcer cases. Distribution analysis and frequencies of resistant mutants in vitro correlated with the absence of cagA gene with metronidazole and ofloxacin resistance., Conclusion: The study confirms the alarming levels of antibiotic resistance associated with the degree of gastric inflammation and cagA gene carriage in H. pylori strains.

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.

Objective: To evaluate the indications, clinical features, complications, and effect on patient management of Endoscopic retrograde cholangiopancreatography (ERCP) in paediatric patients of varying age., Methods: A prospective, descriptive cross sectional study was conducted at the endoscopy suite, Surgical Unit 4, Civil Hospital Karachi; from January 2007 to August 2010. All ERCPs performed during a 3-year period in patients aged 18 years or less were prospectively analyzed. Success was defined as having authentic diagnostic information or a successful endoscopic therapy., Results: A total of 40 children and adolescents (18 Males, 22 Females; mean age 13.6 +/- 3.37 years, range 3 to 18 years) underwent 52 ERCP procedures. Indications were biliary pathology in 21, and pancreatic pathology in 19. The ERCP findings were choledocholithiasis in 12 patients, choledochal cysts in 5, chronic pancreatitis in 8, pancreatic pseudocyst in 5, recurrent pancreatitis in 5, biliary ascariasis in 2, pancreatic divisum in 1, postoperative bile leak in 1, and benign biliary stricture in 1. ERCP was successful in 51 of 52 procedures. Single procedure was performed in 36 patients, where as two patients required 2 procedures and it was repeated 4 and 6 times in the remaining two patients. Endoscopic therapy was performed in 92% of the procedures. The complication rate was 1.9% (1/52 procedures) which included mild pancreatitis, whereas asymptomatic hyperamylasaemia was seen in 11% (6/52 procedures). No mortality related to ERCP occurred. ERCP affected management in 94% (49/52 patients)., Conclusion: ERCP is an effectual and safe therapeutic procedure in children and adolescents of different ages with a variety of pancreatobiliary disorders.

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.

Objectives: To evaluate the effectiveness of capsule endoscopy in the management of patients with obscure gastrointestinal bleeding., Methods: 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., Results: 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., Conclusion: 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.

Objective: To evaluate the effectiveness of endoscopic balloon sphincteroplasty as an adjunct to endoscopic sphincterotomy in removing large and difficult bile duct stones., Methods: 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 15 mm 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 15-18 mm Controlled Radial Expansion (CRE) balloons. All procedures were done as day case under conscious sedation., Results: 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 10-32 mm with a mean of 14.7 +/- 0.44 mm. 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., Conclusion: 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.

Objective: To evaluate the endoscopic dilatation of benign esophageal strictures and its outcome., Methods: A prospective descriptive study was conducted at Surgical Unit 4 of Civil Hospital Karachi, over a period of 24 months, from August 2006 to July 2008. Twenty seven patients with benign esophageal strictures underwent esophageal dilatation under fluoroscopic guidance using Savary Gilliard Dilators and guide wire. Follow up was done weekly for 2 weeks and monthly for a minimum of 6 months. Treatment success was gauged according to improvement of dysphagia., Results: A total of 27 patients were included in the study. There were 16 (59.3%) corrosive strictures, 10 (37%) were peptic strictures and one (3.7%) was due to extrinsic compression. Majority of the corrosive strictures, 11 (68.75%) were suicidal in intent p < 0.001. Mean dilatation frequency for strictures longer than 5cms was 7.10 +/- 5.322 vs. 3.47 +/- 3.281 for strictures < 6cms (p < 0.037). Corrosive strictures were seen more commonly in the upper esophagus as compared to peptic (Mean 22.44 +/- 5.240 cm vs. 30.20 +/- 4.780 cm), p < 0.001. Only 81.4% corrosive stricture could be adequately dilated at initial dilatation as compared to 100% in peptic strictures. Mean symptomatic recurrences per month were 0.6919 +/- 0.300 in corrosives and 0.365 +/- 0.293 in peptic strictures (p < 0.003). There were 4 procedure related perforations, all in patients with corrosive strictures. Overall mortality was 7.4%., Conclusion: Endoscopic dilatation is safe and effective in treating benign and corrosive esophageal strictures, which have a higher complication rate. Mean recurrence rate decreased over a period of time in both peptic and corrosive strictures.

Objective: To evaluate the symptomatic relief of dysphagia after stenting in patients with carcinoma esophagus, Methods: A prospective non randomized descriptive study was conducted at Surgical Unit 4, Civil Hospital Karachi, Pakistan over a period of 1 year, from August 2006 to July 2007. A total of 41 patients with biopsy proven carcinoma esophagus having irresectable disease on the basis of CT scan or poor risk for major surgery were included in the study. Self expandable metallic stents were placed under fluoroscopic guidance in all the patients. Follow up was done weekly for 1 month and monthly for 6 months or till death of the patient. Data was analyzed using SPSS version 11., Results: Age of the study population ranged from 25-80 years with mean age of 51.49 +/- 14.25 years. Male to female ratio was 1.15:1. Preoperative dysphagia for solids was seen in 4.9%, for semi solids in 31.7%, and for liquids in 63.4%. 80.5% of patients had squamous cell carcinoma and 19.5% of patients had adenocarcinoma. Dilatation prior to stenting was done up to 12.8 mm in 65.9%. Complete relief of dysphagia was seen in 73%. No procedure related mortality was seen in our study. Overall complication rate was 29.2%., Conclusion: SEMS is an effective method for the relief of dysphagia in patients with irresectable carcinoma esophagus.

Objective: 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., Study Design: Case series., Place and Duration of Study: Civil Hospital and Lyari General Hospital, Dow University of Health Sciences, from July 2003 to June 2005., Patients and Methods: 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-alpha2a 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., Results: 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., Conclusion: 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.

Objective: To compare hemoglobin, ferritin, and vitamin B12 levels in patients undergoing upper GI endoscopy according to their Helicobacter pylori status., Study Design: Cross-sectional study. Place and Duration of the Study: Civil Hospital and Lyari General Hospitals, Karachi, from March 2004 to June 2006., Patients and Methods: All patients undergoing upper GI Endoscopy were selected, while patients of active peptic ulcers, malignancy, varices, malabsorption and recent blood donation were excluded. Blood samples for CBC, serum ferritin and vitamin B12 were collected and H.pylori status was ascertained by urease test on gastric biopsy. Differences in mean values of age, ferritin, hemoglobin, MCV and vitamin B12 were done by student's 't-test'. Significant confounding factors were identified on multivariate analysis and were further analyzed by univariate analysis., Results: Two hundred and eighty-five subjects were studied, including 171 males and 114 females. H.pylori was positive in 214 (75.1%) patients. Significantly low levels of hemoglobin (p =0.0), ferritin (p = 0.0) and vitamin B12 (p = 0.0) were found in patients with H. pylori infection. Gender, menopause, contraception and history of peptic ulcer disease were identified as significant confounders., Conclusions: Significantly low levels of hemoglobin, ferritin and vitamin B12 were found in patients with H.pylori infection.

Objective: To determine HBV suppression in patients with dual HBV and HDV infection after 48 weeks with 10.0 MIU of interferon-a 2b., Design: Quasi experimental study., Place and Duration of Study: Civil Hospital, Karachi and Lyari General Hospital, Karachi, from July 2003 to June 2005., Patients and Methods: All HBsAg positive patients were screened for anti-HDV, all positives were included. Baseline investigations, liver chemistries and HBsAg; HBeAg; anti-HBcore IgM; HBV DNA quantitative PCR were done. Patients with hepatocellular carcinoma and decompensated cirrhosis were excluded. Patients were treated with Interferon-alpha 10.0 MIU 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., Results: 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., Conclusion: HDV should be screened in all patients eligible for HBV treatment.

This is a report of a rare gastrointestinal stromal tumor of the duodenum in a 75 years old man who presented with recurrent episodes of intestinal obstruction and melena. The patient underwent successful Whipple's procedure.

Objective: 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., Design: Cross-sectional study., Place and Duration of 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., Patients and Methods: 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., Results: 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)., Conclusion: 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.

Objective: To determine the prevalence of HIV, Hepatitis B (HBV) and Hepatitis C (HCV) amongst the health workers of Civil Hospital Karachi (CHK)., Material and Methods: Prospective study. A precoded Proforma was filled out which included questions regarding the knowledge, attitude and practices (KAP) of HIV, HBV and HCV., Setting: Departments of a tertiary health care facility at CHK. Antibodies to HIV, HCV and Hepatitis B surface antigen (HBsAg) were done using enzymes linked immunosorbent assay [ELISA]., Results: Uptake of screening was 98% to those offered. The prevalence was 5.6% for antibodies to HCV, 2.4% for HBsAg, while none of those studied had antibodies to HIV., Conclusion: Our results show the prevalence of antibodies to HCV in health workers are 20 folds higher than health workers in the developed countries. Similarly, the prevalence of HBV although not as high as HCV is significant. Seroprevalence of HIV does not exist in this group. We need to ensure better training; regulations regarding preventive and safety measures also need to be enforced (JPMA 52:92; 2002).

Objective: To determine the correlation between the clinical, endoscopic and histological findings in patients of GERD., Design: An observational, cross-sectional study., Place and Duration of Study: Lyari General Hospital, Dow University of Health Sciences from November 2003 to October 2004., Patients and Methods: Patients complaining of heartburn and/or acid regurgitation at least twice per week for at least 3 months were inducted in the study. Presence of clinical symptoms of epigastric pain, retrosternal burning, and reflux were recorded. Patients were subjected to esophagogastroduodenoscopy and four biopsies were taken from esophago-gastric junction. Correlation/regression analysis was done on clinical, endoscopic and histological findings., Results: A total of 196 patients were selected and endoscopically examined. Most common grade given by patients to epigastic pain was grade-4 (42.9%), retrosternal burning as grade-4 (41.8%) and reflux grade-5 (36.7%). There was significant correlation between the clinical severity of epigastric pain with endoscopic findings (p = 0.002) and reflux (p = 0.0) but no correlation was observed with histological findings (p = 0.19). Out of 109 (55.6%) patients who had normal mucosa on endoscopy but on histology 70 (35.7%) of them had inflammation. Grading of endoscopic and histological findings showed significant correlation with each other (p = 0.0)., Conclusion: Endoscopic negative GERD is common; severity of clinical symptoms does not correlate [corrected] with endoscopic findings while histopathological findings correlate with those of endoscopic findings [corrected]

Recombinant activated factor VII is indicated mainly for the treatment of patients with haemophilia inhibitors. It has also been found successful in the treatment of platelet disorder Glanzmann's thrombasthenia. Recently, its use in trauma patients and in patients with intracereberal haemorrhage has become well established. We present three cases of massive post partum haemorrhage treated with rFVIIa, following caesarean section. The response of these three patients is discussed along with review of literature.

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.

Lipoma of the colon is rare and may lead to intestinal obstruction. We have presented two cases of colonic lipoma. Both were elderly females, one presented with diarrhea and the other with sub-acute intestinal obstruction. After colonoscopy surgical removal was done. Histopathology revealed lipoma

Objective: To determine the prevalence of HIV, Hepatitis B (HBV) and Hepatitis C (HCV) amongst the health workers of Civil Hospital Karachi (CHK)., Material and Methods: Prospective study. A precoded Proforma was filled out which included questions regarding the knowledge, attitude and practices (KAP) of HIV, HBV and HCV., Setting: Departments of a tertiary health care facility at CHK. Antibodies to HIV, HCV and Hepatitis B surface antigen (HBsAg) were done using enzymes linked immunabsorbant assay [ELISA]., Results: Uptake of screening was 98% to those offered. The prevalence was 5-6% for antibodies to HCV, 2.4% for HBsAg, while none of those studied had antibodies to HIV., Conclusion: Our results show the prevalence of antibodies to HCV in health workers are 20 folds higher than health workers in the developed countries. Similarly, the prevalence of HBV although not as high as HCV is significant. Seroprevalence of HIV does not exist in this group. We need to ensure better training; regulations regarding preventive and safety measures also need to be enforced.

Increased amounts of intestinal endotoxin are absorbed in obstructive jaundice. The precise mechanism is not known but the increased absorption may arise from alterations in the luminal contents, in the intestinal flora, in the gut wall or in interactions between all three. To examine the effects of the intestinal flora we have compared the morphological changes in the small intestine in obstructive jaundice in germ free and conventional rats while the effects of bile constituents have been examined by addition of bile constituents to the diet of bile duct ligated rats. Changes in the intestine were examined, histologically, by enzyme histochemistry, and by transmission and scanning electron microscopy. The results showed no differences in response between germ free and conventional rats. Feeding of diets containing bile salts exacerbated the lesion. Feeding of diets containing cholesterol, however, reduced the degree of intestinal changes produced by cholestasis and completely antagonised the increase in damage caused by feeding of bile salts.

In a prospective study, 78 of 157 patients with acute lower-limb ischaemia were considered suitable for thrombolysis. The immediate and 4-year results of 52 patients managed by a single protocol are reported. Of 34 patients alive at 4 years, 23 had limb salvage. Initial treatment produced effective lysis in 38 patients (73 per cent) with significant benefit in 35 (67 per cent); that benefit was sustained for a minimum of 4 years in 30 patients (58 per cent). Seven of the 18 deaths by 4 years occurred within 30 days. Amputation was carried out in six patients within 30 days and in five during the next 4 years. Delayed amputation followed persistent distal occlusion or progression of distal disease. No death or amputation was caused by complication of treatment. In selected patients the risks of thrombolysis can be reduced to an acceptable level by personal supervision and a strict protocol. In survivors, limb salvage is generally sustained for at least 4 years.

The patency of 90 elective femoropopliteal reconstructions was assessed 6 months after surgery. The preoperative white cell count was found to be a highly significant predictor of early graft failure (P < 0.0001) independent of other previously recognized predictors of occlusion such as smoking and run-off.