The Role of MRI Pancreatic Protocol in Assessing Response to Neoadjuvant Therapy for Patients With Borderline Resectable Pancreatic Cancer

BackgroundBorderline Resectable Pancreatic Cancer (BRPC) remains a unique entity that is difficult to categorize due to variance in definitions and the small number of patients. The ultimate goal is to achieve a free resection (R0) after a favorable response to neoadjuvant therapy that is somewhat difficult to assess by current radiological parameters.AimTo evaluate the role of Magnetic Resonance Imaging (MRI) pancreatic protocol, including Diffusion-Weighted Imaging (DWI), in patients with BRPC receiving neoadjuvant therapy, and further compare it to RECIST criteria and outcome.MethodsHistologically confirmed BRPC patients were prospectively included. DWI-MRI was performed pre- and post-therapy. Clinical characteristics with ensuing operability were recorded and correlated to radiological RECIST/apparent diffusion coefficient (ADC) change, preoperative therapy administrated, surgical resection status, and survival.ResultsOut of 30 BRPC cases, only 11 (36.7%) ultimately underwent pancreaticoduodenectomy. Attaining a stationary or stable disease via ADC/RECIST was achieved in the majority of cases (60%/53.3% respectively). Of the 12 patients (40%) who achieved a regression by ADC, 11 underwent surgery with an R0 status. These surgical cases showed variable RECIST responses (PR=5, SD=4, PD=3). Responders by ADC to neoadjuvant therapy were significantly associated to presenting with abdominal pain (p =0.07), a decline in post-therapy CA19-9 (p<0.001), going through surgery (p<0.001), and even achieving better survival (p<0.001 vs. 0.66).ConclusionDWI-MRI ADC picked up patients most likely to undergo a successful operative procedure better than traditional RECIST criteria. An algorithm incorporating novel radiological advances with CA19-9 deserves further assessment in future studies.

Surgical and Anatomic Consideration in Endoscopic Dacryocystorhinostomy of a Patient with Damaged Sinonasal Anatomy Post–Caldwell-Luc Surgery: A Case Report

Background: The Caldwell-Luc (CL) procedure, an outdated operative procedure that is used to treat inflammatory sinus diseases, is rarely performed presently. However, physicians may encounter patients with a history of CL surgery who develop considerable postoperative changes that may lead to diagnostic confusion in imaging evaluation; increase the difficulty of future surgery, such as sinonasal surgery; and increase the incidence of future intraoperative complications. Case summary: A 67-year-old man with a surgical history of chronic sinusitis reported epiphora of the left eye for five years. Balloon dacryocystoplasty was attempted but failed. Endo-DCR (Endoscopic dacryocystorhinostomy) was indicated; however, preoperative CT (computed tomography) imaging and nasal endoscopic examination showed sinonasal anomalies and the loss of internal landmarks for localizing the lacrimal sac. Preoperative CT results indicated previous CL surgery. Endo-DCR was performed with the aid of nasal forceps and a 20-gauge vitreoretinal fiberoptic endoilluminator. A six-month follow-up revealed the complete resolution of symptoms and no signs of recurrence. Conclusions: Epiphora might be a delayed complication of the CL procedure. Before performing endo-DCR, ophthalmologists should be familiar with the sinonasal anatomy and carefully assess preoperative imaging to identify anatomical variations. Nasal forceps and transcanalicular illumination can assist in determining the precise location of the lacrimal sac during endo-DCR.

THE ROLE OF INTRAOPERATIVE NEUROPHYSIOLOGIC MONITORING TO ENHANCE SUCCESSFUL ORTHOPEDIC SURGERY

One of the main advance in orthopaedic surgery domain has a goal to investigates the safest and harmless method in surgical procedures. Less complications means a better outcome of surgery. One of the commonest risks at orthopaedic surgery is central and peripheral nerve injury. The modality of Intraoperative Neurophysiologic Monitoring (IONM) which act to limit the risk of nerve injury during operative procedure through the evaluation of nerve integrity and function enable the surgeon to decrease injury to the nerve associated with orthopaedic surgical procedure in the operating room. This article aims to explain and describe the latest modality of IONM, its basic concept and its function at surgery. The last part of the article discussed about orthopaedic surgical techniques which use IONM. The authors hope that this article will enhance the knowledge of all the readers about IONM. This article was written based on literature study searched at Google Scholar, Medline and PubMed. The references were taken from a relatively up to date study ranging from 2013-2018. The article was selected according to the authors inclusion criteria and six articles was chosen as the references for this review. As a conclusion, IONM has an important role to increase successful rate of surgery through minimizing nerve injury risk during surgical procedure.

Ergebnisse der mit der Obliteration des runden/ovalen Fensters erreichten Behandlungserfolge bei der einseitigen, akut aufgetretenen, idiopathischen sensorineuralen Hörminderung

ZusammenfassungFormerly explorative tympanotomies including sealing of the round/oval window/s have only been used in treating perilymphatic fistulas. During the last years this operation especially in the middle European countries has also been performed more and more in patients suffering from an ISSNHL. In this chapter the effect of this operation including a simultaneous systematic steroid therapy on hearing levels has been collected from data presented in literature and the results will be presented by means of a systematic review. The survey also includes the results of this operative procedure in 41 patients who have been treated by us.Based on 19 publications dealing with the above mentioned topic only 6 studies (4 of them with information about the hearing loss at the time of admission at the hospital and additionally at a follow-up examination (n = 309)) could be integrated in this study and another 2 in which the hearing gains –regardless of the initial hearing loss- according to the modified „Kanzaki“-criteria (n = 288)) have been evaluated- could be used for estimating the therapeutic effects of tympanoscopy with sealing of the round/oval windosw/s in patients with sudden deafness.The follow-up examination had to exceed a 3 weeks interval up from the time of the operation. It is shown that several methods of evaluation the median hearing loss (PTA4 and PTA5) in pure tone audiograms are suitable to be accepted for the analysis of hearing losses in order to compare the results of the treatment.In each study-group collected from literature and two study-groups of our own patients the hearing loss before therapy was significantly higher than that which had been measured at the follow-up examination.Patients in which tympanoscopy was combined with a systematic application of steroids in a „first-line-mode“ (n = 79) had a hearing loss of 94,1 dB. Their hearing improved up to a hearing level of 70,7 dB at the follow-up examination (hearing gain: 23,4 dB; n = 79). Those who first had got systematic steroids followed by the tympanoscopy („second-line-mode“) had an intitial hearing loss of 105,1 dB and a hearing gain of 38,6 dB. So the final hearing level reached 66,5 dB (n = 197).Median hearing thresholds still rose after detamponation of the external ear canal which was usually done 10 days after the operation up to the follow-up examination.Based on the modified „Kanzaki“-criteria 58,7 % of the patients had a restoration in their hearing exceeding 30 dB. In 18,7 % of the cases the hearing improvement was between 10 and 30 dB. 23,1 % of the patients didn`t profit from tympanoscopy.Indications for deciding to perform an explorative tymapnosocopy which are mentioned in literature are collected and discussed.Explorative tympanotomy including sealing of the round/oval window/s seems to be a very valuable method in treating sudden deafness especially when the hearing loss was severe, profound or even when the patients were totally deaf and the therapeutic procedure had been done sequentially after having performed a systematic steroid application before operation. Further studies have to find out if tympanoscopy used in a „first-line-mode“ can also be a method in which the hearing gain is successful enough that this form of therapy can also be recommended.

Eye Camp Surgery

Cataract surgery is the most frequently performed operative procedure in the human body.1 In Pakistan, we have very meagre trained Human Resources and equipment.2 At onetime, eye-camp surgery was promoted by the government to tackle the growing burden of cataract-related blindness. As time passed on, we developed public and private health care delivery services. Now we have ample resources to deal with an ever-growing number of cataracts. In the current scenario, eye camp surgery is not justified. But it seems as if government and regulatory bodies have no intentions to focus on this point.

AUDIT OF MANAGEMENT OF ADULT CHOLEDOCHAL CYSTS

Objective: To analyze the complexity and diversity of type, surgical management and complications in adult choledochal cysts presenting to a Hepatobiliary unit of a tertiary care hospital. Study Design: Case series. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from Jan 2017 to Dec 2019. Methodology: All the patients diagnosed with choledochal cyst and underwent surgical procedure between Jan 2017 to June 2019 were analyzed. The clinical features, types, operative procedure and outcomes of the patients in terms of post-operative morbidity and mortality were assessed. Calvin Dindo classification was used to assess complications. Results: A total of 17 patients were studied, out of which, 13 were females (76.5%) and 4 were males (23.5%) with mean age of 37.41 ± 16.96 years. There were 13 type I (76.5%), 2 type IVa (11.8%) and 1 type II (5.9%) choledochal cysts according to Todani’s classification. Extrahepatic cyst excision with a Roux-en-Y hepatico-jejunostomy was performed on all 17 patients. There was no mortality in the series. Post-operative complications occurred in 4 (23.5%) patients, 2 were grade II, 1 was grade I and 1 grade III according to Clavin Dindo scale. Long-term follow up revealed recurrent cholangitis in 3 (17.6%) patients which settled on antibiotic regime. The median follow up time was 1.5 years. Conclusion: The total extra-hepatic excision with Roux-en-Y hepaticojejunostomy is the treatment of choice for adult choledochal cyst. The procedure has low morbidity and very low mortality.

Desarda versus Lichenstein repair in treatment of inguinal hernia: our experience in KVG Medical College and Hospital

Background: Desarda technique of inguinal hernia repair introduced in 2001 is still not considered standard tissue-based hernia repair technique. The aim of the study was to compare the tissue based Desarda technique with standard Lichtenstein repair in treatment of primary inguinal hernia.Methods: 72 cases were allocated into 2 groups. Desarda (D Group) had 36 and Lichtenstein (L Group) had 36 patients. Primary outcome factors included operative time measured from skin incision to skin closure. Post operative pain scores was using Sheffield scale. Ecchymosis, hematoma, seroma, surgical site infections, foreign body sensation etc. were evaluated as postoperative complications. A follow up examination was planned for 6 month to look for early recurrence (<6 month) and chronic groin pain.Results: Mean age in desarda’s group 44.94±15.5 years while Lichtenstein group was 45.47±13.12 years. The mean duration of surgery 42.83 min (D) versus 50.72 min (L). Duration of hospital stay 3.38 days (D) versus 4.08 days (L). Time taken to return to normal and work activities was significantly less in Desarda group (p=0.001). After 6-month mean follow up period 1 recurrence is noted in each arm (p=1).Conclusions: On comparison of Desarda with Lichtenstein repair. Desarda technique does not use a mesh. Patients after Desarda's operative procedure gets normal activity sooner as compared to the standard Lichtenstein mesh repair. Complications similar to standardized technique. We also found the use of Desarda technique in patients with indirect hernia is a technically sound option than Lichtenstein technique.

Fat graft myringoplasty: A clinical study and review of literature

Objectives: There are numerous surgical techniques that have been demonstrated and utilized to repair small perforations in the tympanic membrane (TM) with various graft materials such as veins, perichondrium, periosteum, and others. In our study, fat was taken as the graft material and the main aim of the study was to evaluate the success rate of graft uptake, assessment of hearing improvement, and complications of the operative procedure. Material and Methods: In this single-center study, 46 patients underwent fat myringoplasty, 52 ears were operated from October 2016 to September 2017 for a period of 1 year. A detailed history, general physical, and a through ear, nose, and throat examination were done. Audiometric assessment was done using pure tone audiometry. Patients between the age group of 15 and 50 years were included in the study. Results: A total of 46 patients were included in the study who met the inclusion criteria. Six patients had bilateral perforations and 40 patients had unilateral perforation, a total of 52 perforations were operated. Forty-three (82.69%) patients had successful graft uptake and graft failure was seen in 9 (17.30%) patients. Maximum gain in hearing was seen in in patients with hearing loss between 20 and 30 dB, that is, 24 patients (46.1%). Conclusion: Fat myringoplasty is a methodized, precise, inexpensive, mini-invasive, and cosmetic outpatient procedure for small perforations of TM. It can be done under local anesthesia and has a good success rate if the patient selection is done appropriately.

The Role of Electrochemotherapy in the Cutaneous and Subcutaneous Metastases From Breast Cancer: Analysis of Predictive Factors to Treatment From an Italian Cohort of Patients

The treatment of cutaneous and subcutaneous localizations from breast cancer (BC) is still a therapeutic challenge. Electrochemotherapy (ECT) is one of the available options, and it is characterized by the association between the administration of a chemotherapic agent (Bleomycin) with the temporary raise of permeability of the cellular membrane induced by the local administration of electrical impulses (electroporation). ECT represents an effective therapy for loco-regional control of this disease. This study aimed to investigate the predictive factors of response in cutaneous and subcutaneous localizations from breast cancer treated with ECT. We decided to evaluate the response to this treatment in 55 patients who underwent ECT between January 2013 and March 2020 at our Institute. We performed a monocentric retrospective cohort study. ECT was administered following the ESOPE (European Standard Operative Procedure of Electrochemotherapy) guidelines, a set of criteria updated in 2018 by a panel of European experts on ECT who defined the indications for selecting the patients who can benefit from the ECT treatment and the ones for technically performing the procedure. The responses were evaluated with the RECIST criteria (Response Evaluation Criteria in Solid Tumor). We found after 12 weeks of treatment a complete response (CR) in 64% of our patients. From the analysis divided for subgroups of covariates is emerged that lower BMI, reduced body surface, and absence of previous radiation treatment could be predictive for a better complete response. This study suggests that the efficacy of the ECT treatment is related to the concurrent systemic therapies while administering ECT. The association between ECT and immunotherapy has offered better results than the association between ECT and chemotherapy (p-value = 0.0463). So, ECT is a valuable tool in the treatment of cutaneous and subcutaneous metastases from breast cancer and its efficacy in local control of these lesions improves when it is well planned in a therapeutic scenario.

A Review on Otitis externa: An Approach to a Etiopathogenesis, Epidemiology, Clinical Features and Management Protocol

Introduction: The external ear is the part of our ears which is seen from outside. It is made up of the auricles (pinna) and external auditory canal; and, includes the outer wall of the middle ear, i.e. the eardrum. Otitis externa is a regular presentation when on call for ENT or at the emergency ENT health clinic or centre. Infective and reaction groups of otitis externa are classified. Methodology: The articles reviewed in this narrative review article have been traced from a variety of links and sources over the internet like PubMed, NCBI, ScienceDirect, NHSINFORM, Uptodate, WebmedCentral, American family physician, ClevelandClinic, StatPearls, and many more. References from high yielding sources were taken and the articles were properly assessed. Results: Paying attention to the scientific elements while performing an operative procedure can give a physician extended results. Which operative modality to be chosen depends on the patient. The patient’s choices are also important in the decision making of the operation. Discussion: External otitis is possibly spotted in almost every peer category. Approximately ten percent (10%) of humans may face this condition during their lifetime. Most of the time, the infection is mixed. Medical intervention of the ear can prove painful for most cases, therefore, post-surgery analgesics must be utilized for a time period which the treating physician prescribes. The aim of curing the patient is to free him/her from the symptoms and getting rid-off any pathogen causing a specific infection. Conclusion: The efficacy of operative modalities of extremes of otitis externa will rely on complete patient examination, history and lab results. Selection of the correct intervention, proper knowlege of the regional anatomy, paying attention to scientific elements and good post-operative care is necessary. It is never easy to avoid otitis externa, but we can make an effort to decrease the risk of developing this problem.