BDI should be repaired within 48 hours, if not then it is better to do it after 4-6 weeks-Prof. Saeed Qureshi


 Proceedings of JPMC’s annual symposium

BDI should be repaired within 48 hours, if not then it
is better to do it after 4-6 weeks-Prof. Saeed Qureshi

During 14 years, we have managed 223 patients of esophageal cancer
and most of them had two stage Esophago Gastrectomy-Prof. Inam Pal

KARACHI: The session devoted to Surgery during the JPMC’s 52nd annual symposium held recently was chaired by Prof. Irshad Waheed along with Dr. Shamim Qureshi and Prof. Shafiqur Rehman from Ziauddin Medical University. Prof. Saeed Qureshi from DUHS/CHK was the first speaker who made a presentation on biliary diseases. He discussed in detail the management of Bile Duct Injuries, what the best time for repair is and who should repair it. BDI management, he said, has to be a multidisciplinary team work. The issues and factors which matter in the outcome include inflammation, operative technique, technical problems, surgeons’ learning curve, surgeon’s mindset, laparoscopic equipment because sometime second hand equipment is used which may break down.

He also referred to strategies to minimize bile duct injuries, how to prevent bile duct injuries, how to identify cystic duct. His suggestions was that one should do intra operative cholangiogram. While going into the dangerous area, stop and seek help from another surgeon if you think it is difficult for you to manage. In biliary leakage and biliary obstruction the first thing to do is ERCP. Put in stent. He also depicted a few slides of bile duct cut off. He then talked about intra operative management. In case of post-operative recognition, repair should be done within forty eight hours and if it is not possible, then wait for four to six weeks and let implants settle down.

Prof. Saeed Qureshi

Prof. Saeed Qureshi then presented details of 226 cases which they had managed at their unit in DUHS/CHK. It included fifty seven cases of obstructive jaundice. Majority of them were female. His conclusions were that surgical therapy was the most durable for the patients. Timing of surgery should be early or within forty eight hours and if not then delay it for four to six weeks. We had done three re-do surgeries. We had mortality in our early phase but now for the last three years we do not have any mortality. Replying to a question Prof. Saeed Qureshi said that one can do repair on third or fourth day as well, the decision has to be based on the circumstances under which you work.

Prof. Inam Pal

Prof. Inam Pal from Aga Khan University Hospital was the next speaker who talked about esophageal cancer.  Title of his presentation was “Taming the Beast- Cancer of mid and lower esophagus”. Prof. Inam Pal pointed out that this field is quite confusing and we cannot replicate the results coming from high quality centers from overseas. It is the eighth commonest malignancy in the world and there is geographic discrepancy.  Squamous cell carcinoma is the most common. Adenocarcinoma is a problem for the West. We have very little problem with this. Squamous cell cancer is more aggressive. Long term survival after surgery is between 17-40%. Over the years there has been no dramatic change in survival which remains within 20-25%.  Radiotherapy is a treatment option. He also discussed the role of adjuvant therapy and its modalities. Post treatment strategies are changing. Therapeutic modalities have also been changing and it was to compare data from various centers due to various reasons.

Giving details of their own experience at AKUH from 2000-2014 Prof. Inam Pal said that we do esophagectomy of neoplasia. Two surgeons do it and we have been doing fifteen to twenty cases every year. Our series had 138 male and 85 female patients. Mean age of these patient was 51 years but about 40 patients, he said, were forty years of age or less than that which accounted for almost 18% of the cases. We do not know the reasons for that and we need to look at that.  We had 164 squamous cell carcinoma and 57 were adenocarcinoma.  As regards their location, one third i.e.  156 were lower and fifty five were in the middle.  During the fourteen years we have managed 223 patients. Most of these patients had two stage Esophago Gastrectomy. About 67% of our patients had anastomosis while we used Stappler in 30% because it is quite expensive. Most of these patients were in stage-III with advanced disease. About 15% of our patients received neo adjuvant therapy.  We had a mortality of seven which comes to about 3%. We do not use ICU anymore which was the case in the past. It has shortened hospital stay. We start feeding the patients with liquids on fourth post-operative day. They stay in the hospital from ten to twenty days. Long term survival is a problem and we have no information about that. We need technical information but there is no proper follow up. About 30% of these patients were followed up for one year. We do not know the overall survival but we need to look at the complete pathological response rate. We offer neo adjuvant therapy to all the patients who can afford to stay for three to four months. Complete clinical response does not equate with complete pathological response. We need proper investigative modalities. Responding to questions during the discussion Prof. Inam Pal said that pain relief is important. There is no increase in complications after the start of neo adjuvant therapy. Prof. Shafiqur Rehman remarked that we send the patient for radiotherapy but the moment they get better, they disappear.

Prof. Asadullah along with Prof. Sughra Parveen Chairperson Organizing Committee presenting mementoes to
Qamar Baloch at the surgical session during the JPMC symposium. Dr. Naseem Baloch is also seen in the
picture. Picture on right shows Prof. Sughra Parveen presenting mementoes to Prof. Shafiqur Rehman.

Also seen on extreme right is Dr. Shamim Qureshi.

Dr. Javed from DUHS Ojha Campus spoke about bariatric surgery. Management of metabolic syndrome he stated includes diet, exercise and life style modifications. Bariatric surgery is now known as metabolic surgery as it offers metabolic benefits like reduction and control in hypertension, diabetes mellitus and solution to obesity problems. Metabolic surgery is a multidisciplinary team work which includes surgeon, cardiologist, gastroenterologist, anesthetist and nutritionist. He then gave details of the 89 cases they had managed. Inclusion criteria was BMI of 40 without comorbidities and BMI 35 with comorbidities.

Dr. Shamimul Haque discussed the management of thirty eight patients of prolactinomas. Their mean age was forty two years. Headache and visual impairment are the most presenting symptoms. CSF leak was seen in six patients who were diabetics, hemorrhage was seen in three patients. All these patients were managed conservatively. Dr. Farrukh Javed spoke about surgical management of posterior cranial fossa tumors. These, he said, are more common in children than adults. His presentation was based on management of 29 male and 31 female patients. CSF leakage, meningitis, wound infection and hematoma were the complications noted. Nine patients died. His conclusions were that these are critical brain lesions and has more morbidity and mortality.

Mr.Abid Saleem from NMI was the next speaker who discussed management of nine patients with Gama Knife Radiosurgery. Total resection he said, was difficult but it is highly effective and safe for CSHs. Dr. Ruba Zahid from Dept. of Psychiatry discussed violence by psychiatric patients and violence on psychiatric patients. Physical and verbal abuse were quite common. About 31% were maltreated by the family because of their mental disease. Her conclusions were that more patients are source of violence as compared to be the victims of violence. Dr. Fareeha Iqbal made a presentation on cross cutting symptoms while Dr. Uzma Ali talked about behavior problems in children. Her conclusions were that it is the mothers who are responsible for behavioral problems in children.


Prof. Irshad Waheed presenting a mementoe to Prof. Sughra Parveen during the
JPMC’s annual symposium. Prof. Shafiqur Rehman is also
seen on extreme right.

Prof. Iqbal Afridi from JPMC highlighted the anxiety and depression in primary healthcare givers. At the psychiatric OPD, he said, we see about five hundred patients of which four to five are admitted. We prefer to treat patients at home. There were one hundred male and eighty female primary care givers in this study. Brothers were more followed by mothers who came at number two as primary care givers and   75% of these care givers were suffering from anxiety and depression. Dr. Saira Shoaib spoke about cranial autonomic symptoms. They saw one hundred five patients in a year one most of them had migraine for the last one year. Dr. Deepak Kumar’s presentation was on Management of Tuberculosis.

Prof. Sughra Parveen in her presentation on Breast Cancer pointed out that to prevent breast related diseases it is important to screen early and diagnose the case before the cancer spreads, Breast cancer patients can be treated with breast conservative surgery if it is diagnosed earlier. It is important to get yearly checkup, self-examination and examination by doctor of both breast and axilla is recommended every month. Women over the age of 40 years should get their mammogram every two years. It was also highlighted that after mastectomy breast reconstruction can be done. Breast cancer if diagnose early then can be manage easily. Social taboos of spreading disease via trucut biopsy and if the mother is a breast cancer patient her daughter will get the disease and about breast cancer contagiousness are all misleading, invalid and insignificant.