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VOL. 9 NO.1 (JANUARY-MARCH 2004) QUARTERLY

JOURNAL OFSURGERYPAKISTANINTERNATIONAL

EDITORIAL

Economics and Surgical Training Irshad Waheed

ARTICLES

PrognostiC Factors for LocoregionalRecurrence of Breast Cancer

Guizar Ahmed 2

Mixed Dentition Analysis for PakistaniPopulation

Nasrullah Mengal 10

Correlation of Clinical Appearance ofNasopharyngeal Carcinoma with TumourStaging

Niamatullah 15

Laparoscopy in the Evaluation ofImpalpable Testes

Muhammad Talat Mehmood 18

An Experience of Intracranial Meningioma Hameedullah Buzdar 22

Anaesthetic Technique in PaediatricPatients with AnkylosedTemporomandibular Joint

Muhammad Boota 26

Paediatric Urolithiasis as a Cause ofChronic Renal Failure

Bilquis Lakhany 30

Ho.rmone Replacement Therapy: Shabnam ShamimAcceptance and Compliance

33

External Abdominal Hernias Muhammad Jahangir 36

Trends of Delivery in Patients with Rubina SohailPrevious one Caesarean Section

39

Osteomalacia in Females Ghulam Mustafa Kaim Khani 42

Epididymal Abnormalities Associated with Muhammad Shahab Atharundescended testis

44

CASE REPORTS

Ischiopagus Tripus Conjoined Twins Sikandar Ali Mughal 47

Shahzia Jalil 50

Gall Bladder Tuberculosis Shabbir Hussain Rana 52

Squamous Cell Carcinoma Foot Arising inDeep Mycosis (Chromomycosis)

Shahid Majeed 54

Port site Metastasis by Exfoliated CellsFrom Occult cholangiocarcinoma

Naqvia. H. Khan 56

EDITORIAL:

ECONOMICS AND SURGICAL TRAINING

As in all fields today, economics has come to play an important and basic role inmedicine as well. No development or meaningful setting up of teaching andtraining is possible without taking this into consideration. Gone are the days whendiscussions of money in the field of education was regarded as abhorrent andtaking of paymentwas an abominable act.

Education and health are fields which are the wellsprings of development. Nosociety or nation is said to be developed or civilized where these are not givendue importance. Howeverby their very nature, they are bottomless pits where themore you put in the more you have to follow up with, otherwise the preciousinvestment goes down the drain. As resources are always limited, somewherethere has to develop a sense of economization or conservation, cutting downcosts and stopping wastage. Nowhere is this more important than in the field ofsurgical training.

Initially the training of surgeons was almost entirely limited to "practice" on actualpatients. However with the passage of time, the legal, ethical and moralconsiderations have proved that this method is no longer desirable. With thisrealization, simulation has developed both in the form of live actors and trainingimplements like dummies etc. However such methods tend to be costly andespecially dummies are very expensive. There is therefore a need for innovationfor the development of alternate inexpensive and disposable methods ofperforming and practicing surgical skills.

Fortunately Pakistan does not lack in intelligent innovators. Many training centersin the country have developed their own skills labs where excellent training work isgoing on. In these labs locally produced training material is being used at afraction of the imported material cost. One such example is the surgical skills labat the College of Physician & Surgeons Pakistan at Karachi. The way theorganizers of this lab have used simple locally made stuff has to seen to bebelieved. Foams, plastic, sheets, tubes, wooden templates, balloons and othersuch material come together to form practice pitches for skin incision closures,laparotomies, tracheostomies and many more such procedures. The cost incurredis very small and affordable by even the most financially handicap institutions,whoare eager to see innovation in the field of surgical skills training.

Dr. Irshad WaheedProfessor of Surgery

1

PROGNOSTIC FACTORS FORLOCOREGIONAL RECURRENCE OF BREAST

CANCER

GULZAR AHMAD, TARIQ MEHMOOD REHAN, MUHAMMAD RASHID CHOUDHARY

ABS1RACTObjectives: To explore prognostic factors for locoregionalfailures among women treatedfor

invasive breast cancer by surgery and adjuvant therapies.

Design Descriptive study.

Place & DurationThe study was conducted at the Surgical Department, Bahawal VictoriaHospital (BVH), Bahawalpur with mutual cooperation ofBahawalpur Institute ofNuclear Medicine & Oncology (BINO)over a period of five years.

Patients And MethodsThe study consisted of 120 women who were treated with a modified radicalmastectomy (85 at BVH and 35 at various district & private hospitals) andenrolled for an adjuvant therapy. A total of 25 patients of breast cancer withnode negative disease received either no adjuvant therapy or a single cycle ofperioperative chemotherapy, and 95 women with node positive disease receivedadjuvant chemotherapy of at least 5 months duration and/or tamoxifen for atleast one year. Meanfollow up was 4.2 years.

ResultsIn women with node negative disease factors associated with increased risk oflocoregionalfailure were vascular invasion (VI)and tumor size greater than 5 cmfor premenopausal and VI for postmenopausal patients. Of the 25 patients, 6(24%)met criteria for the high risk groups. For the node positive group of patientsnumber of nodes and tumor grade were factors for both menopausal groups,with additional prediction provided by VIfor premenopausal and tumor size forpostmenopausal patients. Of the 95 patients, 34 (35.8%) met criteriafor the highrisk groups.

ConclusionLocoregional recurrence is a Significant problem after mastectomy alone even forsome patients with node negative breast cancer, as well as after mastectomyand adjuuani treatment for some subgroups of patients with node positivedisease. In addition to number of positive lymph nodes, predictors oflocoregionalfailures include tumor relatedfactors, such as microscopic vascularinvasion, higher grade and larger size.

KEY WORDS: Breast cancer, Mastectomy, Histological grades,

Correspondence:Dr Guizar AhmadSenior Registrar SurgeryBahawal Victoria Hospital, Bahawalpur

INTRODUCTIONExtensive local and regional treatment often includingradiotherapy was used in the treatment of breast cancer,before the era of adjuvant systemic therapies.:" The

2 Journal of Surgery Pakistan (International) Vol. 9 (1) January - March 2004

GuIzar Ahmad, Tariq Mehmood Rehan, Muhammad Rashid Choudhary

addition of radiotherapies to surgery reduced the number •of local and regional recurrences. Overviews of allradiotherapy trials indicated reduced breast cancer •mortality but failed to show a significant overall survivalbenefit.3 •

Adjuvant systemic treatment of breast cancer improvesthe relapse free survival rate by reduction of local,regional and distant relapses and moderately improvessurvival.' Two randomized clinical trials from Denmark andCanada on radiotherapy together with adjuvantchemotherapy in mainly node positive premenopausalbreast cancer patients" and one study from Denmark onradiotherapy with tamoxifen in postmenopausal patients?found improved survival in radiotherapy arms. There hasbeen concern that the quality of the axillary surgery in theDanish study, in which an average of only seven removedlymph nodes were investigated, as well as less optimaladjuvant chemotherapy= may have contributed to a highrisk of cancer remaining in the locoregional area.

Recent consensus statements have concluded thatlocoregional radiotherapy might be considered to improvethe relapse free and possibly overall survival for somepatients who are at high risk for locoregional relapse ofthe disease despite adjuvant systemic treatment.'>"Because radiotherapy is resource consuming and may befollowed by severe late effects, it should be reserved forpatients who are at high risk. Thus there is a need toexplore the incidence of locoregional relapses aftercontrolled surgery and in connection with systemictreatment. A publication of International Breast StudyGroup has showed that more effective systemictreatments reduced the risk of local and regionalrecurrences compared with the less effective treatmentsfor patients with node positive disease."

The aim of the present study was to expand on theseresults by defining risk groups for locoregional recurrence(with or without simultaneous distant failure) in patientswho were treated with modified radical mastectomy andenrolled in this study for an adjuvant therapy.

PATIENTS AND METHODSThe study included 120 women of breast cancer amongwhom 85 were operated at BVH while 35 at variousprivate and district hospitals and were referred to BINO foran adjuvant treatment for a period of 5 years from 1999 to2003.The analysis was based on information collected onpatients fulfilling the criteria described below. Detaileddefinitions for menopausal status, patient characteristicsand eligibility for the study have also been described inmany similar studies.'6-24The patient's selection criteriaincluded:• All patients who under went modified radical

mastectomy.

The tumors of stage pathologic (p) T1, pT2 or p T3(tumor node metastasis staging system).Margins of tumor resection free of tumor cells andno involvement of skin or fascia.At least four lymph nodes from the axilla examined.

The patients under gone breast conserving surgery,patients fulfilling the above criteria but already taking orcompleted an adjuvant treatment and those with distantmetastasis were excluded from the study.

The individual groups of the patients selected for thestudy and their characteristics were as follows:

Premenopausal patients with node negative diseaseincluded 10 patients, 3 had positive family history and gotsix pulses of classic "FAG"protocol chemotherapy with aninterval of 21 days (5-fluorouracil 500mg/m2 iv day1adriamycin 50 mg/m2 iv day1 and cyclophosphamide500mg/m2 iv day1) and the remaining patients receivedno further treatment. All patients received no radiotherapy.

Postmenopausal patients with node negative disease,included 15 women, 8 received a single course ofperioperative chemotherapy of classic "CMF" protocol(cyclophosphamide 400mg/m2 iv days1 and 8,methotrexate 40mg/m2 iv days1 and 8 and 5-fluorouracil600mg/m2 iv days1 and 8). All patients were put ontamoxifen 20 mg daily for a period of 3 years and nopatient got radiotherapy.

Premenopausal patients with node negative disease,included 55 patients, 45 received 8 pulses of 21-dayclassic "FAG"protocol chemotherapy while the remaining10 patients completed 6 pulses of the same protocolchemotherapy.All patients got no radiotherapy.

Postmenopausal patients with node negative disease,enrolled 40 ladies, 30 patients received 8 pulses of 28-days courses of classic "CMF" chemotherapy along withtamoxifen 20 mg daily for a period of 3 years (women <60years of age) while the remaining 10 patients were put ontamoxifen 20 mg daily for a period of 3 years (women >60years of age).

A few patients enrolled during the year 2003 could notcomplete the advised tamoxifen course but none of thepatient had taken tamoxifen at least less than one year. Inthis study all the patients had four or more lymph nodesexamined histo-pathologically, both for node negative andnode positive groups, with 50% having 8 or more nodesexamined.

On the basis of the eligibility criteria of all the four groups,the information from 120 patients were used for statistical

Journal of Surgery Pakistan (International) Vol. 9 (1) January - March 2004 3

Prognostic Factors For Locoregional Recurrence of Breast Cancer

analysis on SPSS Program with a mean follow up of 4.2years. The following variables and categories weredefined for the analysis: nodal status (0, <4 or > 4 involvednodes), tumor size ( < 5 cm or> 5 cm), estrogen receptorstatus (negative or positive), age « 60 or > 60 years),histological grade (1,2,3) and vessel invasion (yes or no).Some of these variables were missing for some of thepatients. In particular estrogen receptor status, histologicgrade and vessel invasion were not always known,because these variables were not required for theinclusion of patients in to the study. We included anadditional category (unknown) for those variables tocapture this possibility.

Because we focused, on patient and disease relatedfeatures, we did not include type of adjuvant systemictherapy as a variable to define risk factors.All women withnode positive disease received at least 4 months ofchemotherapy and/or at least 1 year of tamoxifen perrandomized assignment; 80% received at least 6 monthschemotherapy and/or 3 years of tamoxifen.

Locoregional recurrence was defined as a first relapse onthe chest wall, the ipsilateral axilla, ipsilateralsupraclavicular or infraclavicular fossa or the ipsilateralinternal mammary region. Categories of sites of failure ofinterest were as follows: isolated locoregional recurrence(LRF) without simultaneous distant failure (DF); localrecurrence with or without simultaneous distant failure(LRF + DF); and distant failure alone (DF).

LRF + DF events were used to define risk groupsseparately for each of the four groups of patients, asfollows.• The risk factor (variable) present in more than 80%

of the patients with LRF + DF was considered todefine .• High risk group" for that specific clinicalgroup.

• The factor present in 50% to 80% of the patientswith recurrences was considered to define "Intermediate risk group" for that group of thepatients.

• The variable present in less than 50% of thepatients with LRF + DF was considered to define"Low risk group" for that clinical group.

The results were analyzed on percentage basis and theChi square test and Pearson test were utilized to assessthe P-value of each variable against the dependentvariable of locoregional failure.

RESULTS

The overall characteristics of the patients for the fourgroups selected for the analysis has been listed in Table I.

The exact site of failure was unknown for a total of 4deceased patients.These patients have been assigned tothe "other" category for site of failure. Table II shows theobserved number of patients for each of the site of failuregroups considered for the analysis. In total, 40 patientsexperienced locoregional recurrence (with or withoutdistant failure) as a first event. The site of failure was, locoregional for 55%, supra/infraclavicular for 7.5%, axilla12.5%, and multiple LRF regions for 5%, distant failuresfor 10% and other failures for 10% of the patients.

1- Premenopausal PatientsWith Node Negative Disease:As shown in Table III & IV, the tumor size and themicroscopic vessel invasion were prognostic factors forlocoregional recurrence + distant failure in this group ofpatients. Either the presence of vessel invasion or a largetumor contributed Similarlyto the increase in risk of failureand a low risk / high risk group was defined accordingly.The 30% of all the patients got failure during a meanfollow up of 4.5 years in whom all 100% had their tumorsize > 5cm and positive vessel invasion microscopically.The high risk factors correspond to larger tumors withvessel invasion and the low risk factors belong to smallertumors without vessel invasion or their isolated negativity.The site of failure in this group was 33.3 % for each of thelocoregional (LRF) only, local + distant failure (DF) andaxillary lymph nodes (ALN) + distant failure. No patientshowed isolated distant recurrence (Table II).

2- Postmenopausal Patients with Node Negative Disease:Vessel invasion and the negative Estrogen Receptorwerethe risk factors that Significantly predicted the outcome inthis group of patients (Table III & IV). The low risk groupcorresponded to the absence of vessel invasion andpositive ER status, whereas the high risk groupcorresponded to the presence of vessel invasion. The20% of the patients included in this group showed failureduring the mean follow up of 3.9 years and all 100% hadtumors with positive vessel invasion microscopically andnegative estrogen receptor.The site of failure in this groupwas 33.3% each for LRF and multiple regional failures(MRF) + distant failure while in the remaining 33.3%patients the site of failure could not be find because ofpatient death with unknown recurrence (Table II).

3- Premenopausal PatientsWith Node Positive DiseaseThe number of positive lymph nodes, vessel invasion andthe tumor grade were important prognostic factors in thisgroup of patients. The presence of microscopic vesselinvasion produced an increase risk of LRF + DF, as didthe presence of a large number of positive lymph nodesand a higher tumor grade corresponding respectively88.9%, 94.9% and 83.4% of the patients with failures asevident in Table III & IV.The 75% of all the patients withdistant metastasis belonged to this group of patients


Guizar Ahmad, Tariq Mehmood Rehan, Muhammad Rashid Choudhary

110 91.710 8.3

Meno. StatusPre 65 54Post 55 46

Lymph NodesNone 25 20.8< 4 25 20.8> 4 70 58.4

Tumor Size-e scrn> 5cm

3585

2971

Tumor Grade1 302 253 40Unknown 25

25.020.833.420.8

ER StatusNegativePositiveUnknown

252075

20.816.762.5

V.lnvasionNoYesUnknown

Meno = Menopausal

10 100

10 100

10 100

0604

6040

03020401

30204010

020305

203050

060301 10

ER = Estrogen receptor

(Table II). The site of failure was local + DF in 50%, DF in17%, LRF in 11% and LRF + DF in 12% while theremaining patients either died without recurrences or withunknown failures (Table II).

4- Postmenopausal Patients With Node Positive DiseaseThe analysis for this group of patients revealed thepresence of three significant prognostic factors: tumorsize, the number of positive nodes and tumor grade. Alarge number of positive lymph nodes, a high tumor gradeand a large tumor size contributed to a higher risk for LRF+ DF corresponding 100%,81.2% and 87.5% respectivelyfor the three factors (Table III & IV). The site of recurrencewas LRF & axillary lymph nodes + DF 25% each, local +DF & supra! infraclavicular lymph nodes + DF 13% eachand other sites 24% cumulatively (Table II).

1302

86.713.3

100

100

4060

55 100

15

15

0609

05030403

33.420

26.720

55 100

040209

26.713.460

,1540

27.272.8

050307

33.320

46.7

1441

110821

101827

V. Invasion = Vessel invasion

DISCUSSIONIn this study we used very simple way by percentageanalysis of each variable to define risk groups for LRFwithin each of the four cohorts. This approach is notsimilar in spirit to the determination of risk groups usingthe Cox model, as it requires a large number of cases todefine a risk index, which is then used to identify thegroups at increasing risk of LRF ± DF events. It should benoted that for the four different data sets, the definitions ofthe risk groups are based on different analysis tests andthus such risk groups cannot be properly comparedacross patient cohorts. For such a comparison werecommend examination of various regressioncoefficients or cumulative incidence functions asrecommended by Wallgren et al".



I 'Failure!--- '-'-'-".

,TABLE·II SUMMARY OF FAILURES OBSERVED IN VARIOUS GROUP

LRF Local±DF(n)

! (n) %

LRfOnly(n)

LN~de -ne~ative: Premenopausal 55L~?de-J)~~~L __: Postmenopausal 40iNode - positiverTotarw~H---.I. (percentage)

3(7.5)

N = Total no of patients n = no of failures LRF = Locoregional failure OF = Distant failure SIILN = Supralinfrac/avicular lymph nodes ALN = Axillary lymph nodeMRF =Multiple regional failures OF = other failures, includes deaths without recurrences and the deceased patients for whom site of recurrence was unknown.

TABLE-III RISK FACTOR DESCRIPTIONS OBSERVEDIN DIFFERENT GROUPS

(With Respect to locoregional Failure 1: Distant Failure)

i Iliski Factor'

~'I

,P~, Node Negative

!,{"JJl. %'

PcsrmeeopausalNode Negative '

l'i.=U .%

PremenopausalNode Positive

N"'~~

PcstmenopaesalNode Posidve

N=40'N .

f Total Faihi'es 100 100. i Ly~Node

[ None\/.'-,,<4

>5cmj 'Unkndvm

: 0: 3 100'0

33 7 38.9 ,I 6.333 5 27.1 14 87.533 6 33.4 I 6.3

33 0 067 2 11.1 I 6.3

15 83.4 13 81. 2I 5.5 2 12.5

: T7Grade

[..·.·.. 21---.:3f-"Unknown

1.0i 01 33

i Yessel-.lnyaSionI No .0 0 50; Yes • 3 100 16 88. 9 12.5~_ .._Uokno?",-",wo,-__ -"..o_~__ ~__ _2 ~6 '31: ..5_ER StatusNegative • 0 3 100 11. I ; 2 12. 5Positive ' 1 33 0 33.4 •6 . • 37. 5

~okoown,- __ :.."-2 -",6,-7---=-0 ------' ..••IO'---- __ ...55,Ls..... U_.S<l-:Q....

N = Total number of patients included in the group.n= Total number of locoregional failures + distant failures observed during follow up.% = Percentage of the failures (recurrences) with respect to total failures for a given variable.

TABLE-IV PREDICTORS OF HIGH RISK PATIENT(With respect to locoregional recurrence)

valueTumor> 5 CIll+ Vessel InvasionNegative ER__'t-cyesselInvasion+LN>4 94.5High grade Tumor 83.4

i"> ,+VesselIIlvasion 88.9P()stmenopauSal~- :+ t:N~>4- .~ ----- 100---Node positive Tumor> 5 CIll 87.5,,,~__,,._~~~ .!!i~~~.c:t.eT1.l.!!1~I'.._81.2

0.0010_0080.0060.0080.0070.0000.0090.021

ER = Estrogen Receptor LN = Axillary Lymph Node% = Percentage of the patients with locoregional failure in which thegiven risk factor (variable) was positive.

In patients without axillary lymph node involvement, VI(pre or postmenopausal patients) and tumor size morethan 5cm (premenopausal patients only) defined riskgroups. Thus size of the tumor and VI might define agroup of patients with axillary node negative disease whohave a high risk of locoregional recurrence suggesting areasonable ground to indicate some postoperativeadjuvant treatment including radiation therapy," It isevidenced by the fact that overall results according to thisrandomized treatment showed a reduction in LRF ± OFforpatients with node negative disease who received thesingle cycle of eMF compared with those who receivedno adjuvant therapy.Additional study is required however,to determine how much the risk of LRF is reduced byadequate adjuvant systemic chemotherapy selectedaccording to the endocrine responsiveness of the primarytumor as suggested by Goldhirsch A et al."

For patients with lymph node metastasis, the number ofinvolvednodes and histologic grade were predictors of theLRF for both pre and postmenopausal women. VIprovided supplementary prognostic information forpremenopausal patients and size of tumor providedsupplementary prognostic value for postmenopausalwomen. Generally the patients with four or more involvednodes had high cumulative risk of LRF during follow up.Among patients 1-3 involved nodes, premenopausalpatients with histologic grade 3, tumors with VI andpostmenopausal patients with grade 3, tumors greaterthan 5cm also belonged to the high risk group. Thisreinforces the importance of accurate pathologicevaluation of the specimen, which is usually not stressedor considered important in our setup as evidenced by thefact that in more than 65% cases the ER status, morethan 45% VI and in more than 25% cases the tumor gradewas not known by the available data.



Currently it is general consensus that postoperativeradiotherapy should be given to certain groups of patientswith breast cancer who receive adjuvant systemictreatment not only with the aim of reducing the risk of LRFof the disease, but also to improve breast cancersurvival.'?" This applies to the group of patients with fouror more lymph node metastasis but there is a lack ofconsistent knowledge concerning the impact of otherpredictors of a clinical benefit such as postoperativeraoiotherapy." The overviews of radiotherapy trials showsimilar proportional reductions of locoregional relapses aswith systemic treatment in different treatment qroups":"but absolute differences rather than relative differencesshould guide decisions about adjuvant treatmentprotocols. Therefore this study was performed to exploresome other prognostic factors responsible for theprediction of the disease outcome.

In our study only patients with radically removed tumorswithout involvement of skin or fascia were included in thetrial and it required a minimum of four lymph nodesexamined for the inclusion of patients. The number oflymph nodes removed has been found in some studies tobe of prognostic importance for LRF, possibly as a resultof understaging and perhaps of undertreatment of theaxilla." It has been suggested that the high frequency ofLRF of some clinical trials might in fact result from lessoptimal surgical techniques which also result in fewretrieved lymph nodes.'

The recently published retrospective studies exploredvarious factors of prognostic importance for LRF.31-33The study of Recht et al was based on approximately2000 patients who had been treated with mastectomy andpostoperative adjuvant chemotherapy. Number of lymphnode metastasis, number of examined nodes, tumor size,estrogen receptor protein, menopausal status and age ofthe patients were analyzed and rates were based oncumulative incidence functions. In a multivariate setting,number of involved nodes, tumor size and estrogenreceptor status significantly contributed to thelocoregional recurrence. Katz et al32-33investigated about athousand patients who had been treated with a modifiedradical mastectomy and received adjuvant "FEC"chemotherapy protocol but without radiotherapy. The firstreport focused on clinical features," and the secondreport focused on tumor related factors." A multivariateCox regression analysis revealed that the presence of fouror more involved nodes, tumor size greater than 5 cm,close or positive surgical margins or clinically or grosspathologically multicentric disease but not the presence oflymph vascular space invasion was an independentpredictor of LRF. Presence of lymph vascular space

invasion however was a significant predictor in theunivariate analysis. All these results are in consistent toour randomized multivariate study. It is thus noteworthythat in addition to the number of involved nodes and sizeof the tumor, multifocal disease, invasion in skin or nippleor positive surgical margins predicted a high rate ofrecurrence in these studies but because of our restrictedinclusion criteria for the patients none of our patients haspositive margins.

It is difficult to compare the frequencies of locoregionalfailure among different studies. The selection and thetreatment of patients vary as well as the definition ofrecurrences. In some studies only local relapses arescored as LRF; supraclavicular nodes are sometimescounted as distant relapses and sometimes as LRF. In ourstudy as well as those of Recht et aJ31and Katz et aJ32

relapses on the chest wall and the axilla, supra orinfraclavicular fossae and internal mammary nodes werescored as LRF. Statistics may be based on a firstappearance of LRF without or with coincident distantfailure or on LRF appearing at any time, In our studyfigures are given for LRF appearing either alone or withdistant failure as a first event and the statisticalconsiderations are based on LRF as a first event with orwithout distant failure.

It is evident from our study that local and regional relapsesconstitute a therapeutic problem in breast cancer despitecontrolled surgery and adjuvant cytotoxic and/orendocrine treatment. Although the study about the riskfactors for breast cancer in Pakistan" was conducted butno literature is available regarding the prognostic factorsof the disease. Available studies consistently show thatan increasing number of involved axillary lymph nodesalso increase the risk of such failures and that the size ofthe tumor adds to the risk. Especially among the womenwith 1-3 involved nodes enrolled for any trials ofprospective adjuvant treatment, there is a need to exploreother possible predictors of recurrence includinghistological grade and vascular invasion as identified inour study.25-26Every effort should be carried out to excludethe category "unknown" in any predicting variable for thelocoregional recurrences in future study. In our ongoingstudy the methodology of the predictors of locoregionalfailure of breast cancer in comparison with the westernliterature may be somewhat confusing due to smallnumber of cases. This ambiguity is hoped to be over afterour trial target achievement of thousand patients when thebetter reports will be available by the help of a regressionhazard models2B-30like western studies and we well be inposition to predict valuable 10-year expectant survivalanalysis.


,Philadelphia PA, American College of Radiology,2002,1153-1170.

14.Goldhirsch A, Gelber R, Glick J et al: MeetingHighlights: International Consensus Panel on thetreatment of primary breast cancer.J Clin Oncol 2001,19:3817-3827,.

15.Goldhirsch A, Gelber RD, Price KN et al: Effect ofsystemic adjuvant treatment on first site of breastcancer relapse. Lancet 1994.343:377-381,

16. Ludwig Breast Cancer Study Group: A randomizedtrial of adjuvant combination chemotherapy with orwithout prednisolone in premenopausal breast cancerpatients with metastasis in one to three axillary lymphnodes. Cancer Res 1985.45:4454-4459,

17. Ludwig Breast Cancer Study Group: Chemotherapywith or without oophorectomy in high riskpremenopausal patients with operable breast cancer.J Clin Onco11985. 3:1059-1067,

18. Ludwig Breast Cancer Study Group: A randomizedtrial of chemoendocrine therapy, endocrine therapyand mastectomy alone in postmenopausal patientswith operable breast cancer and axillary nodemetastasis. Lancet 1: 1984. 1256-1260,

19. Castiglione M, Gelber RD, Goldhirsch A: Adjuvantsystemic therapy for breast cancer in the elderly: JClin Onco11990. 8; 519-526,

20. Castiglione Gertsch M, Johensen C, Goldhirsch A etal : The international breast cancer study group trialsI-IV- 15 years follow up. Ann Onco11994. 5: 717-724,

21. Ludwig Breast Cancer Study Group: Combinationadjuvant chemotherapy for node positive breastcancer: Inadequacy of a single perioperative cycle. NEngl J Med 1988.319:677-683,

22. Ludwig Breast Cancer Study Group: Prolongeddisease free survival after one course of perioperativeadjuvant chemotherapy for node negative breastcancer. N Engl J Med 1996. 320:491-496,

23. The international breast cancer study group: Durationand reintroduction of adjuvant chemotherapy for nodepositive premenopausal breast cancer patients. J ClinOncol 1996. 14:1885-1894,

24. The international breast cancer study group:Effectiveness of adjuvant chemotherapy incombination with tamoxifen for node positivepostmenopausal breast cancer patients. J Clin Oncol1997.15:1385-1393,

25. Davis BW, Gelber RD, and Goldhirsch A et al:Prognostic significance of tumor grade in clinical trialsof adjuvant therapy for breast cancer with axillarynode metastasis. Cancer 1986.58: 2662-2670,


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5. Overgaard M, Hansen PS, Overgaard J et al:Postoperative radiotherapy in high riskpremenopausal women with breast cancer whoreceive adjuvant chemotherapy: Danish BreastCancer Cooperative Group 82b Trial. N Engl J Med1997.337:949-955,

6. Ragaz J, Jackson SM, Le N, et al: Adjuvantradiotherapy and chemotherapy in node positivepremenopausal women with breast cancer. N Engl JMed 1997.337:956-962,

7. Overgaard M, Jensen MB, Overgaard Jet al;Postoperative radiotherapy in postmenopausal breastcancer patients given adjuvant Tamoxifen; Lancet1999.353:1641-1648,

8. Gold Hirsch A, Cotes AS, Colleoni M, et al.Radiotherapy and chemotherapy in high risk breastcancer. N Engl J Med 1998. 338; 330-331,

9. Gold Hirsch A, Colleoni M, Coates AS et at Addingadjuvant CMF chemotherapy to either radiotherapy ortamoxifen: Are all CMFs alike. Ann Oncol 1998.9:489-493,

10. Betheseda MD, National Institute of Health: Adjuvanttherapy for breast cancer: NIH consensus statement2000, PP 1-23.

11. Recht A, Edge SB, Solin LJ et al: Postmastectomyradiotherapy: Clinical practice guidelines of theAmerican Society of Clinical Oncology. J Clin Oncol2001.19:1539-1569,

12.Harris JR, Halpin Murphy P, McNeese M et al:Consensus statement on postmastectomy radiationtherapy. Int J Radiat:Oncol Bioi Phys 1999.44: 989-990,

13. Taylor M, Haffty B, Shank B et al: Postmastectomyradiotherapy, in ACR Appropriates Criteria,

8 Journal of Surgery Pakistan (International) Vol. 9 (1) January March 2004

i~

..


26. Davis BW, Gelber RD, and Goldhirsch A et al:Prognostic significance of peritumoral vessel invasionin clinical trials of adjuvant therapy for breast cancerfor axillary node metastasis. Hum Pathol 1985. 16:1212-1218,

27. Wallgren A, Bonetti M Gelber R.D et al: Risk factors forlocoregional recurrence among breast cancerpatients. J Clin Onco12003. 21(7): 1205-13,

28. Casella G, Berger RL: Statistical Inference. PacificGrove, Ca, Wadsworth brooks/ Cole, 1990.

29. Kalbfleisch JD, Prentice RL, The statlsttcal analysis offailure time data. New Yark, NY Wiley, 1980.

30. Gray RJ: Aclass of K sample tests for comparing thecumulative incidence of a competing risk. Ann Stat1988.16: 1141-1154,

31. Recht A, gray R, Davison NE et al: Locoregional failure10 year after mastectomy and adjuvant chemotherapywith or without tamoxifen without irradiation: J ClinOncoI1999.17:1689-1700,

32. Katz A, Strom EA, Buchholz TA et al: Local recurrencepatterns after mastectomy a~ doxorubicin basedchemotherapy': Implication for postoperativeirradiation. J Clin Oncol 2000.18:2817-2827,

33. Katz A, Strom EA, Buchholz TA et al: The influence ofpathologic tumor characteristics on locoregionalrecurrence rates following mastectomy. Int J RadialOneal Bioi Phys 2001. 50:735-742,

34. Pervez T, Anwar M, Sheikh AM. Study of risk factorsfor carcinoma breast in adult female generalpopulation in Lahore. JCPSP 2001; 11(5): 291-93.


MIXED DENTITION ANALYSIS FOR PAKISTANIPOPULATION

NASRULLAH MENGAL, AMBREEN AFZAL

ABS1RACTObjectives: To examine the applicability of the Tanaka & Johnston method of prediction and

to.find the significant difference in Pakistani population.

Design Comparative cross sectional study.

Place & DurationThe study was conducted at Karachi Medical & Dental College, Karachi; fromSeptember 2001 to September 2003.

Patients And MethodsThe 300 study dental plaster casts of Pakistani subjects under the age of 21years. who presented with complete eruption of permanent mandibular incisors,canines and premolars, as well as maxillary canines and premolars weremeasured. The measuring device was a modified. Boley's gauge. The samplingtechnique was non-probability with a comparative study design. Statisticalanalysis was made by using SPSS version-10. Descriptive statistics was usedfor data presentation. Students t- test and test of linear correlation was usedfortesting the null hypothesis. Level significance was taken at p<O.OOO.

ResultsThe difference between the predicted widths of the canine and premolars withthe Tanaka and Johnston equations and the actual widths were highlysignificant in the statistical sense, indicated by t test. The actual widths of themaxillary and mandibular canine and premolars showed a significantdifference in size (p < 0.000) from the widths predicted by the Tanaka andJohnston method. The data illustrates the limitation of Tanaka and Johnstonmethod when applied to our population.

ConclusionThe Tanaka and Johnston prediction method does not accurately predict themesiodistal diameters of unerupted canines and premolars in Pakistanipopulation.

KEY WORDS: Mixed dentition, Analysis, Method

INTRODUCTION of orthodontic literature for the last few years indicatesincreased interest in beginning orthodontic treatmentduring the period of mixed dentition'. The trend towardsearlier treatment reflects better comprehension ofmalocclusions and their diagnosis2•

A large number of cases of malocclusion starting duringthe mixed dentition stage may be reduced in severity or~y~~.~!i!!'l~~t~~.~!1tl~~tx.~¥.!i!!,~lymanagement. A surveyCorrespondence:Dr Nasrullah MengalOrthodontics DepartmentDental Section, Karachi Medical & Dental CollegeKrurnchi .

Two recent reports are of interest to define the scope ofthe problem.The journal of Clinical Orthodontics survey of


Nasrullah Mengal, Ambreen Afzal

cIaCJ10sis and therapeutics noted that approximately 25%01 aR patients are treated in a two-phase manner3. TheAN) bulletin indicated that approximately 1.3 millionpersons in 1992 elected orthodontic treatment. At 25%penetration, at least 30,000+patients are in a two-phasetreatment program. There are only 900,000+ growingpatients since adults comprise 20% to 25% of the patientpopulation', It means that at least 90% of all growingpatients can be treated successfully in only one phase bystarting treatment in the late mixed dentition stage oftreatment-identified by the exfoliation of all deciduousteeth except the deciduous second molars or the "E"S.4

An important aspect of diagnosis in the mixed dentition isthe determination of the tooth size-arch lengthrelationship. Such a determination is often made prior toeruption of the permanent canines and the first andsecond premolar". Maintaining space allows manypatients to obtain good occlusion and proper growth andfacial development. Determining tooth size in the mixeddentition requires accurately predicting the mesiodistalwidths of the unerupted permanent premolars andcanines. The mixed dentition of the arch analysis is animportant criterion in determining whether the treatmentplan is going to involve serial extraction, guidance oferuption, space maintenance, space regaining, or justperiodic observation of the patient.

Three methods of prediction have been used: directmeasurements of interrupted tooth sizes on radiographs,as recommended by Stale et al" and de Paula et aF;calculations from prediction equations and tables, asreported by Moyers8, Tanaka and Johnston", andFegusson et al": and combination of radiographicmeasurements and prediction tables, as recommendedby Hixon and Oldtather", Staley et a16,and Bishara et al",

The Hixon and Oldfather" approach is considered themost accurate=", but it is complex, and many find itdifficult to use. The Tanaka and Johnston predictionequations and tables are widely used", but they weredeveloped for white North Americans children, and it isreasonable to question their use in other populationsbecause tooth size vary significantly between and withindifferent racial groupS11.14.15.Few odontotometric data areavailable in the literature for African children", Turner andRichardson17reported significant differences inmesiodistal tooth diameters in Kenyan and Irishpopulations. Otuyemi and Noar" indicated that meanmesiodistal tooth sizes for all the teeth were significantlylarger in Nigerians than in their British counterparts. In thestudy we report our experience of this condition.

PATIENTS AND METHODS

The SamplesThe dental models of the dentition of 300 Pakistanipeople, who presented with complete eruption ofpermanent mandibular incisors, canines and premolars,as well as maxillary canines and premolars, wereobtained from the Orthodontic Department of KarachiMedical andDental College. The, criteria for selection were based oncomplete fulfillment of the following:(1) The patient had to be of Pakistani background for at

least one Prior generation, that is, both parent had tobe of Pakistani.

(2) The dental casts had to be of quality, and free ofdistortions.

(3) The teeth measured had to be free of restorations,fractures, or proximal caries as determined bybitewing radiographs and the dental casts.

(4)There had to be no evidence of hypoplasia oranomalous form to the teeth being measured.

(5) A maximum of 21years of age was considered topreclude any discrepancies based on significantproximal wear.

The Mesuring DeviceThe mesiodistal widths of teeth were obtained bymeasuring the greatest distance between contact pointson the proximal surfaces. A modified Boley gauge with avernier scale to read to the nearest 0.1 mm was heldparallel to the occlusal surface if the tooth appeared to bein normal alignment. Otherwise, The mesiodistal crowndiameter was obtained by measuring between the pointswhere contact with the adjacent tooth would normallyoccur.

Teeth MeasuredThe teeth measured were the mandibular permanentcentral and lateral incisors, the maxillary and mandibularpermanent canines, and the maxillary and mandibularfirst and second premolars. Values obtained for the rightand left posterior segments were averaged so that therewould be one value for the maxillary canine andpremolars and one value for the mandibular canine andpremolar for each value of the mandibular incisors.

Measurement ReliabilityThe investigator took double measurements of themandibular incisors of 20 of the casts in the sample. Thesecond measurements were taken after the taking of allthe first measurements, so that the first measurement didnot prejudice the second.


Mixed Dentition Analysis For Pakistani Population

Statistical AnalysisThe Tanaka and Johnston prediction method currentlybeing used on the white population were tested on thePakistani orthodontic patient samples. In this method, thesums of the mesiodistal widths of the four mandibularincisors were correlated with the sum of the mesiodistaldiameters of the mandibular and maxillary canines andpremolars for both the right and left sides in male andfemale subjects. The Tanaka and Johnston predictiontable is given in table I.

TABLE-I TANAKA AND JOHNSTONPREDICTION TABLE

balf ci them:siodisfal+ 1O.51D1ll

oftbefourlow••.width ofI

mandibular canine and i

~------------~&~~~a~~7m~wiJ:~~:I~!+11.0 mm canine and premolars in one

uadraDl

TABLE-II COMPARISON OF ACTUAL ANDPREDICTED WIDTH OF MAXILLARY

CANINE AND PREMOLARS

299 <.000

TABLE-III COMPARISON OF ACTUAL ANDPREDICTED WIDTH OF MANDIBULAR

CANINE AND PREMOLARS

Tanaka and Johnston develop a way to use the width ofthe lower incisors to predict the size of the uneruptedcanines and premolars. The method has a good accuracy.It requires neither radiographs nor reference tables (oncethe method is memorized), which makes it veryconvenient.

The difference between the predicted widths of the canineand premolars and the observed widths of the canine andpremolars were tested for significance with the t test withan alpha level equal to 0.05 by using the data obtained.

•••

t14'~35

f2~1

alt'ls.19

16

• c

SO Q

0:;0 Q 1;:1 0:::1 • C

Q Q ~ ~ B c Co ob g gO

~ Q OC ~o::b8a =c=Jl=o~g 0 c

c ,pc Dg a 1::1rg" c c

20 22 2418

actual md width of canine and premolar

Fig1.Predicted measurements of mandibular buccal segment using Tanaka andJohnston's table versus actual measurements.

26~---------------------------------'

actual width of maxillary canine and premolars

Fig 2. Predicted measurements of maxillary buccal segment using Tanaka andJohnston's table versus actual measurements.

The range, the mean and the standard deviation of thetooth groups were computed and table-1 was usedclinically for prediction of tooth size in Pakistanipopulation. The standard error of the predicted maxillaryand mandibular incisors was also computed.

RESULTSThe difference between the predicted widths of the canineand premolars with the Tanaka and Johnston table andthe actual widths were highly significant in the statisticalsense, indicated by t test. The actual widths of themaxillary and mandibular canine and premolars showed asignificant difference in size (p <O.OOO)from the widthspredicted by the Tanaka and Johnston table.

Fig 1 is a graph of the mandibular canine and premolarsplotted against the predicted widths of the mandibularcanine and premolars by using the Tanaka and Johnston'stable. The figure reveals a significant difference in thepredicted widths and that of the actual measurements.When the mesiodistal width of the canine and premolarsis small, the Tanaka and Johnston table overestimates theactual size of the canine and premolars. However, whenthe mesiodistal width of the canine and premolar is large,the Tanaka and Johnston underestimates the actual sizes


Nasrullah Mengal, Ambreen Atzal

of the canine and premolars similar findings are observedwith the maxillary arch. In figure 2 the actualmeasurements of widths of the maxillary canine andpremolar are plotted against the predicted widths of themaxillary canine and premolars by using the Tanaka andJohnston's table. The figure reveals a significantdifference in the predicted widths and that of the actualmeasurements. When the mesiodistal width of the canineand premolars is small, the Tanaka and Johnston methodoverestimates the actual size of the canine andpremolars. Where as, when the mesiodistal width of thecanine and premolar is large, the Tanaka and Johnstonunderestimate the actual size of the canine andpremolars: Maxillary r = 376 and Mandibular r = 475.

The mean, difference, standard deviations for two groupsof the teeth measured are presented in table II formaxillary teeth and in table III for mandibular teeth.

DISCUSSIONThe most' important factor in the reliability of the data ischaracteristic of the sample. The sample could bequestionable because of its size (n= 300), and the ethnicdistribution among this population. However, it is anhospital based study ever done in Pakistan, and for thesexes combined, the sample size could be acceptable.Also, odontometric data collected from an adult samplecan be extrapolated for children if dental attrition isminimal. The combined mesiodistal crown diameter of thecanine-premolar segments and the mandibular incisorsseemed relatively smaller than those of black southAfricans, whose teeth are the largest of all groups, butcomparable to those African American, Thai, and HongKong Chinese groups. Definite racial and ethnicdifferences in tooth size have been emphasized in severalstudies", Descriptive statistics also showed that themesiodistal diameters of the mandibular incisors and themaxillary and mandibular canine and premolar segmentswere greater in men than in women (p <000). Significantsexual dimorphism has also been noted in otherstudies.':"

The current finding was that the t-test between thepredicted widths derived from the Tanaka and Johnstonmethod and the actual measured widths from the studycasts of the Pakistani patients showed significantdifferences in both the maxillary and mandibular arches (p< 0.000). the linear correlation are Maxillary r = 376 andMandibular r = 475

The different results obtained could be due to thedifferences in the ethnic origins of the samples, as AI-khadra' also found different results when applying theTanaka and Johnston equations, method to the SaudiArabia population.

Sharon t.ee-cnan- et al in a mixed dentition analysis forAsian - Americans generated formulas- regressionequations- that can be used Clinically in tooth sizepredictions in much the same way as the Tanaka andJohnston equations. Specifically, significantly differentregression equations were derived and simplified for thesize prediction of maxillary and mandibular canines andpremolars in an Asian-American population:

Maxillary: y= 8.2 + 0.6 (X)Mandibular: Y = 7.5 + 0.6 (X)X =Mesiodistal width of the four mandibular incisors inmillimetersY =Mesiodistal width of the canine and premolars in onequadrant in millimeters

Falu Diagne etar in a mixed dentition analysis in aSenegalese population: Elaboration of prediction tablesfound that, in the maxilla, the Tanaka and Johnstonmethod overestimated the sizes of the canine andpremolars. Schirmer and Wiltshire4 reported similarresults in a population of black South Africans.

The research to date, as well as this study, supports theview that racial differences are likely to be importantvariables in tooth size prediction equations. The results ofthis study indicate that the currently popular predictionmethod, the Tanaka and Johnston equations, would notbe as accurate when used in a Pakistani originpopulation. Further study with a larger sample size isindicated to confirm these findings and to draw a separateregression equation for this population.

CONCLUSION1. The Tanaka and Johnston prediction method does not

accurately predict the mesiodistal diameters ofunerupted canines and premolars in Pakistanipopulation.

2. The discrepancies observed could be the result racialdiversity in the Pakistani group.

3. The accuracy of Tanaka and Johnston predictionmethod should be further tested in various ethnicgroups in Pakistan.

4. Further study with a larger sample size is indicated toconfirm these findings and to draw a separateregression equation for this population

REFERENCES1. Staley RN, O'Gorman TW, Hoag JF, Shelly TH.

Prediction of the widths of unerupted canines andpremolars Am Dent Assoc 1995; 107: 309- 13.

2. De Paul S, Almeida AO, Lee PC. Prediction of


Mixed Dentition Analysis For Pakistani Population

mesiodistal diameter of unerupted lower canines andpremolar using 45 deg cephalomerlc radiography. Am.J Orthod Dentofacial Orthop 1995; 107: 309-13

3. Moyers RE. Handbook of orthodontics. 4th ed.Chicago: Year Book Medical

4. Tanaka MM, Johnston LE. The prediction of the size ofunerupted canines and premolars in a contemporaryorthodontic population. J Am Dent Assoc 1974;88:798-801.

5. Ferguson FS, Macko OJ, Sonnenberg EM, ShakunML. The use of regression constants in estimatingtooth size in a Negro population. Am J Orthod1978:73:68-72.

6. Samir E. Bishara and Robert N.Staley.Mixed-dentitionmandibular arch length analysisi: A step-b stepapproach using the revised Hixon-Oldfather predictionmethod.Am. J. Orthod -1983 :363-373,

7. Moyers RE. Handbook of orthodontics. 4th

ed.Chlcago: Year Book Medical Publishers; 1988.p.577.

8. Tanaka MM, Johnston LE. The prediction of the size ofunerupted canines and premolars in a contemporaryorthodontic population. J Am Dent Assoe 974;88:798-801.

9. Proffit W. Contemporary Orthodontics.St Luis:CVMosby;1996

10. Hixon EH, Oldfather RE.Estimation of the sizes ofunerupted cuspids and bicupids teeth. Angle Orthod1958;28:236-40.

11. Hanihara, K. Statistical and comparative studies of theAustralian aboriginal dentition.The UniversityMuseum, the University of Tokyo, Bulletin, No.11.1976.

12. Frankel HH, Benz EM. Mixed dentition analysis forblack Americans. Pediatr Dent 1986;8:226-30.


A CORRELATION OF CLINICAL APPEARANCEOF NASOPHARYNGEAL CARCINOMA WITH

TUMOUR STAGING

NIAMATULLAH, ABDUR REHMAN

ABS1RACTObjectives: To correlate the clinical appearance of nasopharyngeal carcinoma with tumour

staging.

Patients And MethodsThis study was conducted in the ENT department of Postgraduate MedicalInstitute, Lady Reading Hospital. Peshawar for the duration of seven years fromMarch 1994 toMarch 2001. The number of cases in this study was ninety whichinclude endophytic or submucosal to advanced stage tumour. Tumour stagingwas undertaken according to computerized tomography scanjinding.

ResultsThefemale to male ratio was 2.5:1. The age of patients was ten years to eightyfive years with average offortyfive years. Seventy patients (77.8%) had obviousmalignant lesion.

ConclusionAlmost 25% of the patients with nasopharyngeal carcinoma had tumour Whichappeared inconspicuous in the post nasal space and these tended to be inpatients with early tumour. Such cases have excellent prognosis if diagnosedand treated early.

KEY WORDS: Nasopharyngeal carcinoma, Clinical appearance, Prognosis

INTRODUCTIONNasopharyngeal carcinoma is not an uncommonmalignancy.The behaviour of nasopharyngeal carcinoma(NPC) is such that endophytiC and submucous growthpatterns are common. In a study by Sham et all, 13.8% ofpatients with NPC exhibited submucosal spread andanother 51.4% exhibited occult microscopic extensionwhich was not apparent by inspection of the post-nasal(PNS). Given such a tendency for endophytic andsubmucosal spread, it would be useful to know clinically ifNPC remained inconspicuous in the PNS, even in latestages of the disease. It is stressed that video endoscopicexamination of the nasopharynx is a valuable procedure.The aim of this study was, therefore, to correlate clinical

Correspondence:Dr. NiamatullahENT Department,Postgraduate Medical Institute,Lady Reading Hospital, Peshawar.

appearance of NPC in the nasopharynx with tumourstage.

PATIENTS AND METHODSThis study was conducted in the ENT department ofPostgraduate Medical Institute, Lady Reading Hospital,Peshawar for the duration of seven years from March1994 to March 2001. The case records and pre-radiotHetapy computerized tomography (CT) scans ofconsecutive patients were reviewed. The tumours in thePNS were classified according to whether they appearedto be obviously malignant or not, when inspected clinicallyby the otolaryngologist using the posterior rhinoscopy.Lesions were classified as obviously malignant if theyappeared to be grossly irregular or ulcerative. Theselesions were deemed unlikely to be missed or passed offas benign by a physician inspecting the PNS. In contrast,lesions classified as not obviously malignant were those


A Correlation of Clinical Appearance Of Nasopharyngeal Carcinoma With Tumour Staging

which the otolaryngologists had difficulty in recognizingas cancerous by mere inspection. These were deemedliable to be missed or passed off as benign lesions in thepost-nasal space, especially by inexperienced doctors.These included endophytic tumors, symmetrical, smoothor subtle mucosal lesions. Tumour (T) staging of thetumour- (Table 1), was undertaken according to the CTscan finding. The chi-squared test was used to find outwhether a relationship existed between tumourappearance and T staging. Bone scan was done forsecondries. Unfortunately viral studies were not availablein our unit and it was too costly to send the patients toother centers.

RESULTSA total of 90 patients were studied. Seventy patients(77.8%) had obvious malignant-looking lesions and 20patients (22.2%) had lesions which were not obviouslymalignant. Tumour appearance was found to correlatewith tumour staging (p=0.023) (Table2); that is, advancedtumours usually appeared overtly malignant whereasearly tumours usually did not look particularly malignant.

TABLE-I TUMOUR STAGING FORNASOPHARYNGEAL CARCINOMA

TABLE·II CORRELATING TUMOUR STAGEWITH TUMOUR APPEARANCE (P=O.023.

CHI·SQUARE TEST)

DISCUSSIONAlthough endophytic growth and submucosal spread iscommon in NPC, this study revealed a tendency foradvanced tumours to appear as clinically malignant-looking lesions in the PNS, whereas early tumours tended

to appear innocent.These findings have important clinicalimplications. Nasopharyngeal carcinoma (NPC), has adistinctive epidemiological pattern. Its incidence amongChinese and other south east Asian is about 10 to 50 timehigher than that of other countries.

Patients with advanced tumours may present to theneurologist with cranial nerve deficits. In the local context,such patients are often sent to the otolaryngologist for aPNS evaluation to exclude NPC. In the past, it wasunclear how the tumour was likely to look in the PNS,given the tendency for endophytic growth. This studyrevealed that the PNSwas more likely to show an obviousmalignant-looking tumour. This information wouldcontribute to the decision-making process as to whetherto proceed to further investigation specifically to excludeNPC in such patients.

The results of this study also highlights that massscreening programmes, involving inspection of the PNS todetect an early NPC, are likely to pose difficulties. Theappearances of a normal PNS have many variations.Thefrequent presence of normal Iympho-epithelium results inmasses or irregularities and can make the differentiationbetween an early tumour and a normal variant, verydifficult'. This is particularly so in screening programmeswhere patients may not have the alerting symptoms orsigns of NPC to assist the clinician in decision making.·

NPC carries an excellent prognosis if treated early.However, it has been observed that patients with NPCoften present late for treatment', presumably because thePNS is often not examined due to its relativeinaccessibility and difficulty in examination. It has beenargued that the solution for early diagnosis is to trainprimary care physicians how to examine the PNSproperly", In the light of the results of the present study,this issue ought to be looked at more closely.

Assessment of the PNS to detect NPC can be difficult,particularly to the primary health physicians whogenerally does not have much experience in examiningand managing NPC patients. Firstly, PNS examinationusing the mirror is notoriously difficult, especially in thosewith sensitive throats, and the view obtained is oftenlimited. It takes considerable training and practice beforethe technique of PNS examination can be learned. Analternative approach is the use of the endoscope, but thismay not be readily accessible to primary physicians.Secondly, as pointed out earlier, the wide ranges ofnormality of the PNS and the frequent subtle signs ofearly NPC in the PNS can make the detection of earlytumours very difficult, even to an experiencedotolaryngologist. It would be reasonable, therefore, toassume that the more experience one has in examiningthe PNS and managing NPC, the less the likelihood of


--

~--

Abdur Rehman, Niamatullah

. . 19 a NPC, particularly if it was an early tumour.'tile argument that primary care physicians who are betterfIIIined in the technique of PNS examination are moreIIEIy to diagnose NPC earlier, may not necessarily be•••. On the contrary, it can be argued that the risk ofIIIissed or delayed diagnosis of early NPC may beincreased, as these are the ones most likely to appearh:onspicuous or innocuous in the PNS. It would be morepudent to focus on educating primary care physicians ontae clinical presentations and behaviour of NPC and toencourage them to refer patients suspected of havingNPC for early specialist advice".

CONCLUSIONNearly 25%, half of the patients with NPC had tumourswhich appeared inconspicuous or innocuous in the PNSand these tended to be in patients with early tumours.Patients with advanced disease tended to have tumourswhich appeared obviously malignant in the PNS, althoughthere is a tendency for NPC to have submucosal spreadand endophytic growth.

REFERENCES1. Sham JS, Wei WI, Kwan WH, Chan CW, Choi PH,

Choy O. Fiberoptic endoscopic examination andbiopsy in determining the extent of nasopharyngealcarcinoma. Cancer 1989;64:1838.

2. Tsao SY. The case for a new working staging system:the Singapore experience. Asian J Surg 1993;16:267.

3. Low WK. The contact bleeding sign of nasopharyngealcarcinoma. Head Neck 1997;19:617.

4. Skinner OW, van Hasselt CA, Tsao SY. Nasopharyngealcarcinoma: modes of presentation. Ann Otol RhinolLaryngol 1991 ;200:544.

5. Indudharan R, Valuyeetham KA, Kannan T, Sidek OS.Nasopharyngeal carcinoma: clinical trends. J LaryngolOtol 1997:111 ;724.

6. WK LOW, JL Leong. Correlating clinical appearance ofnasopharyngeal carcinoma with tumour stating. JRoyal coil. Surgeon Edinburgh. 2000; 45(3): 146.


LAPAROSCOPY IN THE EVALUATION OFIMPALPABLE TESTES

MUHAMMAD TALAT MEHMOOD , SALEEM KHAN, JAVED AHMED,

MUHAMMAD SHAHAB ATHAR , SAJJAD ASHRAF, JAMSHED AKHTAR*

ABS1RACTObjectives: To examine the role oflaparoscopy in the evaluation of the non - palpable testes.

Design A descriptive study.

SettingThe study was conducted in the Department of Pediatric Surgery, Dow MedicalCollege & Civil Hospital Karachi, some of the private hospitals from July 1997to July 2003 & Pediatric Surgical unit B, National Institute of Child Health,Karachi, from January 2001 to July 2003.

Patients And MethodsAll the patients with impalpable testes had ultrasound examination & wereevaluated laparoscopically.

ResultsTwenty patients with 25 impalpable testes were seen during the study period.Ultrasound examination was inconclusive in all cases. Laparoscopicexamination was helpful in the diagnosis of presence or absence of impalpabletestes in all cases.

ConclusionLaparoscopy is a safe reliable and effective method for the evaluation ofimpalpable testes.

KEY WORDS: Impalpable testis, Laparoscopy, Ultrasound

INTRODUCTIONUndescended testis has an incidence of 0.8% to 2% and11-20% of these are non-palpable.' Management ofimpalpable testes poses a diagnostic and therapeuticchallenge to all pediatric surgeons. Different diagnostictechniques such as ultrasound, computerizedtomography, MRI, selective testicular arteriography andvenography have all been utilized to locate the testis withnon specific reliability'", However, nowadays,laparoscopy has been widely used as a diagnostic tool forlocating an impalpable testis or proving its absence withreliability and accuracy",

<=~;;e~p·ondence:··················Muhammad Talat MehmoodAssistant professorDepartment of Pediatric Surgery,Dow Medical College & Civil HospitalKarachi

In this study we present our experience of laparoscopyin the evaluation of impalpable testes.

PATIENTS & METHODSAll the patients with impalpable testes seen in thedepartment of Pediatric Surgery, Dow Medical College &Civil Hospital Karachi & some of the private hospitalsduring July 1997 to July 2003 and Pediatric Surgical unitB, National Institute of Child Health, Karachi from Jan2001 to July 2003 were included in this study. Everypatient was examined at least twice and in most of thecases by two different consultants. All the patients hadultrasound examination. One of our patients already hadCT scan before being referred to us. All the patientswere subjected to laparoscopy for evaluation of the nonpalpable testes.


Muhammad Talat Mehmood , Saleem khan, Javed Ahmed, Muhammad Shahab Athar , Sajjad Ashraf, Jamshed Akhtar"

PROCEDUREAJI patients underwent laparoscopy under generalanesthesia. Each patient was re examined after inductionof anesthesia to determine if the testes were palpable. Allpatients were catheterized with 10 Fr feeding tube todecompress urinary bladder & feeding tube was removedat the end of surgery. With the patients in theTrendelenburg position, an umbilical skin crease incisionwas made including linea alba and a 10mm Hassonblunt trocar was inserted into the peritoneum under directvision . A purse string suture applied around the portincluding both linea alba and peritoneum. The peritonealcavity was insufflated with C02 (pressure 10-12 mm Hg.).Intraperitoneal examination for a unilateral non palpabletestis began with examination of normal contra lateralinternal inguinal ring. Anatomical orientation wasfacilitated by noting intraperitoneal landmarks such asmedial umbilical ligament (obliterated umbilical arteries),median umbilical ligament (urachal remnant), spermaticvessels, vas deferens, and external iliac vessels.Additional maneuvers such as putting pressure on theexternal inguinal ring, pulling the scrotum, assisted in theidentification of the internal inguinal ring. The contralateral inguinal ring was examined in search of testis orvas and vessels. The three likely findings at laparoscopyfor non palpable testis are

1. Blind ending vessels above the internal ring.2. Cord structures (vas & spermatic vessel leash)

entering the internal ring indicating a testis or remnantin the groin.

3. An intra-abdominal testis.

At the completion of the procedure the abdomen wasagain inspected to rule out any injury. C02 was thenallowed to flow out of abdomen & the linea alba and skinwere closed with absorbable suture.

RESULTSTwenty patients with 25 impalpable testes underwentlaparoscopy. Age ranged from 2 years to 10 years.Maximum number of patients were between ages 4-6years. Fifteen patients had unilateral and 5 bilateralimpalpable testes. Ultrasound examination failed to locatetestes in all the patients and CT scan in one patient wasinconclusive to locate impalpable testis. The laparoscopicfindings were as follow:

Nineteen testes were intra-abdominal (Fig-I), 3 werefound near the deep ring. In 2 patients vas andhypoplastic vessels were seen entering the internal ring,while blind ending vessels were seen in one case(vanishing testis). We could not recognize PMDSanomaly in one patient laparoscopically. In anotherpatient we could not recognize persistent Mullerian ductsyndrome (PMDS) with transverse testicular ectopia (TIE)

FIG-I LAPAROSCOPIC VIEW OF INTRA-ABDOMINAL TESTIS.

laparoscopically. In this patient there was a high index ofsuspicion (strong family history) for PMDS and TIE.

Inguinal exploration revealed atrophic testes in twopatients in whom vas and vessels were seen entering thedeep ring. No further surgical exploration was done inpatient with blind ending vessels (vanishing testis).Postoperative complications were seen in 2 patients. Onepatient developed port site hematoma, which was drainedand other had subcutaneous emphysema which wasmanaged conservatively.

DISCUSSIONManagement of impalpable testes remains a diagnosticas well as a therapeutic challenge. Several diagnosticmodalities have been used to identify the impalpabletestes. These include hormonal evaluation,ultrasonography, computed tomography, magneticresonance imaging as well as more invasive proceduressuch as venography, arteriography, laparoscopy and evensurgical exploration.v'"

In this series, we used two modalities for locating thetestis: ultrasonography and laparoscopy. Ultrasound,which is non invasive and does not exposes the patient to


Laparoscopy in the Evaluation of Impalpable Testes

radiations, has been reported to have some success inpicking up intra-canalicular normal testes but has verypoor results in identifying intra abdominal testes=. In ourcases ultrasound failed to recognize any intra-abdominaltestis and even intra-canalicular atrophic testes weremissed.

Since Cortesi described the use of laparoscopy for theevaluation of nonpalpable testes in 197611, severalauthors have reported on accuracy of laparoscopy inlocalizing the impalpable testis or in diagnosing thevanishing testis syndrome without an abdominalexploration. The accuracy of laparoscopy in locating atestis or proving its absence ranges from 88-100% invarious series8,9,12.13.Despite its embryological origin at theinferior renal pole, majority of the intra abdominal testesare found in the pelvis or near the internal ring2. In thisstudy 22 testes were in this region. Laparoscopicobservation of vas and hypoplastic vessels entering theinternal ring is associated with either testicular absence(intra-canalicular vanished testis) or atrophic testis Iepididymal remnant which was also our observation intwo cases. The need for groin exploration in these caseshas been questioned but it is wise to excise the atrophictesticular tissue in view of potential risk of malignantchanges.7,14

Laparoscopic identification of blind ending testicularvessels prior to entering the internal ring is sufficient todiagnose a vanishing testis, which requires no furtherexploration. In our series, there was only one patient withan absent testis. This is lower than the reported incidence,where up to 59% unilateral and 5% of bilateral impalpabletestes were due to vanishing testicular syndrome,":":"Thus we are able to diagnose presence or absence oftestes correctly in 100% of cases.

Complications following laparoscopy and technical failureare invariably related to Veress needle closed puncturetechnique which should be avoided in children'v"?".Although the open Hasson blunt trocar insertiontechnique has its advantages over the blind insertion ofVeress needle but blunt bowel injury has been reportedwith Hasson technique", In this series we did notencounter any major complication from this technique.

We conclude that laparoscopy in the evaluation of theirnpatpable testis has proven to be safe and accurate. It

. permits the planning of further management (orchidopexyor orchidectomy) or indeed avoids extensive explorationfor an absent testis when blind ending vessels are seen.

REFERENCES1. Poenaru D. Laparoscopic management of impalpable

abdominal testis. Urology 1993;42:574-8

2. Chui CH, Jacobsen AS. Laparoscopy in the evaluationof the nonpalpable undescended testes. SingaporeMed J 2000; 41 :206-208

3. Malone PS, Guiney EJ. A comparison betweenultrasonography & laparoscopy in localizing theimpalpable undescended testes. Br J Urol. 1985;57:185-186

4. Liu CS, Chin TW, Wei CF. Impalpable cryptorchidism- a review of 170 testes. Zhonghua Yi Xue Za Zhi.2002 ;65 : 63-8

5. Friedland GW, Chang P. The role of imaging in themanagement of the impalpable undescended testes.AJR 1988; 151:1107 -1111

6. Hinman F Jr. Localisation and operation fornonpalpable testes. Urology 1987;30: 193-8

7. Tenenbaum SY, Lerner SE, Mc Aleer 1M, et al.Preoperative laparoscopic localization of thenonpalpable testes: A critical analysis of a 10 yearexperience. J Uro11994; 151: 732-734

8 Barqawi AZ, Blyth B, Jordan GH, Ehrlich RM, KoyleMA. Role of laparoscopy in patients with previousnegative exploration for impalpable testis. Urology2003; 61: 1234-7.

9 Galvin OJ, Bredin H. The role of laparoscopy in themanagement of the Impalpable testicle. Ir Med Sci.2002; 171-73-5

10 Wright JE . Impalpable testes: a review of 100 boys. JPediatr Surg. 1986; 21 :151-153

11 Cortesi N, Ferrari P, Zambarda E ,Manenti A, BaldiniA, Morano FP. Diagnosis of bilateral abdominalcryptorchidism by laparoscopy. Endoscopy 1976; 8:33-34.

12 Bloom DA, Ayers JWT, McGuire EJ. The role oflaparoscopy in the management of the non-palpabletestes. J Urol 1988 ;94:465-470.

13 Diamond DA, Caldamone AA. The value oflaparoscopy for 106 impalpable testes relative toclinical presentation. J Urol1992 ; 148: 632-634.

14 Plotzker ED , Rushton HG, Belman AB eta I.Laparoscopy for non palpable testes in childhood: isinguinal exploration also necessary when vas andvessel exist the inguinal ring? J Urol 1992 148635-637

15 Cendron M, Huff OS , Keating MA , et al. Anatomical,morphological and volumetric analysis : a review of759 cases of testicular maldescent. J Urol1993;49:570-3

16 Moore RG ,Peters CA, Bauer SB, et al. Laparoscopic


-.

Muhammad Talat Mehmood , Saleem khan , Javed Ahmed • Muhammad Shahab Athar , SajJadAshraf, Jamahed Akhta~

20 Vaysse P. Laparoscopy & Impalpable testis : aprospective multicentric study ( 232 cases).GECI.Groupe d' Etude en Coeliochirurgie Infantile. Eur JPediatr Surg 1994 ; 4:329-332

21 Retik AS, Peters CA. Laparoscopic management ofthe impalpable abdominal testis. Editorial comment .Urology 1993;42 :578 -579

evaluation of the nonpalpabe testis: a prospectiveassessment of accuracy .J Ural 1994; 151: 728-31.

17 Poenaru D,HomsyYL,Peloquin F,et al. Laparoscopicmanagement of the impalpable abdominal testis.Urology1993;42:574 -578

18 Froeling FM, Sorber MJ, de la Rosette JJ, et at, Thenon palpable testis & the changing role oflaparoscopy.Urology 1994 ; 43:222-227

19 Heiss KF , Shandling S. Laparoscopy for theimpalpable testis: experience with 53 testes. J PediatrSurg 1992 ; 27: 175-178

ACKNOWLEDGEMENT

We are thankful to Prof. Saeed Qureshi and Dr Shafiqueur Rehman for helping us in few cases.


AN EXPERIENCE OF INTRACRANIALMENINGIOMA

HAMEEDULLAH BUZDAR, BAHADUR KHAN

ABS1RACT

Meningiomas are benign twrwurs of brain. Surgical rerrwvalincluding resection of involvedbone and dura is curative in 90 percent of cases. However complete rerrwvalmay entailunwarranted risk if the tumour involve or is adjacent to venous sinuses or neural structure.Thirty three cases of meningiomas were treated in the Department of Neurosurgery, BolanMedical CoUege,Quettafrom 1992 to 2002. There were 5 perioperatiue deaths. Nineteenpatients underwent complete tumour rerrwvalwhile in 14 patients subtotal or decompressivesurgery was performed. Pre and postoperative neurological status of patients was mtedaccorted to Karnofsky mting scale. Six patients had karnofsky ratinq scale below 70preoperatively. The average survival time with good quality of life was 8.5 years. Thepreoperative clinical condition, size of tumour, age and location and postoperativecomplicationsaffected the overalloutcome and quality of life.Four patients develop recurrenceof tumour:

KEY WORDS:Brain tumour; Meningioma.

INTRODUCTIONMeningiomas are benign tumours of brain. They arisefrom the arachnoid cap cells and constitutes 15-20percent of all intracranial turnouts'. The tumour locationand proximity to vital structures are directly associatedwith symptoms and proqnosis'. The rate of tumour growthand the pattern of growth also affect the overall outcome".Meningiomas of the cranial base can grow to compressthe brainstem and occasionally narrow the proximalintracranial vessels'. These tumours rarely metastasize,Numerous reports on observed' and expected survivalassociated with this tumours have been published, whilequality of life has received little attention", This study

...reports on the morbidity, mortality and quality of life aftersurgery in patients having intracranial meningiomas.

PATIENTS AND METHODSThis study comprised of 33 patients diagnosed andtreated in the Department of Neurosurgery BolanMedical College, Quetta from 1992 to 2002. There were22 male patients. Age rangedwas 8-65 years. Location of.....•...••.•..•.•..••...•........Correspondence:Prof. Hameedullah BuzdarDept. of NeurosurgeryBolan Medical College,Quetta

the onqm of meningiomas is shown in table I. Fourpatients were diagnosed having meningioma afterradioisotope scanning and operated before the CT era(before 1995). One of them had percutaneous carotidangiogram in the department.

The quality of survival was assessed both pre andpostoperatively and graded according to the Karnofsky6rating scale. Six out of 33 patients failed to achieve akarnofsky rating scale of 70 preoperatively.Altogether 37craniotomies were performed in 33 patients.Two patientswith large petroclival and posterior convexity tumourswere operated in two stages. Two patients underwentsecond craniotomy after tumor recurrence. One patienthad parasagittal while the second had olfactory groovemeningioma. Both were operated within one year ofrecurrence though with apparently gross tumour removalduring the first craniotomy.

Gross total removal was achieved in 57 percent of cases(19 cases). This included all convexity and olfactorygroove, 2 tentorial, 3 sphenoid ridge, 3 parasaggital--andone suprasellar meningioma. In the remairunqpatients(14,43%) subtotal or surgical decompression ofthe tumours was carried out. Post operative complicationsare given in table II.


Hameedullah Buzdar Bahadur Khan

- ':'SlE I SITE OF TUMOUR WITH RELATION TO SE

ABLE II POST OPERATIVE COMPLICATION

Wound infectionNeurological defi cit

Transient hemiparesis......• Persistent hemiparesis

. . ... Transient dysphasiaPost op status epilepticusFacial nerve paresisPoSt op CSF leakPost op hemorrhagePneumonia

o131212

lOTAL 14

FIG. I THE EFFECT OF DEGREE OF INITIAL TUMORREMOVAL ON SURVIVAL TIME

10

I :VI

~ 7: 6B 5,'0!i 4~ 3'& 21 1 ~

o

" Mean Survival forTotal No of Cases

o with K70 & Above

19(1) 7(3) 3(1) 2(1)Total No. of cases

1(0)

Radiotherapy was offered to two patients only due toincomplete tumour removal. The remaining 11 patientsrefused radiation therapy.Of these patients with posteriorfossa tumour presented with recurrence of symptoms butlater on refused rexploration.

RESULTSIn this series 28(84%) patients survived. There were 5,perioperative deaths. The average duration of observedsurvival with satisfactory quality of lifewas 8.5 years in themajority of cases (78 percent) with Karnofsky score of 70or above. Six patients never achieved Karnofsky score of70 preoperatively. Their scoring did not improve aftersurgery. Three of them were blind and remained blindafter surgery. One had petrous meningioma with 5th, 7thand 8 cranial nerve palsy.We removed tumour partiallywith no improvement in cranial nerve functions. She

survived but is living with support. Two patients had largesphenoid wing meningioma and were decompressedrelieving headache but survived with hemiparesis andmoribund as they were before surgery. One of thesepatients died after 4 years of surgery due to some othermedical problem.

Patients with convexity, olfactory groove, sphenoid ridgeand parasagittal achieved a longer duration of goodquality life than those of posterior fossa and suprasellarmeningiomas.Two patients with enplaque posterior fossaand petrous Meningiomas underwent incomplete tumourremoval. Post operatively visual acuity improved in two ofthese patients.

Patients with complete tumour excision achieved longerobserved survival time with better quality of life (57percent versus 43 percent of cases). Tumourwere dividedinto three groups according to their size. GiantMeningioma 7cm or more (8 cases), meningiomabetween 4-7cm (11 cases) with remaining 13 patientshaving 4.5 cm (14 cases). Interestingly there was nomajor difference in the survival rates between the tumoursof varying size (Fig.I). One of the most importantdetermining factor for postoperative survival was thepreoperative clinical condition of the patient.

The diagnosis of tumour recurrence was made when theradiological findings confirmed clinical suspicion ofsymptomatic recurrence. Two patients presented withrecurrent symptoms of their disease.One had parasagittaltomour while the second one was operated for olfactorygroove meningioma, both were reoperated. Patient withparasagittal meningioma had post operative CSF leakafter surgery and died of meningitis later on, while patientwith olfactory groove meningioma survived withacceptable quality of life.

DISCUSSIONThe prognosis for patients with intracranial meningiomasdepends on many factors including preoperative clinicalconditions of the patients, age, size of the tumour degreeof removal, location, histology, and various therapeuticmodalities including radiotherapy. Mccarty and Taylor'reviewed 682 craniotomies and found a one monthpostoperativemortality rate of 5.1 percent.This figure hassignificantly reduced in the recent literature due toavailability of modern diagnostic and therapeuticfacultles=. In our series, 3 patients died in the pre CTperiod while two died in the post CT period, with a totalmortality of 15 percent. This was partly due to nonavailability of operating microscope in the earlier days andpartly due to very large size of meningiomas (larger than8 cm). In our series, the average duration of acceptablequality of life was 8.5 years. Out of 6 patients who hadKarnofsky score below 70, 4 improved their Karnofsky


An Experience of Intracranial Meningioma

score above 70 and are still with acceptable quality formore than 8 years. The important predicting factors in thepatients' outcome in our series have been, preoperativeclinical condition, age, size and location of tumour.

Postoperative seizures also affected the outcome in ourseries. One patient died of status epilepticus while onewho did not take epileptic drug postoperatively, detioratedand recovered later. Tumour removal should be as radicalas possible if it does not warrant any additionalneurological deficit or compromise the quality of life. InSimpson detailed analysis, 9 percent of the tumorsreccured after removal of tumour totally with excision ofdura. In our series 57 percent(19 cases) had completeremoval with their dural partial tumour removal and only2 presented with recurrence of tumour clinically andradiologically.

Meningiomas involving the cavernous sinus are difficultlesions to treat because of their potential morbidity. Usinglife table survival analysis the series from MassachusettsGeneral hospital showed recurrence or prognosis ratesfor parasellar and sphenoid ridge meningiomas to be 19and 34 percent respectively for 5 years", MirimanoffB et alfound that the extent of resection and the location oftumour were the factors most associated with recurrence.They obtained a 28 percent complete resection insphenoid ridge meningiomas and a 57 percent completeremoval in parasellar meningiomas. In our series 3 out of9 patients had complete removal of sphenoid ridgemeninqiomas. However none of the above patients haveyet presented with recurrence of symptoms, though theyare on continuous follow up. When tumour involves thesagittal sinus, with complete obliteration of sinus,complete resection may be possible. But more commonly,the tumour partially obstructs the sinus thereby preventingcomplete tumour resection. Surgical occlusion of middleand posterior 1/3rd of superior sagittal sinus results inbrain edema and hemorrhagic venous infarcton. Subduralresection of these tumours is associated with highprobability of recurrence. On the other hand Mahmood etal9 found an 8 percent recurrence rate even after totalresection of parasagittal meningioma. Chan andThompson'? reported a 23 percent recurrence rate aftersurgery for 80 of patients with parasagittal meningiomas,including a 13 percent recurrence rate when a Simpsongrade 1 resection was performed. Before CT era, Backand Dewindt" presented their findings of a similar rateafter a grade 1 resection for parasagittal meningiomas.This rose to 21 percent with grade 11 resection and waseven higher for grade 111 and 1V resections. In ourseries out of 5 patients with parasagitttal meningiomas, 3had total excision (grade 1) while 2 had grade 11 tumourremoval. One with grade tumour removal presented withsymptomatic recurrence after one year of surgery andwas reoperated.

In the 30 year review presented by Giombini et aP2resection of parasagittal meningiomas was associatedwith a mortality rate of 7.3 percent and a neurologicalmorbidity of 24 percent in survivors at 5 years. 47 percentof survivors were not fit for employment. Recurrenceswere frequent after incomplete excision. Sachsenheimerand Blmrnier= performed a quality life assessment for aseries of patients who had undergone meningiomaresection(43 had parasagittal tumour) and found a 80percent incidence of postoperative depression.

Mirimanoff et al" addressed to the probability of secondoperation 5,10,15 years after a first meningioma subtotalresection as 25,44 and 84 percent respectively. Conda etaP4 reported a 70 percent rate of tumour progressionwithin 10 years after subtotal resection whenpostoperative radiation was withheld. When radiotherapywas administered to subtotally resected meningiomas,Taylor et aP5improved the 10 year local control rate from18 to 82 percent. Nevertheless 18 percent of the patientsdeveloped tumour growth despite external beamfractionated irradiation.

To conclude, appropriate goals for meningiomas surgeryinclude long term control and maintenance orimprovement of neurological functions. This can beachieved by continue improvements in operativetechniques, and intraoperative neurophysiologicalmonitoring which have enabled safe and completeremoval of the majority of intracranial meningiomas,However tumours located at the base of skull and thoseinvolving the cavernous sinus still pose difficulty in radicalexcision and total excision of the tumours located at theselocations and is not without additional morbidity andmortality. Since meningiomas grow very slowly, werecommend partial/incomplete excision of tumours atthese areas if not possible to excise completely to avoidneurovascular injuries and development of additionalmorbidity.

REFERENCES1. Cushing H, Eisenhardt L: Meningiomas: Their

classification, Regional behaviour, life-history andsurgical End Results.Springfield, 111 :Charles CThomas, 1938,785.

2. Cusimano Md, Sekhar LN, SenCN, Pomonis S,Weight DC, Biglan AW, Jannetta PJ: The result ofsurgery for benign tumours of the cavernous sinus.Neurosurgery1995 37: 1-10,

3. Jaaskelainen J, Haltia M, Laasonene E, Wahlstrom T,Valtonen S: The growth rate of intracranialmeningiomas and its relation to histology:an analysisof 43 patients. Surg Neuro11985: 24 165-172.


Hameedullah Buzdar Bahadur Khan

4_ Leonetti Jp, Reichman OH, Smith PG, Grubb Rl,Kaiser P : Meningiomas of the lateral skull base :Neuro-Otologicical manifestations and pattern ofrecurrence. Otolaryngol Head NeckSurg1990.103:972-980,

5. De Monte F,Smith HK, Almefty 0: Outcome ofaggressive removal of Cavernous SinusMeningiomas. J Neurosurgery1994 81: 245-251,.

6. Karnofsky D, Burchenal J: in Macleod CM(ed):evaluation of chemotherapeutic Agents. New York,Columbia University press, 1949, pp191-205

7. McCarty Cs, Taylor WF: Intracranial meningiomas:experience at the Mayo Clinic. Neurol Med Chir 197919:569-574.

8. Mirimanoff RO, Dosoretz DE, Linggood RM, OjemannRG, Martuza Rl : Mening, 1985. Meningioma :Analysis of recurrence and progression followingneurosurgical resection. J Neurosurgery 1985.62:18-24,

9. Mahmood A, QureshiNH, Malik GM: Intracranialmeningiomas: analysis of recurrence after surgicaltreatment. Acta Neurochir (wein) 1994.126:53-58,

10.Chan R, Thompson GB: morbidity, Mortality andQuality of life following surgery for intracranialmeningiomas. J Neurosurg 1984. 602 : 52-60,

11.Beck JF, Dewindt Hl: The recurrence ofSupratentorial meningiomas after surgery. ActaNeurochir (wein) 1988.95: 3-5,

12.Giombini S, Solero Cl, lasia G, Morello G :Immediate and late outcome of operations forparasagittal and falx meningiomas. Report· of 342cases. Surg Neurol 1984.21 : 427-435,

13.Sachsenheimer W, Bimmler TH : Assessment ofquality of survival in patients with surgically treatedmeningiomas. Neurochirugia 1992.35: 133-136,

14.Condra Ks,Buatti JM, MendenhallWM, FriedmanWA,Marcus RB Jr, Rhoton Al benign meningiomas :Primary Treatment selection affects survival. Int JRadiat Oncol Bioi Phys1997. 39: 427-436,

15.Taylor BW, Narcus RB Friedman WA, Ballinger WE,Million RQ. The meningioma controversy: Postoperative radiation therapy. Int J Radiat Oncol BioiPhys 1988. 15 : 299-304.


ANAESTHETIC TECHNIQUE IN PAEDIATRICPATIENTS WITH ANKYLOSED

TEMPOROMANDIBULAR JOINT

MUHAMMAD BOOTA, T.M MUFTI

ABSTRACT

This study was carried out to evaluate the anaesthesia technique in 50 cases of severetrismus because of ankylosed temporo-mandibular joint. Patients managed successfullybetween years 1999-2002 are reported. A technique for securing the airway by blind nasalintubation. a combination of halothane. oxygen and nitrous oxide through a facemask andventilation through a nasopharyngeal airway or nasotracheal tube was used. Increments ofpropofol mixed with lignocaine plain 2% were used to obtain adequate depth ofanaesthesia. The technique was studied tofind. out the difficulties and.failure rate in achievingthe nasotracheal intubation. By applying gentleness in manipulation and patience. airwaywas secured in 1-3 attempts. Tube position was confirmed by chest auscultation andcapnography. Only ten patients (20 %) could be intubated infirst attempt. while thirty patients(60%) could be intubated in second attempt and remaining ten (2096) in third attempt. Therewas nofailure, no patient required preoperative tracheostomy. Adequate mouth opening wasachieved in 100% cases at the end of surgery. Although we achieved a 10CPIosuccess inintubation on multiple attempts. the expertise is defmitely required. However the need of afiberoptic laryngoscope cannot be overlooked.

KEY WORDS: Anaesthesia technique. Ankylosed temporomandibular joint, Nasotrachealintubation.

INTRODUCTIONTemporomandibular joints are highly specialized bilateraljoints comprising an articulation between the cranium andmandible. The articulating complexes of bone carry theteeth, the morphology and position of which exertconsiderable influence upon the movements of the [oint'.The articular surfaces are covered with a vascular fibroustissue rather than hyaline cartilage. Its ankylosis is anunusual problem. It starts insidiously after some trauma.In an overpopulated country with large families, the childwith trismus gets noticed only when he or she couldn't biteoff and masticate solid food. The management of theairway prior to intubation of the trachea is difficultchallenge in a child who is not likely to allow the airway tobe secured while awake-. in this study we describe ourexperience of this condition in paediatric population.

Correspondence:Dr. Muhammad BootaP A F. Hospital Rafiqui Base.Shoorekot

PATIENTS AND METHODSFifty patients were included in this study who hadtemporomandibular joint ankylosis (TMJA). They wereanaesthetized between year 1999 and 2002 in ourhospital. None of them were intubated in a routine mannerwith formal laryngoscopy.

Our study included patients whose trismus was toosevere to allow laryngoscopy.They were seen two to threetimes preoperatively to establish a good rapport andexplain the anaesthetic procedure to them. The generalcondition, associated problems such as malnutrition,upper respiratory tract infection, and additional problemsof the airway such as sleep apnoea, snoring andpreference for sleeping on any particular side were noted.The inter-incisor, distance (Table I) and the ability of thetip of the Magill's and nasal forceps to go through it wasassessed. Mobility of head and neck and intensity ofbreath sounds through each nostril were noted. Theairway was assessed with anteroposterior and lateral


'-'

Muhammad Boota, T.M Mufti

TABLE I INTER- INCISOR DlSTANC

head and neck. Theinfection was treated with antibiotics, bronchodifators andchest physiotherapy etc.

ECG monitoring, oximetery and capnography wereensured during the procedure. Anaesthesia was inducedwith oxygen and halothane by a face mask in sittingposition as per the patient's preference, however verysoon the patient was put on to the supine position. Theywere observed for severe respiratory obstruction, whichwas relieved, by an immediate and a little advancement ofportex polar preformed tracheal tube (North nasal 6.0mmID) being used as nasopharyngeal airway initially till agood PEC02-- curve reappeared besides no change inthe Pa02 readings which was continuously beingmonitored.

Injection propofol, 25 mg increments mixed withlignocaine plain 2% was given intravenously alongwithoxygen I nitrous oxide and halothane inhalation. Gentleblind nasal intubation with the head in sniffing positionwas attempted while adequate depth of anesthesia hadbeen achieved. If this was unsuccessful, two moreattempts were made while observing reservoir bagmovements, listening to the breath sounds, rotating thetube and advancing during inspiration with cephaladtraction. The SpO 2 and PEC02 curve through the nasaltube remained normal during the several attempts atintubation. when the trachea was intubated bilateral chestauscultatlon and end tidal carbon dioxide tracingconfirmed the position of the tube.

In view of the extreme risk of difficult intubation,spontaneous ventilation was retained with nitrous oxide,oxygen and halothane 1.5-2%. Surgery was started withbupivacaine 2.5% infiltration at operative site. Once themouth could be opened atracuriumO.5mglkg, midazolam0.05mglkg, nalbuphine 0.05mglkg were added and theventilation control achieved. At the end of surgery which

resulted in excellent mouth opening patient wasextubated when fully awake.

RESULTSIn this study of 50 patients, 25 were male. The -Age

ranged from 3 to 12 years. Sleep disturbance was presentin 20 patients whife 24 could not lie supine. Ten patients(20 %) were intubated in first attempt, thirty (60%) insecond and remaining ten (20%) in third attempt. Therewas no failure, no patient required preoperativetracheostomy .. Adequate mouth opening was achieved in100% cases at the end of surgery. All patients wereextubated when awake, however only two patientsrequired postoperative tracheostomy in immediatepostoperative period by virtue of extreme difficulty inmaintaining the airway and risk of aspiration and choking.Nasopharyngeal airway was left in place to ease outbreathing till fully conscious. All patients were nursed inlateral head down position initially and then in semi sittingposition. Post operative analgesia was provided by use ofinjectable NSAIDS. No narcotic was used to avoidrespiratory depression and obstruction in immediatepostoperative period.

DISCUSSIONThe causes of TMJA may be congenital (forcepsdelivery), trauma, infection and idiopathic. Unusualcauses include rheumatoid arthritis, psoriatic arthritis,ankylosing spondylitis, fibrodysplasia ossificantsprogressiva, infectious diseases such as measles,pseudoankylosis after supratentorial craniotomy':' etc.Younger patients have greater tendency towardsreankylosis.

The difficult intubation in TMJA in children results fromsevere trismus, associated mandibular hypoplasia withunequal growth of two halves of mandible, reducedmandibular space with overcrowding of soft tissues, amaxillary overbite and/or hypoplasia. The ankylosis maybe within or external to the joint. The fusion at the articularlevel may be fibrous or bony in nature. When the fusionoccurs during the growth of the mandible, varyingdegrees of facial deformity results. Since the child growswith the facial asymmetry, the position of the larynx maybe altered.

In TMJA the limitation of movements is such that even thehinge movement is affected, so direct laryngoscopy isimpossible. Since the attachment of the lateral pterygoidmuscle to the condyle and meniscus may also be altered,the patient presents with limited protrusion anddiminished excursion, as well as trismus',

There are no predictors of difficult intubation such asMallampatti signS, Patils's sign7 Wilson's crlteria'; etc., inpediatrics. We had no established standards at different


Anaesthetic Technique In Paediatric Patients With Ankylosed Temporomandibular Joint

ages for comparison and sensible interpretation of thyro-mental distance. Mallampatti sign was obviously difficultto elicit. Our main guide was the shadow of the airway. Theproblems to TMJA are superimposed on the usualdifficulties of pediatric airway9,1O.Blind nasal intubation,achieving intubations over a wire passed retrograde fromtrachea fiberoptic laryngoscopy or tracheostomy aredescribed alternatives for securing the airway':":"Fiberoptic laryngoscopy and intubation, the idealalternative, is not without difficulties, is quite expensiveand a variety of sizes are needed in pediatrics. Fiberopticscopes from 2.2mm outer diameter onwards would benecessary for passing through the 3-6 mm inner diametertubes, used in our patients. Larger sizes with a suctionchannel would be preferred wherever possible. With ourfinancial restraints, procuring scopes of various sizes isimpossible. That leaves us only with alternative of blindnasal intubation, which, even, in expert hands, has a highpossibility of failure, trauma and bleeding because of thedistorted soft tissue anatomy. The tube can be obstructedby any of nine points around the larynx, such as the twohalves of vallecula between the epiglottis and cords orbetween the true and false cords in the vestibule, two paralaryngeal and pharyngeal spaces or pass into theesophagus. The tip of the tube was in the valleculas onrepeated occasions. To enter the larynx, the tube has totraverse an initially anterior and then an inferoanteriorangle. To guide the tube through these changing anglesby remotely controlling the other end of the tube isdifficult. Blind nasal intubation is not an art; it is everytimea new experience, needs patience, gentleness of handlingand manipulation of airways. Use of inhalationalanesthetic with propofol alongwith lignocaine 2% inincremental doses up to 50 mg helps to suppress thereflex response and reflex laryngospasm and to achieveadequate depth of anesthesia. Arrangements for securingsurgical airway should be at hand.

The semiblind technique has been described, ismodification of blind nasal intubation. At no time is anyattempt made to see the larynx. A tongue depressor andfibreoptic light source, which are easily available in alloperating theatres, allow some vision to determine thecorrect direction for the tube. This reduces the time taken,chances of trauma and failure. Magill's forceps correct thewrong angle of the tube by placing its tip away fromobstructions, as near to the glottiS opening as possible.The fiberoptic light source is bright enough to illuminatethe back of the throat. Use of topical anaesthesia andsuperior laryngeal nerve block allow the invasivemanipulations for blind intubation and the later semi blindattempts at lighter planes of anesthesia. ThePhysiological reflex responses to airway instrumentationare obtunded; nasopharyngeal insufflation of an oxygenrich mixture of inhalational anesthetics improves safety

even in patients with extreme difficult airway.Sevoflurane is an attractive choice for deep inhalationalinduction while halothane remains a cheap alternativewhere sevoflurane is not available. Isoflurane is likely tobe more transient with the risk of the patient waking up.The infiltration of bupivacaine for surgery ensures a verylight plane of anaesthesia and postoperative comfortwithout recourse to sedative analgesics. This, togetherwith spontaneous ventilation gives us theoretical safety incase of any accidental extubation intraoperatively. Thesesmall details assume importance in situations wheresmall problems can lead to a catastrophe in difficultpatients.

In conclusion, patients with TMJA pose a difficult airwaythat requires careful planning. The use of combinedgeneral, local and topical anaesthesia offers considerableadvantage in these children with severe trismus. Surgicalairway expert team should be standing by alert. Althoughwe could achieve a 100% success in intubation onmultiple attempts where the expertise is the main factor ofsuccess. However the need of a fiberoptic laryngoscopecannot be overlooked which remains the only acceptableoption in difficult and failing desperate situations whereexpertise is again definitely required to be successful.

REFERENCES1. Block C Brecner VL Unusual problems in airway

management 11. The influence of tempromandibularjoint, the mandible and associated structures onendotracheal intubation. Anesth Analg 1971; 50: 1.

2. Roelofse JA, Morkel JA. Anaesthesia fortemporomandibular arthroplasty in quadriplegicpatients: a case report. Anaesth Pain control Dent1992: 1:153-156. temporomandibular joint ankylosis. Jcranniomaxillofac Surg 1996; 24; 96-103.

3. Luchetti W, Cohen RB, Hahn GV et al Severerestriction in jaw movement after routine injection oflocal anaesthetic in patients who have fibrodysplasiaossificans progressiva. Oral Surg, Oral Medicine, OralRadiol Endo 1996; 81 :21-25.

4. Kawaguchi M, Sakamoto T, Furuya H et al. Pseudoankylosis of the mandible after supratentorialcraniotomy. Anesth Analg1996; 83; 731-734.

5. Dasgupta D. Endotracheal intubation in bilateraltemporomandibular joint ankylosis. Indian J Anaesth1987; 35:367-373.

6. Mallampatt! SR, Gatt Sp, Gugino LD et al. A clinicalsign to predict difficult intubation. Can Anaesth Soc J1985; 32: 429-434.

7. Patil VU, Stehling LC, Zaunder HL et al. FiberopticEndoscopy in Anesthesi. Chicago, IL: Year book


~-

Muhammad Boota, T.M Mufti

Medical Publishers Inc., 1983.

8. Wilson ME, Spiegelhalter D, Robertson JA et al.Predicting difficult intubation. Br J Anaesth 1988; 61;211-216.

9. Berry FA. Difficult intubation. In: Berry FA, ed.Anaesthetic Management of difficult and RoutinePediatric Patients, 2nd Edn. New York: ChurchillLivingstone, 1990:373-382.

10. Brown TCK, Fisk GC. Anaesthesia for Children, 2ndedn. Melbourne: Blackwell Science, 1992.

11. Divekar VM, Samtani RJ Anaesthesia for children,2nd edn. Melbourne: Blackwell Science, 1992.

12.Sanchez AF, Retrograde intubation . Difficultintubation. Anesthesiology Clinics of North America1995; 13:439-473.


l_

PAEDIATRIC UROLITHIASIS AS A CAUSE OFCHRONIC RENAL FAILURE

BILQUIS LAKHANY, JAMSHED AKHTAR*, YASMIN KAZI

ABS1RACT

Objectives: To study the clinical presentation of chronic renal failure (CRF) due tourolithiasis.

Type of StudyDescriptive study

Place & Duration StudyThe study was conducted at National Institute of Child Health. Karachi fromJanuary 2002 to June 2002.

Patients And MethodsInclusion criteria: (1) Presence of features of CRF. (2) Creatinine clearance lessthan 25%. This was measured by using Schwartz formula.Creatinine clearance = Height in cm x 0.55

Serum creatinine

All patients under went detailed history and clinical examination. Radioimagingwas performed in all cases.

ResultsTotal number of patients was 50. Males were 44(88%). Most common cause ofCRF was bilateral renal stone. Common presenting symptoms were anemia(90%) and growth retardation (80%). Significant number of patients werehypertensive. Surgery was done to remove stone in 25 cases. Most common typeof stone removed was calcium oxalate (48%).

ConclusionEarly detection and prompt treatment of renal stone can prevent progress to CRFand its sequale ERSD,

KEY WORDS: Urolithiasis, Chronic renal failure, Child

INTRODUCTIONPaediatric urolithiasis is endemic in our part of the world.It is a common urological problem in children. Itconsistutes about 13% of all admissions to Renal unit.

Urolithiasis is a preventable cause of chronic renal failure(CRF). Stone disease can be prevented by variety oftreatment regimens. Paediatric urolithiasis show malepredominance and 90% stones are found in the kidneysor ureters.' Chronic renal failure is defined as.proqresslveirreversible loss of renal function and may range inseverity from mild renal insufficiency to end stage renaldisease (ESRD).2 In this study we describe ourexperience of this apparently benign condition in children.

...................................Correspondence:Dr. Bilquis LakhanyAssociate Professor,Dept. of Pediatric Medicine,National Institute of Child Health, Karachi.• Department of Paediatric Surgery.


Bilquis Lakhany, Jamshed Akhtar', Yasmin Kazi

PATIENTS AND METHODSA total number of 50 cases with CRF due to urolithiasiswere included in this study and followed up for six monthsAge ranged from 1-12 years. Male to female ratio was 8:2.50% had positive family history of stone disease. (Table.I)History of patients regarding all relevant information andclinical examination were recorded on specially designedperforma. Routine and specific investigations fordiagnosis were done. Radio imaging (x-ray, ultrasoundKUB and IVP) of kidney, ureter and urinary bladder werethe main stay of diagnosis and assessment.

TABLE I AGE AND SEX DISTRIBUTION (N = 50

l Femalej 01

Male01

Ag.e__~~ __ ~~ !1Jt~_~< 3 years 08

11 03 3 - 5 years 20

11

11

RESULTSOut of 50 patients of CRF the most common cause wasbilateral renal stones (50%) followed by ureteric stone(30%) and both renal and ureteric stones 20%. Apart fromobstruction and urinary tract infection poorsocioeconomic status, diet rich in rice and cereals, low inprotein, neglect and delay in diagnosis and treatment leadto the development of CRF in these patients. 50% ofpatient had positive family history of stone disease and60% of these patients had bilateral stones and 80% hadassociated urinary tract infection (UTI). E.coli was thecommonest organism involved. Twenty-five childrenunderwent surgery for removal of stones.

Many patients had more than one clinical presentations.The most common presentation was anaemia (90%),followed by growth retardation (80%) Symptoms related tourinary tract infection hematuria (60%), hypertension andrenal osteodystrophy (40%) were also present. Howeverthey usually presented with sign and symptoms of uremia.(Table.l!)

TABLE II CLINICAL PRESENTATION ( N=50

Family HlO Stone disease 25 50%

Renal osteodystrophy

-HypertenSIOn

20 40%20 ----.__.----- - --40%

The initial management of these patients requiredperitoneal dialysis along with medical management ofCRF. Patient who presented with hydronephrosis andpyonephrosis, percutaneous nephrostomy was the mainstay of treatment. Open surgery was done to providedefinitive management. Stone analysis showed calciumoxalate stone (48%), urates 20%, mixed 12% and uricacid 8%.

DISCUSSIONIn most developing countries urolithiasis is a major causeof CRF. Pakistan lies in what is referred to as "stone belt"stretching from Egypt through Iran, Pakistan India andThailand to lndonesia." In Pakistan 12% admissions tonephrological unit are for renal failure from calculousdisease.' Our patients came from all parts of the Sindhprovince. Majority of the patients were referred from'remote basic health units. Most of the patients werebetween 3-10 years. Most of the workers from stone beltcountries and our country had reported similar findings.4-s

In our experience there is a preponderance of malepatients; this observation is also seen in western worldand also in developing countries.'

The commonest clinical presentation was anaemia (90%of cases) followed by growth retardation (80%). 50% ofpatients have positive family history of stone disease andthis has been reported by other workers" 80% of patientshad associated urinary tract infection E.coli was thecommonest organism involved. Correlation of thisorganism with calculous disease is uncertain. Hematuriaand abdominal pain were 3rd most common symptoms.Hypertension and renal osteodystrophy was seen in 40%of cases. 25 children under went surgery for removal ofstones,

Like the rest of the world, Pakistan has its share of urinaryproblems and more so in the form of calculous diseaseleading to CRF and ESRD_ It causes more suffering fromrenal damage than any other renal problem. Theconsequences of calculous disease in children areserious and only early detection may prevent the loss ofnephrons. The awareness of urolithiasis a complexproblem that effect paediatric patients, is important forpaediatrician, paediatric urologist and paediatricnephrologist. Every effort should be made to stabilize therenal function by removing the obstruction and infectionby early recognition of this preventable problem.

CONCLUSIONUrolithiasis is a preventable and treatable cause of CRF.Early and appropriate management before and after thedevelopment of CRF may prevent or delay the progress toESRD. In our study 65% of patients had good recovery ofrenal function because of provision of treatment bypaediatric nephrologist and paediatric surgeon under oneroof.


Paediatric Urolithiasis As A Cause Of Chronic Renal Failure

REFERENCES1. Kher KK. Chronic renal failure. Clinical Paediatric

Nephrology editors Kanwal K Kher and Sudesh P.Makker.Mc Graw-Hill. 1992:501-41.

2. Williams DJ.The cause of CRF, Medicine Int 1991 4:3563-5.

3. Benador D, Benador N, Siosman D, Nussle D,Mermillod B, Giradin E, Are younger children athighest risk of renal sequelae after pyelonephritis ?Lancet 1997349:17-19.

4. Sriastora RM, Marwaha RK Koehar GS, Chaudry VP.Incidence and causes of irreversible renal failure.Indian Paediatr, 1983, 20: 95-98.

5. Abdunahman MH, AI Mugeren M. AI Rasheed SA.CRF in children in Saudia Arabia. Nephrol. 1999 2:93-96.

6. Aydan S, Servine E, Etiology of CRF in Turkishchildren. Pediatr.Nephrol 1985 9: 549 - 552.

7. Stull TL, liPuma JJ, Epidemiology and natural historyof urinary tract infections in children. Med Clin NorthAm 1991 75:287-297.

8. Biggi A, Dardanelli L, Cussino P,Pomero G, Noello C,Sernia 0, Spada A, Camuzzini G Prognostic value ofthe DMSA scan in children with first urinary tractinfection. Pediatr Nephrol 2001 16:800-804.

9. Morris, AI Tosel CWOEvaluation of Sleight plasmacreatinine formula in measurment of GFR: Arch Dischild 1981,58: 611.

10. Schwartz GJ. Hay Cock GB. Edeiman CH Jr, SpitzerAA simple estimate of GFR in children derived frombody length and plasma creatinine. Paediatric 199658: 259-263.


HORMONE REPLACEMENT THERAPY:ACCEPTANCE AND COMPLIANCE

SHABNAM SHAMIM, TAZEEN FATIMA

ABSTRACTA quasi-experimental study carried out at Abbasi Shaheed hospital over a period of 14months, from January2003. Fifty menopausal women presenting with post menopausalsymptoms were given hormone replacement therapy .The benefits of therapy in short termuse were studied and the satisfaction and compliance were observed. Mean age of womenin study was 57.3 years. Hormone therapy when given in short term showed good responsein improvement of symptoms. Hotjlushes disappeared in 91 % and 86% of depressed patientcame with a feeling of well being. The main problem identified. was in the compliance ofpatients due to return of regular bleed (45%) and fear of cancer (30%).The study suggestedthat to improve a woman's quality of life, more emphasis should be given to the counselingand use of nonbleeding HRT.

KEY WORDS: HRT, Post menopausal symptoms, Compliance

INTRODUCTIONHormone replacement therapy (HRT), although a muchcontroversial issue; is still regarded an importantcomponent of preventive health care for post-menopausalwomen. HRT has come a long way since the days ofBrown Sequard who in Paris in 1893, was reported tohave prescribed two sheep's ovaries in a sandwich ofbread for the treatment of hot flushes, followed byinjection of ovarian extracts in 18971• In recent years, HRThas increasingly been promoted for its long term benefitsas preventive care for osteoporosis. Nevertheless, itsprimary use continued to be short term for relief of earlymenopausal symptoms such as hot flushes, night sweats.Vasomotor, psychological and genitourinary complainsare real sufferings for these women and badly effect notonly the quality of life but also day to day activity; notforgetting the impact of them on the rest of the family.Although the studies in breast carcinoma in women usingestrogen and progesterone replacement therapy suggestan increase incidence of cancer in estrogen users- thework and research is still going on; and newer regimenare found. Scientist maintains that, if used differently it canstill help to protect against neurological andcardiovascular diseases'. In Italy after the WHO report,·cor;esj)onde~ce;··················Shabnam Shamim,Assistant Professor. Unit III,Abassi Shaheed Hospital,Karachi Medical and Dental College,Karachi

the sale and prescription of tissue specific Tibolone hasincreased many folds. Tibolone is a tissue specific drugwith weak estrogenic activity, has no effect on breasttissues and works without stimulating the endometriumwhere its effects are mainly proqestronic'. Whetherestrogen or Tibolone, continuance is perhaps the biggestobstacle in the optimal effectiveness. Motivating patientsto continue HRT long term is challenging but even in shortterm the record of compliance is discouraging and studiessuggest within two years after starting a hormone regimen80% of women stop it5• The aim and object of our studywas to observe the benefits of HRT in short term use andto access the satisfaction and compliance of patients withdifferent types of HRT.

PATIENTS AND METHODSThis quasi experimental study was carried in the Gynae.Unit III of Abbasi Shaheed Hospital, Karachi from January2003 to February 2004. Sample included 50 postmenopausal women with menopausal symptoms and withno contraindications for HRT. Sampling was done onpurposive, non-probability sampling technique. Themenopausal symptoms of vasomotor, psychological andurogenital entity were included. An informed consent wastaken. Bleeding (combined estrogen progestin) and nonbleeding (tibolone) HRT were given for one year. Thechoice was made according to the patients' wishes andpresence and absence of uterus. 20 patients were given ableeding type of HRT and 30 a non bleeding type. Follow-


Hormone Replacement Therapy-Acceptance and Compliance

up was done at bi- monthly interval and at each visit aquestionnaire was filled and effectiveness of treatmentevaluated in terms of improvement of symptoms.Compliance and satisfaction of patients were observed.The main outcome measures were "satisfied or not",compliance and "improvement in symptoms". Thedependent variables were same as above. Theindependent variables included age of patient and type ofHRT. Data was analysed statistically and percentagesused to evaluate the result.

RESULTSFifty patients were given HRT and the mean age was 57.3years {table 1).17 (34%) were not satisfied and the mainreason was return of monthly bleed that was present in60% (table 2).The effectiveness of HRT in short term use was verysignificant as shown in table 3. The most commoncomplaints were hot flushes which markedly improved in91% of cases. The vasomotor symptoms of night sweatshowed 90% excellent result. In patients with depression,86% reported to have a feeing of well being. The mainproblem was compliance of patients, 78% stopped takingmedicine within six months. The major reason was thereturn of the monthly bleed followed by fear of breastcancer. The side effects were minimal and therapy waswell tolerated. In almost all of those who stopped therapythe symptoms recurred.

DISCUSSION

TABLE I AGE DISTRIBUTION

! Age at presentation (years) No. of patients (N=50)!51to55- ----ilO· -

i 56 to 60 ! 32

TABLE II PATIENTS SATISFACTION TO TREATMEN

Type of HRT Satisfied(~~L __

Non .Bleeding 25 (83%)HRTBleedingHRT - 68 (4()O/~)

N=33 Not satisfied N=17(3~%L_ _ __ ._...05 (17%)

12 (60%)·

TABLE III IMPROVEMENT IN SYMPTOMS AFTER USING HRT.

'Response Hot Night! Anxiety! Depression Irritability Vaginal Urinary. Flushes." Sweats: (N,,20) i (N=30) (N=38) Dryness Symptoms

(N=35) . (N=20) .1 i (N=5) (N=8)Excellent 32. iii 18 .. ! 20 .: ,26 ... 30 .04. .i 5

(9!..%) :(~.t<40%).-LJ8!i~ __ (7~L.J..(80'*'2_i(62,5,*,) c

02.02 i13 .04 06 01 02(5.7%) . (10%) f (65%) 1(14%) (16%) . (20%) (25%)01 :00 ioo~Too--·--66---00--'Ol--

S::t:::-S··.J·(3,3) .. ~ __ . . _.m·2'*'1 _

Menopause is not life threatening but for most womeninterferes with the quality of life. Less than 25% of thewomen experience a symptom free menopausal transitionand over 25 % suffer severe symptoms', These symptomsalthough effects the women but the entire family isinvolved. The depression and easy to be angry and hotflushes which is usually expressed by patients as suddenepisodes of fever, are distressing. The use of HRT is notvery popular not only among patients but the physiciansare also hesitant in prescribing and motivating. As a resulta large number of these ladies are continuously suffering.Hot flushes and other menopausal symptom usually donot recur after 2 years. Our study supports the evidencesavailable which strongly suggest that the benefits of HRTsignificantly out weighs its risks for menopausal womenparticularly in the short term'. It is a loss that so manypatients discontinue the hormone therapy before giving ita chance to work properly. The idea of genuinereplacement therapy with short and long term therapeuticbenefits is understood by very few. In this study a highproportion of patients were satisfied but the main reasonof poor compliance was return of bleeding. HRT notnecessarily means estrogen replacement always as newtherapies are constantly in progress. Drugs like Serm andTibolone have been available, Tibolone is a non-bleedingHRT It is tissue specific gonadomimetic and can beoffered to such patients and similarly Serm is used forlong term prevention from osteoporosis. Although withestrogen the incidence of breast cancer increased in HRTusers as compared to non users, but depending on theduration of therapy which was after five years or mores.

The results of this study are comparable to theinternational studies that show 58% of patients stoppedHRT and 20% did not return after first visit". The need isto educate our patients, give them the right informationand to ensure that they continue the therapy. In thisregion, to let the patients improve their quality of life, ashared decision should be made jointly by patients anddoctors and not simply be imposed on them. In view of ourreligious temperament of women in that age, a non-bleeding HRT should be preferred with explanation aboutthe early break through. Hand outs and reading materialsshould be given to them. Women's personal values,expectation and believes should be listened and clarifiedonly then we can have greater compliance.

In conclusion the gynecologist must be well aware aboutrecent HRT trend to give accurate information to thewomen about her health status. With this knowledge shemust also be equipped with materials to give a clearpicture of the effects of HRT and the impacts in terms ofdevelopment of illness and quality of life.

REFERENCES1. Novak E. The management of the menopause. Am J

Journal of Surgery Pakistan (International) Vol. 9 (1) January - March 2004

Shabnam Shamlm, Tazeen Fatima

Obstet Gynecol 1940; 40: 589-595

2. Writing Group for WHO. Risks and benefits ofestrogen plus progestin in healthy post menopausalwomen. WHO randomized control trials. JAMA 2002'288:321-33 '

3. Brower V. A second chance for HRT. Embo Rep.,2003; 4(12):1112-1115

4. Kloosterboer H.Tibolone; A steroid with tissue specificmode of action. J steroid biochem Mol Bioi 2001; 76:231-238

5. Ballard K. Women's use 'of hormone replacementtherapy for disease prevention: results of a communitysyrvey.Br J Gen Pract 2002;52:835-7

i,

6. Porter M, Penney G C, Russell D.A population basedsurvey of women's experience of menopause. Br JObstet Gynaecol 2002; 103: 1025-1028

7. Grady, 0, Rubin, SM, Petitti, and BO et at Hormonetherapy to prevent disease and prolong me in postmenopausal women. Ann Intern Med 1992;117:1016-1037

8 Collaborative group on hormonal factors in breastcancer. Breast Cancer and HRT. Collaborativereanalysis of data from 51 studies. Lancet.1997;350:1047-1059

9 Lawton Beverly. Changes in HRT after report fromWHI: Cross sectional survey of users.BMJ2003;327:845-846

Journal of Surgery Pakistan (International) Vol. 9 (1) January March 2004 35

EXTERNAL ABDOMINAL HERNIAS

MUHAMMAD JAHANGIR, M. I. BABAR, MUHAMMAD ALl BUKHARI

ABS1RACTObjectives: To docwnent our experience of external abdominal hernias at Rahim Yar Khan

Design A descriptive study.

Place & DurationThis study was conducted in Surgical Unii-Il of Sheikh Zayed Hospital, RahimYar Khanfrom May, 2002 to August, 2002.

Patients And MethodsAll patients admitted with the diagnosis of external abdominal hernia wereregistered for the study. History, Clinical presentation and relevant investigationwere recorded.

ResultsCommonest type of external abdominal hernia was the inguinal hernia (65%).Second commonest was paraumbilical hernia (16%). Third in series wasincistonai hernia (8%). Remaining varieties, in descending order were umbilical(5%), ventral (3%), epigastric (2%) andfatty hernia of linea alba (1%).

ConclusionMost of the .findings were similar to those found in other parts of the countryexcept that in our study no adult male suffered from ventral, epigastric orumbilical hernia. Complications were very low and no case of femoral herniawas seen.

KEY WORDS: External abdominal hernia, Epidemiology

INTRODUCTIONThe word hernia is a Latin term that means rupture of aportion of a structure'. Weakness of the abdominal wall,congenital or acquired in origin, results in the inability tocontain the visceral contents of the abdominal cavitywithin their normal confines. Hernia is a commoncondition afflicting both the sexes, and all age groups.Theexternal abdominal hernias are the most frequent form",Epidemiological studies regarding incidence of externalabdominal hernia have been conducted in various parts ofthe country=". We are presenting a similar study fromRahim Var Khan, Punjab......•••..............•...........Correspondence:Dr. Muhammad JahangirConsultant SurgeonSheikh Zayed HospitalRahim Yar Khan.

PATIENTS AND METHODSThis study was conducted in Surgical Unit-II of SheikhZayed Hospital, Rahim Var Khan from May, 2002 toAugust, 2002. Inclusion criterion was every case admittedin this unit with the diagnosis of external abdominalhernia. Apart from the clinical examination of the patients,their heights and body weights were also recorded to findout any relationship between the body weights and thecausation of external abdominal hernia.

RESULTSA total of 100 cases of external abdominal hernia wereregistered for the analysis. These were 70 males. Wedivided our patients with reference to age, broadly, intotwo groups, children (up to the age of 14 years) andadults. Age range in our series was from 1 month to 75


Muhammad Jahangir, M. I. Babar, Muhammad Ali Bukhari,

)188IS. Adult cases were 70 and children, 30. Types ofexternal abdominal hernia in descending order offrequency are given in table.1

TABLE-I EXTERNAL ABDOMINAL HERNIAS

Inguinal hernia was the most common (65% of total). Allthe 40 adult cases were males. Youngest patient was afemale child of two months who suffered from left inguinalhernia and the oldest, of 75 years. One suffered frombilateral direct inguinal hernia and the other right directinguinal hernia. In 40 adult cases, 21 had indirect inguinalhernia, 13 on right side and 8 on left side while 18 patientshad direct inguinal hernia, 7 on right side, 4 on left sideand 7 were bilateral. Only one patient was havingcombined variety i.e. indirect as well as direct inguinalhernia and that also on right side. In all 25 children,(Female-4) inguinal hernia was of indirect type, 19 onright side and 6 on left side.

Paraumbilical hernia was the second common externalabdominal hernia in our series (16%). In adults 13 caseswere females and 02 males. The only child who sufferedfrom paraumbilical hernia was a boy of 4 months and hewas having supraumbilical hernia. In 15 adult cases 10were supraumbilical, 3 were infraumbilical and 2 werehaving combined variety i.e. supraumbilical as well asinfraumbilical. Age range in adults was from 25-50 years.

In our series third group was of incisional hernia (8%). Allthese cases were adults. No child suffered from incisionalhernia. Out of these 8 cases, 3 were males and 5 females.In males, one had repair of stab wound on anteriorabdominal wall, second had left pyelolithotomy and thethird had developed incisional hernia at the site ofcolostomy closure. In females, two had undergonelaparotomy through right paramedian incision, oneunderwent abdominal hysterectomy and another C-section through lower midline incision and fifth one hadcholecystectomy through right subcostal incision.

There were 5 cases of umbilical hernia, 4 were childrenand one was an adult female. In 4 children, 2 were malesand 2 were females. Age distribution was from 1 month to

01 year. There were 3 adult females of 22, 35 and 40years with ventral hernia. There were 2 females patientsof 30 and 60 years with epigastric hernia. There was onlyone case who was an adult male with fatty hernia of lineaalba.

Out of 46 male adults, 28 were underweight and 12 wereoverweight. Out of 24 female adults 2 were overweight.Out of 24 male children, 14 were underweight, 06 wereoverweight and only 04 were of normal weight while out of06 female children, 05 were underweight, no one wasoverweight and only 01 was of normal weight.

DISCUSSIONHighest prevalence of inguinal hernia amongst externalabdominal hernia is a universal truth. Amongst children5.71% girls had inguinal hernia in our study while thisfigure ranged from 4.19% to 9.7%. Preponderance ofinguinal hernia on the right side is documented by severallocal series?". Incidence of bilateral inguinal hernia was10.77% in our study while it was 21% from Nawabshah",Obstructed hernia was met with in only 02 cases. These02 cases were of inguinal hernia and that also only inmales. No female with any type of external abdominalhernia presented with any complication.

Percentage of incisional hernia amongst women was20.83% while this figure is 26% from Nawabshah", Maleto female ratio was 3:5 while this ratio has been reportedas 1.7:1 from Nawabshah", 1:3 from Karachi" and 3:4 fromLahore".

In this series umbilical hernia in female constituted 10%while this percentage is 15.18% from Nawabshah". Inchildren, male to female ratio is equal in our study whilethis ratio is 2:1 from Nawabshah'. In our study noepigastric hernia was found in males but preponderanceof males amongst epigastric hernia cases was reportedfrom Nawabshah' in the ratio of 18 males to 14 females.

No femoral hernia was detected in our series while 08%incidence of femoral hernia in females has been reportedfrom Nawabshah",

CONCLUSIONMost of the findings in our study are in harmony withthose of other studies conducted in various parts of thecountry with the striking differences as follows:• No male adult suffered from ventral, epigastric or

umbilical hernia.• Complication rate was very low and no female patient

with any type of external abdominal hernia presentedwith any complication.

• No case of femoral hernia was seen.


· External Abdominal Hernias

REFERENCES1. Ger, R.: The laparoscopic management of groin

hernias. Contemp. Surg., 1991.39:15,

2. Bailey and Love's Short Practice of Surgery, 23rdedition, p. 1143. Mufti TS, Khan M. A study of theincidence of external

hernias in NWFP. J Pakistan Med Assoc 1982; 32:119-21.

3. Attar Z, Nizam-ul-Hasan,TsugawaC, MurajiT. Inguinalhernia in paediatric age group. The Pakistani andJapanese experience.PakistanJ Surg 1991;7:9-11.

4. Sheikh NA, Sheikh NM, Oonwala ZG. Incisionalhernias- why do they occur? Pakistan J Surg 1997;13:63-6.

5. Manzar S. Inguinal hernias- incidence, complicationsand management. J Coli Physicians Surg Pak 1992;2:7-9.

6. Manzar S. Hernias in Children - Nawabshahexperience. Pakistan J Surg 1994; 10: 29 - 3.

7. Manzar S. Hernial emergencies. Pakistan J Surg1992; 8: 1-4.

8. Manzar S. Hernias other than inguinal at Nawabshah.Pakistan J Surg 1993; 9: 78-81.

9. Memon A, Memon JM, Ali SA. Management of Inguinalhernia: experience of 334 cases at Hyderabad. J ColiPhysicians Surg Pak 1993; 3: 50-53.

10. Shoukat M, Sadiq J, Abdul Hamid. Routine bilateralgroin exploration in patients with unilateral inguinalhernia. Pakistan J Surg 1991; 7:7-8.

11. Ikram MS. Incisional Hernia: a study of aetiologicalfactors. Pakistan J Surg 1995; 11: 146-8.

12. Manzar S. External Hernias in women. J ColiPhysicians Surg Pak 1999; 9:43-


TRENDS OF DELIVERY IN PATIENTS WITHPREVIOUS ONE CAESAREAN SECTION

RUBINA SOHAIL, NYLA MEHBOOB, FARRUKH ZAMAN

ABS1RACTObjective oj the study was to monitor the mode oj delivery in patients with previous oneCaesarean section. This study was carried out at Services hospital onfive hundred patientswith previous one Caesarean section (CS) over a period oj ten months. Out oj 500 patients211 had repeat elective Caesarean section, while 289 were selected for trial of labour: Out ojthese patients two thirds achieved vaginal delivery (VBAC). The overall Caesarean sectionrate was 57.6% and VBAC rate was 42.4%. It was thus concluded that repeat Caesareansection could be avoided in well selected patients with low morbidity

KEY WORDS: VBAC, Caesarean section

INTRODUCTIONCaesarean section rate all over the world is increasing. Amajor reason for this increase in the number is the factthat more and more women are presenting with previousCaesarean sections. Many of these women end up havinga repeat Caesarean section, mostly due to fear of ruptureof the uterus. A Caesarean birth implies greater maternaland fetal morbidity, longer hospital stay and greaterexpenditure.

In the absence of a recurring indication one previouslower segment Caesarean section no longer dictates anelective repeat C-section. The American College ofObstetricians & Gynaecologists perceives vaginal birthafter Caesarean section as a major strategy in reducingthe proportion of caesarean births and has formallyendorsed a policy of trial of labour under mostcircumstances', Current medical evidence indicates that60-80% of women can achieve a vaginal delivery followinga previous lower segment Caesarean section.2,3,4,5,6Despite a plethora of published articles indicating that avaginal delivery following one previous lower segmentCaesarean section is associated with a low risk ofadverse sequelae, only 19.5% of women in United States,13.3% of women in Scotland and 5.7% of women inNorway deliver vaginally after a Caesarean section. InSweden, vaginal birth after Caesarean section is morecommon, with 53% of women delivering vaginally afterprevious one Caesarean section.

Correspondence:Dr. Rubina SohailAssistant ProfessorDepartment of Obstetric & GynecologyPostgraduate Medical InstituteLahore.

VBAC is considered safe in carefully selected pregnant ofwomen. Patients who undergo safe vaginal birth after CSexperience fewer blood transfusions, fewer post partuminfections, shorter hospital stay and generally no increasein perinatal rnortallty."

The high Caesarean section rate begins with highfrequency of primary Caesarean section. Therefore aconcentrated effort should be made to decrease theprimary rate." In year 2000, of all births in the UnitedStates, 23% were Caesarean, 37.5% of which wererepeat Caesarean births. Approximately 60% ofCaesarean' births were elective repeat Caesareansections." The objective of present study is to documentthe mode of delivery in patients with previous oneCaesarean section at our institute.

PATIENTS AND METHODSIt was a descriptive study carried out in the Department ofObstetrics and Gynaecology at Services hospital Lahoreunit two on five hundred patients with previous oneCaesarean section. The study period was from July 2001to May 2002. The vaginal birth after Caesarean deliverywas calculated with a denominator equal to the number ofall women who gave birth after a previous Caesareandelivery including those who were not candidates for atrial of labour", At 36 weeks of gestation, the patient wasevaluated for giving the trial of labour. The patient's wisheswere taken into consideration before decision making. Ifthe patient did not go in to spontaneous labour till 40weeks, re-evaluation was done and decision for inductionof labour taken.


Trends of Delivery in Patients with Previous One Caesarean Section

Patients selected for vaginal delivery had a non recurrentcause of previous Caesarean, prior Caesarean not inrural area, previous lower segment Caesarean sectionand no postoperative infection. In the current pregnancyaverage size of baby with cephaliC presentation,engagement of the fetal head and adequacy of the pelviswere criteria for selection for vaginal delivery. In additionfacility for one to one fetal monitoring and Caesareansection within half an hour of decision were ensured.

Elective Caesarean section was performed on patientswith prior Classical Caesarean section, previouscaesarean section at remote area, history ofpostoperative infection, mal presentations, medicaldisorders of pregnancy such as PIH, diabetes mellitusand obvious cephalopelvic disproportion

RESULTSTotal number of planned vaginal deliveries during thestudy period was 3120. This included 500 patients willprevious one CS. Out of these repeat elective CS wasperformed in 211 cases while 289 were selected for trialof labor (Tal). Out of 289 who underwent Tal, 212delivered vaginally while repeat emergency CS wasperformed in 77 (26%) cases. Outcome of vaginaldeliveries after repeat one CS is given in table I

TABLE I VAGINAL DELIVERIES WITH PREVIOUS 1 CS

Fetal and maternal complications are given in table II.

TABLE II FETAL AND MATERNAL COMPLICATION

DISCUSSIONIn this study 289 (57%) out of 500 women with priorCaesarean section were selected for trial of labour. Twothirds of these women delivered vaginally but out of thetotal 500, repeat CIS rate was 58% (both elective andemergency) and 42% women delivered vaginally.Therefore although the vaginal delivery rate in patientsselected for trial of labour was good but on initialassessment almost 50% patients had a repeat electiveCS. Repeat Caesarean section can be avoided in wellselected patients for vaginal delivery with low morbidity.

An audit of 197 patients with previous one CS wasundertaken by Singh T et al over one year period todetermine rates of vaginal deliveries and main indicationsfor repeat Caesarean deliveries. Trial of labour wasattempted in 51.3% of women, of whom 65.3% hadsuccessful vaginal delivery, VBAC was howeversuccessful in only 33.5% of women", This low rate wasdue to a large number of repeat elective CS. The resultsof this study match closely the results of the current study.In another study on 468 women, with a prior scar during1986 - 1999 at the Akashi Municipal hospital, trial oflabour was attempted on 322 women and successfulVBAC achieved in 77.8%.13

In a retrospective cohort study at the division of Maternal-Fetal medicine at the University of California from 1997 -2000, a total of 1516 subjects underwent VBAC andsuccess rate were 79.5%14 In another study in California,at Cedars Sinai Medical Center in 1995, only 61.4% ofattempted VBAC out of 314 8 were successful." Similarlya retrospective review of records of 310 consecutivewomen from JICHI medical school hospital in a 6 yearperiod elective CS was carried out on 31%. VBACattempted on 69%, successful VBAC was achieved in43% women."

All these studies reflect that the obstetricians should offerthe option of trial of labour, because more than one half ofwomen with previous one CS might have successfulvaginal delivery, and maternal mortality rates do not differbetween women undergoing trial of labour and repeatelective Caesarean delivery. The answer seems to lie inreducing the primary CS rate, rigorous auditing of unitsCS rates, change in attitude of doctors, midwives andpatients towards VBAC.

In a survey of practice in New Zealand and Australia, theconsensus of practice was to offer VBAC as an option andinduce labour if needed. VBAC is preferred in a level 2 or3 hospital with an anesthetist, neonatologist and anoperating theatre available within 30 minutes of decision.The use of continuous electronic fetal heart monitoringand intravenous access is recommended."


Rubina Sohall, Nyla Mehboob, Farrukh Zaman

CONCLUSIONRepeat Caesarean section can be avoided in well.aected patients for vaginal delivery with low morbidity.AIIBy strategy to reduce Caesarean section rates is topromote vaginal birth as an alternative to elective repeatCaesarean deliveries. Strategies to improve VBAC ratesmude educating women for risks of complications andbenefits of VBAC, ensuring careful selection of VBACcandidates, developing guidelines for management oflabour and educating health care providers aboutreducing VBAC risks.

REFERENCES1.ACOG practice patterns vaginal delivery after previous

caesarean birth. Int J. Gynaecol Obstets 1995, 52,90-98

2. Rosen MG, DickensonJC. Vaginal birth aftercaesarean section; a Meta analysis of indicators forsuccess. Obstet Gynecol, 1990 76,865-869

3. Flanmm Bl, Newman LA, Thomas SJ, Fallown 0,Yoshida MM, Vaginal birth after caesarean delivery;results of five year multicenter collaborative study.Obstet Gynecol,1990 76,750-754

4. Miller DA, Diaz FG, Paul RH Vaginal birth aftercaesarean; ten year experience. Obstet Gynaecol,1994 84,255-258

5. Cowan RK, Kinch RAK, Ellis B, Anderson B Trial oflabour following caesarean delivery; Obstet Gynecol.1990 83,933-936

6. Flanmm Bl, Going JR, lui Y, Wolde-Tsadiq G Electiverepeat caesarean delivery versus trial of labour: aprospective multicenter study. Obstet Gynaecol, 199483,927-932

7. Audit commission, First class delivery: improvingmaternity services in England and Wales. Abington:Audit commission publications, 1997

8. Mushinks M, Average charges for uncomplicatedvaginal, caesarean and VBAC deliveries: regionalvariations, United States, 1996.Stat Bull Metrop Insurco 1998; 79(3):17-28

9. Mastrobattista JM, Vaginal birth after caesareandelivery Obstet Gynecol Clin North Am. 1999 26(2):295-304

10. Anonymous Vaginal birth after caesarean birth, 1996- 2000; MMWR Morbid Mortal Wkly Rep. 8;51(54):996-8

11. Reddy UM, DiVito MM, Armstrong JC, Hyslop T,Wapner RJ. Population adjustment of the definition ofthe vaginal birth after caesarean rate; Am J ObstetGynecol.2000 183(5):1166-9

12. Singh T, Justin C, Haloob R An audit on trends ofvaginal delivery after previous one caesarean section;J Obstetrics and Gynaecol, 2004; 24(2): 135 - 138

13. Mizunoya F, Nataka M, Kondo T, Yamashita S, InoueS. Management of vaginal birth after caesarean; JObstet Gynaecol Res. 2002; 28(5): 240-4

14. Huang WH, nakashima OK, Rumney PJ, Keegan KA,Chan K. Interdelivery interval and the success ofvaginal birth after caesarean delivery Obstet Gynecol.2000;99(1): 41-44

15. Gregory KD, Karst lM, cane P, Platt lD, Kahn K.Vaginal birth after caesarean and uterine rupture ratesin California Obstet Gynecol. 1999;94(6): 985-9

16. Obara H, Minakami H, Koike T, Takamizawa S,Matsubara S, Sato L. Vaginal birth after caesareandelivery: results in 310 pregnancies J ObstetGynaecol Res, 1998; 24(2) : 129- 34

17. Dodd J, Crowther CA, Vaginal birth after caesareansection; a survey of practice in Australia and NewZealand. Aust NZ J Obstet Gynaecol, 12003;43(3):226- 31 r


OSTEOMALACIA IN FEMALES

GHULAM MUSTAFA KAIM KHANI, M.A QUARASHI

ABSTRACTThis is a descriptive study conducted in Orthopaedic unit 1. Civil Hospital Karachi fromJanuary 2000 to December 2003. Tuio hundred female patients were included in this seriesof which 128 were unmarried, 52 were multipara having more than 5 children. 128 werestudents. Main presenting symptoms were waddling gait and generalized body pain. Serumcalcium was low in 60 patients, serum alkaline phosphatase level was elevated in all cases,serum phosphorus was below normal in 108 patients. serum P.T.H. was elevated in 108patients. Serum vitamin D2 level was decreased in 140 patients. Loosers zone was mainradiological finding noted in 130 cases

KEY WORDS: Pseudo fractures. Multipara. Hypovitaminosis D

INTRODUCTIONOsteomalacia is a metabolic bone disease, although rarein western world, is prevalent in South Asian countriesdespite abundant sunlight', It results from inadequate ordelayed mineralization of osteoid in mature cortical andspongy bone-, Osteomalacia is characterized byabnormal quantities of osteoid coating the surfaces oftrabeculae and lining the haversian canals in the cortex.There is an abnormally high ratio of osteoid to mineralizedbone". Human produces Vit.D in their skin followingexposure to ultraviolet light, present in the sunrays. It isthen hydroxylated by the liver to form 250HD. It is thenfurther hydroxylated by the kidney as needed to form thephysiologically active form of the hormone 1, 25(OH)2D.

The disease is characterized by generalized body pain,especially around hip, muscle weakness, difficulty inwalking (waddling gait), low or lower normal serumcalcium, hypophosphatemia, increased serum alkalinephosphatase, hypovitaminosis D and pseudo fractures(looser zone). Biopsy taken from iliac crest showspresence of osteoid volume greater than 10%, osteoidwidth greater than 15 microns and delayed mineralizationassessed by double tetracyclinelabellnq', In this study wepresent our experience of management of these patients.................•••••....•••....••Correspondence:Ghulammustafa Kaim KhaniConsultant Orthopaedic SurgeonCivil Hospital Karachi.

PATIENT AND METHODThis is a descriptive, study conducted in OrthopaedicO.P.D. Unit 1 Civil hospital Karachi from January 2000 toDecember 2003. Two hundred female patients wereincluded in this study. Patients suffering from pre-existingdiseases like renal disease or patients taking medicineslike steroids, antiepileptic drugs, which can causeosteomalacia, were not included in this study.

RESULTSOut of 200 patients 128 were unmarried and 128 werebetween 15 to 20 years of age. Out of 72 married women,52 patients were having 5 or more children. 128 patientswere students, 72 patients were housewives. Mainpresenting symptoms were waddling gait and generalizedbody pain. In 32 patients backache was the onlypresenting symptom.

Serum calcium level was normal or near normal in mostof the cases (n-140), while in 108 patients serumphosphorus was below normal. Serum alkalinephosphatase was elevated in all patients. In 60 patientsserum parathormone level was normal and in 140patients it was elevated.

Serum vit D level was decreased in 160 patients and in 40patients level was within normal limit. In 140 patients 24hours urine calcium was below normal limit. In 120patients there was hyperphosphaturia (24 hours) and in80 patients it was within normal range.


Ghulam Mustafa Kaim Khani, M.A Quarashi

Pseudofracture (Ioosers zone) was the main radiologicalfinding noted In 130 patients. In 70 patients it was seen intemoral neck, in 30 patients only pubic rami were involvedand in 25 patients pubic rami and femoral neck wereinvolved. In 3 patients loosers zone was seen in pubicrami and in proximal femur just below the lessertrochanter. In 2 patients fibula was also involved alongwith femoral neck.Generalized osteopenia was seen in allcases. Biopsy was done in 40 patients where diagnosiswas not established by routine investigations. In 32patients biopsy confirmed the diagnosis. Biopsy wastaken from iliac crest.

DISCUSSIONDespite abundance of sunlight, osteomalacia is prevalentin Southeast Asia'. Awumey-FMet al has reported that vit.o level was low in Asian immigrants in USA as comparedto Caucasians, so Asians are at high risk for developingosteomalacia". In dark skinned women there is reducedproduction of vit.D from skin, may be due to skinpigmentation6• In our series disease was common inMemon and Pushto speaking communities. Memonsusually live in flats, where sunlight is very poor andMemon girls are usually students of Deeni Madarsah andstrict pardah observing. Pushto speaking patients weremostly married and having 5 or more than 5 children andwearing veils. These patients do not observe familyplanning methods.

In our series loosers zone was present in 130 patientswhere as Reginato et al has reported loosers zone in 7patients out of 26 cases. In our series hypovitaminoses Dwas present in 160 patients whereas Reginato et al hasreported in 5 patients out of 26 cases, whereas Plotnikoffhas noted hypovitaminosis D in 93% of patients sufferingfrom nonspecific musculoskeletal pains.It was observed inthis series that there was no correlation between serumcalcium, serum alkaline phosphatase and serum P.T.Hlevel.

l

IIt is important to note that the disease is much more

common in our society than we thought.This could be dueto low level of serum vit. 0 level, poor nutrition, high birthrate, strict pardah observation and wearing heavy viels.We can prevent this disease by proper nutrition, anddietary supplementation of vit. D. For adults 200 i.u. (Smicrogram) of vit .D dietary allowance may prevent thedisease in the absence of sunlight. Total body sunexposure easily provides the equivalent of 250 microgram(10,000 i.u) vit. D per day.

REFERENCES1 Goswami R, Gupta N. Prevalence and significance of

low 2S-hydroxyvitamin D concentration in healthysubjects in Delhi Am. J Clinic Nutrition. 2000 72 (2)472-S.

2 Medline Amersham health. 2004, 1 3 13.03.

3 Medline UW Radiology Main Online teaching file2004.

4 Reginato AJ, Falasca CF Pappu R. Musculoskeletalmanifestation of osteomalacia, Report of 26 cases.Semin Arthritis Rheum. 1999 28(5) 287-304.

S Awumey Fm, Mitra DA, Hollis DW,Kumar R.Vitamin Dmetabolism is altered in Asian Indian in SouthernUnited States: a clinical research study. Clinic.Endocrinol Metabolism. 1998. 169-73.

6 Rasmussen LB, Hansen G I, Hansen E.Vitamin D:Should the supply in the Danishpopulation beincreased? Int J Food Science Nutrition. 2000.51 (3)209-13.

7 Vieth R, Vitamin D supplementation , 25hydroxyvitamin D concentration and safety Am J ClinicNutrition. 1999 69(5) 825-6

8 Plotnikoff G A, Quigley J M. Prevalance of severehypovitaminosis D in patients with persistentmusculoskeletal pain. Mayo Clinic Proc. 200378(12)1463-70.


EPIDIDYMAL ABNORMALITIES ASSOCIATEDWITH UNDESCENDED TESTIS

MUHAMMAD SHAHAB ATHAR, MUHAMMAD TALAT MEHMOOD, SAJJAD ASHRAF.

ABSTRACT0ldectives: To identify and record the number and type of epididymal abnormalities (EA)

associated with undescended. testis and its correlation with the location of thetestis.

Design Descriptive study.

Place & DurationDepartment of Pediatric Surgery. Dow Medical College and Civil Hospital.Karachi

Patients And MethodsAll patients with undescended. testis operated in this unit from September. 1997to October 2003 were included. Clinical data & surqical findinqs were recorded.A new method of classification for the anomalies was employed to makecomparison between various studies easy and meaningful.

ResultsA total of 107 testes in 97 patients were operated. Epididymal anomalies werefound. wIth 37 testes. Obstructive anomalies werefound with 19 testes and nonobstructive anomalies were found with 18 testes. Obstructive anomalies weremore frequent with the testes located high up in the inguinal canal or intra-abdominally.

ConclusionUndescended testes that are non-palpable and located high up are more likelyto have associated epididymal anomalies causing obstruction to the spermconducting pathway.

KEY WORDS: Epididymal anomalies. Undescended testis

INTRODUCTIONThe association of epididymal anomalies (EA) withundescended testis (UT) has long been known'", Theseanomalies are considered to be one of the importantfactors affecting prospects for fertility of these patients asadults3.4,7.There are studies reporting infertility aftersuccessful orchidopexy. with good testicular histologyeven in unilateral UT, with obstruction to sperm

conducting pathways as a possible cause'.

On the other hand reports published during the lastdecade have shown percutaneous & microsurgical spermextraction techniques combined with In-vitro fertilizationhave resulted in successful pregnancies when applied toazoospermic men with congenital bilateral atresia of vasdeferences .........••....••..•.•••...••..•••..

Correspondence:Muhammad Shahab AtharSenior RegistrarDepartment of Pediatric surgeryDow Medical College and Civil Hospital,Karachi.

This study was conducted to identify & record the numberand type of epididymal abnormalities (EA) associated withUT & its correlation with the location of the testis.


Muhammad Shahab Athar. Muhammad Talat Mahmood. Sallad Ashraf.

MTiENTS AND METHODSA total of 107 undescended testes (UD) in 97 patientsCJperated in our department from September 1997 toOctober 2003 were included in the study. Operative&1dings like the size & location of the UT were observedand effort was made to identify the presence & type ofepididymal anomaly.

A simple & practical classification of EA was employedwhich has the added advantage of predictive value forprospects of fertility in the future (table I & fig 1)

RESULTSA total of 107 testes in 97 patients were studied. 81 wereunilateral & in 16 patients UT were bilateral. Out of thebilateral cases. 31 testes were operated (1 patient did notturn up for the second orchidopexy). EA were found with37 testes (29% of the testes).

TABLE-I CLASSIFICATION OF EPIDIDYMALABNORMALITIES

, A J Atresia aepiddyrris(my ~ atretic segment)

A OBSTRUCTIVE ANOMAlIES B [ON-OBSTRUCTIVE ANOMALIES lB)IA 1 IAbsence 01flidi:lymiS Bongated ·C· shaped Epiddynis

B1 ( gap beIw_ the testis & epiddyrrismils tip cJ index finger)

IA2 Delached heal orlimsyatlachmentof". ePddymis wi1h the testis

B2 Bongated epiddynis (EpddymiseJI1elllilg 1 & hatlines a merebelow1he testis)

. ".

FIG. 1 CLASSIFICATION OF EPIDIDYMALABNORMALITIES

2 A 3

Detached Atresia of

Epididymis Epididymis

cl at62

Elongated

Epididymis

(>l'i2time of

testis)

45Journal of Surgery Pakistan (International) Vol. 9 (1) January - March 2004

Obstructive anomalies were found in 19 patients (51% ofanomalies). out of these one (2.7%) was absence ofepididymis and this testis was located above the deepring. Detached epididymis or flimsy attachment was foundwith 15 testes (40.5% of anomalies). Out of these 2 werefound above the deep inguinal ring. 10 were intra-canalicular & 3 in the superficial inguinal pouch. Atresia ofepididymis was present with 3 testes (8.1% of anomalies).1 was at the deep ring & 2 were intra-canalicular.

Non obstructive anomalies were found with 18 testes(48.6% of anornalles), out of these 2 were at the deepring. 4 were intra-canalicular &. 12 testes were found inthe superficial Inguinal pouch. ( only the testes where thegap between the testis & epididymis admitted the tip ofthe index finger were included in the "Long C shaped"category. many testes with lesser degree of separationwere not classified as abnormal) Table II.

TABLE-II RELATIONSHIP BETWEEN EPIDIDYMALANOMALIES & LOCATION OF

UNDESCENDED TESTES (37 TESTES)

TYPE OF ANOMALY LOCATIONOBSTRUCTIVE ANOMALES19 (51.4% of anoma rleS)

.Absent Epididymis (1 EStis) Above deep ringDetached Epidid)ll1al head 2atdeep ringOr flimsy attachment 10 inta~nalicul a-(15 Eses) 3 at supedicial pouch

Atresia of Epididymis (3 testes) 1aIDR.2 intra-canalicular

NON OBSTRUCTIVEANOMALES 18 (48.6% ofanomalies)Elongated 'C' shaped or 12 at superficial pouchunroiled Epididymis (18 testes) 4intra-canalicular

2 at deep ring

TABLE·II INCIDENCE OF EA REPORTED BY OTHERAUTHORS COMPARED WITH THIS SERIES

AUTHOR YEAR NO.OF NO.OF ..... OBSTRUCTIVE!& Ref. No. TESTES ANOMAUES NON·

OPERATED OBSTRUCTEDMarsha Iet al (2) 1979 38 15 416Mollaeia n et aI 1987·92 652 235 152183(8)Koff et a1(10) 1990 82 65 25140This series 1997·2003 107 37 19f18

DISCUSSIONThe association between undescended testis &epididymal abnormalities was reported as early as 1947'.Since then sporadic reports have appeared shedding lighton incidence & type of anomalies. The relationshipbetween severity of the anomaly & the level of arrest oftesticular descent has also been highlightedG.7• A higherincidence of obstructive EA have been have beenreported in the cryptorchid testes7 and the findings of thisstudy are in agreement with other reports (Table III).

Epididymal Abnormalities Associated With Undescended TestiS

One aspect which has not received due attention is anagreement upon a generally accepted classification forEA. A number of different methods have been used byvarious authors making comparison between the studiesdifficulf·4•8, so much so that epididymal configurationdescribed as abnormal 'elongated' or 'uncoiled' by someauthors', has been described as a common feature in85% of normally descended testes explored for reasonsother than UT 9.

While the implications of 'obstructive anomalies' areobvious, the significance of 'non-obstructive anomaliesremain unknown. These have been suspected to beassociated with sperm maturation & transport problems-& cases of epididymal immaturity have been described inthe literature".

The above discussion highlights the importance of carefulobservation & recording of EA at the time of orchidopexy,especially in testes that are found within or above theinguinal canal. This observation along with appearance &size of the testis supported by histology can identify asubgroup of patients who if found azoospermic in later life,can be helped by testicular or epididymal spermextraction & in-vitro fertilization techniques.

REFERENCES1- Lazarus JA, Marks MS.Anomalies associated with

undescended testis, complete separation of a partlydescended epididymis and vas deferens in anabdominal testis.J Urol 1947; 57:567

2- Marshall FF, Shermeta DW Epididymal abnormalities

associated with undescended testis. J Urol 1979;121 :341-3

3- Toth J, Merksz M, Szonyi P States causing infertility inadulthood in children with undescended testis. ActaChir Hung 1987; 28:243-6

4- Heath AL, Man DW, Eckstein HB Epididymalabnormalities associated with maldescent of thetestis. J Pediatr Surg 1984; 19:47-9

5- Un YM, Hsu CC, Wu MH, Un JS.Successful testicularsperm extraction and paternity in an azoospermic manafter bilateral postpubertal orchiopexy. Urology. 2001;57:365.

6- Cicigoi A, Bianchi M Seminal duct abnormalities incryptorchidism: our experience with 334 cases]. ArchItal Urol Nefrol Andro11991; 63:107-11

7- Gill B, Kogan S, Starr S, Reda E, Levitt S Significanceof epididymal and ductal anomalies associated withtesticular maldescentJ Urot 1989; 142:556-8discussion 572

8- Mollaeian M, MehrabiV, Elahi B.Significance ofepididymal and ductal anomalies associated withundescended testis: study in 652 cases. Urology. 1994;43:857-60.

9- Turek PJ, Ewalt DH, Snyder HM 3rd, Duckett JWNormal epididymal anatomy in boys. J Urol1994;151 :726-7

10- Koff WJ, Scaletscky RMalformations of the epididymisin undescended testis. J Urol 1990; 143:340-3


ISCHIOPAGUS TRIPUS CONJOINED TWINS

A CASE REPORT

SIKANDAR ALl MUGHAL, ++MAHMOOD SHOUKAT, SIRAJUDDIN SOOMRO,

*JAN MOHAMMAD SHAIKH, *MOHAMMAD PINYAL ABBASSIABSTRACTConjoined twins are one of the rarest congenital anomalies. We present a case of Ischiopagustripus conjoined twins. The twins werefused at abdomen and pelvis, having two wellformedlower limbs and one abnormal lower limb. There was only a single fused pelvis and only oneset of well formed male external genitalia and absent anal opening. Anoplasty was done forimperforate anus and later on surgical separation attempted.

KEY WORDS: - Conjoined twins, Ischiopagus, Imperforate anus.

INTRODUCTIONConjoined twins are some of the most challengingpatients faced by the Paediatric surgeons'. They occurone in every 50000 to 200000 live births=, Despiteextensive preoperative investigations precise definition ofthe conjoined anatomy is often only possible at surgery'.Ischiopagus twins, constituting approximately 9% of allconjoined twins, are believed to arise from union in thecloacal membrane, sharing the perineum, bony pelvis andthe lower abdomen', with three limbs (tripus) or four limbs(tetrapus). A significant number of conjoined twins aremalformed.

CASE HISTORYFull term conjOined babies weighing jointly 5.5Kgs, werebrought to our unit. One baby was complete having wellformed head, neck, thorax, abdomen and all the fourlimbs. This baby was termed Twin I. The 2nd baby termedparasite was fused on the left side of the lower part of theabdomen of twin I. It had complete head, neck, thorax,two upper limbs, upper abdomen and a single lower limb-that was attached on the (R) posterolateral aspect of the

Correspondence:Dr. Sikandar Ali MughalAssistant ProfessorDepartment of Paediatric SurgeryChandka Medical College Hospital Larkana++ Department of Paediatric Surgery Children Hospital & Institute ofChild Health Lahore*Department of Anaesthesiolgy Chandka Medical College HospitalLarkana

common pelvis of the twins. (Fig. I). Single umbilical cordwas attached at the center of the conjoined abdomen. Theperineal examination revealed Single perineum withabsence of anal opening. Genital examination showedwell formed single set of normal external gentalia.

Fig I: Ischiopagus twins

CVS & CNS examinations were normal. Furtherinvestigations showed low type of imperforate anus, singlebony pelvis with fusion of vertebral columns. There wassingle liver with two kidneys but single urinary bladder.

After resuscitation, the patients underwent surgery forimperforate anus. Anoplasty was done and their intestinalobstruction relieved (Fig II). At the age of one month,definitive surgical separation was done. Each twin was


Ischiopagus Tripus Conjoined Twins

anesthetized separately by two teams ofanesthesiologists. At operation the twin II was found tohave separate heart, lungs and diaphragm.The abdomencontained separate stomach and only short smallintestine, which was fused with terminal ileum of the twinI. The twins were found to have single normal liver andsingle spleen. The twin I had stomach, small and largeintestine up to rectum. There were two kidneys and oneurinary bladder.The spine of the twin II was fused with thepelvic bones of the twin I.The parasite was separated butdied.The defect on the side wall of twin I was repaired byutilizing the diaphragm and attached skin of the twin II.Postoperatlvely the twin I developed acute respiratoryfailure and died on the following day after surgery.

DISCUSSIONIt is important to report every case of duplication becausethe collective analysis of a larger series may addinformation to our knowledge of the mechanismsoperating in the earliest stage of human development".The exact etiology of conjoined twining is not known, butthe formation of these anomalies is currently believed tobe related to incomplete cleavage of the embryo atapproximately two week gestations.The simplifiedclasslticatlon" of different types of typical conjoined twinson the basis of ventral (anterior) and dorsal (posterior)union includes _

A)Ventral; (1)Cephalopagus (2) Thoracopagus(3) Omphalopagus (4) Ischiopagus (5) Parapagus.

B)Dorsal: (1) Craniopagus(2) Pygopagus (3) Rachipagus.

Ischiopagus twins are united ventrally from the umbilicusdown to a large conjoined pelvis with two sacrums andtwo symphyses pubis.The external genitalia and anus arealways involved and there are four arms and four legs.

Although there are numerous accounts of separation ofconjoined twins in the literature", the unique technical

problems they present justify individual description.Despite genetic identity the internal anatomy of conjoinedtwins frequently shows discordant anornalles'. Typicalcases of ischiopagus have union in the perineum, thepelvis and the lower abdominal wails.The present caseunder study belongs to typical variety of ischiopagustwins. In this case the Twin II was incomplete andpresumed to be unable to survive after separation and theparents were aware of this fact. This facilitated thesurgical separation to salvage the pelvic organs and thedistal spinal cord of Twin I.

Approximately 6% of fusions extend from the umbilicalarea to include the lower trunk and pelvis with three limbs(Tripus) as was our case or four limbs (Tetrapus)'. Thebodies usually line along a long axis and the heads liepolar.The foregut and the proximal midgut are separatedbut it is fused from the level of Meckel's diverticulum andthe distal midgut and hindgut are common and end in aSingle anus, as was in our case. Genital fusion is alsocommon as in our patient. Kidneys and bladders areusually separate.The pelvic cavity fused to correspondingsites on the other twin constituting a single pelvic cavity.Each bladder receives two ureters, one from each twin.However,a rare complex variant has been reported wherethere was a single bladder with one kidney in each twin,this phenomenon of one kidney from each twin was alsopresent in our patient under study.The common rectum isin the centre of the pelvic cavity and the internal genitaliaare on either side. Vascular abnormalities of the commoniliac vessels may be present, if there is single limb on oneside with two on other side. This single limb may havesevere skeletal abnormalities and thus functionallyuseless, as was present in our patient. The abdominalwall has normal muscles but the two recti of each twin arewidely separated at the lower half to gain attachment tothe pubic bones located laterally. These patients havesingle anus and rectum which may be imperforate, ourpatient was also imperforated. The pelvic floormusculature is fused along a raphe extending from onepubic symphysis to the other",

The present case under study belongs to the typicalvariety of ischiopagus tripus twins. In this case the Twinllwas incomplete and presumed to be unable to surviveafter separation and the parents were also aware of thisfact, which facilitated the surgical separation.

REFERENCES1. Kim SS, Waldhausen JH, Weildner BC, Grady R,

Mitchellen M, Sawin R. Perineal reconstruction offemale conjoined twins. J Pediatr Surg 2002; 37: 1740-3.

2. Hwang EH, Han SJ, Lee JS, Lee MK.An unusual caseof monozygotic epigastric heteropagus twinging.JPediatr Surg 1996; 31:1457-60. .


*Sikandar Ali Mughal, ++Mahmood Shoukat, *Sirajuddin Soomro, **Jan Mohammad Shaikh, **Mohammad Pinyal Abbassi

Spitz L, Keily EM. Experience in the management ofconjoined twins. Br J surg 2002: 89: 1188-92.

4. Spitz L, Crabbe DCG, Keily EM. Separation ofthoraco-omphalopagus conjoined twins with complexhepato-bihary anatomy. J Pediatr Surg 1997; 32: 787-89. .

5. Spencer R. Minimally united ischiopagusw twins:infraumblical union with cloacal anomalies. J PediatrSurg 1996; 31: 1538-45.

6. Mughal S, Mangan U. Atypical Conjoined twins: Acase report and review of classification. JCPSP 1997;8: 17-19.

7. O'Neill JA Jr, Holcomb GWIII, Schnaufer L et al;surgical experience with thirteen conjoined twins. AnnSurg 1988; 208: 299-312.

8. Votteler TP: Conjoined twins, in Welch KJ, RanolphJG, Ravitch MM et al: Pediatric Surgery, Chicago, IL,year Book Medical, 1986: 771-79.

9. Spencer R: anatomic description of conjoined twins; aplea for standardized terminology. J Pediatr Surg1996.

10. Spencer R: Conjoined twins; Theoretical embryologicbasis. Teratology 1992; 45: 591-602.

11. Hoyle RM: surgical separation of conjoined twins. SurgGynecol Obstet 1990; 170: 549-62.

12. Ramakrishan MS. Conjoined twins. Pediatric Surgery,New Dehli, Jaypee brothers medical publishers, 1996;668-75.


CONGENITAL MIDLINE CERVICAL CLEFT

A CASE REPORT

SHAHZIA JALIL, JAMSHED AKHTAR, SOOFIA AHMED, AQIL SOOMRO, TAYYABA BATOOL,

ANWAR ARAIN, RAEES TAQVI

ABS1RACTHere in we present a case of Cervical mid line cleft to illustrate its clinical picture. theembryology and the surgical treatment.

KEY WORDS: - Cervical cleft. Branchial anomalies.

INTRODUCTIONCongenital midline cervical cleft is a rare developmentalanomaly of the ventral neck. Less than 100 cases havebeen reported in literature till 1997 and none fromPakistan'. It characteristically occurs in the midline ventralneck and consists of a cephalad skin tag. a mucosalsurface and a caudal sinus . Embryologically it has norelationship to the thyroglossal apparatus. Theabnormality is of cosmetic importance and the preferredoperative correction requires complete excision of thecleft with its underlying fibrous cord and closure withmultiple Z plasties'. Herein we report our experience ofone such lesion.

CASE REPORTA 4 months old baby girl was brought with the history ofmucoid discharge from small midline defect on the ventralaspect of neck since birth. She had no other associatedcongenital defect. Family history of facial deformity suchas cleft lip or palate or of thyroid disease was negative.Onexamination the lesion consisted of a cephalad skin tag, amucosal surface and a caudal sinus in the midline ofventral neck between the chin and suprasternal notch. Itwas approximately 3 cm long and 1 cm wide. Sinogram ofthe lesion showed a blind tract going behind sternum.Thepatient was treated surgically and the cleft with itsunderlying fibrous cord that was attached with sternum

Correspondence:Dr Shahzia JalilPediatric SurgeonPediatric Surgical Unit BNational Institute of Child HealthKarachi. 75510

excised. The vertical wound was closed with multiple Zplasties. On histological examination the cleft was partlylined by keratinized stratified epithelium with sebaceousgland and partly by non- keratinized stratified squamousepithelium. Underlying the epithelium were smallcollection of seromucous salivary glands. Surroundingtissue was densely fibrocollagenous and richly suppliedwith blood vessels. The postoperative course wasuneventful. Patient is on follow up.

DISCUSSIONCongenital cervical midline cleft is a rare anomaly that ispart of a continuum of morphogenetic defects that mayoccur in the anterior neck. Developmentally midlinecervical clefts represent failure of the branchial arches tofuse in the midline. In the normal embryology, thebranchial arches grow medially and merge in a cephaladto caudal direction. Prior to fusing mesodermal tissuemigrate between the arches, pushing ectoderm out wardsto flatten the ventral furrow'.

Several mechanisms have been proposed to explain thepathogenesis of midline cervical cleft. Pressure of thepericardial roof on the most distal branchial arches andvascular anomalies may both result in necrosis andscaring with subsequent cleft deformity2,3.Failure of themesenchyme to penetrate the midline or poor interactionbetween mesoderm and ectoderm may also precludenormal fusiorr',

It is a sporadic disorder with a predilection for whitefemales. There is an associated submucosal fibrous cord


· 8IIIt1Zia Jalil, Jamshed Akhtar, Soofia Ahmed, Aqil Soomro, Tayyaba Batool, Anwar Arain, Raees Taqvi

which is occasionally tethered to the mandible and/ orSlemum causing neck contracture. It has been associatedwith a spectrum of midline anomalies related to branchialarches including a median cleft of lower lip, mandible orclefts of tongue and rarely cystic lesions of lung. Ourpatient had none of theses. Midline clefts of the lower lip,mandible, tongue, and neck are rare congenitaldeformities and are classified as facial cleft no. 30 byTessie~.

The preferred operative correction requires completeexcision of cleft with its underlying fibrous cord andclosure with multiple Z plasties', We performed sameprocedure in our patient. The possibility of recurrenceafter Z plasty, during the follow up emphasizes theinportance of regional hypoplasia in certain cases andmay require tissue supplementation. Our patient is onregular follow up so as to detect early any suchhappening.

REFERENCES1. Ayache D, Ducroz V, Roger G, Garabedian EN. Midline

cervical cleft. Int J Pediatr Otorhinolaryngol. 1997 20;40(2-3):189-93

2. Eastlack JP, Howard RM, Frieden IJ.. Congenitalmidline cervical cleft: case report and review of theEnglish language literature. Pediatr Dermatol. 2000;17(2):118-22.

3. Maschka DA, Clemons JE, Janis JF. Congenitalmidline cervical cleft. Case report and review. AnnOtol Rhinol Laryngol. 1995 Oct; 104( 10 Pt 1):808-11.

4. Vander Staak FHJ, Pruszczynski M, Severijnen RSVMet al, The midline cervical cleft. J Pediatr Surg 1991;26(12): 1391-93

5. Hirokawa S, Uotani H, Okami H, Tsukada K, FutataniT, Hashimoto I.. A case of congenital midline cervicalcleft with congenital heart disease. J Pediatr Surg.2003 ;38(7):1099-101.

6. Kececi V, Gencosmanoglu R, Gorken C, Cagdas A.Facial cleft no. 30. J Craniofac Surg. 1994; 5(4):263-4


GALL BLADDER TUBERCULOSIS

A CASE REPORT

SHABBIR HUSSAIN RANA, SYED INAMULLAH SHAH, AURANGZEB KHAN.

ABS1RAcrTuberculosis of the gallbladder (GBW) is so rare that only about 50 cases have been reportedto date. Most of these cases are diagnosed only on histological examination aftercholecystectomy. Gallbladder tuberculosis may also be associated with tuberculosis of otherorgans. A case of gallbladder tuberculosis with associated tuberculous omentitis is beingreported here.

KEY WORDS: - Gallbladder; Tuberculosis.

CASE REPORTAn 80-year old man presented with mild right upperquadrant abdominal pain of six months duration. The painexacerbated off and on. Clinical examination of the patientrevealed a mildly tender right hypochondrium. No mass orenlarged viscus was palpable. Ultrasonography ofabdomen revealed a contracted gallbladder containingmultiple calculi. Chest X-ray was suggestive of chronicobstructive airway disease (COAD). His hemoglobin was12.6 gm/dl and total leukocyte count was 5.6x109/L.Neutrophils were 65% while lymphocytes were 30%.Blood glucose levels and liver function tests were withinnormal limits. Hepatitis B surface antigen and anti-HCVantibodies were negative. Peroperatively, gallbladder wasseen to be contracted and had thickened walls. Its serosalsurface was granular. The greater omentum and.mesentery were studded with nodules. No spread was'seen into the gallbladder fossa or into the liver. Lymphnode of Lund and those in the mesentery were enlarged.Gallbladder contained multiple small calculi. The resectedgallbladder and a biopsy of greater omentum were sentfor histopathology, which revealed gallbladdertuberculosis with caseating granulomas, as well astuberculous omentitis. Patient is on anti-tuberculosistherapy and is improving steadily.

DISCUSSIONThe normal gallbladder is highly resistant to tubercularinfection. Although tuberculosis is common in the

Correspondence:Dr Shabbir Hussain RanaClassified SurgeonCMH Jhelum Cantt.

developing and the underdeveloped parts of the world,only about 50 cases of gallbladder tuberculosis (GBTB)have been reported in the literature so far'·2. Presence ofinhibitory factors in the bile is reported to be responsiblefor this special resistance'. The presence of an underlyingpathology in the form of cholelithiasis or cystic ductobstruction is said to be essential for the development ofgallbladder tuberculosis'.

Four types of GBTB have been described: miliarytuberculosis in children with ulcerating tubercles in thegallbladder; GBTB in association with severe generalizedtuberculosis; isolated GBTB; and gallbladder involvementin association with tuberculosis in other intra- peritonealorqans", The fourth group is said to be the commonesttype. Our case belonged to this type because of thepresence of tuberculosis in the omentum and mesentery.The route of infection in GBTB can be canalicular,lymphatic or hematoqenous':',

The clinical presentation is often vague and non-specific.Anorexia, fever, weight loss, abdominal pain, diarrhoeawith or without jaundice have been descrlbed'>'. It isdifficult if not impossible to diagnose GBTBpreoperatively. Imaging morphology of GBTB has rarelybeen described. Gallbladder with abnormally thickenedwalls with underlying cholelithiasis has been described inthe available literature. Gulati et al have described the CTscan image of gallbladder tuberculosis as multiloculated,thick walled galibladderJ. Jain et al have reported a casewherein the gallbladder was enlarged with thickenedwalls, presence of gallstones and an intraluminal masssimulating a gallbladder carcinomas. A dilated gallbladderwith a large stone located in the neck simulating acute


Shabbir Hussain Rana, Syed Inamullah Shah, Aurangzeb Khan.

cholecystitis has also been reported", Presence offeatures like portal and mesenteric lymphadenopathy,mesenteric thickening and ascites favour the diagnosis ofmberculosts=. In our case, peroperative findings weresuggestive of a tumour and the diagnosis was made onhistopathology.

REFERENCES1. Abu-Zidane F. M, Zayat I. Gallbladder tuberculosis (a

case report and 'a review of the literature).Hepatogastroentrol 1999, 46(29):2804 Bergdahl L,Boquist L. Tuberculosis of gallbladder. Br. J Surg 1972;59:289-292.

2. Abasca J, Martin F, Abreu I et al, Atypical hepatictuberculosis presenting as obstructive jaundice. Am JGastro Enterol 1985; 83: 1183-1186.

3. Gulati MS, Seith A, Paul SB. Gall Bladder TuberculosisPresenting as a Multiloculated Cystic Mass on CT. IndJ Radiollmag 2002; 12:2: 237-238

4. Park K. Tuberculosis. In: K Park. Park's Textbook ofpreventive and social medicine. Jabalpur: MIsBanarsidas Bhanot. 1997: 138-151.

5. Jain R, Sawhney S, Bhargava D, Berry M. Gallbladdertuberculosis: sonographic appearance. J. OllnUltrasound 1995; 23:327-329.-6.


SQUAMOUS CELL CARCINOMA FOOTARISING IN DEEP MYCOSIS

(CHROMOMYCOSIS)

A CASE REPORT

SHAHID MAJEED *ARFAN UL BARI

ABS1RACTCutaneous squamous cell carcinoma (SCC) is the second most common Jorm oj skin cancerand frequently arises on the sun-exposed skin oj middle-aged and elderly individuals,Involvement oj Jeet is not very common and tumour over dorsal surface of the Joot is evenrare. It may arise in setting oj pre existing chronic granulomatous disorders. We describe anold man who developed see on the dorsum oj the Joot secondary to chronic lesions oj deepmycosis.

KEYWORDS: - Skin cancers, Squamous cell carcinoma, Chromomycosis.

INTRODUCTION:see of skin is a malignant tumor of the most abundantepidermal cells (keratinocytes). It is much more commonin areas with a high incidence of sun exposure. see iscommon in whites and rare in African Americans', Here inwe describe a case of see arisinq in deep mycosislesion.

CASE REPORTAn 87 years old male. presented with a large foul smelling,fungating and suppurative growth over dorsum of left foot.The lesion started about 25 years ago as a small softnodule which slowly increased in size to involve most partof the dorsal surface of the foot and transformed into averrucuous and crusted plaque in about two decadestime. The lesion remained largely asymptomaticthroughout until during last one year, when it increased insize rather rapidly to involve the ankle region and lowerpart of the leg and he also started complaining of pain inthe lesion. During last two months it became moresuppurative and foul smelling. There was no history ofSimilar lesions else where over the body and the patientdid not loose any significant weight during this period ................•....••...••...••••Correspondence:Dr. Shahid Majeed,Department of Surgery PAF Hospital,Sargodha

* Dermatology Department PAF Hospital Sargodha

Some times in the past the lesion was diagnosed as ofdeep fungal infection (chromoblastomycosis) for which hereceived systemic antifungal (itraconazole) irregularly andthe response to treatment was not satisfactory.

On examination a large fungating and verrucous growthwith fairly well defined margins and having hard crustsand few ulcers over the surface was seen involving dorsalaspect of the left foot, ankle region and extending up tothe lower part of the leg but sparing all the toes. (Fig. I).Inguinal lymph nodes were not appreciably enlarged oneither side. Laboratory investigations including blood

Fig/:Verrucuous and

crusted growth overdorsum of foot andanterolateral aspect

of lower leg.


Shahid Majeed· Arfan ul Bari

complete picture, serum urea, creatinine, electrolytes,her function tests, ultrasound of abdomen and pelvis andchest x-ray were all with in normal limits. X-ray of left footdid not show any underlying bone involvement.Considering the previous diagnosis of deep mycosis hewas started on oral antibiotic (cefadroxil 500 mg bid) andantifungal (itraconazole 200mg bid). There was noimprovement in 3-4 weeks. An incisional biopsy wasperformed and tissue was sent for histopathologicalstudies. On histological analysis it turned out to be wellcifferentiated squamous cell carcinoma. Subsequently

, 1horoughsurgical shaving of the lesion was done undergeneral anaesthesia and patient was sent to oncologydepartment for radiation therapy.

DISCUSSIONCutaneous see frequently arises on the sun-exposedskin of middle-aged and elderly individuals, but to findsee on sites, which are not exposed to sun is by nomeans rare'", When it occurs on feet it is mostly seen onplantar aspect'. It may present with a variety of primarymorphologies with or without associated symptoms", Thismorphological variation is mostly seen when it occurs asa complication of long-standing chronic granulomas suchas venereal granuloma, syphilis, lupus vulgaris, leprosy,lupus erythematosis, chronic ulcers, osteomyelitssinuses, old burn scar, sand hideradenitis suppurativa orwhen it complicates scarring dermatoses such aspoikiloderma congenitale, dystrophiC epidermolysisbullosa and porokeratosis of Mibelli. Subcutaneous fungalinfections that have rarely been reported in associationwith see include chromoblastomycosis, lobomycosis and

yalohyphornycosls-". Our case is one of such rareoccurrence where a long standing deep fungal infectionwas complicated into a malignant skin tumour. Exactmechanism of developing see in various chronicgranulomatous diseases in unknown. Emergence of agrowth-activated immunophenotype may be a possiblecause in such cases",

REFERENCES1. Gray DT, Suman VJ, Su Wp, et al: Trends in the

population-based incidence of squamous cellcarcinoma of the skin first diagnosed between 1984and 1992. Arch Dermatol 1997; 133: 735-40.

2. Johnson TM, Rowe DE, Nelson BR, Swanson NA:Squamous cell carcinoma of the skin (excluding lipandoral mucosa).JAm Acad Dermatol1992;26:467-84

3. Bernstein se, Urn KK, Brodland DG, Heidelberg KA:The many faces of squamous cell carcinoma.Dermatol Surg 1996; 22: 243-54

4. Arid I, Johnson HD, Lennox B et al. Epitheliomacuniculatum. A variety of squomous carcinomapeculiar to the foot. Br J Surg 1954; 42: 245-50.

5. Barbosa de Silva 0, Ribeiro de Marianda MF.Alteracao carcinomatosa em chromoblastomicose.Med eutan-Ibero-Latino-Americana 1995; 23: 303.

6. Smoller B. Recessive dystrophic epidermolysisbullosa skin displays a chronic growth-activatedimmunophenotype. Implications in carcinogenesis.Arch Dermatol 1990; 126: 78.

.Ioumal of Surgery Pakistan (International) Vol. 9 (1) January - March 2004 55

.PORT SITE METASTASIS BY EXFOLIATEDCELLS FROM OCCULT

CHOLANG IOCARCI NOMA

A CASE REPORT

NAQVI A. H, KHAN. M. N, WHELAN.J, CATHAL 0 CEAILAIGH.

ABSTRACTAforty years old man presented with port site metastasis after laparoscopic cholecystectomyfor benign disease from an occult cholangiocarcinoma (Klatskin' s tumour). After diagnosis thepatient was referred to hepatobiliary unit for further treatment.

KEY WORDS: Port site, Metastasis, Occult cholangiocacinoma.

INTRODUCTION:Laparoscopic cholecystectomy has become the standardsurgical procedure in the treatment of symptomatic gallstones. But it is necessary to take into account someproblems and risks that can arise from this technique.One of the most dangerous risks is port site metastasis'.Laparoscopic cholecystectomy is the most commonlyperformed procedure among laparoscopic interventions.Port site metastasis following laparoscopiccholecystectomy with unsuspected gall bladdercarcinoma is a serious problem. But luckily it is a rarephenomenon on reviewing the literature", Herein wereport the first case of port site metastasis from occultcholangiocarcinoma

CASE REPORTA forty year old man underwent laparoscopiccholecystectomy for symptomatic gall stones. Thehistological report of removed gall bladder was benign.The patient presented with a nodule at port site one yearafter the cholecystectomy.The nodule was removed andhistopathologyrevealedadenocarcinoma.Histopathologicalreview of the removed gallbladder again revealed abenign result. All investigations for diagnosis of primaryremained equivocal. The patient again presented with

·<3~;;;sj;~~d~~~~;··················Dr. Syed Abull Hussan NaqviSolas Apartments Longford ROadMusllingar WesttneathIreland

obstructive jaundice three months after removal of thenodule. Investigations (CT Scan and ERCP) revealed anodule at hilum of biliary ducts causing obstruction at thatlevel with dilatation of intrahepatic bilary ducts. Brushcytology revealed hilar cholangiocarcinoma. This caseillustrates that exfoliated cells of bile duct tumourmetastasized by transluminal route and caused port sitemetastasis after laparoscopic cholecystectomy. Thepatient is referred to hepatobiliary surgeon for furthertreatment.

DISCUSSIONPort site metastasis is a well known complication oflaparoscopic intervention for malignant cases. But portsite recurrence of occult malignancies followinglaparoscopic procedures for benign condtion is a rarephenomenon in current existing world literature. Port siteimplantation after diagnostic laparoscopy for upper GImalignancy is uncommon and does not seem to bedifferent from open incision site recurref)ce, and occurs inthe setting of advanced disease.Therefore, the risk of portsite recurrence cannot be used as an argument againstlaparoscopy in upper GI malignancy.3

Pathogenesis and means of prevention of port sitemetastasis after dealing the malignant cases are stillunclear. Probably free cancer cells appear to attach theport sites after C02 pneumoperitoneum and these areassociated with the development of port site metastasis',A multifactorial mechanism may be responsible, in which


Naqvi A. H, Khan. M. N, Whelan.J, Cathal 0 Ceailaigh.

1he key factors could be a long operative procedure, thehigh pressure pneumoperitoneum, tumoral manipulationduring dissection and forced extraction of unprotectedspecimens. Under C02 pneumoperitoneum, exogenoushyaluronic acid increased the frequency and weight ofport site metastasis in a murine model. Hyaluronic acidsecreted from mesothelial cells may be associated with1he formation of port site metastasis after laparoscopicsurgery for cancer under pneumoperitoneum." Preventivemeasures in suspected malignant cases may be: use ofgasless laparoscopy, slow deflation, trocar site wash out,wound site protector, and use of specimen baqs', Onestudy suggested that tumor implantation afterfaparoscopic surgery and port-site metastasis might beprevented by the intraperitoneal or systemicadministration. of cytotoxic agents. Further studies areneeded to determine whether these findings can beapplied to clinical practice".

Laparoscopy with carbon dioxide insufflation seems tostimulate the growth of dormant tumour cells into overtiver metastass. Gasless laparoscopy on the other handmay have a protective effect against metastatic disease inthe liver. The promoting and inhibiting effects offaparoscopic procedures on growth of liver metastasesneed further evaluation" . A full laparotomy incisionpromotes greater tumour growth than does carbondioxide pneumoperitoneum. Surgical manipulationstimulates local tumour spread more than theestablishment of a carbon dioxide pneumoperltoneum".Treatment includes port site excision with control of theprimary tumour. Port site metastasis after laparoscopicprocedures for benign diseases is rare in the literature.Only few cases are reported of occult carcinomametastasising to port sites. One case was port sitemetastasis after cholecystectomy for benign disease fromoccult pancreatic tumour". Another case of postcholecystectomy port site metastasis was reported fromoccult adenocarcinoma of ascending colon", Anotherpresented case was a port site adenocarcinoma withundiagnosed primary in spite of the all investiqatlons".Our case is first ever presented case of port sitemetastasis from occult Klatskin's tumour.

REFERENCES1. Napolltano L, Artese L, Innocenti P Seeding from

early stage gall bladder carcinoma after laproscopiccholecystectomy :Ann Ital Chir 200172;721 ,4

2. Reddy Vp, Sheridan WG Port site metastasis followinglaproscopic Cholecystectomy :Eur J Surg Oncol 200026;95-8

3. Shoup M, Brennan MF, Karpeh MS Port sitemetastasis after diagnostic laparoscopy for uppergastrointestinal tract malignancies: an uncommonentity. Ann Surg Oncol 2002 ; 9(7):632-6

4. Hirabayashi V, Vamaguchi K, Shiraishi N, Adachi V,Kitamura H, Kitano S Development of port-sitemetastasis after pneumoperitoneum. Surg Endosc2002 16;864-

5. Martinez J, Targarona EM, Balague C, Pera M, Trias MInt Surg 1995 80:315-21

6. Vamaguchi K, Hirabayashi V, Shiromizu A,Enhancement of port site metastasis by hyaluronicacid under C02 pneumoperitoneum in a murinemodel. Surg Endosc 2001; 15(5):504-7

7. Schneider C, Jung A, Reymond MA, Efficacy ofsurgical measures in preventing port-site recurrencesin a porcine model. Surg Endosc 2001;15(2):121-5

8. Neuhaus SJ, Watson 01, Ellis T, Influence of cytotoxicagents on intraperitoneal tumor implantation afterlaparoscopy. Dis Colon Rectum 1999;42(1):10-5

9. Gutt CN, Riemer V, Kim ZG, Impact of laparoscopicsurgery on experimental hepatic metastases. Sr JSurg 2001 88(3):371-5

10 .Gutt CN, Riemer V, Kim ZG. Impact of laparoscopiccolonic resection on tumour growth and spread in anexperimental model. Br J Surg 1999 86(9):1180-4

11. Lane TM, Cook AJ, Port-site metastasis afterlaparoscopic cholecystectomy for benign disease. JLaparoendosc Adv Surg Tech A 1999 9:283-4

12. Neuhaus S, Hewett P, Disney A. An unusual case ofport site seeding. Surg Endosc 2001 ;15(8):896

13. Mintz V, Lotan C, Goitein 0, Muggia-Sullam M,Laparoscopic port site metastasis of an undetectedprimary tumor. Surg Laparosc Endosc 1999 9:68-9.


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