Objective: To study the role of gastrointestinal procedures, namely oesophago-gastroduodenoscopy (OGD) and colonoscopy, in helping to establish a definitive primary tumour site in cancer of unknown primary. Study Design: Prospective observational study. Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore Pakistan, from Jan 2018 to Jan 2019. Methodology: A total of 115 patients included in the study were those, who underwent OGD and a colonoscopy for the diagnosis of a cancer of unknown primary. Data collected included demographics, baseline clinical characteristics, definitive diagnosis, tissue diagnosis and immune-histochemical stains. Primary outcome was the attainment of a definitive diagnosis via OGD and/or colonoscopy. Results: A total of 115 patients underwent a diagnostic gastrointestinal procedure. Of these 70 (61%) were males. Mean age was 63 ± 12.6 years (range 22-88 years). Abdominal pain comprised the most common presenting complaint, found in 61 (53%). The most common tissue diagnosis of the metastatic sites was adenocarcinoma 81 (70.45%). Tumour markers including carcinoembryonic antigen, alpha-fetoprotein and carbohydrate antigen 19-9 were checked in 90 (78.2%), 46 (40%) and 69 (60%) patients respectively. No patient reached a definitive diagnosis by means of OGD and/or colonoscopy. Conclusion: OGD and colonoscopy when done collectively as diagnostic procedures to look for a primary tumour, have no value in the evaluation of patients with cancer of unknown primary.

Objective: To analyze the management of severe necrotizing pancreatitis in a specialized center of a lower middle-income country, Pakistan using multiple outcome measures. Methods: All the patients in this prospective observational study with severe necrotizing pancreatitis being referred to Pak Emirates Military Hospital from January 2017 to December 2019 were followed over the course of their admission. Demographic data and disease outcomes were duly noted. Cox regression analysis was used to predict fatality outcome. Results: A total of 57 patients with 48 (84.6%) infected necrotizing pancreatitis were managed in our set up. The most common etiology reported was gall-stones (37%) with male preponderance (72%) and a mean age of 50±11.3 years. The most common complications were acute-kidney-injury (63%), splenic-vein-thrombosis (21%) and ascites (21%). Fourteen patients required mechanical-ventilation with a mean duration of 7±1.4 days on respiratory support. Eight (14%) patients required Endoscopic-Ultra-Sound guided drainage and six (10.5%) underwent surgical-necrosectomy depending upon the patients’ condition and collections characteristics. Mortality, as one of the main outcome measures, was reported to be 12.3% and was statistically related to mechanical-ventilation, organ failure and surgical-necrosectomy while 22 (38.6%) patients were discharged on pancreatic enzymes supplements and 7% required insulin. Conclusion: Survival outcomes with acute severe necrotizing pancreatitis are improving in a dedicated hepato-biliary unit internationally in lieu with a multidisciplinary team approach. Percutaneous and EUS guided drainage of pancreatic collections have turned out to be an important procedure to manage infected pancreatic necrosis that helps to avoid a morbid procedure in the form of necrosectomy. doi: https://doi.org/10.12669/pjms.37.3.3440 How to cite this:Alam L, Khan RSA, Kazmi SKH, Rafi ud Din. Outcome of patients with acute severe necrotizing pancreatitis in a dedicated hepato-biliary unit of Pakistan. Pak J Med Sci. 2021;37(3):---------.   doi: https://doi.org/10.12669/pjms.37.3.3440 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To determine the demographics, indications and frequency of interventions and complications endoscopic retrograde cholangiopancreatography (ERCP). Study Design: Cross-sectional study. Place and Duration of Study: Department of Gastroenterology, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Jan to Dec 2019. Methodology: The study included all the elective and emergency ERCP procedures from January 2019 to December 2019. Results: Out of 1030 patients who underwent endoscopic retrograde cholangio-pancreaticography, 903 were enrolled. Sixtyone percent of the participants were males. The mean age was 56 ± 16 years, with the majority of the patients lying in the age range of 41-65 years. The most common indication for ERCP in this study was choledocholithiasis (47%), the most common complication encountered was acute pancreatitis (2.1%), and a mortality rate of 0.2% was reported. The complication rate was statistically related to the intervention rather than the age and gender of the patients. Conclusion: The most common indication for ERCP remains choledocholithiasis, with the most common ERCP complication being acute pancreatitis followed by stent migration. Biliary fistulae, post-surgical biliary leaks and strictures, pancreatic pseudo cysts, acute cholangitis, choledocholithiasis and cholestasis secondary to as cariasis were found in a relatively younger group. The success rate was above 95% for high volume centres.

Objective To determine the diagnostic accuracy of endoscopic ultrasound guided (EUS) fine needle aspiration in patients who had inconclusive endoscopic biopsies of the same lesion Methodology This retrospective study was conducted at Pak Emirates Military Hospital, Rawalpindi, Pakistan from Jan 2018 to July 2020. Patients who underwent EUS guided FNAC from June 2017 to July 2020 were screened. The FNAC results of patients satisfying the inclusion ciritera were compared with either a surgical biopsy in patients in whom surgeries were done, while in the remaining patients, EUS FNAC results were compared with a 3 months radiological and/or 6 months clinical follow-up. The final diagnosis was defined based on the following criteria: (1) Malignant lesions (n=36), histopathologic diagnosis obtained based on surgery resected samples (n=18) or clinical diagnosis as neoplasm based on clinical follow-up of symptoms (n=30) or radiologic diagnosis based on imaging follow-up at 3 months (n=13) (2) Benign lesions (n=18), benign cytopathologic histopathologic findings and clinical follow-up with no evidence of malignant progression or metastasis. Results EUS-guided FNA cytology turned out to be malignant in 60 percent (n=36) of the specimens. 30 percent of the samples showed benign epithelial cytology ( n=18) while in 10 percent  of the cases (n=6), the tissue samples were deemed insufficient for cytological diagnosis. The accuracy came out to be 66.6 percent (n=10 were true negative), sensitivity 93.4 percent, and specificity 100 percent.  Conclusion EUS guided-FNA cytology of the sub-mucosal upper GI lesions is highly sensitive and specific for upper GI lesions, which are negative on endoscopic biopsies.

Objective: To compare the efficacy and safety of left lateral decubitus versus prone position during endoscopic retrograde cholangio-pancreaticography (ERCP). Methods: This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January to June 2021. Patients requiring ERCP were subsequently allotted LL or PP group randomly (unequal randomization) except patients with recent abdominal surgery, in-dwelling catheters, raised intra-abdominal pressure, cervical spine abnormalities and limb contractures. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and student T or Mann Whitney U-test. Results: A total of 114 patients were enrolled according to the inclusion criteria with 62(54%) males and majority of the patients (42%) belonging to the age group 31-45 years. The most common ERCP indication was choledocholithiasis (36%). Technical success was achieved in 109(96%) patients with no statistically significant difference between the two groups. The total time of procedure, time for deep cannulation, time for acquiring therapeutic goal and ERCP complexity level were all similar between the two groups. The rate of inadvertent PD cannulation and PEP were relatively higher for the PP group but were statistically non-significant through univariate and logistic regression analyses and the only outcome measure that showed significance was multiple cannulations in the PP group. Conclusion: The study concludes that LL is non-inferior to PP and both positions have comparable outcomes with non-significant differences in terms of technical success rate, complications (specifically PEP), total procedure time, time required for deep cannulation and attainment of goal, ERCP complexity level and inadvertent PD cannulation. doi: https://doi.org/10.12669/pjms.39.5.6932 How to cite this: Alam L, Khan RSA, Saeed F, Sher F, Khan RZA. Does patient’s position count during Endoscopic Retrograde Cholangiopancreatography? Left lateral decubitus versus prone position. Pak J Med Sci. 2023;39(5):---------. doi: https://doi.org/10.12669/pjms.39.5.6932 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To compare the awareness regarding the mode of transmission in educated and uneducated patients presenting to OPDs of five hospitals in Sindh province. Study Design: Cross-sectional survey. Place and Duration of Study: Five Combined Military Hospitals, of Sindh province; Badin, Chhor, Hyderabad, Malir and Pano Aqil, Pakistan, from April to July 2022. Methodology: Patients presenting to the five Combined Military Hospitals were included through non probability consecutive sampling technique. The questionnaire was reviewed by two medical education experts for content validity and piloted among ten patients before being tested. Results: A total of 121 participants were included in the study. Participants had better knowledge regarding sharing of shaving equipment (p=0.008), unsafe blood transfusions (p<0.001), using contaminated surgical instruments in surgeries (p<0.001) and dental extractions (p=0.005) and sharing of needles (p<0.001) as potential sources of HCV spread. The disparity was quite clear by comparing the ratio of correct responses given by educated participants with uneducated. Conclusion: Our general public lacks basic information regarding modes of transmission of HCV, and the low level of education in the masses is one of the most important reasons.

Objective: To determine that early needle-knife sphincterotomy does not increase post-ERCP pancreatitis in patients with difficult biliary cannulation as compared to standard cannulation. Method: This prospective single-centre cohort study was carried out at Pak Emirates Military Hospital from January 2021 to June 2021. Patients requiring ERCP were enrolled in the study (according to inclusion and exclusion criteria) and were subsequently allotted different groups according to the technique used for deep biliary cannulation. Qualitative data was analysed using frequencies and chi square statistics whereas, quantitative data was analysed using mean±SD and one way ANOVA test. Result: The cohort included 114 patients with 52.6% male patients and predominance of relatively younger age group (31-45 years). The most common indication for ERCP was choledocholithiasis (36%) with an overall technical success rate of 96%. Deep cannulation was achieved either through standard cannulation (56%), double guidewire and/or pancreatic stent assisted (10.5%), use of early Needle-Knife Sphincterotomy (19%), NKS as a last resort (3.5%) or Transpancreatic Stenting and/or combined sphincterotomy (6%). Pancreatitis as a complication occurred in 4(3.5%) patients, bleeding in 2(1.8%), on-table desaturation in 2(1.8%) and perforation in 1(0.9%) patient. The occurrence of pancreatitis was only related significantly to inadvertent PD cannulation through univariate and logistic regression analysis whereas, multiple cannulations (>5), gender, age, classification of papilla and the use of early NKS had no impact on pancreatitis or the occurrence of other complications. Conclusion: NKS is an effective and safe modality for deep biliary cannulation and achieving technical success where cannulation is deemed difficult and does not increase the risk of PEP if done by experienced endoscopists in high volume centres. doi: https://doi.org/10.12669/pjms.39.3.6777 How to cite this: Khan RSA, Alam L, Saeed F, Sher F, Khan RZA. Does early application of needle-knife sphincterotomy (NKS) in patients with difficult biliary cannulation increase the risk of postERCP pancreatitis? A single centre study. Pak J Med Sci. 2023;39(3):698-703.  doi: https://doi.org/10.12669/pjms.39.3.6777 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To determine the characteristics of Hepatocellular carcinoma (HCC) in patients visiting PEMH Rawalpindi. Study Design and Setting: Cross-sectional Study conducted at Department of Gastroenterology/hepatology in Pak Emirates Military Hospital Rawalpindi (PEMH) from Oct 2015 to Jan 2018. Methodology: In this study total 100 patients, with HCC of both genders were included. All the cases were discussed in multidisciplinary team (MDT) meetings which were held once every week. A decision on the best possible management for the given case was arrived at in the MDT meeting. All the relevant features of each case were recorded in the Performa. Descriptive statistics were used to calculate mean, standard deviation and frequencies for gender, various presenting features, co-morbidities and clinical features. Data was analyzed on SPSS version 21. P value <0.05 was considered as statistically significant. Results: Sixty seven men and 33 women with HCC were included in this study with a mean age of 58.23 years. The abdominal pain was the most common symptom present in 66 (66%) patients. Edema was seen in 30 (30%) and palpable splenomegaly in 26(26%). Diabetes mellitus was the most common co-morbidity found in 20(20%) patients. HCV was the commonest cause of HCC present in 79(79%) patients. Vascular involvement was seen in 15 (15%) patients. Most (62%) patients had a single HCC lesion and most belonged to Child –Pugh class A (68%) and BCLC stage B (42%). ECOG performance status was good in most patients with 49% patients scoring 0. The AFP levels were raised in 58 (58%) of the patients. Conclusion: HCV was the most common underlying etiology. Most of the patients were asymptomatic at the time of diagnosis. Majority of subjects reported with the complaint of abdominal pain and had no underlying co morbidity. The metastasis was negative in majority of cases