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The Society of Surgeons of Pakistan and The Society of Surgical Oncology of Pakistan with factions from various major centres comprising of surgical oncology, medical and radiation oncology collaborated to reach consensus on breast cancer management guidelines and a framework of "good practice" minimum standards of care. The aim of the task force was to enhance treatment standards, which have a direct correlation with improving patient mortality and morbidity and long-term survival whilst taking into consideration economic limitations of access to leading centers of excellence as well as minimum expertise required in health care. These multidisciplinary guidelines, whilst not exhaustive, aim to provide an algorithm of care for breast cancer patients at tertiary care centres and district level hospitals to provide most appropriate treatment.

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Objective: To determine the impact of the trial on surgeon practice patterns at our institution. Methodology: A comparison of patients undergoing surgery for early breast cancer before and after the implementation of the new guidelines was done. We adopted the new guidelines in April 2015. Patients meeting Z0011 inclusion criteria were identified. For group A (Pre Z0011) patients operated between Jan to Dec 2013 were studied. And for Group B (Post Z0011) patients operated between July 2014 to Jun 2015 were included. Clinicopathologic data were compared between the two groups. Results: There were 318 patients with clinical T1-2 tumors planned for breast conservation. 68% patients had T1 tumor and 32% had T2. 92% of the patients had IDCa. There were 150 patients in the pre-Z0011 group and 168 post-Z0011. 68% of the patients in Group A were ER+ve while 70% in group B. 38 (25.7 %) patients were sentinel lymph node (SLN) positive in the pre-Z0011 group versus 34 (21 %) post-Z0011 (p = 0.392). Before Z0011 100 % (38/38) of SLN-positive patients underwent axillary node dissection (ALND) versus 17 % (6/34) after Z0011 (p < 0.01). Median no of SLNs identified in group A were 1.3 and group B were 1.4. There was a decrease in median operative times of the two groups (80 vs. 60 min, p < 0.01). There was a significant decrease in the overall hospital stay of sentinel lymph node positive patients in between the two groups (2.1 days vs 1.3 days p value < 0.01). Conclusions: Implemention of Z0011 guidelines has resulted in significant short term advantages in terms of reduced axiilary dissections, shorter operative times and shoter hospital stays.

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BACKGROUND: Restoration of proper anatomy and physiology is an integral part of cleft palate repair. The senior author has devised a new technique of radical release of greater palatine vessels, which helps in achieving tension-free closure of palatal cleft. In addition, release and transposition of palatal muscles is performed without the use of operative microscope, resulting in improved palatal function. This technique is applicable to all types of clefts of the palate and can be performed on adult patients as well. MATERIALS AND METHODS: This is a retrospective case series of cleft palate repairs performed over a period of 3 years. Single-stage repair with modified Bardach's technique for complete cleft palate and von Langenbeck's technique for incomplete cleft palate with radical release of greater palatine vessels and levator complex retropositioning was performed. The outcome measures were closure of palatal defect and speech production. A follow-up of at least 6 months was completed in each patient. RESULTS: A total of 1568 patients were included in the study. Their age ranged from 9 months to 54 years. The overall fistula rate was 6.1%. Improvement of speech was observed even in adult patients. CONCLUSIONS: Radical release of greater palatine artery and levator complex transposition can dramatically improve results of cleft palate repair. This technique helps in dynamic reconstruction of cleft palate and can be effectively applied in all age groups.

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Laparoscopic Pancreatic Pseudocyst (PP) surgery can be performed via anterior or posterior cystogastrostomy, endoscopy-assisted surgery and cystojejunostomy. We conducted a prospective analysis of our patients undergoing laparoscopic cystogastrostomy to analyse the merits and demerits of the procedure. In a period of 3 years from January 2010 to December 2012 all the patients who underwent laparoscopic drainage of pancreatic pseudocysts were prospectively analysed. A total of 12 patients underwent a transgastric anterior cystogastrostomy with a stoma size of 4.5cms. There was no intraoperative or postoperative bleeding or leakage on anastomotic lines. Post-op pain score on the first post-op day was 4 (2-5) on the Visual Analogue Scale (VAS). Average hospital stay was 4.1±2.3 days. All patients had complete resolution of symptoms on follow-up. Follow-up computed tomography (CT) scans on 8 patients showed complete resolution of the cysts. Laparoscopic cystogastrostomy is a safe and feasible method and provides efficient drainage of PP.

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OBJECTIVE: To compare the improvement of intraoperative laparoscopic skills by measuring GOALS score between residents who have undergone simulator training with those who have not received any simulator training. STUDY DESIGN: A randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Surgery, Services Hospital, Lahore, from August 2013 to February 2014. METHODOLOGY: Thirty residents belonging to year 1, 2 and 3 were included in the study. They were randomly divided into 2 groups. Both groups had a baseline evaluation with GOALS score while performing dissection of gallbladder from liver bed during laparoscopic cholecystectomy. Group-A underwent formal training on simulators whereas group-B did not receive any formal training on simulators. After 6 months, a repeat evaluation was done again by measuring GOALS score while performing gallbladder dissection. RESULTS: Baseline GOALS scores of both the groups were similar. Group-A baseline score was 7.66 ± 0.93 and group-B score was 7.46 ± 1.04 (p = 0.585). However repeat scores for group-A showed a significant improvement (an increase of 7.16 ± 1.48 to 14.76 ± 1.67, p < 0.001) from baseline scores. Residents in group-B improved their scores by 2.30 ± 0.99 to 9.76 ± 0.79 (p < 0.001). When inter group comparison was done the second score of group-A was significantly higher than that of group-B (14.76 ± 1.67 vs. 9.76 ± 0.79, p < 0.001). Inter-rater reliability was moderately significant (Kappa 0.540).

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Patients undergoing laparoscopic splenectomy were observed for their postoperative recovery and development of complications. It was a retrospective analysis done at Services Hospital and National Hospital and Medical Center, Lahore, from January 2010 to December 2012. A total of 13 patients underwent laparoscopic splenectomy and were included in the study. Patients were followed for their postoperative recovery and development of any complications. The median age of patients was 19 years ranging from 13 to 69 years. Accessory spleens were removed in 3 patients. Mean operating time was 158 minutes. One operation had to be converted to open because of uncontrolled hemorrhage. Six patients experienced postoperative complications including unexplained hyperpyrexia (n=2), pleural effusion (n=4) and prolonged pain > 48 hours (n=1). No deaths or infections were seen. Seven out of 8 patients with idiopathic thrombocytopenic purpura developed a positive immediate response to the splenectomy, defined as a platelet count greater than 100 x 109/L after the surgery, which was maintained without medical therapy. Mean hospital stay was 5.5 days. Average time to return to activity was 15 days. All patients were followed for 6 months and no follow-up complications were noted.

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