Colonic Strictures after Necrotizing Enterocolitis in Infants: Case Series.

The fate of neonates with necrotizing enterocolitis is variable, with colonic strictures being one rare phenomenon after the insult. We describe here two infants with colonic strictures, which developed secondary to neonatal necrotizing enterocolitis. Infants recovered or in the process of recovery after it should be investigated for possibility of development of colonic strictures.

Childhood Intussusception: A Prospective Institutional Study at BPKIHS.

Introduction: Intussusception is the commonest cause of bowel obstruction in infancy and childhood. The present study deals with the presentation, management and outcome of children presenting with intussusception at the Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal. Materials and Methods: Forty-seven children presenting at Department of Surgery, B. P. Koirala Institute of Health Sciences over a 5-year period were prospectively studied. Results: There were 27 (58.6%) males and 20 (41.4%) females, with male-to-female ratio of 1.4:1. The ages ranged from 2 months to 13 years, with a median age of 30 months. The mean duration of presentation was 10.7 ± 30.66 days (range 1-180 days). The triad of abdominal pain, bloody mucoid stools and palpable abdominal mass was seen in 10 (21%) of the cases. Surgical exploration was done in 42 (89.3%) patients. The commonest lead point was non-specific hyperplastic lymph nodes, occurring in 22 (54.3%), followed by idiopathic variety (16.6%), Meckel’s diverticulum (9.5%), ileocaecal junction (7.1%), submucous lipoma (4.7%), Non- Hodgkin’s lymphoma (4.7%), appendix (2.3%) and a mucosal polyp (2.3%). Overall mortality rate was 6.3%. Conclusion: The presenting age group and the time of presentation are higher than other studies. The mortality rate of 6.3% is comparable to other studies in the developing world. Earlier presentation could have avoided surgery, with a higher possibility of cases being managed conservatively.

Pediatric femoral hernia.

Pediatric femoral hernias account for less than 1% of all groin hernias. Pediatric femoral hernias are rather uncommon more so in males, often overlooked, misdiagnosed and treated as inguinal hernia. Femoral hernia masquerading as inguinal hernia in a seven year old male is reported along with review of relevant literature.

Correlation of prostate volume with international prostate symptom score and quality of life in men with benign prostatic hyperplasia.

The aim of this study was to correlate the prostate volume with international prostate symptom score (IPSS) and quality of life (QOL). Hundred consecutive patients diagnosed as having benign prostatic hyperplasia were included. All patients were interviewed using standardized questionnaires for International Prostate Symptom Score, which include one single disease-specific quality of life question. Transabdominal ultrasonogram was used to assess the prostatic volume. Data was analyzed using the statistical package for social sciences (SPSS) for Windows. The mean age and median duration of symptom was 67.5 years and 12.0 months respectively. The mean volume of prostate was 42.5 cm3. Most of the patients had severe symptoms with mean IPSS of 23.5 and single disease-specific QOL score of 5.2. The correlation between the prostate volume and age, IPSS, and QOL score were not statistically significant except for two domains; incomplete emptying and nocturia that appear to be correlated with prostate volume. The correlation between IPSS and QOL score was strong. Similarly, correlation between QOL score and age was significant but weak. In conclusion, prostate volume had no correlation with age, symptom score, and quality of life score. So prostatic size should not be an only and important consideration; moreover, we should assess the impact of symptoms while treating the cases.

Port exteriorization appendectomy: is it the future?

The time honoured surgical procedure open appendectomy seems to be on the decline, it may be replaced in the modern era by laparoscopic appendectomy ("in appendectomy") performed with three trocars, or by the port exteriorization appendectomy ("out appendectomy") which can be done with two ports or even one. These techniques combine the benefits of decreased tissue trauma and operative time in addition to other advantages of minimal invasion. We conducted this study to know the effectiveness of Port Exteriorization Appendectomy, to analyze its complications and to assess the conversion rate. A one year prospective study consisted of fifty cases; a combination of emergency and elective group. They were operated under general anaesthesia and different variables were documented. Mean operative time, conversion rate, hospital stay, complications and patient satisfaction. There were 27 females with the (F: M) ratio of 1.17:1. The operative time of 23.3 mins, conversion in 4 (8.0%) patients and 2.4 days of hospital stay contributed to 86.0% operative success rate. Surgical site infection was seen in 5 (10.0%) patients and one (2.0%) developed pelvic abscess. On analysis of the satisfaction level, 44(93.6%) were completely satisfied and one (2.1%) patient seemed disappointed with the technique for cosmesis though, 42 (89.3%) remained completely satisfied and 5(10.7%) didn't like their scars. Port exteriorization appendectomy's efficacy can be verified by 86.0% success rate, operative time of 23.3 mins, indoor stay of 2.4 days, and minimal undesirable sequlae. However, more authentic results could be obtained if this technique is compared to open or laparoscopic appendectomy in a well designed randomized controlled clinical trial.

Role of serum C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in Nepalese population.

Various diagnostic modalities have been reported to influence the negative appendicectomy. C-reactive protein (CRP), an acute phase reactant, may improve the accuracy of diagnosing acute appendicitis. The present study was undertaken to evaluate the utility of CRP as a diagnostic tool among patients clinically suspected to have acute appendicitis. The role of total leukocyte (WBC) count was also studied. A total of 145 diagnosed cases of acute appendicitis were studied over a period of one and half years. CRP was raised in 91 cases and was normal in 54 cases. The sensitivity and specificity of CRP estimation in diagnosing appendicitis was 74.8% and 66.7% respectively and the sensitivity and specificity for total WBC count was 78.6 and 54.8% respectively. The present study suggests that we cannot rely wholly on CRP or on WBC count for operative decision. Clinical judgment is still the best modality for the diagnosis and operative management of acute appendicitis. It seems wiser to use active observation, which should identify most patients with non-specific pain and reserve operation for those who need it most.

Oxidative stress in patients with benign prostate hyperplasia.

Benign Prostate Hyperplasia (BPH) is a common health problem in aging male. Free radicals and Reactive Oxygen Species (ROS) are produced in overwhelming quantity with advancement of age. When in oxidative stress, these reactive species cause extensive damage to various organ in the body, may be associated with pathogenesis of BPH also. This study aimed at assessing Malondialdehyde (MDA), the marker of lipid peroxidation and anti-oxidants e.g. alpha-Tocopherol and Ascorbate status in plasma in BPH patients. Forty eight (n=48) cases of BPH and forty six (n = 46) healthy age matched controls were enrolled. Plasma MDA level showed 4.81+/-1.87 nmol/ml in cases compared to 3.69+/-1.56 nmol/ml in healthy controls (p<0.001). There were significant decrease in plasma alpha-Tocopherol and ascorbate level which were 0.85+/-0.12 mg/dl and 0.93 +/- 0.13 mg/dl in cases compared to 1.37+/-0.31 mg/dl and 1.44+/-0.38 mg/dl in healthy controls respectively. Inverse correlation of plasma MDA with alpha-Tocopherol (r = -0.09, p>0.05) and Ascorbate (r =-0.51, p=0.008) was found in BPH patients. There was mild elevation of PSA in BPH patients compared with control but was not statistically significant. Thus, our study showed the evidence of association of oxidative stress in BPH patients.

Validating breast self examination as screening modalities for breast cancer in eastern region of Nepal: a population based study.

Breast cancer is one of the most common causes of death in many developed countries amongst middle-aged women and is becoming common in developing countries as well. AIMS AND OBJECTIVES: The objective of this study was to evaluate the performance of Breast Self Examination (BSE) against examination conducted by the trained health personnel. METHODOLOGY: A descriptive evaluative study was conducted among women aged 15 to 60 years undertaken in urban and rural areas. It was a population-based study and non-probability sampling method was used for data collection. Respondents conducted Breast Self Examination on their own, and then investigators did clinical examination of breasts of the respondents to verify their findings. RESULTS: Mean age of the respondents was 34.54 +/- 9.12 years. Nearly half (44.8%) of the respondents were illiterate. On comparison of each variable of breast self- examination with the physical examination of breast, it was observed that size of the breasts and lump found in the breast had significant relation to performance during examination (P<0.1). The result of Kappa test showed 68% agreement between findings of examinations done by the experts and respondents. CONCLUSION: Breast Self Examination can be used as an important tool for primary prevention of breast cancer in Nepal, where sophisticated method like screening mammography for general public cannot afford.

Change in urinary symptoms and quality of life in men with benign prostatic hyperplasia after transurethral resection of prostate.

The aim of this study was to determine the improvement in symptoms and quality of life in men with Benign Prostatic Hyperplasia (BPH) after transurethral resection of prostate (TURP). Fifty consecutive patients fit for undergoing TURP for BPH were included in this study. All patients were assessed prior to definitive surgical treatment using standardized questionnaires of international prostate symptom score (IPSS) which includes single disease-specific quality of life (QOL) score. Follow up of these patients was done at three months with same questionnaires. Data was analyzed using the statistical package for social sciences (SPSS) for Windows. The mean age and duration of symptom was 68.3 years and 26.7 months respectively. The average volume of prostate was 46.1 cm3. Preoperative IPSS and QOL score were 23.4 and 5.2 respectively; 56.6% of the score was contributed by obstructive symptoms. At three months follow up, the mean IPSS reduced down to 7.9 and QOL score improved to 1.5. The average change in IPSS and QOL score were 15.6 and 3.6; these changes were statistically significant and correlated with preoperative symptom severity. Most of the patients presented with severe symptom associated with decreased QOL. After TURP, there was significant improvement in IPSS and QOL scores. The improvement was graded as good out come and strongly related to preoperative symptom severity.

Iliopsoas abscess: analysis and perspectives from an endemic region of Eastern Nepal.

OBJECTIVE: To evaluate the clinical profile and outcome in patients with iliopsoas abscess. METHODS: A descriptive study was carried out in B.P. Koirala Institute of Health Science, Dharan, Nepal from February 2005 to March 2006. The medical records of all thirty six patients admitted in surgery ward with diagnosis of iliopsoas abscess during the study period were analyzed. RESULTS: Thirty six patients were included the study. There were 22 (61.1%) males and 14 (38.9%) females with a mean age of 24.33 +/-19.19 years. Demographic distribution of the patients revealed the highest number 13 (36.1%) from Sunsari district, eastern part of the country. Right sided unilateral involvement was the most common presentation and only 2 cases had bilateral involvement. In none of our patients the dorsolumbar spine radiograph revealed any involvement of the bone. The most common complaints were pain in lower abdomen and lump in iliac fossa with flexion deformity at hip joint. All the patients underwent open surgical drainage and their outcomes were analyzed in term of cure, morbidity and mortality. Staphylococcus aureus was the most common organism 24 (61.5%) isolated. Twenty two (91.66%) of Staphylococcus aureus samples were sensitive to ciprofloxacin. There was one mortality in the group who died of septicaemia secondary to necrotizing fascitis. Six patients had wound infection, which were cured by regular dressing. CONCLUSION: On the basis of our experience and review of available relevant literature, we can conclude that a high index of suspicion and awareness of the varying clinical picture are required to diagnose this condition properly. Ultrasonography should still be the preferred imaging modality as it is cheap, safe, cost effective and readily available. Ciprofloxacin should be used as a first line drug. Image guided aspiration may be practical in selected cases having little pus and traditional open drainage should be considered without hesitation.

Factors influencing mortality in perforated duodenal ulcer following emergency surgical repair.

Duodenal perforation is a common abdominal catastrophe with excellent outcome if prompt resuscitation and surgical repair of perforation are done. The aim of this study was to identify factors associated with death after surgery in patients with duodenal perforation. One hundred and forty-five patients who underwent Graham's patch repair for perforated duodenal ulcer between 14 April 2002 and 31 December 2004 were studied. The mean age was 45.99 years and 61 patients (42.07 %) were referrals. There were 124 (85.52 %) males and 21 (14.48 %) females. There were 10 deaths (6.9 %). The mean time delay was 2.46 days. It was 2.37 days in survivors, 3.7 days in non-survivors. The time delay was 3.25 days for females and 3.13 days for patients referred from another hospital. The mortality was significantly associated with time delay between perforation and operation (p<0.01), presence of co-morbid conditions (P<0.04), respiratory rate (p<0.02), raised blood urea (p<0.01) and serum creatinine (p<0.001), size of perforation (p<0.005), amount of peritoneal fluid (p=0.003) and requirement of postoperative intensive care unit support (p=0.003). Time delay between perforation and operation, preoperative blood urea and serum creatinine, size of perforation and amount of peritoneal fluid, presence of co-morbid conditions and need for post operative ICU support are the important predictors of outcome after emergency surgery for duodenal perforation.

Gall bladder carcinoma: stroke as first manifestation.

Clinical presentation of gall bladder carcinoma with distant metastasis is extremely rare. We report a 73-year-old lady who presented with right-sided hemiparesis. CT scan showed a left frontal lobe tumor. Excision of the tumor resulted in improvement of neurological functions. Further workup revealed a gall bladder mass with liver nodules.

Chest radiographs and their reliability in the diagnosis of tuberculosis.

Radiology plays an important role in the diagnosis of pulmonary tuberculosis. Many medical practitioners believe in and rely primarily on the chest x-ray for the diagnosis of pulmonary tuberculosis. This study attempts to evaluate the reliability and validity of chest radiographs. This study was carried out in the tuberculosis clinic of BPKIHS. 75 radiographs were chosen for the study and viewed by 25 physicians of varying qualifications. Their findings were compared with the gold standard. The overall sensitivity and specificity was 78% and 51% respectively. There was poor agreement between the best physician and the best radiologist. This study has demonstrated an unsatisfactory sensitivity and specificity of chest x-rays in the diagnosis of pulmonary tuberculosis. The over-diagnosis and over-treatment due to chest x-rays could lead to an unmanageable burden on the resources of a poor country like Nepal. Private practitioners should be made aware about the importance of bacteriological diagnosis of tuberculosis before initiating drug therapy.

Tuberculous splenic abscess--a case report and review of literature.

Splenic abscess due to tuberculosis is a rare condition and is mostly diagnosed in immuno-compromised hosts. A case of tuberculous splenic abscess detected incidentally after splenectomy without any underlying disease is reported in an immuno-competent patient.

Solitary tuberculous abscess of liver.

Tuberculous liver abscess (TLA) is an extremely rare condition even in the country where tuberculosis is an alarming public health problem. Here a case of TLA is reported from Nepal with diagnostic and management principles and review of literature.

Congenital infantile fibrosarcoma of the upper extremity.

Congenital-infantile fibrosarcoma is an unusual childhood tumor that occurs mainly in children under 5 years of age. More than 300 cases have been reported in the literature so far, very few of them at birth. A distinction must be made between it and its adult counterpart because of differences in their clinical behaviour. We report here a case of congenital fibrosarcoma in a 4-day-old female infant.

Hydatid cyst presenting as a breast lump.

We report a 33-year-old woman who presented with a breast lump which, on pathological examination, was found to be a hydatid cyst. There was no evidence of any coexistent lesion elsewhere. To our knowledge, this represents the first case of hydatid disease of the breast reported from Nepal.

Antibiotic prophylaxis in elective cholecystectomy: a randomized, double blinded study comparing ciprofloxacin and cefuroxime.

A prospective, randomised and double blind study was undertaken to compare the prophylactic efficacy of ciprofloxacin and cefuroxime in 155 patients undergoing elective cholecystectomy. Patients with past history of jaundice or presence of jaundice, diabetes mellitus, common bile duct stones and previous biliary tract surgery were excluded. Patients were allocated to the following groups: group A-no antibiotic (n = 30); group B-ciprofloxacin (200 mg i/v before surgical incision and a second dose after 12 hrs) (n + 45); group C-ciprofloxacin given only post operatively (200 mg i/v, 12 hourly X 2 days followed by oral 500 mg twice daily X 3 days) (n = 35); group D-cefuroxime (750 mg i/v before surgical incision and a second dose after 12 hrs) (n = 45). Efficacy of the antibiotic was defined as a patient being free of post operative wound infection. Maximum numbers of infection occurred in group A (26.67%) and group C (25.71%). The incidence of wound infection was significantly lower when ciprofloxacin was used as prophylaxis (group B) than when used post operatively (group C) only (P < 0.05). Patients who received ciprofloxacin (group B) and cefuroxime (group D) as prophylaxis had significantly reduced incidence of infection (4.44% and 6/67% respectively); no statistically significant difference was found between these groups. Ciprofloxacin could be used as prophylactic antimicrobial in elective cholecystectomy in developing countries because of its effectiveness, economy and ready availability.