Stapled haemorrhoidectomy in the operative treatment of grade III and IV haemorrhoids.

Stapled haemorrhoidectomy (SH) is a minimally invasive intervention that uses a stapling device which avoids the need for wounds in the sensitive anal area and reduces the pain after surgery. This study was undertaken in Nepal Medical College Teaching Hospital from January 2010 to December 2012 to evaluate the efficacy of this modality of treatment among patients (32) who presented in the Surgery OPD with grade III and grade IV haemorrhoids. The results of SH were evaluated by the relief of symptoms, severity of post operative pain, and complications of SH. Twenty five (78.1%) patients had grade III and 7 (21.9%) presented with grade IV hemorrhoids. The most frequent presentation reported in our study was bleeding per rectum with perianal prolapse. Mean operating time was 40-60 minutes whereas mean hospital stay was 1.9 days. Urinary retention was the most common complication found in 12 (37.5%) patients in the immediate post operative period. SH is a safe, rapid, and convenient surgical remedy for grade III and grade IV hemorrhoids with low rate of complications, minimal postoperative pain, and shorter hospital stay.

The reverse sural fasciocutaneous flap for the coverage of soft tissue defect of lower extremities (distal 1/3 leg and foot).

Soft tissue defect of the lower extremities especially over the distal third leg, ankle region, tendo achilies area, heel and foot has always been challenging for the Plastic surgeon. Though with introduction of Microsurgery, the expertise and its advances, free flap surgery to cover the defect is not possible in every center due to the sophisticated instruments, equipments and lengthy procedures. The reverse sural fasciocutaneous flap is a viable option for the soft tissue coverage of distal third leg and foot. Between Nov 2008 till Nov 2010, 11 patients with moderate size soft tissue defect (5-15 cm defect) with exposed bone, tendons and hardware of ankle joint, posterior aspect of heel, and dorsum of the hind foot and mid foot were treated with reverse sural artery fasciocutaneous flap. Out of 11 cases, 10 cases had uneventful postoperative course. In one case, we encountered complete necrosis of the flap due to venous congestion that occurred in 3rd post op day. In all other cases, the flap survived completely without any marginal necrosis. Split thickness skin graft was well taken in donor site in all other cases. The sural artery fasciocutaneous flap is versatile and reliable procedure, easy and quick to elevate, due to the long pedicle, distalization up to the dorsum of the mid foot can be achieved and also a good alternative to microsurgical procedures where such facilities are not available and the surgeon is not well familiar with the procedure.

Choledochoduodenostomy in the management of dilated common bile duct due to choledocholithiasis.

Choledochoduodenostomy (CDD) is the operative procedure for Choledocholithiasis in the presence of a dilated common bile duct (CBD). It has been reported as a most effective treatment of CBD stones than T-tube drainage but is regarded as a obsolete therapeutic method due to fears of higher morbidity, cholangitis, "sump" syndrome etc. This study was done prospectively to assess the aforementioned issues analyzing our two years (July 2009 - June 2011) experience.CDD was performed in 31 patients (22 females and 9 males) with aged 18 - 72 years. CBD stones were the only indications in all patients with 18 (45.1%) patients had cholangitis, 8 (35.4%) had cholecystitis and 5 (19.3%) had biliary colic. Abdominal sonogram revealed dilated CBD with single or multiple calculi. The diameter of CBD varies from 14 - 29mm with stone size being ranged from 10- 26mm.Early post operative complications were seen in 4 (12.9%) patients. Only one patient had recurrent cholangitis presented lately due to intrahepatic stones.CDD is a highly effective treatment for choledocholithiasis in all age group with low morbidity and mortality provided a wide anastomosis is accomplished.

Prevalence study of H. pylori infection in dyspeptic patients coming to Nepal Medical College Teaching Hospital, Jorpati, Kathmandu.

Helicobacter pylori (H. pylori) is one of the most common human infections worldwide particularly in the developing countries. It has been established as etiology of chronic gastritis and peptic ulcer disease, gastric adenocarcinoma and mucosal associated lymphoid tissue lymphoma (MALT). During this decade, there have been some reports showing a decline in global prevalence of H. pylori infection and peptic diseases including many Asian countries. Hence to determine prevalence of Helicobacter pylori infection in dyspeptic patients, this descriptive, non-interventional study was carried out at the Endoscopy sub-unit of the Surgery Department from April 2011 to February 2012. Three hundred nineteen dyspeptic patients (Male 161 and female 152) with a mean age of 20.12 years were examined for the presence of H. pylori infection by histology staining. The prevalence of H. pylori infection was 50.47%. The most common endoscopic findings was gastritis (47.6%) followed by normal findings 57 (17.87%). A total of 8.47% of gastric Ulcer, oesophagitis 5.64% and gastric cancer 0.94% were detected. All three cases of gastric cancer were positive for H. pylori infection. Among gastritis, H. pylori was observed in 67 (44%) cases and 18 out of 57 (5.6%) of normal gastric mucosa showed H. pylori. The endoscopic findings such as gastritis, gastric ulcer, duodenal ulcer and gastro duodenal reflux are significantly associated with H. pyloric infection. The prevalence of H. pylori infection is still high in peptic diseases. H. pylori infection is significantly correlated with peptic ulcer diseases than with non-ulcer dyspepsia. Further studies are required to establish the H. pylori positive cases with that of other tests such as serological detection of anti H. pylori antibody by ELISA/ICT and culture to establish a diagnosis quickly without any invasive method and institute proper management thus reducing morbidity.

Outcome analysis of breast cancer patients treated at Nepal Medical College.

Breast carcinoma is second most common malignancy among women in Nepal and is also still a killer carcinoma in our context. We are encountering with more cases of breast cancer, may be due to increase number of cases because of life style modification or due to more diagnostic facilities available in the country. Yet we most often encounter more advanced stage of breast carcinoma. In our study we had total of 21 patients who suffered from breast carcinoma. Among those patients most were elderly with mean age of 54.33 +/- 11.25 years. Among 21 patients, 13 patients were either of locally advanced type or with advanced breast carcinoma with metastasis. In our institution these patients were offered evidence based treatment as per their requirement. Since most of these patients are unaware of self breast examination and hence presented lately. Even though they were managed properly, 1 patient had local recurrence and 4 patients later presented with distant metastasis.

Pain during rigid cystoscopy: a prospective randomized controlled study comparing the benefit of cooled and room temperature lignocaine gel.

Lignocaine gel is an established topical anesthetic agent for cystoscopy in awake patients. We performed a prospective randomized study to evaluate whether cooling the lignocaine gel to 4 degrees C decreases the pain perception during cystoscopy in male patients. Sixty consecutive male patients undergoing rigid cystoscopy were randomized into two groups. Group I received 15 ml of 2% lignocaine hydrochloride gel at 4 degrees C and group II received the same agent at room temperature (20 degrees C). Cystoscopy was performed and pain perceived during the procedure was assessed by independent evaluator using Wong-Baker FACES pain scale rating chart. The mean pain score in group I was lower (4.32 +/- 1.70) than that in group II (5.28 +/- 1.99), but this difference was statistically not significant (p=0.191). However significantly greater percentage (84% Vs 52%) of patients with cooled lignocaine wished to have same anesthetic in future for similar procedure (p=0.032). In conclusion, cooling the lignocaine gel to 4 degrees C does not decrease the pain perception during rigid cystoscopy in male patients.

Inguinal herniotomy in children: a one year survey at Nepal Medical College Teaching Hospital.

This was a prospective study done at Nepal Medical College Teaching Hospital from July 2008 to June 2009 which covers our experience in inguinal herniotomy in children. Our study included 63inguinal hernia repairs in 61 children up to the age of 15 years. Out of 61 patients 2 had bilateral inguinal hernia and 59 had unilateral. Among 59 patients with unilateral hernias, 7 patients had emergency presentation. In children with unilateral hernias, it was found that it is more common at right side and regarding complication it is more common in emergency group. There were 5 recurrences and 5 wound infection among all patients.

The incidence of thyroid carcinoma in multinodular goiter: prospective study.

Thyroid carcinoma (TC) is a relatively rare tumour, but it represents the most frequent form of cancer of the endocrine glands. Epidemiologically ascertained risk factors are ionising radiation, the presence of thyroid adenoma and multinodular goiter (MNG). Multinodularity of goiter should no longer be considered an indicator of probable benign disease. A prospective analysis was performed on patients operated for multinodular Goiter at Nepal Medical College from January 2009 to November 2011, in order to establish the incidence of carcinoma. The results of this study, demonstrate that in 13.63 % of the patients operated for goiter, the presence of a carcinoma was noticed in the definitive histopathologic examination. Such incidence percentage of MNG is in accordance with the data reported in published reports. Thus, we conclude that the risk of malignancy in MNG has not to be underestimated, and that a dominant nodule in MNG should be valued as if it were a solitary nodule in an otherwise normal gland.

Factors predicting the success of a trial without catheter in acute urinary retention secondary to benign prostatic hyperplasia.

Trial without catheter (TWOC) is a common practice in acute urinary retention (AUR) secondary to benign prostatic hyperplasia (BPH) although it is not successful in all patients. We conducted this study to identify the factors predicting the success or failure of TWOC in this subset of patients. Sixty-four patients with first episode of AUR secondary to BPH were enrolled in this study. These patients were given tamsulosin 0.4 mg daily for 3 days and TWOC was performed. Baseline international prostate symptom score (IPSS), residual volume of urine drained after catheterization (RU), prostate size (PS) and intravesical prostatic protrusion (IPP) by transabdominal ultrasound were recorded. TWOC was successful in 28 (43.75%) and failed in 36 (56.25%) patients. Discriminant analysis was done to evaluate the predictive factors. IPP, IPSS, PS and RU were found to predict the outcome of TWOC. A prediction model, using cut off values, was derived using receiver operating characteristic curves (ROC). A cut-off value of 8 mm for IPP detected failures with specificity of 89% and success with a sensitivity of 92% with area under ROC (AUROC) of 0.98. Similarly cut-off values of 16 for IPSS (specificity 84%, sensitivity 81%, AUROC = 0.90), 40 gm for PS (specificity 73%, sensitivity 84%, AUROC = 0.89); and 800 ml for RU (specificity 82%, sensitivity 64%, AUROC = 0.81) were derived. IPP, baseline IPSS, PS and RU can predict the outcome of TWOC. Among these factors, IPP is the most accurate in predicting the success of TWOC.

Role of systemic anticoagulation in patients undergoing vascular access surgery.

The role of per-operative systemic heparin to improve primary patency rate of vascular access surgery is controversial. The aim of this study was to assess the risk and benefit of systemic heparin during creation of vascular access for hemodialysis in patients with chronic renal failure. Patients undergoing creation of side to end radio-cephalic arteriovenous fistula over distal forearm for hemodialysis were prospectively randomized into two groups. First group received 5000 IU of intravenous heparin during surgery whereas second group did not receive any anticoagulation. Post-operative complications and outcome of surgery were compared between the two groups. Among 50 patients, 25 received heparin and 25 did not. Although there was no significant difference in operative times between these two groups (p = 0.24), early post-operative bleeding complication was more common in patients receiving heparin (p < 0.01). The primary 6-week patency was 96.0% for patients receiving heparin and 92.0% for those not (p = 0.46). Thus per-operative systemic anticoagulation during vascular access surgery is associated with increased incidence of bleeding complication and offers no benefit in terms of primary patency

Epidemiological and bacteriological profile of burn patients at Nepal Medical College Teaching Hospital.

This study was conducted to know the epidemiological and bacteriological profile of burn patients at Nepal Medical College Teaching Hospital. The charts of 50 burn patients admitted in department of surgery were reviewed retrospectively. All the epidemiological characteristics, mode of injury, time taken to reach hospital and involved body surface areas were noted. The charts were also reviewed for bacterial isolates from burn wounds and its sensitivity pattern for various antibiotics. Data was analyzed using the statistical package for social sciences (SPSS) for Windows. The mean age of patients was 31.8 years with male:female ratio of 1.3:1. Half of the patients were from Kathmandu. Fifty two percent of patients directly came to our hospital while rests were referred from other hospitals. The average time taken to reach hospital was 11.3 hours. Those patients who were referred from outside the valley took longer time (p = 0.002). Flame burn was the leading cause for injury (66.0%) followed by scald burn (16.0%), electric burn (14.0%) and acid burn (4.0%). Staphylococcus aureus (28.0%) was the commonest organism isolated from wound swab culture. Others were Klebsiella (16.0%), Pseudomonas (13.0%), Proteus (13.0%) and E.coli (13.0%). No growth was noted in 17.0% of patients. During the treatment, 14.0% of patients died and 4.0% left against medical advice. Remaining patients were discharged after complete recovery. Body surface area involvement was found to be a significant predictor of mortality (p < 0.001) and the length of hospital stay was significantly low for them (p = 0.05).

Gallbladder stones analyzes, bile and wound cultures in cholelithiasis.

One hundred and fifty-two consecutive cases of cholelithiasis were studied. The gallbladder stones were analyzed to determine the constituents, the bile specimens were cultured and correlated with the cultures when wound infection occurred. Mixed gallstones were the commonest type (58.5%), pigment stones (27%) and cholesterol stones (14.5%). Positive bile cultures were found in 41 patients (27%) and Escherichia coli was the commonest organism isolated. The rate of wound infection was 14.5% and the most common organism cultured from the wound was staphylococcus epidermidis.

Management of hydatid cysts of the urinary tract.

Eleven patients with hydatid disease of the urinary tract have been seen in the last 5 years. Seven patients had cysts of the kidneys and 4 had large retrovesical hydatids. Seven of the 8 patients with renal hydatids presented with loin pain and mass. Three patients with renal communicating hydatids also presented with haematuria which was due to passing "grape skin" (hydatid membrane) in the urine. Two patients with retrovesical hydatids had bladder outflow obstruction and 2 had bilateral ureteric obstruction leading to uraemia. Eight of 11 patients had associated hydatids of other organs such as the liver (4 patients), peritoneal cavity (2) and lungs (1). Computed tomography was the most useful and specific investigation. In both renal and pelvic (retrovesical) hydatid cysts, endocystectomy with either partial excision or plication of the ectocyst is the standard treatment. In renal communicating hydatids the options are either nephrectomy (partial or total) or endocystectomy with closure of the communication. The use of cryocone and scolicidal agents is mandatory during surgery.

Gastric torsion: Not such a rare entity.

We describe seven patients who suffered chronic gastric torsion, seen during a 28-month period. Four were children, of which three were infants. The infants had projectile vomiting and two also had failure to thrive. The adults presented with epigastric pain and vomiting. Upper gastrointestinal series clinched the diagnosis in all patients. The classic radiographic presentation of a stomach lying across the epigastrium with the cardia and fundus in a dependent position to the body of the stomach and pylorus may be overlooked in some cases. Choice of surgical procedure in its management has been discussed. There was no associated abnormality in four of the six operated cases. One infant had an atretic bowel, vascular anomalies, umbilical hernia, and previous meconium peritonitis; a second infant had jejunojejunal intussusception. A high index of suspicion is warranted in patients presenting with recurrent abdominal pain or in infants with unexplained vomiting and failure to thrive. Upper gastrointestinal series in adults should preferably be performed while the pain is present.