Benign duodenojejunal junction stricture: a case report.

Introduction: Duodenojejunal stricture is a rare entity that has been attributed to peptic stricture, malignancy, chronic pancreatitis, Crohn's disease and other benign causes. Case presentation: The authors present a case of a 67-year-old male who presented with upper abdominal pain for 2 weeks, 2 episodes of bilious vomiting, and inability to pass stool and flatus for 1 day. He had a history of chronic upper abdominal pain over the last 40 years and pulmonary tuberculosis 50 years back.Computed tomography (CT) scan of the abdomen and pelvis showed short segment narrowing in the fourth segment of the duodenum with dilated first, second and third segment duodenal loops. Resection and end-to-end duodenojejunal anastomosis was performed and the outcome was normal. Discussion: Benign duodenojejunal can be treated with balloon dilatation, stenting, strictureplasty and resection anastomosis. Treatment should be offered considering efficacy, availability, complications of these modalities and aetiology. Conclusion: Anterograde push enteroscopy and CT scan can aid in preoperative diagnosis of duodenojejunal stricture. Even in older age groups without prior surgical history, benign duodenojejunal stricture can be the cause of intestinal obstruction. Resection and end-to-end duodenojejunal anastomosis can be safe and effective treatment modalities for duodenojejunal junction stricture.

Hepatic angiomyolipoma masquerading as abdominal pain: A case report.

INTRODUCTION AND IMPORTANCE: Hepatic angiomyolipoma (HAML) is a rare liver tumor composed of blood vessels, smooth muscle, and fat cells. HAML occurs across a wide age range, with symptoms including abdominal discomfort, bloating, and weight loss. Diagnosis is challenging due to varied imaging appearances, but histopathological examination supplemented by immunohistochemical analysis, particularly using HMB-45, is definitive. CASE PRESENTATION: A 33-year-old man presented with a two-year history of right upper quadrant abdominal pain, occasionally relieved with analgesics but worsening over the past month and a half. Examinations revealed a soft, non-distended abdomen with a palpable liver. Laboratory tests, including viral markers and tumor markers were normal. Contrast-enhanced CT revealed a well-defined oval mass in liver segment III with heterogeneous enhancement leading to provisional diagnosis of HAML. The patient underwent a successful en bloc excision with no intraoperative or postoperative complications. CLINICAL DISCUSSION: Surgical resection is recommended for symptomatic cases or inconclusive biopsies, with stringent follow-up necessary due to the potential for recurrence and association with other malignancies. CONCLUSION: HAML may present with prolonged nonspecific abdominal symptoms. CT imaging aids in diagnosing cases with abundant fatty tissue. En bloc tumor excision proves safe and effective in treating symptomatic presentations.

Pelvic and peritoneal hydatidosis: An uncommon presentation of the common entity.

Key Clinical Message: The pelvic and peritoneal hydatidosis occurs mostly after the traumatic rupture or surgical spillage of Echinococcus from liver or spleen. The treatment is surgical aiming to eradicate local disease, preventing complications, and reducing recurrences. Abstract: We report a unique case of a 26-year-old male who presented with acute urinary retention and abdominal distention. Later, CT-urography revealed peritoneal and pelvic hydatidosis behind this presentation, which was managed surgically.

Chicken bone-induced ileal perforation peritonitis mimicking duodenal perforation peritonitis: a case report.

Introduction: Foreign body ingestion can lead to bowel perforation and peritonitis. We present a case of a 54-year-old male who ingested a chicken bone, resulting in ileal perforation that mimicked duodenal perforation peritonitis. Case Presentation: The patient has a history of peptic ulcer disease and regularly used non-steroidal anti-inflammatory drugs over the counter, adding more evidence to the provisional diagnosis of duodenal perforation. Exploratory laparotomy revealed the ileal perforation and the chicken bone was successfully removed. Wedge resection of the perforated segment and ileo-ileal anastomosis were performed. Discussion: Although history, examination, and investigation were more in favor of duodenal ulcer, our patient had ileal perforation due to chicken bone. Prompt identification and early surgical intervention are crucial to prevent complications and reduce mortality rates. The patient had an uneventful recovery. Conclusion: Timely referral to a tertiary care center is essential for early surgical intervention and successful management of bowel perforation caused by a foreign body.

Complete small intestinal obstruction due to band formation in low-grade appendiceal mucinous neoplasm: A rare case report and literature review.

INTRODUCTION: Intestinal obstruction due to external compression is a rare condition, and those caused by appendiceal neoplasms like low-grade appendiceal mucinous neoplasms are extremely rare. PRESENTATION OF CASE: A 67-year-old post-menopausal female, with no history of prior abdominal surgery, presented to the emergency room with constipation for 2 days, and peri-umbilical pain and non-projectile bilious vomiting for 19 h. There was mild abdominal distension and diffuse tenderness. After ultrasonography and Computed Tomography (CT) of the abdomen and pelvis, a provisional diagnosis of complete small bowel obstruction secondary to perforated mucinous neoplasm of the appendix was made. An emergency exploratory laparotomy was performed followed by ileo-cecal resection and ileocolic anastomosis. Intraoperative findings revealed bands extending from the appendix to the ileum forming a closed loop with gangrenous spots in the distal ileum and ascitic fluid with mucin. Later, histopathological examination findings were consistent with low-grade appendiceal mucinous neoplasm (LAMN). DISCUSSION: We reviewed three cases of intestinal obstruction, caused by compression from a LAMN, including the presented case. Preoperative diagnosis of the cause of small intestinal obstruction on CT is sometimes challenging. Hence, in patients with intestinal obstruction with a transition point in the right lower quadrant of the abdomen on CT, a high index of suspicion for an appendiceal etiology is required. CONCLUSION: LAMN with an associated band should be considered as one of the differential diagnoses in the patient presenting with symptoms of complete small intestinal obstruction without prior abdominal surgery.

Utility of the Parkland Grading Scale to determine intraoperative challenges during laparoscopic cholecystectomy: a validation study on 206 patients at an academic medical center in Nepal.

BACKGROUND: Most of the scoring systems to predict difficult laparoscopic cholecystectomy are based on pre-operative clinical and radiological findings. Recently the Parkland Grading Scale system was introduced as a simple intra-operative grading scale. This study aims to utilize the Parkland Grading Scale system to assess the intraoperative challenges during laparoscopic cholecystectomy. METHOD: This was a prospective, cross-sectional study done at Chitwan Medical College and Teaching Hospital, Chitwan, Nepal. All the patients underwent laparoscopic cholecystectomy from April 2020 to March 2021. Based on the initial intra-operative finding, Parkland Grading Scale was noted and at the end of the surgery, the level of difficulty was given by the operating surgeon. All the pre-operative, intra-operative, and post-operative findings were compared with the scale. RESULTS: Out of 206 patients, there were 176 (85.4%) females, and 30 (14.6%) males. The median age was 41 years (Range 19-75). The median body mass index was 23.67 kg/m2. There were 35(17%) patients with a history of previous surgery. The rate of conversion to open surgery was 5.8%. According to Parkland Grading Scale, 67(32.5%), 75(36.4%), 42(20.4%), 15(7.3%), and 7(3.4%) were graded as grade 1, 2, 3, 4, and 5 respectively. There was a difference in the Parkland grading scale in patients with a history of acute cholecystitis, gallbladder wall thickness, pericholecystic collection, stone size, and body mass index (p < 0.05). The total operative time, level of difficulty in surgery, rate of help needed from colleagues or replacement as the main surgeon, bile spillage, drain placement, gallbladder decompression, and conversion rate all increased with an increase in scale (p < 0.05). There was a significant increase in the development of post-operative fever, and post-operative hospital stay as the scale increased (p < 0.05). The Tukey-Kramer test for all pair-wise comparisons revealed that each grade was significantly different from each other (p < 0.05) on the difficulty of surgery except for grade 4 from 5. CONCLUSION: Parkland Grading Scale system is a reliable intra-operative grading system to assess the difficulty in laparoscopic cholecystectomy and helps the surgeon to change the strategy of surgery. An increase in scale is associated with an increased difficulty level of the surgery.

Acute abdomen due to rupture of a hydatid cyst of the liver: a rare complication - a case report.

Hydatid cyst is a parasitic disease that is transmitted from animals to humans caused by the larval stage Echinococcus, especially Echinococcus granulosus. A complication of a hydatid cyst of the liver is its rupture, either traumatic or spontaneously. Case presentation: A 19-year-old male presented with an acute abdomen for 12 h. After clinical assessment, contrast-enhanced computed tomography showed a rupture of the anterior wall of the hepatic hydatid cyst with intra-abdominal and pelvic dissemination. Exploratory laparotomy was performed with the evacuation of the daughter cyst and peritoneal lavage. The patient recovered well and was discharged with albendazole therapy. Clinical discussion: Hydatid cyst rupture is a rare but serious complication. Computed tomography has high sensitivity in demonstrating cyst rupture. The patient underwent laparotomy, where disseminated cysts were evacuated, and the anterior wall of the cyst was deroofed, along with the removal of a ruptured laminated membrane. Emergency surgery plus albendazole therapy are recommended protocols for cases like ours. Conclusions: A patient from an endemic region with acute presentation of right upper quadrant pain can have spontaneously ruptured hydatidosis as a differential diagnosis. Intraperitoneal rupture and dissemination of hydatid cysts of the liver can be life-threatening if intervention is delayed. Immediate surgery is life-saving and prevents complications.

Xanthogranulomatous Cholecystitis Mimicking Carcinoma Gallbladder.

Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and can mimic gallbladder carcinoma. Distinguishing XGC from gallbladder cancer preoperatively is challenging. We present a case of a 62-year-old male who presented with features of carcinoma gallbladder in the CECT abdomen and MRCP. Intraoperatively, there was a mass in the gallbladder and extension into the adjacent structures with involvement of the hepatic artery, 1st part of the duodenum, portal vein, and hepatic flexure of the colon, and thus a palliative cholecystectomy was done. The histopathological report came out as XCG. The case aims to outline the clinical presentation of XGC and differentiate it from carcinoma gallbladder.

Open Cholecystectomy among Patients undergoing Laparoscopic Cholecystectomy in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: In the current era, laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstone disease. The aim of this study is to find out the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy in a tertiary care centre. Methods: It is a descriptive cross-sectional study done among 345 patients at the Department of Surgery of a tertiary care centre from June, 2020 to May, 2021 after receiving ethical clearance from the Institutional Review Committee (Reference number: CMC-IRC/0770798-271). Convenience sampling was done. Successive patients who underwent elective laparoscopic cholecystectomy during the study period were included. Standard 4 port laparoscopic technique was used for the laparoscopic cholecystectomy and sub-costal Kocher incision was used for the open cholecystectomy respectively. After data collection, entry and analysis were done in Microsoft Excel. Point estimate at a 95% Confidence Interval was calculated along with frequency and percentages for binary data. Results: Out of 345 patients, the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy was 6 (1.73%) (0.35-3.11 at a 95% Confidence Interval). Conclusions: This study showed that the prevalence of open cholecystectomy among patients undergoing laparoscopic cholecystectomy was lower when compared to similar studies conducted in similar settings. Keywords: cholecystectomy; cholelithiasis; laparoscopic cholecystectomy.

Complications among Patients Undergoing Pancreaticoduodenectomy in Tertiary Care Centers of Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Pancreaticoduodenectomy (Whipple procedure), even after significant evolution, continues to be associated with a high morbidity. The study aimed to find out the prevalence of complications following pancreaticoduodenectomies performed by a single surgeon over a span of 20 years in tertiary care hospitals of Nepal. METHODS: This was a descriptive cross-sectional study conducted from hospital records of patients who underwent pancreaticoduodenectomy between 1999 and 2019 at different institutions in Chitwan, where the principal author was involved. Ethical clearance was taken from the Institutional Review Committee. Convenience sampling was done. Patients' clinical characteristics and diagnoses were noted. Data entry was done using Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage. RESULTS: Out of 327 patients who underwent pancreaticoduodenectomy, complications were found in 125 (38.2%) (32.9-43.7 at 95% Confidence Interval). Respiratory complications were the commonest 32 (9.8%), followed by septicemia 25 (7.6%) and cardiac complications 24 (7.3%). Delayed gastric emptying and postoperative pancreatic fistula were seen in 11 (6.8%) and 4 (2.5%) in the first decade respectively. In the second decade, delayed gastric emptying was noted in 2 (1.2%) and postoperative pancreatic fistula in 1 (0.6%) patient. CONCLUSIONS: The prevalence of complications in our study was comparable to other national and international studies. Surgery-specific complications such as delayed gastric emptying and postoperative pancreatic fistula showed a decline over the decade.

Role of liver enzymes in patients with blunt abdominal trauma to diagnose liver injury.

BACKGROUND: The liver is the second most injured organ following blunt abdominal trauma (BAT) after the spleen. Although the computed tomography (CT) scan is considered as the gold standard for diagnosing liver injury in BAT, it may not readily available in all the hospitals. This study was performed to evaluate the role of aspartate transaminase (AST) and alanine transaminase (ALT) in patients with BAT and its significance in predicting the diagnosis and severity of the liver injury. METHOD: The study was conducted in Chitwan Medical College Teaching Hospital (CMCTH) from February 2019 to May 2020. It was a prospective observational study. All the patients with BAT were received by on-duty surgical residents in the emergency department. Based on the imaging and operative finding, patients with liver injury and without liver injury were noted with the associated injury. For comparisons of clinical and grading characteristics between the two groups (liver injury and no liver injury), the chi-squared test was used for categorical variables as appropriate, and the Mann-Whitney U test used for quantitative variables (AST and ALT). The comparisons between more than two groups (grade of injury) were performed using the Kruskal-Wallis test. The receiver operating characteristic (ROC) was used to calculate the optimal cut-off value of AST and ALT. RESULTS: Among the 96 patients admitted with BAT, 38 patients had liver injury and 58 patients had no liver injury. The median length of the intensive care unit (ICU) stay of patients with liver injury was higher than without liver injury. There was a significant difference in the median level of AST and ALT (< 0.001) between patients with liver injury and no liver injury. The area under the ROC curve of AST was 0.89 (95% confidence interval 0.86-0.98) and of ALT was 0.92 (95% confidence interval 0.83-0.97). The area under the curve demonstrated that the test was a good predictor for the identification of liver injury and also the severity of liver enzymes. The cut-off values for the liver injury were 106 U/l and 80 U/l for AST and ALT, respectively. Based on these values, AST ≥ 106 U/l had a sensitivity of 71.7%, a specificity of 90%, a positive predictive value of 86.8%, and a negative predictive value of 77.6%. The corresponding values for ALT ≥ 80 U/l were 77.8%, 94.1%, 92.1%, and 82.8%, respectively. CONCLUSION: In conclusion, we report the optimal cut-off value of AST and ALT for liver injury in BAT as ≥ 106 U/l and 80 U/l, respectively. The elevated level of AST and ALT might assist the emergency physicians and surgeons to timely refer the suspected patients with the liver injury to a tertiary center.