Initiation of Liver Transplant in Nepal: A Milestone.

Background: The incidence of chronic liver disease is increasing in the Nepalese population. Liver transplantation (LT) is the best option for patients with end-stage liver disease (ESLD). Nepal's first liver transplant was performed in 2016 in an international collaborative effort at Shahid Dharmabhakta National Transplant Centre (SDNTC), Bhaktapur, Nepal. We aim to report details of the first five patients who had undergone liver transplantation in SDNTC before the beginning of the COVID-19 outbreak in the history of transplantation in Nepal. Method: A descriptive analysis of the clinical data of five adult recipients of liver transplantation at SDNTC was done. We described the patient's demographics, length of stay, and survival of all the first five patients who had undergone four living donor liver transplantations and one brain-dead donor liver transplantation in SDNTC before the beginning of the COVID-19 outbreak. Results: Recipients were between 36 and 63 years old. The recipients of the four live donor liver transplants (LDLT) and one brain-dead donor liver transplant (DDLT) had alcoholic liver disease and cryptogenic liver disease, leading to end-stage liver disease. The model for end-stage liver disease (MELD) scores ranged from 23 to 34. Out of five, four recipients and four donors are doing well and relishing the prospect of a normal life, while the recipient of a brain-dead donor liver transplant passed away due to postoperative primary graft failure. Conclusion: Despite the small number of liver transplants that have been done, the success of these has created confidence in a sustainable liver transplantation program in Nepal.

Kidney transplantation from brain-dead donors in Nepal: Report of first six cases.

Introduction: and importance: Kidney transplantation is one of the best treatment options for patients with end-stage renal disease. More than 90% of patients awaiting renal transplantation die without getting the kidney for transplantation. Brain dead donor kidney transplantation can bridge this gap proficiently. We aim to report details of the first six patients who had undergone brain-dead donor kidney transplantation in the history of transplantation in Nepal. Case presentation: We conducted a descriptive analysis of clinical data of six adult recipients with kidney transplantation from three brain-dead donors. We described postoperative complications, length of stay, graft function which was documented with serum creatinine, acute rejection episode, delayed graft function, and patient/graft survival of recipient. Recipients were between 15 and 56 years old. Three patients experienced delayed graft function. Urinary tract infection was observed in two patients, both of whom were treated with antibiotics. One patient had acute graft rejection. None of our patients required reoperation. Length of hospital stay ranged from 9 to 32 days. The postoperative graft function was 100% in all patients. There was no graft loss, and no death was observed during follow-up. Clinical discussion: Following the initiation of the brain-dead donor transplantation program, a lot of work needs to be done to make it a regular practice. Thus, this program needs support from all sections of society and government. This can be the only solution to decrease the huge gap between the supply and demand of organs in Nepal. Conclusion: This case reports indeed revealed impressive success in initiating a brain-dead donor kidney transplantation program in a developing country that in terms of quality, meets comprehensive standard with acceptable graft function and patient/graft survival in under limited resources healthcare setting.

Impact of society and national guidelines on patient selection for lung cancer surgery in the United Kingdom.

OBJECTIVES: We sought to evaluate the impact of different national clinical guidelines (with consistent and conflicting recommendations) on clinician's practice in the UK. METHODS: In this cohort study, we analysed data from National Lung Cancer Audit comprising all patients diagnosed with lung cancer between 2008 and 2013 within England and Wales for consistent (British Thoracic Society and National Institute of Clinical Excellence) recommendations for lower/more permissive lung function but opposing stage (N2) selection parameters for surgery. RESULTS: From 2008 to 2013, data from 167 192 patients with primary lung cancers were included. The proportion of patients undergoing surgery for lung cancer increased from 9.5% to 20.5% in 2013 (P < 0.001) as the number of general thoracic surgeons in the UK increased from 40 to 81 in the corresponding timeframe. Mean forced expiratory volume in 1 s of surgical patients increased from 76% (22) to 81% (22) in 2013 (P < 0.001). Of the patients undergoing surgery, the proportion of patients with N2 disease across the 6-year interval was broadly consistent between 8% and 11% without any evidence of trend (P = 0.125). CONCLUSIONS: Within 3 years of new clinical guideline recommendations, we did not observe any overall change suggesting greater selection for surgery on lower levels of lung function. When presented with conflicting recommendation, no observable change in selection was noted on surgery for N2 disease. The observed increase in surgical resection rates is more likely due to greater access to surgery (by increasing number of surgeons) rather than any impact of guideline recommendations.

Results of surgery for chronic pulmonary Aspergillosis, optimal antifungal therapy and proposed high risk factors for recurrence--a National Centre's experience.

BACKGROUND: Surgery for pulmonary aspergillosis is infrequent and often challenging. Risk assessment is imprecise and new antifungals may ameliorate some surgical risks. We evaluated the medical and surgical management of these patients, including perioperative and postoperative antifungal therapy. METHODS: Retrospective study of patients who underwent surgery for pulmonary aspergillosis between September 1996 and September 2011. RESULTS: 30 patients underwent surgery with 23 having a preoperative tissue diagnosis while 7 were confirmed post-resection. The median age was 57 years (17-78). The commonest presenting symptoms were cough (40%, n = 12) and haemoptysis (43%, n = 13). Twelve (40%) patients had simple aspergilloma (including 2 with Aspergillus nodules) while the remaining 18 (60%) had chronic cavitary pulmonary aspergillosis (CCPA) (complex aspergilloma). Most of the patients had underlying lung disease: tuberculosis (20%, n = 6), asthma (26%, n = 8) and COPD (20%, n = 6). The procedures included lobectomy 50% (n = 15), pneumonectomy 10% (n = 3), sublobar resection 27% (n = 8), decortication 7% (n = 2), segmentectomy 3% (n = 1), thoracoplasty 3% (n = 1), bullectomy and pleurectomy 3% (n = 1), 6% (n = 2) lung transplantation for associated disease. Median hospital stay was 9.5 days (3-37). There was no operative and 30 day mortality. Main complications were prolonged air leak (n = 7, 23%), empyema (n = 6, 20%), respiratory failure requiring tracheostomy /reintubation (n = 4, 13%). Recurrence of CCPA was noted in 8 patients (26%), most having prior CCPA (75%). Taurolidine 2% was active against all 9 A. fumigatus isolates and used for pleural decontamination during surgery. CONCLUSIONS: Surgery in patients with chronic pulmonary aspergillosis offered good outcomes with an acceptable morbidity in a difficult clinical situation; recurrence is problematic.

Is type and screen only policy safe for patients undergoing elective lobectomy?

OBJECTIVE: The purpose of this study was to establish the safety and feasibility of a recently adopted policy to type and screen (TS) (group and save) only for selected patients who had low likelihood of transfusion requirement. METHODS: The TS only policy was applied to patients undergoing first-time elective lobectomy with Hb of >11 g/dl, aged <70 years, with no clotting abnormality and no history of neoadjuvant therapy. A retrospective analysis of prospectively collected data was made of 208 consecutive patients undergoing elective lobectomy from November 2009 to October 2010. The patients who were only type and screened (Group TS, n = 87) were compared with those who had preoperative cross matching (XM) (Group XM, n = 121). The perioperative characteristics, transfusion requirements and outcomes were compared between the two groups. RESULTS: Preoperative characteristics of the two groups were similar, except that the XM group were significantly older, with lower mean preoperative haemoglobin levels. Postoperative complications (9 vs 13%, P = 0.24) and hospital mortality (0 vs 0.8%, P = 0.5) were similar between TS and XM, respectively. On the day of operation, 16 patients (13%) required transfusion in the XM group. Six patients in the TS group were cross matched, of whom only 3 (3.4%) actually required transfusion. The mean postoperative Hb levels in XM were also significantly lower (12.96 vs 10.88 gm/dl). In the XM group, 260 units of blood were unnecessarily cross matched and had to be returned to the blood bank compared with zero units in the TS group. There was no delay caused by unavailability of blood at the time of clinical need. CONCLUSION: Our data suggest that it is safe and feasible to adopt a policy of type and screen only in selected patients undergoing elective lobectomy, who have low likelihood of transfusion requirement.

Aortic valve replacement: is porcine or bovine valve better?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'Is porcine or bovine valve better for aortic valve replacement?' Altogether, 562 papers were found using the reported search, of which 15 represented the best evidence to answer the question. All papers represent either level 1 or 2 evidence. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This best evidence paper includes 9880 patients from 1974-2006 to compare both valve types. All studies compared either all or some of the following outcomes: complication, durability, mortality, functional status and haemodynamic function. Ten of 15 papers assessed the complication profile due to aortic valve replacement in both valve types. Four papers concluded that bovine valves are superior, whereas only one favoured porcine valves. Five papers showed a similar complication profile between both valves. Six of 15 papers commented on valve durability. Both porcine and bovine valve groups have two papers each to support their superiority in valve durability. Two papers demonstrated similar durability in both valves. There are 11 papers comparing the postoperative mortality. We suggest that there is no difference in mortality profile as eight papers showed that both valves had similar mortality profiles. Two papers supported bovine valve and one paper supported porcine valve in this aspect. There were four papers assessing the postoperative functional status, with three papers suggesting that both valve types had similar clinical improvement postoperatively. Eleven papers compared the haemodynamic function. Nine papers were in favour of bovine valves. Two papers demonstrated similar haemodynamic profiles in both valves. In conclusion, the bovine valve is superior in its complication and haemodynamic profiles. Both bovine and porcine valves have comparable results with regard to the mortality, postoperative functional status and valve durability. Significant variability between the valve manufacturers, study designs, study period and patient population in the above studies impose limitations to the comparison of both valves.

Active treatment rates for lung cancer in south Manchester: are we doing enough?

In an effort to improve the current lung cancer treatment outcomes in Britain, National guidelines were published followed by the introduction of National Lung Cancer Audit (LUCADA) project. LUCADA has defined active treatment as any therapeutic intervention with the aim of improving the quality or length of patients' survival irrespective of whether it is curative or palliative. From August 2003 to December 2006, all patients diagnosed to be new primary lung cancer referrals were enrolled into a prospective study. Out of the total of 433 patients the majority of patients were male (62%) and the mean age was 69 years. The histologies were small cell lung cancer (SCLC), non-small cell lung cancer (NSCLC) and other cancers in 67 (15.5%), 306 (70.7%) and 11 (2.5%) patients, respectively, while 49 (11.3%) patients had no histological confirmation. Overall, the active treatment rate was 72% with 74 (18%), 158 (36%), 66 (15%) and 11 (3%) undergoing surgery, chemotherapy, radiotherapy and other methods, respectively. The active treatment rates for histologically proven SCLC, NSCLC and all lung cancers excluding SCLC were 83%, 77% and 71%, respectively, compared to the LUCADA national average of 73.5%, 66% and 56.5%, respectively. Among the NSCLC patients overall five-year survival was 27.4%. The stage specific survivals were 64.0%, 58.3%, 24.1% and 11.5%, respectively, for stages I, II, III and IV. These reassuring results show that south Manchester has good active treatment rates for lung cancer with survival outcomes comparable to other major series.

Emergency redo mitral valve replacement and caesarean section in a patient with previous atrioventricular septal defect repair in childhood.

A 19-year-old primigravida, with a history of mechanical mitral prosthesis at the age of six years following previous repair of an atrioventricular septal defect, presented at 26 weeks' gestation with cardiogenic shock secondary to obstruction of the mitral prosthesis. She underwent successful emergency redo mitral valve replacement and caesarean section. At operation the prosthesis was found to be virtually completely obstructed with pannus. Both mother and baby had an excellent outcome following surgery. The case report is presented with a brief review of the literature.

Implications of a negative bronchoscopy on waiting times to treatment for lung cancer patients: results of a prospective tracking study.

OBJECTIVE: To ascertain the causes of delays in treatment to all patients presenting to our centre with a working diagnosis of lung cancer. All were entered prospectively into a 'tracking study'. METHODS: Of 342 consecutive confirmed cases of newly diagnosed lung cancer presenting between September 2003 and December 2005, 193 were general practitioner referrals and 149 presented through casualty and internal referrals. The former group formed the basis of the study. Of GP referral patients, 92 had a positive diagnostic bronchoscopy (group Bronch+). Their waiting times were compared with 94 others with negative result (group Bronch-). For uniformity of comparison the non-GP referral patients were excluded from this study. RESULTS: There were no significant differences in the age, clinical presentation or clinical staging of the two groups. Bronch+ had higher proportion of male patients (p=0.05). Bronch+ group had higher proportion of small cell and squamous cell carcinoma whereas Bronch- group had higher prevalence of adenocarcinoma (p=0.02). More patients in Bronch- underwent curative (36 vs 18, p=0.01) intent treatment. Though the median intervals (days) between the referral to first chest outpatient appointments were similar between the two groups (1 vs 1, p=0.89), the intervals from out-patient to decision-to-treat (33 vs 57, p=0.001) and decision-to-treat to treatment (8 vs 12, p=0.05) were significantly longer for Bronch- group. Overall the median referral to treatment interval for Bronch- was significantly longer compared to Bronch+ (45 vs 75, p=0.001). Most of these delays occurred in the intervals from outpatient appointments to decision-to-treat. CONCLUSIONS: A negative initial bronchoscopy in a suspected lung cancer patient implies a greater potential for excessive delays in diagnosis and treatment in spite of a greater chance of curative treatment. Most of the delay occurs in the interval from the outpatient appointment to decision-to-treat. Patients with negative bronchoscopy require a more concerted effort to achieve a timely diagnosis and treatment.

Long-term event-free survival with an embolised prosthetic valve leaflet in the thoracic aorta.

We report the case of a patient who underwent a redo surgery for a leaflet escape from a Bjork-Shiley tilting disc mitral prosthesis inserted 18 years previously. The escaped disc remained lodged in the thoracic aorta without any complication. She ultimately died of terminal heart failure 13 years after the second operation. We believe this to be the longest survival with a dislodged leaflet from a mechanical valve. Removal of dislodged disc is recommended in literature but there may be a place for watchful observation in exceptional cases with no haemodynamic compromise.

Cardiac compression following cardiac surgery due to unrecognised hiatus hernia.

A 76-year-old man who had undergone a routine coronary artery bypass grafting operation developed severe haemodynamic instability in the early postoperative period in spite of multiple inotropic supports. Due to persistent instability of haemodynamics and worsening acidosis his chest was re-explored with detection of no obvious abnormality. An intra-aortic balloon pump (IABP) was inserted for additional support. The chest had to be left open overnight and closed formally next morning. A chest X-ray at that stage showed a large hiatus hernia with huge gastric dilatation compressing the heart. Decompressions of the stomach lead to dramatic improvement in his circulatory status with rapid weaning of inotropes and IABP and he could be extubated. This case illustrates the importance of recognising the presence of hiatus hernia in preoperative chest X-ray and prophylactic NG tube insertion at the time of cardiac surgery in these cases.

Lung cancer resection rate in south Manchester: is it comparable to international standards? Results of a prospective tracking study.

The UK has been reported to have the lowest resection and survival rates for lung cancer patients. These reports were based largely on retrospective data from the cancer registry and are now outdated. To monitor the present day surgical resection rate at our institution all newly diagnosed cases of lung cancer presenting to us were enrolled into a prospective tracking study. From September 2003 to March 2005 all suspected primary lung cancer referrals to the North West Lung Centre were tracked to identify patients with newly diagnosed lung cancer. The histology of 247 patients confirmed to be new lung cancer cases were small cell (SCLC), non-small cell (NSCLC) and mixed cancers in 33 (16%), 170 (83.5%) and 1 (0.5%) patients, respectively, while 43 patients had no histological confirmation. Overall, 43 patients (17%) underwent surgery while chemotherapy and radiotherapy were used in 91 (38%) and 43 (17%), respectively. Out of 170 confirmed NSCLC patients, 43 (25%), 65 (38%) and 27 (16%) patients underwent surgery, chemotherapy and radiotherapy, respectively. The remaining 35 (20%) did not receive any treatment because of patient wishes or poor condition. The surgical resection rates were 17% for all lung cancers and 25% for NSCLC. Current surgical resection rates at the South Manchester University Hospital are comparable to international standards. Similar data from the rest of the UK are required to determine the national resection rate, which may not be as low as once thought to be.

Primary cardiac sarcoma: reports of two cases and a review of current literature.

Primary cardiac sarcomas are rare tumors with an unfavourable prognosis. Complete surgical resection is currently the only mode of therapy proven to show any benefit. We report the cases of two patients presenting with features of obstruction and embolism and a presumed diagnosis of left atrial myxoma. At operation they were unexpectedly found to have large tumours raising strong suspicions of malignancy. Due to the extensive involvement of intracardiac structures with little possibility of reconstruction together with poor general condition of the patient, debulking was deemed to be the only viable option. Subsequent histology confirmed the diagnosis of sarcoma in both patients. Surgery produced immediate and effective symptom relief. The first patient died four months after the operation and second patient is still alive at 12 months after her operation. A brief review of literature on cardiac sarcoma is presented.

Are we achieving the current waiting time targets in lung cancer treatment? Result of a prospective study from a large United kingdom teaching hospital.

BACKGROUND: Recent United Kingdom National Cancer Plan guidelines have specified a number of waiting time targets to prevent delays in the treatment of lung cancer. This study was performed to compare our waiting times with national recommendations. METHODS: All newly diagnosed cases of lung cancer presenting to our institution were entered into a prospective tracking study by a dedicated audit officer. From September 2003 to December 2005, a total of 342 patients were entered into the study. Of these, 193 (56%) were referred by general practitioners; the remaining 114 (46%) were internal referrals. The Cancer Plan waiting time targets are mainly applicable to general practitioners referrals, which formed the study group. RESULTS: All the patients were seen in chest outpatient clinics within the recommended 2-week period. However, there was a delay in starting all forms of treatment. The median waiting time to any form of treatment was 60 days (recommendation, 62 days for all patients). From specialist referrals, the median waiting times for radiotherapy, surgery, and chemotherapy were 43, 25, and 16.5 days compared with recommended maximums of 28, 28, and 7 days, respectively. CONCLUSION: These data demonstrate that although patients receive outpatient consultation in the recommended time period, the National Cancer Plan treatment target of 62 days for patients referred by general practitioners is not being achieved. A concerted effort by all clinicians is required to meet the prescribed target times.

UK waiting time targets in lung cancer treatment: are they achievable? Results of a prospective tracking study.

BACKGROUND: Recent guidelines have specified a number of waiting time targets to prevent delay in the treatment of lung cancer. This study was carried out to assess the quality of lung cancer services and compare with national recommendations. METHODS: All newly diagnosed cases of lung cancer presenting to our institution via general practitioner referral were entered into a prospective tracking study by a dedicated audit officer. From September 2003 to March 2005 a total of 247 patients were entered into the study. Of these 133 (54%) were referred by general practitioners and the remainder 114 (46%) were internal referrals. The Cancer Plan waiting time targets are mainly applicable to GP referrals, which formed the study group. RESULTS: All the patients were seen in chest out-patients clinic within the recommended two weeks period. However there was a delay in starting all forms of treatment. The median waiting time to any form of treatment was 60 days (recommendation 62 days for all patients). CONCLUSION: This data demonstrates that although patients receive out patient consultation in the recommended time period, the National Cancer Plan 62 days GP referral to treatment target is not being achieved. A concerted effort by all clinicians is required to meet the prescribed target times.

Preoperative embolization followed by surgical excision of an intrapericardial pheochromocytoma.

A teenager with palpitations and hypertension was found to have an intrapericardial pheochromocytoma of the left atrium with multiple feeding collaterals. Radiologic embolization was carried out on the major feeding arteries to the tumor preoperatively with good angiographic result. Surgery was carried out the following day through a median sternotomy approach and cardiopulmonary bypass. Minimal bleeding was observed due to prior embolization. The patient made a rapid postoperative recovery and was discharged 7 days later.

Effect of risk-adjusted, non-dialysis-dependent renal dysfunction on mortality and morbidity following coronary artery bypass surgery: a multi-centre study.

OBJECTIVE: As little is known about the impact of non-dialysis-dependent renal dysfunction on short- and mid-term outcomes following coronary surgery we have conducted a large multi-centre study comparing patients with no history of renal dysfunction to those with preoperative renal dysfunction. METHODS: Data was prospectively collected on 19,625 consecutive patients undergoing isolated coronary surgery between 1997 and 2003 from four institutions. Sixty-seven patients had a history of dialysis support prior to coronary surgery, and were excluded from the main analysis of the study. The remaining 19,558 patients were divided into two groups based on preoperative serum creatinine level, patients with preoperative renal dysfunction with serum creatinine levels >200 micromol/L without dialysis support and control patients with preoperative serum creatinine levels <200 micromol/L. Case-mix was accounted for by developing a propensity score, which was the probability of belonging to the non-dialysis-dependent renal dysfunction group, and included in the multivariable analyses. RESULTS: There were 19,172 patients with preoperative serum creatinine levels <200 micromol/L and 386 patients with serum creatinine levels >200 micromol/L without dialysis support. The propensity score included sex, body mass index, co-morbidity factors (respiratory disease, diabetes, cerebrovascular disease, hypertension, and hypercholesterolemia), ejection fraction, left main stem stenosis, emergency status, prior cardiac surgery, off-pump surgery, and the logistic EuroSCORE. After adjusting for the propensity score, patients with preoperative non-dialysis-dependent renal dysfunction had significantly higher in-hospital mortality (adjusted odds ratio 3.0, p < 0.001), stroke (adjusted odds ratio 2.0, p = 0.033), atrial arrhythmia (adjusted odds ratio 1.5, p = 0.003), prolonged ventilation (adjusted odds ratio 2.1, p < 0.001), and post-op stay > 6 days (adjusted odds ratio 2.6, p < 0.001). One thousand one hundred and eighty-three (6.1%) deaths occurred during 58,062 patient-years follow-up. After adjusting for the propensity score, the adjusted hazard ratio of mid-term mortality for non-dialysis-dependent renal dysfunction was 2.7 (p < 0.001). CONCLUSIONS: Patients undergoing coronary surgery with non-dialysis-dependent renal dysfunction have significantly increased perioperative morbidity and mortality. Mid-term survival is also significantly reduced at 5-years.

Acute intraoperative malfunction of aortic valve due to surgical glue.

The use of surgical glues in aortic surgery has gained wide popularity due to their hemostatic and tissue reinforcing properties. Reports of acute complications associated with application of glue are rare. We report the case of a 52-year-old fragile, steroid-dependent woman who developed acute intraoperative dysfunction of an aortic prosthetic valve due to use of BioGlue surgical adhesive. A brief literature review of the acute and long-term complications of the glue is presented.

Off pump coronary artery bypass grafting in a patient with tracheopathia osteoplastica.

Tracheopathia osteoplastica is a rare disease of the tracheobronchial tree, which is often misdiagnosed and recognised only at post-mortem. We report the case of a 66-year-old man with this condition, mistakenly thought to be suffering from chronic bronchiectasis. He underwent successful coronary artery bypass grafting for unstable angina using an off-pump technique. A case report and brief literature review is presented.

Benign gastro-bronchial fistula - an uncommon complication of esophagectomy: case report.

BACKGROUND: Gastro-bronchial fistula (GBF) is a rare and devastating complication following esophagectomy. Making the correct diagnosis is difficult and there is no agreement on the treatment for this rare condition. CASE PRESENTATION: We report the case of a 56-year-old man who presented with features of repeated aspiration and chest infections six years following an esophagectomy for Barrett's esophagus. Despite extensive investigations the cause of symptoms was difficult to determine. The correct diagnosis of fistula from stomach to right main stem bronchus was made at bronchoscopy under general anesthesia. After ruling out local recurrence of cancer, a successful primary repair was carried out by resection of fistula and direct repair of gastric conduit and bronchus. He is well after 6 months of treatment. CONCLUSION: Late development of gastro-bronchial fistula is a rare complication of esophageal resection that may be difficult to diagnose. Surgical resection and direct closure is the treatment of choice, although the method of treatment should be tailored according to the anatomy of the fistula and the patient's condition.