Systemic Inflammatory Response Syndrome following Gastrointestinal Surgery.

INTRODUCTION: Systemic inflammatory response syndrome symptoms immediately after surgery have lately been regarded as potential warnings of impending post-operative complications and multiple organ failure. This study was conducted to find out the clinical significance of systemic inflammatory response syndrome in postoperative patients and to investigate the relationship between the duration of post-operative systemic inflammatory response syndrome and the post-operative morbidity and mortality. METHODS: Total 30 patients who received different gastrointestinal surgery and fulfilled the diagnostic criteria for systemic inflammatory response syndrome between 2006 and 2008 at Kathmandu Medical College Teaching Hospital were included. Patients were analyzed for preoperative physiologic status, surgical stress parameters, and postoperative status of systemic inflammatory response syndrome, complications, and end-organ dysfunction. RESULTS: Duration of systemic inflammatory response syndrome or positive criteria's number of systemic inflammatory response syndrome after surgery significantly correlated with surgical stress parameters (blood loss/body weight and operation time). Septic complications and prolongation of systemic inflammatory response syndrome were associated with multiple organ dysfunction syndrome and increased mortality. CONCLUSIONS: Systemic inflammatory response syndrome is a useful criterion for the recognition of postoperative complications and end-organ dysfunctions. Early recovery from systemic inflammatory response syndrome may arrest the progression of organ dysfunction, thus reducing the mortality.

Retroperitoneal hamartoma: a rare entity.

Retroperitoneal hamartoma in adult is an extremely rare entity. Here we report a case of 23-years-old lady who presented with a large retroperitoneal mass and abdominal pain. The mass was surgically removed and the diagnosis of hamartoma was made on histological findings.

Biliary complications after laparoscopic cholecystectomy.

BACKGROUND: The reported prevalence of biliary tract disruption following laparoscopic cholecystectomy has ranged from 0% to 7% in early reports. Bile leaks are the most common biliary complication of laparoscopic cholecystectomy. METHODS: Total 530 patients who had undergone laparoscopic cholecystectomy from January 2004 to November 2006 at Kathmandu Medical College Teaching Hospital were studied for biliary complications after laparoscopic cholecystectomy. RESULTS: We reviewed 500 laparoscopic cholecystectomies performed at our institution and found 13 cases of bile extravasation and/or biloma formation and/or bile duct injuries (prevalence, 2.6%). One bile duct transection was acutely recognized and treated with hepaticojejunostomy. Three lateral bile duct injuries were also acutely recognized, two of them were managed with primary repair of CBD without T tube and the other was managed with repair and T-tube drainage. Two patients had postoperative generalized biliary peritonitis, one of whom was undergone exploratory laparotomy and found to have lateral injury on CBD which was managed with repair and T-tube drainage, whereas the other was undergone diagnostic laparoscopy with clipping of duct of Lushka. Two patients presented within seven days with biloma, one was treated with percutaneous drainage alone, the other treated with percutanous drainage was found to be complete transection of CBD on subsequent ERCP and managed with late hepaticojejunostomy. One patient with continued bile leak from surgical drainage tube for more than one week was managed with ERCP, diagnosed to be bile leak from duct of Lushka, managed by sphincterotomy and bile duct stenting. One patient presented with obstructive jaundice 6 months after laparoscopic cholecystectomy was found to have Bismuth type II bile duct stricture and was undergone hepaticojejunostomy. The remaining three had bile leak from surgical drainage which resolved within one week without further complication. CONCLUSIONS: Laparoscopic cholecystectomy appears to be associated with a higher incidence of bile duct injury than previous reports of open cholecystectomy. Possible explanations include variant anatomy plus failure to obtain an operative cholangiogram, inadequate dissection, injudicious use of cautery or clip placement, inherent limitations of the procedure, or the learning curve associated with a new technology.

Histomorphological spetrum of breast lesions.

BACKGROUND: Cancer of the breast is the second most common cause of cancer in women. Mass in the breast, whether benign or malignant is a cause of anxiety to the patients and the family members. All breast lumps are considered to be carcinomas until proved otherwise and are the causes of concern both for the patient and surgeon. METHODS: This is a retrospective study conducted in Kathmandu Model Hospital for a total duration of three years from August 2007 to August 2010. RESULTS: 114 sample of breast tissue sent for histopathology were studied. Peak incidence of benign lesion was in between 21-30 years and malignant lesions in between 31-50 years. No breast lesions were seen in the first decade of life. Cancer of the breast was seen in 12.28% of cases. Fibroadenoma and fibrocystic disease were the commonest benign lesion and infiltrating ductal carcinoma was the commonest malignant lesion. Specimens from 10 male breasts were received. Gynaecomastia was the most common lesion encountered in males. Infiltrating ductal carcinoma was seen in a 70 year old male. CONCLUSIONS: Breast cancer is one of the commonest causes of breast lump particularly in women and is growing public health problem in Nepal.

Early experience of day care surgery in Nepal.

INTRODUCTION: The day care laparoscopic cholecystectomy (DCLC) is found to be safe and effective in developed countries. However, it has not been well accepted in our part of the world probably because of lack of infrastructures,established norms and published reports. We have analyzed the safety and feasibility of the procedure in the recently established first dedicated day care surgery centre of the country. METHODS: All the patients with American society of anaesthesiologist (ASA) score I and II admitted for laparoscopic cholecystectomy are included. Operation are performed in the morning and closely observed till evening. Patients found to be medically fit to discharge; having a responsible person at home and who can make their own arrangements in case of problems were advised for discharge. Follow up was done by telephone call from next morning. RESULTS: Total 35 patients underwent laparoscopic cholecystectomy. Age range was between 16-65 years and most of them were females (88%). Only 30 patients were operated in early morning and were eligible for day care surgery. 25 (83%) Patients were advised for discharge but only 10 (33%) could make arrangement. Other 15 patients could not go home mainly due to different psychosocial reasons. Only one patient needed readmission and Complications observed were minor and relatively few. CONCLUSIONS: Day care laparoscopic cholecystectomy is safe and feasible in our set up. Acceptance of the procedure is expected to increase once it is regularly practiced and awareness in improved.

Use of percutaneous thread loop to hold the vermiform appendix during laparoscopic appendectomy.

INTRODUCTION: Laparoscopic appendectomy, although not as widely performed as laparoscopic cholecystectomy, it has got definite advantage over the conventional open procedure. Controversy exists regarding the closure of stump. Our institute practices intracorporeal knot tying using 3 ports. Difficulties are observed in three port technique to hold the appendix during knot tying. We use a percutaneous thread loop. Advantage of the use of loop was evaluated. PATIENTS AND METHOD: Prospective study was carried out during 18 months. Total cases were randomly divided in non-loop and with loop group. Operative procedure was same. Cases were compared in terms of operating time, post-operative hospital stay and complications. RESULTS: Total patients were 66. Thirty two in non-loop group and 34 in with loop group. Mean age was 27.89 yrs. Most of the cases were females (62%). Mean operating time was less in loop group although statistically not significant. There was no difference in post operative hospital stay. Use of loop was not associated with added complications. CONCLUSION: Use of percutaneous loop to hold the appendix reduces the operating time and replaces the need of fourth port. It is safe and effective without any increased morbidity. Key words: Laparoscopic appendectomy, Intracorporeal knot, Percutaneous loop.

Ultrasound: an extension of clinical examination.

AIMS AND OBJECTIVES: To study the impact the use of portable ultrasound can have for the benefit of the patients when used by doctors other than radiologist, in this case surgeons. METHODS: Ultrasound performed by surgeons in the pre-operative, operative and post-operative period was studied. Patients presenting to the Hospital with acute abdomen was subjected to ultrasound. They were either pre-operative or post-operative patients. Five patients were scanned intraoperatively. The impact of these scans to the patients as well as the clinicians was studied. RESULTS: This is an ongoing study and preliminary results of the scans show two pre-operative diagnosis of acute appendicular collection and one acute hydronephrosis. In the operation room, ultrasound was done on 5 cases. On three occasions, it was to locate renal stones so that it could be extracted with ease. On two of the case, it was t to confirm the adequacy of common bile duct exploration thereby allowing primary closure of the common bile duct. Post-operatively, it was used in four cases of which in two cases post-operative hemorrhage were detected timely within hours. In the other two cases, the surgical team was assured that the patient's complaint was not surgically related. CONCLUSION: Ultrasound should be an extension of the clinical examination when indicated and all clinicians should be proficient in its use in their respective fields.

Mandibular reconstruction.

One of the most difficult problem in reconstructive surgery is the replacement of lost bone from trauma, tumour, infection or congenital anomaly. This is a case report of a 20 year old male who had suffered a blast injury of his lower jaw. From his first admission in the Plastic unit of Bir Hospital on Feb 19, 2003, he had undergone multiple operations until Nov 2003. This is a description of a follow up surgery done in Kathmandu Medical College (KMC), Sinamangal. Difficulties encountered and options available have also been discussed.