Correlation of the Nutritional Risk Screening 2002 Score With Post-operative Complications in Gastrointestinal and Hepatopancreatobiliary Oncosurgeries.

Introduction The Nutritional Risk Screening 2002 (NRS 2002) is a reliable tool for assessing patients' nutritional status and for identifying those who may benefit from nutritional support before undergoing surgery. However, its application and correlation with post-operative outcomes for Nepalese patients undergoing gastrointestinal and hepatopancreatobiliary oncosurgeries remain unexplored. The objective of this study was to correlate the NRS 2002's nutritional risk with post-operative complications classified by the Clavien-Dindo Classification. Methods A prospective analytical study was conducted at Kathmandu Medical College and Teaching Hospital, with 74 adults who underwent gastrointestinal and hepatopancreatobiliary oncosurgeries between 1st March 2021 and 30th August 2022. The study was conducted following ethical clearance from the Institutional Review Committee of the Hospital. A convenience sampling method was used. Data were analyzed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York, United States). Results Among the 122 patients admitted during the study period, 74 met the inclusion criteria. Using the NRS-2002, 37.8% were found to be at nutritional risk. Such patients had a higher risk of complications and extended hospital stays, supported by an odds ratio of 1.647 (95% confidence interval: 1.223 -2.219) and a p-value of <0.001. Nutritional risk emerged as an independent predictor of post-operative complications. Conclusion The study suggests the potential of NRS-2002 as a significant predictor of outcomes after surgeries for gastrointestinal and hepatopancreatobiliary malignancies in the South Asian context, particularly in Nepal. Tools such as NRS 2002 play a pivotal role in early risk identification, which could subsequently influence both pre-operative and post-operative care strategies, ultimately enhancing patient outcomes.

Laparoscopic anatomical segmentectomy: A paradigm shift towards minimally invasive liver surgery in Nepal: A cohort study.

Laparoscopic liver resection is taking stride in slowly replacing open surgeries for various hepatic pathologies in many developed countries. However, due to high cost and lack of expertise, there are only a handful of centres in the low-medium income countries who perform advanced laparoscopic liver resections regularly. In this study, a prospective analysis was carried out to assess and report the outcomes of laparoscopic anatomical segmentectomy (LAS) from a single centre in Nepal. Methods: The clinical data of all patients who underwent LAS between 1 October 2021 to 30 September 2022 were prospectively recorded. Demographics, pathological diagnoses, types of resections performed, perioperative parameters, postoperative length of stay, postoperative complications data and IWATE score were collected and analyzed. All operations were performed using the extrahepatic Glissonean technique with the use of indocyanine green dye as an adjunct during the intraoperative period. Results: In the study period, a total of 16 LAS were performed in our centre for various indications. The mean age of the patients in the series was 41.6 years, and seven of 16 patients were male. The majority of the cases were segment 2/3 resection indicated for various pathologies and segment 4b/5 indicated for carcinoma gallbladder. The median hospital stay was 6 days and only two cases developed major complication. There were no mortalities in our series. Conclusions: Taking into account the results produced from a single centre in a low-medium income country, laparoscopic anatomical segmentectomy is technically feasible with an acceptable safety profile.

Blunt Abdominal Trauma among Patients Admitted to the Department of Surgery at a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Blunt abdominal trauma bears significant morbidity and mortality worldwide and needs careful evaluation and management for a better outcome, where the resources are limited and the impact of the financial burden is very important. Previously, many cases used to be managed with operative procedures, and now the trend has been shifting to non-operative management. This study aimed to determine the prevalence of blunt abdominal trauma among patients admitted to the Department of Surgery of a tertiary care centre. Methods: This was descriptive cross-sectional study done between 1 February 2022 to 31 January 2023 after taking ethical approval from the Institutional Review Committee (Reference number: 2312202103). The decision of non-operative versus operative treatment was decided with dynamic clinical evaluation and severity of intraabdominal injuries. Demographic data, the mechanism of injury, and both conservative and operative management were studied. All the patients who were more than 18 years of age, and admitted to the Department of Surgery were included in the study. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among a total of 1450 patients, the prevalence of blunt abdominal trauma was 140 (9.65%) (8.13-11.17, 95% Confidence Interval). A total of 61 (43.57%) were young within the age group of 18-30 with a male-female ratio of 4:1. Road traffic accidents 79 (56.43%) were the most common mechanism followed by falls from heights 51 (36.43%). Conclusions: The prevalence of blunt abdominal trauma among patients admitted to the Department of Surgery was found to be higher than in other studies done in similar settings. Keywords: blunt injuries; conservative management; operative surgical procedure.

Laparoscopic Cholecystectomy in Situs Inversus Totalis with Stage 5 Chronic Kidney Disease: A Case Report.

Situs inversus totalis is a rare congenital anomaly in which the abdominal and thoracic organs are transposed in a mirror image. Diagnosis and management of cholelithiasis in patients with situs inversus totalis pose a challenge due to the anatomical variation. A laparoscopic cholecystectomy in such a case can be technically challenging, especially for a right-handed surgeon. In this case report, we present a case of a 38-year-old male with symptomatic cholelithiasis in a chronic kidney disease stage five patient under maintenance hemodialysis planned for recipient renal transplant. A laparoscopic cholecystectomy considered the gold standard for symptomatic cholelithiasis was performed with a three-port technique. The technical challenges anticipated due to anatomical variation were managed by intraoperative modifications. In conclusion, laparoscopic cholecystectomy in patients with situs inversus totalis can be done with technical modifications and re-orientation of visual motor skills. Keywords: case reports; cholecystectomy; situs inversus.

Previous Abdominal Scars among Patients Undergoing Laparoscopic Cholecystectomy in a Tertiary Care Centre.

Introduction: Abdominal scars result from various open abdominal surgeries. Laparoscopic surgery in previous open abdominal surgery possesses various challenges to the surgeon like gaining access to the abdominal cavity, and difficulty in dissection due to dense adhesions from previous surgeries for various intraabdominal pathologies. This study aimed to find out the prevalence of previous abdominal scars among patients undergoing laparoscopic cholecystectomy in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients undergoing laparoscopic cholecystectomy in a tertiary care centre from 1 May 2022 to 30 April 2023 after taking ethical approval from the Institutional Review Committee. Palmer's point approach via Hassen open technique or direct optical entry was used for cases with previous abdominal scars to gain access to the abdominal cavity. Patients with symptomatic gallstone diseases were included in the study whereas patients with cholecystitis, pancreatitis, and previous cesarean scar were excluded. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 160 patients undergoing laparoscopic cholecystectomy, previous abdominal scars was found in 40 (25%) patients. Conclusions: The prevalence of previous abdominal scars contributing to intraoperative and post-operative difficulties among patients undergoing laparoscopic cholecystectomy was found to be higher than in studies done in similar settings. Keywords: laparoscopic cholecystectomy; open surgery; prevalence.

Strategies in the Management of Pancreatic Ductal Adenocarcinoma Involving Aberrant Right Hepatic Artery Arising From the Superior Mesenteric Artery.

Introduction The prevailing guidelines do not include the involvement of an aberrant right hepatic artery (aRHA) arising from the superior mesenteric artery in classifying borderline resectable pancreatic ductal adenocarcinoma (BR PDAC). Our novel classification aims to distinguish different entities depending on the location and degree of tumor involvement of aRHA and propose a strategy to manage tumor involvement of aRHA in PDAC. Material and methods The patients who underwent pancreaticoduodenectomy (PD) from September 1, 2018, to August 31, 2022 were analyzed retrospectively, and patients with aRHA were included in the study. Depending on the radiological data, arterial involvement of the aRHA was classified into group I with proximal involvement of the aRHA up to 2 cm from its origin in the superior mesenteric artery (SMA) and group II with distal involvement of aRHA beyond 2 cm from its origin in SMA. In addition, the resection margin status was correlated with the technique employed for managing the tumor-involved artery. Results A total of 122 patients underwent PD during the study period. Eight patients were identified to have tumor involvement of the aRHA arising from the SMA. Among the five patients in group I, three patients who had upfront surgery showed R1 resection regardless of periarterial divestment or resection/reconstruction of the involved artery, whereas R0 resection was achieved in the two patients who had neoadjuvant therapy. All patients in group II had R0 resection regardless of receiving neoadjuvant therapy. There were no significant morbidity and mortality in our series. Conclusion The aRHA should be considered in the classification of BR PDAC. Management strategies should be tailored based on the location and the degree of tumor involvement in the aRHA. We advocate neoadjuvant therapy for proximal involvement and upfront surgery for distal involvement of aRHA to achieve good oncological clearance.

Early Oral Feeding with Vascular Resection among Patients Undergoing Pancreatoduodenectomy in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Pancreatoduodenectomy with vascular resection is performed in locally advanced periampullary malignancies. In our practice, early oral feeding is initiated in patients undergoing pancreatoduodenectomy. This study aims to find the prevalence of early oral feeding with vascular resection among patients undergoing pancreatoduodenectomy. METHODS: This was a descriptive cross-sectional study conducted among hospital records of 152 patients who underwent pancreatoduodenectomy in the department of surgery of a tertiary care hospital from 2016 to 2020. Ethical approval was taken from the Institutional Review Committee (Reference number: 0812202102). Convenience sampling was done. Patients clinical and sociodemographic data were collected and analyzed using Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency, percentage, mean, and median. RESULTS: Among 152 patients undergoing pancreatoduodenectomy, early oral feeding with vascular resection was done in 17 (11.18%) (6.17-16.19 at 95% Confidence Interval). Portal vein and superior mesenteric artery were resected in one (5.88%) and hepatic artery in one (5.88%) patient. Type I, III and IV reconstruction was done in nine (52.9%), five (29.41%) and one (5.88%) respectively. Clinically relevant delayed gastric emptying and postoperative pancreatic fistula were seen in two (11.7%). Complication of Clavien-Dindo Grade III or higher was seen in one (5.88%) patient. One (5.88%) mortality was noted. CONCLUSIONS: The prevalence of early oral feeding with vascular resection among patients undergoing pancreatoduodenectomy was similar to other studies done in similar settings. Early enteral feeding is well tolerated in patients undergoing pancreatoduodenectomy with vascular resection.

Primary Grynfeltt Lumbar Hernia: A Case Report.

A weakening or defect in posterolateral abdominal wall can lead to development of lumbar hernia. These defects are particularly common in Petit's inferior triangle or Grynfeltt-Lesshaft superior triangle. There are very few cases of primary lumbar hernias that have been described in literature till date. As it is a rare entity, it is often misdiagnosed, leading to delay in management. We present a case of a 66-year-old male with no previous surgery who presented with a mass in left lumbar region for last ten years. The mass gradually increased in size and caused vague dragging pain. On Computed tomography, the diagnosis of Grynfeltt hernia was made. The patient underwent a laparoscopic mesh repair and had an uneventful postoperative hospital stay. Although a rare entity, there should be a high degree of suspicion of a lumbar hernia when evaluating a case of a lumbar mass. Early diagnosis by computed tomography and management with open or minimally invasive techniques can prevent complications.

Arterial Divestment and Resection in Post-neoadjuvant Pancreatic Adenocarcinoma.

Introduction The advent of neoadjuvant therapy in the management of pancreatic adenocarcinoma has significantly improved the prognosis of the disease. Nevertheless, the only chance of long-term disease-free survival in pancreatic cancer is achieved with complete tumor resection, and artery involvement by the tumor is one of the major determinants in its resectability. We aim to evaluate the feasibility of a novel technique, namely, the periarterial divestment, which has allowed surgeons to clear the tumor tissues off the visceral arteries without the need for arterial reconstruction. Materials and methods In this single-center, retrospective, descriptive, cross-sectional study done between August 2019 and July 2021, seven consecutive patients with histologically confirmed pancreatic ductal adenocarcinoma (PDAC) who underwent neoadjuvant therapy were included. Arterial divestment was performed in six of seven patients and arterial reconstruction was performed in one of the patients. The data on perioperative and the early oncological outcome were recorded. Results Five patients underwent periarterial divestment, one underwent sub-adventitial divestment, and one underwent superior mesenteric artery reconstruction due to deeper tumor infiltration into the arterial wall. The intraoperative frozen section of periarterial tissue was positive in three cases and the final histopathological specimen after the divestment showed a positive margin in two of the cases. The clinically significant postoperative pancreatic fistula was noted in two patients, and one patient experienced grade C post-pancreaticoduodenectomy hemorrhage due to a hepatic artery pseudoaneurysm. Four patients, all of whom underwent periarterial divestment, experienced postoperative diarrhea. There were no mortality and the median postoperative hospital stay was seven days. Conclusion The need for arterial reconstruction in borderline and locally advanced pancreatic cancer can be avoided by using the periarterial divestment technique. Divestment of arteries is technically feasible and can be carried out safely without compromising the patient's oncological outcome. However, further validation of this technique must be done by well-designed studies with a greater sample size.

Safety and Efficacy of Percutaneous Nephrolithotomy in Children.

BACKGROUND: Renal stone disease is a common problem in children in developing countries. Its prevalence in children varies from 5% to 15%. It is suggested that anatomic abnormalities, recurrent urinary tract infections, metabolic disturbances, dietary and environmental factors are the predisposing factors.The aim of this study is to evaluate the safety and efficacy of percutaneous nephrolithotomy in children. METHODS: Between May 2012 and Dec 2016, 25 children with renal stone diseases underwent percutaneous nephrolithotomy and were evaluated for stone free rate, complications, blood transfusion rate, sandwich therapy, etc. RESULTS: The mean age of children was 9.3 years (7-15 years) and the mean size of the stone was 20 mm (13-27 mm). The anatomical location of stone was important in terms of stone clearance. Three patients needed blood transfusion. The overall stone free rate was 88% before discharge. Three patients had residual stones and were treated with extracorporeal shockwave lithotripsy. Complications included fever, haematuria, ileus and urine leak. No major complications were noted. There were no significant differences in haemoglobin and creatinine levels before and 12 hours after the surgery. CONCLUSIONS: Percutaneous nephrolithotomy (PCNL) can be considered a safe, effective and feasible modality of treatment for children with an average of 2 cm sized renal stones.