Experience with common bile duct exploration at Lumbini Medical College.

Common bile duct stones represent a significant danger to patients, because they can lead to biliary colic, obstructive jaundice, cholangitis, or pancreatitis. Common bile duct stones either migrate from the gallbladder or form primarily within the bile ducts themselves. Primary stones are more common in South Asia and are usually sequelae of biliary infection and stasis. In the United States and other Western countries, common bile duct stones are predominantly secondary stones, having formed in the gallbladder. In patients who have gallstones, and in whom a cholecystectomy is considered, common bile duct stones can be found preoperatively, intraoperatively, or postoperatively. Ten percent to 15% of patients undergoing a cholecystectomy will be found to have choledocholithiasis at some point during their treatment. We present our case of 16 patients of common bile duct stones with or without cholelithiasis from April 2011 to March 2012. To review the treatment and outcome of patients with common bile duct (CBD) stones who underwent cholecystecomy with open common bile exploration (CBDE). We analysed the fact that cholecystectomy with commonbile duct exploration still holds as a good modality of treatment where ERCP (Endoscopic Retrograde cholangio pancreaticogram) is not available. All 16 persons in age group of 20-65 years, all females with body weight in the range of 45-60 kgs undergoing inpatient common bile duct exploration during April 2011- March 2012 were included. Common bile duct exploration was successful in all patients. Mean operating time was 120 +/- 40 minutes and length of hospital stay was 13 +/- 3days. 3 complications (18.75%) were recorded, 2 cases of retained stone (12.5%) who underwent choledochoduodenostomy. In 16 patients undergoing common bile duct exploration, CBD stones were discovered with flexible choledochoscope and intraoperative cholangiography. None of the Gallbladder specimen revealed any feature of malignancy in final histopatholgical report. All patients are doing fine till date. Open common bile duct exploration can still be a gold standard technique in set up where ERCP is not available. The results of common bile duct exploration are good with less complications in experienced hands.

Acute appendicitis in elderly patients: a challenge for surgeons.

The classic symptoms of acute appendicitis are seldom seen in the elderly patient. More subtle symptoms and the more virulent pathologic course allow the disease to progress rapidly and insidiously. This leads to delayed hospitalization, diagnosis and treatment. The high incidence of concomitant diseases and the multiplicity of differential diagnostic possibilities in this age group are also factors. The aim of this study is to compare the results of appendicitis operated at Lumbini Medical College, Pravas, in patients younger than 60 and patient elder than 60 years of age. All patients aged 60 years and older who underwent appendectomy for appendicitis between January 2008, and December 2011, were studied and compared with the patients who were younger than 60 years of age. All the operations were performed by consultant surgeons at Lumbini Medical College, Pravas, Tansen. Preoperative USG was done in all the cases. Preoperative antibiotics were given in all the cases. All patients underwent appendectomy as an emergency basis. The results were compared with regard to age, sex, pre-operative evaluation, operative duration and findings, postoperative course, duration of hospital stay, and mortality rate. There were 50 patients in group 1 and 150 patients in group 2 who met the inclusion criteria. The mean age (64 years for group 1 and 28 years for group 2), sex, preoperative suggestion of appendicitis (group 1, 35 [70%] of 50 patients; group 2, 135 [90%] of 150 patients), and duration of the preoperative hospitalization over 24 hours (group 1, 1 patients [20%]; group 2, 30 patients [20%]) were similar in both groups. Laparoscopy was used in (group 1, 5 patients [10%]; group 2, 6 patients [4%] and associated with no significant difference in the duration of hospitalization, frequency of appendiceal perforation or abscess, occurrence of complications, or mortality. The length of operating time was more in the first group. The mean hospital stay was 5.3 in group 1 and 2.2 in group 2 (p < 0.05). Also duration of Hospital stay was 9.5 days for perforated appendicitis and 5.4 for non perforated appendicitis in both group (p < 0.05). Advanced age adversely affects clinical diagnosis, the stage of the disease and the outcomes. Late presentation, delayed diagnosis, presence of perforation and co-morbidities are associated with poor outcome from surgery.

Haemorrhoidectomy: Ferguson's (closed) vs Milligan Morgan's technique (open).

This study was done to compare the efficacy of closed Vs open haemorrhoidectomy. The study design was unblinded randomised control trial at Dhulikhel Hospital, Kathmandu University Hospital. Total number of patients was 56 all with 3rd and 4th degree haemorrhoids. Post operative pain was taken as main outcome measures. Operation time varied from 200 seconds for each haemorroidal cushion with open technique to 626 seconds by closed technique. The blood loss was not quantifiable in closed technique. Pain was scored on visual analogue scale. In closed group, the pain score was 4.9 immediate post operative period and 2.3 (24 hours later). In the other group, the scores were 7.8 and 6.9. These differences were significant. At the end of study we came to a conclusion that haemorrhoidectomy using closed technique has more advantages.

Evaluation of septic complications in patients undergoing biliary surgery for gall stones in a tertiary care teaching hospital of South India.

BACKGROUND: One of the etiologies of formation of gall stones is infection and bile is a good media for microorganisms to grow. Acute cholecystitis and spillage of bile intraoperatively can lead to sepsis and postoperative complications. An attempt to study the nature of organisms and their antibiotic sensitivity is important to take appropriate steps. OBJECTIVE: Present study was done to assess the rate of infected bile in patients undergoing cholecystectomy for gallstones and to study its influence on postoperative infective complications. METHODS: This prospective study was conducted over a period of two years (from July 2003 to July 2005) in a tertiary care teaching institute in South India. Bile samples of 100 patients undergoing biliary tract surgery were collected and cultured for aerobic and anaerobic bacteria. Patients were divided into two groups which included 84 cases who underwent laparoscopic cholecystectomy and 16, open cholecystectomy. All the patients received prophylactic antibiotic. RESULTS: Bile culture was positive in 8 cases. Two cases developed postoperative wound infection; however in these bile culture was sterile. No significant postoperative complications were observed in any of the group apart from 1 case that developed intra abdominal abscess along with wound infection requiring re-exploration. Six cases developed postoperative fever that subsided on its own. CONCLUSION: The overall rate of septic complications following biliary surgery was extremely low. Present study does not show any correlation between infected bile and septic complications that is in accordance with the published literature. Present study also highlights the fact that good surgical techniques and judicious use of prophylactic antibiotics are two major factors for lower incidence of septic complications, if any, after biliary tract surgery.

Vernal keratoconjunctivitis: modes of presentation in Nepalese population.

OBJECTIVE: To determine pattern of clinical presentation in Vernal Keratoconjunctivitis (VKC) in our context. METHODS: Thirty-four VKC patients were included in this study. RESULTS: The study revealed prepubertal onset with male preponderance and most frequently encountered symptom in the study among VKC cases was itching (100%) followed by redness of eyes and discharge (76.5% each) and the commonest sign was tarsal papillae (100%) followed by conjunctival hyperemia (91%) in 68 eyes of 34 cases of VKC. CONCLUSION: The clinical presentation of VKC cases in our country is very much similar to the findings of other parts of the world.