An Audit of the Outcomes of Thymic Surgery.

Most pathology of the thymus gland warrant its surgical removal; and this requires significant expertise and adequate medical set-up. This study aimed to audit the results of thymectomies performed in a specialised tertiary level centre in a resource-poor country. The outcomes of open and minimally invasive video-assisted thoracoscopic surgery (VATS) thymectomies were also compared. Out of 58 patients operated at Department of Thoracic Surgery, Manmohan Cardiothoracic Vascular and Transplant Center, Maharajgunj, Kathmandu, Nepal between October 2012 and January 2019, 33 patients underwent open thymectomy and 25 had VATS thymectomy. We conducted a retrospective search to look at operative time, blood loss and length of postoperative hospitalisation. The open surgery group was followed for an average of 32 months, and the VATS cohort for 38 months. No significant differences were found in mean operative times and overall survival between groups. In selected cases, thymectomy via VATS is safer and comparable to open thymectomy in terms of operative safety and oncological completeness. Key Words: Thymus, VATS, Thymectomy, Outcome.

Esophageal 'pyocele': thoracoscopic management.

Mucocele of the native esophagus is a rare complication after esophageal bypass surgery for various indications. Esophageal mucoceles rarely get infected, forming a 'pyocele' which becomes symptomatic. Various approaches have been utilized in the management of such pyoceles. We report a similar patient managed successfully in our center utilizing a thoracoscopic deroofing and partial excision of the pyocele.

Secondary angiosarcoma in a hormone receptor negative breast cancer patient.

Post-irradiation angiosarcoma arising in the irradiated breast after breast-conserving surgery is uncommon though being reported with increasing frequency. Such cases are reported mainly in hormone-receptor positive patients who had received hormonal therapy along with radiation. We describe a rare case of post-irradiation angiosarcoma in a 71-year-old hormone-receptor negative female who did not receive hormonal therapy.

Surgery for parasitic lung infestations: roles in diagnosis and treatment.

Pulmonary parasitic infestations are a worldwide problem associated with significant morbidity and socioeconomic impact. They are known to have varied clinical presentations and radiological appearances. Prevention of parasite transmission and medical treatment of cases form the two pillars of control of these diseases. The role of surgery is limited to the diagnosis and definitive treatment of the minority of pulmonary parasitic afflictions, most notably hydatidosis. Despite surgery being established as the treatment of choice in pulmonary hydatid cysts (PHCs) for over half a century, variations and unresolved controversies persist regarding the best surgical technique. Complications brought on by cyst rupture, multiplicity and multi-organ involvement add complexity to treatment decisions. The development of video-assisted thoracoscopic surgery (VATS) brings the promise of reduced peri-operative morbidity but is yet to be universally accepted as a safe technique. In this review, we endeavor to discuss the common pulmonary infestations focusing on the current trends and controversies surrounding surgery for PHC.

Doege-Potter Syndrome, cause of nonislet cell tumor hypoglycemia: the first case report from Nepal.

Doege-Potter syndrome (DPS), a paraneoplastic syndrome, presents as a hypoinsulinemic hypoglycemia from the ectopic secretion of insulin-like growth factor II from a solitary fibrous tumor which may be intrapleural or extrapleural in origin. We report a case of severe hypoglycemia in a 70-year old female initially admitted for resection of left sided solitary fibrous tumor of pleura. Investigation revealed true hypoglycemia, and DPS was diagnosed. The tumor was completely resected, after which no further hypoglycemic episodes were seen in 2 years follow-up. This is the first case of solitary fibrous tumor of pleura with DPS reported from Nepal.

Successful surgical management of a rare esophageal inflammatory myofibroblastic tumour: a case report.

Inflammatory myofibroblastic tumour (IMT) is an uncommon mesenchymal tumour, which can occur anywhere in the body, rarely in esophagus. Mostly, the diagnosis is postoperative, after the hispathological evaluation of the specimen. There are no definite guidelines regarding the diagnosis and management. Here, we report a 60 year old lady presenting with dysphagia, diagnosed to have a submucosal esophageal tumor with Barium esophagogram and contrast enhanced computed tomography. She was managed successfully with surgical enucleation with the final histopathological diagnosis of IMT. Surgical excision is not only therapeutic but also diagnostic in such cases.

Intercostal muscle flap and intracostal suture to reduce post-thoracotomy pain.

BACKGROUND: Thoracotomy is considered to be the most painful surgical access, the main culprit being intercostal nerve injury. Despite the use of many techniques, this remains a major problem, pointing towards prevention as a better strategy. The effect of protecting both the upper and lower intercostal nerves during surgery has attracted many researchers. METHOD: A prospective study spanning 15 months was undertaken in 48 patients randomized to a conventional group (n = 25) and a study group (n = 23). Pericostal sutures in the former and intracostal sutures in the latter were used for closure. An intercostal muscle flap was harvested at the start of the operation in the study group only. The groups were comparable in terms of baseline characteristics. With a similar pain protocol, pain scores and analgesic consumption were recorded and analyzed. RESULTS: Times for pedicle harvest, intracostal suture, and pericostal suture were 5.2 ± 1.56, 3.65 ± 0.71, and 6.4 ± 1.20 min, respectively, in the study group. Total operative time was similar in both groups. Postoperative pain scores and the overall frequency of pain were consistently lower in the study group. CONCLUSION: these techniques lead to a reduction in the acute and chronic post-thoracotomy pain, without increasing complications.

Low lung cancer resection rates in a tertiary level thoracic center in Nepal--where lies our problem?

BACKGROUND: Resection rates of lung cancer are low in general and especially in countries like Nepal. Advanced stage at presentation and poor general condition of the patient are the usual causes. MATERIALS AND METHODS: In this prospective observational study, one hundred cases of lung cancer who presented at the Thoracic Surgery Unit between October 2011 and October 2012 were included. RESULTS: Those aged in the 6th and 7th decades together accounted for 72/100 patients. The male to female ratio was 2:1. There was a mean-29.2±14.2 pack yrs smoking history with only five non-smokers. Seventy-six patients presented with locally advanced disease while 21 had metastases. Only three had local disease. The average time between onset of symptoms to first contact with a doctor was 2.3±5.3 months (range: 0-35.6 months). Average time between first contact to referral was 50.4±65.7 days (range-0-365). Only three patients were resected, one after neo-adjuvant chemotherapy. Advanced disease was the cause of unresectability in 95 cases. One of three patients with local disease had pulmonary functions allowing the warranted resection. N2 disease with T1-3 on CT scan was found in 47. Three of these patients underwent mediastinoscopy and all confirmed uninvolved N2. CONCLUSIONS: Lung resection rates in our center remain low. Late presentation leading to advanced disease and poor pulmonary reserves preclude resection in most cases. More liberal use of mediastinal staging and better assessment of pulmonary functions may allow us to improve resection rates.

Breast cancer in young women from a low risk population in Nepal.

BACKGROUND: The overall incidence of breast cancer in South Asian countries, including Nepal, is low compared to Western countries. However, the incidence of breast cancer among young women is relatively high. Breast cancer in such cases is characterized by a relatively unfavorable prognosis and unusual pathological features. The aim of this study was to investigate clinico-pathological and biological characteristics in younger breast cancer patients (<40 years) and compare these with their older counterparts. MATERIALS AND METHODS: Nine hundred and forty four consecutive female breast cancer patients, admitted to the Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal between November 1997 and October 2012, were retrospectively analyzed. RESULTS: Out of the 944 female breast cancer patients, 263 (27.9%) were <40 years. The mean age was 34.6 ± 5.0 years among younger patients compared to 54.1 ± 9.9 for those ≥ 40 years. The mean age at menarche was also significantly lower (13.5 ± 1.5 vs 14.2 ± 1.5 years p=0.001) while the mean duration of symptoms was significantly longer (7.6 vs 6.5 months p=0.004). Family history of breast cancer was evident in 3.0% of the young women versus 0.3% in the older one. Mammography was performed less frequently in younger patients (59.7%), compared to older (74.4%), and was of diagnostic benefit in only 20% of younger patients compared to 85% of older ones. At diagnosis, the mean tumor diameter was significantly larger in young women (5.0 ± 2.5 vs 4.5 ± 2.4 cm, p=0.005). Axillary lymph nodes were positive in 73% of younger patients and 59% of older patients. In the younger group, the proportion of stage III or IV disease was higher (55.1% vs 47.1%, p ≤ 0.05). The proportion of breast conserving surgery was higher in young patients (25.1% vs 8.7%) and a higher proportion of younger patients receive neoadjuvant chemotherapy (9.9% vs 2.8%). The most common histological type was ductal carcinoma (93.1% vs 86%). The proportion of histological grade II or III was higher in younger patients (55.9% vs 24.5%). Similarly, in the younger group, lymphatic and vascular invasion was more common (63.2% vs 34.3% and 39.8% vs 25.4%, respectively). Patients in the younger age group exhibited lower estrogen and/ or progesterone receptor positivity (34.7% vs 49.8%). Although statistically not significant, the proportion of triple negative tumors in younger age group was higher (22.4% vs 13.6%). CONCLUSIONS: Breast cancer in young Nepalese women represents over one quarter of all female breast cancers, many being diagnosed at an advanced stage. Tumors in young women exhibit more aggressive biological features. Hence, breast cancer in young women is worth special attention for earlier detection.

Migration of a piece of shrapnel: femoral vein to superior vena cava-azygous junction.

We report a case of a shrapnel injury to the right thigh in which a foreign body had lodged in, and moved freely from, the femoral vein to the inferior vena cava and right atrium. However, instead of going into the right ventricle and pulmonary artery, it lodged itself in the superior vena cava-azygous junction. During the entire period, the patient remained asymptomatic and the foreign body was surgically retrieved uneventfully.

Nepalese breast cancer in relation to reproductive factors: comparison between Nepalese and Japanese cases.

The characteristics of Nepalese breast cancer in relation to reproductive factors have not been studied. One hundred and nine Nepalese breast cancer patients were compared with 108 Japanese breast cancer patients and the expression of estrogen (ER) and progesterone receptor (PgR) was evaluated immunohistochemically in 27 Nepalese breast cancer cases. In the Nepalese cases, the age at menarche was significantly older (14.1 vs 13.3 years), while the age at menopause was similar (49.0 vs 49.9 years). The mean age at first full-term pregnancy was significantly lower (20.6 vs 26.6 years), the average number of children was significantly larger (3.1 vs 2.1) and the cumulative duration of lactation was significantly longer (26.9 vs 17.1 months) in the Nepalese cases. In both groups, approximately 60% of breast cancer was premenopausal. The average age of Nepalese breast cancer patients, particularly premenopausal breast cancer patients, was significantly lower (38.6 vs 44.9 years). ER and PgR expression was 11% and 15%, respectively, in Nepalese breast cancer. Nepalese breast cancers were in an advanced stage when discovered. Nepalese breast cancer cases, particularly premenopausal breast cancer patients, were seen at a relatively young age with late menarche, early first full-term pregnancy, long duration of lactation and a large number of children, when compared with Japanese cases. Breast cancer in Nepal may involve mechanisms independent of estrogen exposure.