Prediction of Postoperative Major Complications in Pancreaticoduodenectomy -a Prospective Comparative Analysis of Braga and WHipple-ABACUS Scores.

Background Major complications following pancreaticoduodenectomy have a severely deleterious effect on postoperative course, rather than just occurrence of pancreatic fistula. Surgical risk stratification with Braga and WHipple-ABACUS have been proposed and validated. Objective The study aimed at comparing the Braga and WHipple-ABACUS scores for prediction of major complications following pancreaticoduodenectomies. Method This was a prospective observational study at the Tribhuvan University Teaching Hospital from February 2018 to April 2019. After ethical approval, all consecutive 41 patients who underwent pancreaticoduodenectomies were included. Each patient was graded in Braga and WHipple-ABACUS scores. Perioperative events occurring over 30 days were graded as per Clavien -Dindo complications for pancreatic surgery. The predictive value of the scores were assessed using a receiver operating characteristic curve analysis. The categorical data were compared using the Pearson χ2 test or Fisher's exact test. Result Over period of 14 months, total of 41 patients (M:F=2.15:1) with median age of 58 years (range, 21-86) underwent pancreatoduodenectomy. The mean scores were Braga (4.6±3.1) and WHipple-ABACUS (1.8±1.6). Major complications over 30 days were developed in 11 patients with five mortality. There were significant differences in mean values of Braga score (7.0±3.4 vs 3.7±2.6, p-value=0.02) and WHippleABACUS score (3.2±1.8 vs 1.3±1.3, p-value=0.01) in patients with major complications to those without respectively. The area under curves for Braga and WHipple-ABACUS scores were 0.800 and 0.779 respectively. Conclusion Both WHipple-ABACUS and Braga scores are easy to calculate and predict the development of major complications significantly in patients undergoing pancreatoduodenectomy.

En bloc Pancreaticodudenectomy with Colectomy for Locally Advanced Right Sided Colon Cancer.

A 57 year old male presented to our outpatient clinic with history of on and off melena, weight loss and decreasing appetite for 10 months duration and a noticeable mass on the right upper quadrant. Abdominal examination revealed an intra-abdominal lump in right upper quadrant which was subsequently evaluated by colonoscopy, which revealed an ulcero-proliferative growth in the hepatic flexure and the biopsy from it confirmed well-differentiated adenocarcinoma. Contrast enhanced computed tomography demonstrated hepatic flexure mass with possible invasion into adjacent duodenum without features of advanced disease. After completion of necessary preoperative assessment and investigations, patient was explored with curative intent and underwent extended right hemicolectomy with en bloc pancreaticodudenectomy. Patient was discharged on 10th postoperative day and at 14 months follows up; he was doing well without any evidence of recurrence.

Association between Helicobacter Pylori and Gastric Cancer.

INTRODUCTION: A casual relation has been thought to exist between Helicobacter pylori infection and gastric cancer. The present study was carried out to find correlation between H. pylori and gastric carcinogenesis. METHODS: A case control study was performed in the department of endoscopy, Tribhuvan University Teaching Hospital, between January 2008 and February 2009. All patients having carcinoma stomach on endoscopic evaluation later confirmed by histopathological examination were included. Total 50 healthy individuals, with no positive finding in endoscopy were included in control group. RESULTS: Total 37 cases were analyzed. There were 23 (62.2%) males and 14 (37.8%) females. Majority were above 60 years (46%). Blood group A was commonest group found in patients with carcinoma stomach. Distal part, antrum, 20 (54%) was commonest location of tumor and Borrmann type three was commonest endoscopic type of tumor presentation. Majority of patients received triple therapy and H. pylori detection was low in those treated with triple therapy. Distal tumors were significantly associated with increased prevalence of H. pylori positivity. Total incidence of H. pylori in cases was 54% (20/37). In 15 (75%) cases, H. pylori could be detected by both ELISA and biopsy method. Incidence of H. pylori in controls was 64% (32/50). There was no statistically significant difference in H. pylori presence in cases and control. CONCLUSIONS: Our study couldn't establish association between H. pylori and gastric cancer. More prospective trials can help find out correlation between combination of risk factors and gastric cancer.

Retroperitoneal schwannoma: a rare presentation.

The Schwannoma is nerve sheath tumor originating from Schwann cell of peripheral nerve and is commonly found in head,neck and flexor surface of extremities. Only few cases have been reported to be found in retroperitoneum. Here, we describe a 21 year old female lady who presented to our centre with lump and pain in right iliac fossa and was found to have Schwannoma by CT scan and Fine needle aspiration cytology. She underwent laparotomy and excision of tumor and was confirmed to have Schwannoma on histopathological examination.

Altemeier rectosigmoidectomy for strangulated rectal prolapse.

A 70 year old gentleman presented in the emergency department of Tribhuvan University Teaching Hospital, Kathmandu, Nepal with strangulated complete rectal prolapse. After complete evaluation and necessary investigations, patient underwent Altemeier perineal rectosigmoidectomy and had an uneventful recovery. This case report tries to highlight the importance of Altemeier procedure as the only option for managing rectal prolapse when patients present with incarceration or strangulation of the prolapsed rectum with very good outcome.

Mucinous cystic neoplasm masquerading a pseudo pancreatic cyst.

Owing to recent improvements in pancreatic imaging, an increasing number of cystic lesions have been identified in asymptomatic as well as in patients presenting with jaundice, pancreatitis, or abdominal pain. In spite of many diagnostic modalities, pseudocysts of pancreas still create confusions with pancreatic cystic neoplasms. Here we report a 38 year old lady who presented with abdominal lump and jaundice following an episode of pain abdomen suggesting acute pancreatitis. She was fully investigated and managed for pseudocyst of pancreas. The diagnosis of mucinous cystic neoplasm was evident only after the biopsy from the wall of the cyst.

Tzanakis score vs. Alvarado score in acute appendicitis.

INTRODUCTION: Acute appendicitis is a common surgical emergency. Accurate diagnosis and timely intervention reduces mortality and morbidity. This study compared the efficacy of Tzanakis and Alvarado score in diagnosis of acute appendicitis. METHODS: A prospective, non randomized study was conducted in 100 consecutive patients who had undergone emergency appendectomy from May 2008 to October 2008. Tzanakis and Alvarado scores were obtained at the time of admission. Final diagnosis of acute appendicitis was based on histological findings. RESULTS: The sensitivity, specificity and overall diagnostic accuracy of Tzanakis score was 91.48% and 66.66% and 90% respectively. The sensitivity, specificity and overall diagnostic accuracy of Alvarado score was 81.91% and 66.66% and 81% respectively. Negative appendectomy rate was 6%. CONCLUSIONS: Tzanakis score is an effective modality to establish the accurate diagnosis of acute appendicitis.

Revisiting appendicular lump.

INTRODUCTION: Appendicular lump is a well known sequalae of acute appendicitis encountered in 2-6% of patients. Successful management of appendicular lump is controversial with different approaches. As many controversies are arising regarding management of appendicular lump. The aim of this study was to find out the outcome and evaluate possible need of changing our management strategy of appendicular lump. METHODS: A retrospective analysis of the patients managed with appendicular lump were done. All the patients admitted with diagnosis of appendicular lump and managed between, over two and half years, were included in the study. All age groups and both sex were included. Any patients whose diagnosis was changed after initial diagnosis of appendicular lump were excluded from the study. RESULTS: Total 75 patients had appendicular lump suggesting 10% incidence. Age varied between 11-83 years with nearly equal incidence in both sexes. Majority had onset of symptoms between 2 to 14 days with an average of 4 days. Average stay was 3 to 4 days. During study period, 12 (16%) came with recurrence and 13 (17%) cases came for elective appendectomy. CONCLUSIONS: Based on our finding, it is not sufficient to change our classical management strategy of appendicular lump and suggests a need for long term prospective study in this very common clinical condition.