Comparison between novel zipper device and conventional methods for skin closure: a systematic review and meta-analysis.

Introduction: The zipper device is a wound closure device that can be directly applied over the intact skin on either side of the wound edges and does not need anchoring into the skin or subcutaneous plane. The noninvasive nature of the zipper device makes it less time-consuming and less painful, but its effectiveness and related complications need to be studied. Methods: Prospective registration of the protocol followed in this study was done. Electronic databases were searched for relevant articles, and their screening was completed, followed by data extraction and analysis. The odds ratio, mean difference, or standardised mean difference were used as an effect measure per the nature of the variables. Surgical site infection, wound dehiscence, skin closure time, scar score, and patient satisfaction were compared in this study. Results: A total of 10 studies were identified, out of which eight compared zippers with sutures and two compared zippers with stapler devices. Compared to the suture, the zipper device took 4.9 min less to close the incision, and the scar scale outcome reported after one month was inferior, while other results were not significant. Staples showed a lower patient satisfaction level and no difference in complications. Conclusion: The zipper device is a less technically demanding and less time-consuming method of skin closure, with no significant difference in the complication rate compared to conventional methods. The zipper device is an effective measure to use in settings with less expertise or at health institutions after assessing the cost at the local level.

Comparison of negative pressure wound therapy against normal dressing after vascular surgeries for inguinal wounds: A systematic review and meta-analysis.

Background: Negative Pressure Wound Therapy (NPWT) is a therapeutic technique of applying sub-atmospheric pressure to a wound to reduce inflammation, manage exudate, and promote the formation of granulation tissue. It aims to optimise the natural physiological processes of wound healing for more effective recovery, and NPWT has emerged as a promising alternative to traditional dressings. Methods: The protocol followed in the study was prospectively registered. Appropriate search terms and Boolean operators were used to search electronic databases for relevant articles. Screening of articles was performed, and data extraction was done. The effect measure was chosen according to the nature of the variable, and the effect model was chosen as per heterogeneity. Forest plot was used to give visual feedback. Results: This study included 11 randomized controlled trials (13 publications) with a total of 1310 patients (1497 inguinal wounds). The NPWT group had lesser odds of developing surgical site infection (OR: 0.40; 95 % CI: 0.29-0.54; n = 1491; I2 = 20 %; p-value ≤0.00001) and lesser odds of needing surgical wound revision (OR: 0.48; 95 % CI: 0.26-0.91; n = 856; I2 = 0 %; p-value = 0.02) as compared to the normal dressing group. No significant difference was observed in duration of hospital stay, cost of care, wound healing time, or other complications. Conclusion: NPWT application in inguinal wounds significantly reduces the surgical site infection and the need for wound revision in patients who have undergone vascular surgery.

A rare case report on neonatal complications from Nepal: solitary neonatal hepatic abscess.

Neonatal liver abscess is a rare condition with a high mortality rate. However, in a low-resource setting, high clinical vigilance and the use of readily accessible diagnostic modalities can help in early diagnosis and, along with appropriate medical management, prevent lethal complication. Case presentation: We present the case of a patient who presented with one day of sudden abdominal distension and two episodes of projectile nonbilious vomiting. A solitary liver abscess was diagnosed using ultrasonography and contrast-enhanced computed tomography findings, and the patient was treated conservatively with parenteral broad-spectrum antibiotics. Following the completion of the antibiotic dose, an ultrasound of the abdomen reveals that the size of the liver abscess has decreased. Clinical discussion: Neonatal liver abscess is a rare clinical condition that causes significant morbidity and mortality in premature and term babies. In a neonate with potential risk factors, a high index of suspicion is required to make the diagnosis. Baseline tests, as well as computed tomography with or without contrast, aid in the definitive diagnosis of a hepatic abscess. For management, a multidisciplinary approach should be considered, including correction of the predisposing factor as well as appropriate medical and/or surgical intervention. Conclusion: Neonatal liver abscess is frequently overlooked due to its rarity. Thus, whenever a neonate exhibits the aforementioned clinical spectrum, it should be considered in the differential diagnosis, and a diagnostic workup and treatment should be initiated as soon as possible to avoid debilitating complications.

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma: a case report.

Xanthogranulomatous cholecystitis (XGC) is an uncommon type of chronic cholecystitis. Clinical presentation, laboratory findings, and radiological analysis mimic gallbladder carcinoma. A definitive diagnosis is made by histological study. Cholecystectomy, along with adjuncts as required, is performed for management. Case Presentation: We present a case of a 67-year-old female who was planned for interval cholecystectomy for gallstone pancreatitis. Her clinical, laboratory and radiological findings were suggestive of cholelithiasis and was planned for laparoscopic cholecystectomy. Her intraoperative findings mimicked gallbladder carcinoma. The surgery was aborted, and a biopsy was sent for histopathological analysis. XGC was diagnosed, and the patient underwent laparoscopic cholecystectomy with no postoperative complications during the 6-month follow-up period. Discussion: XGC is a rare disorder resulting from chronic inflammation of the gallbladder. There is the presence of xanthogranuloma with predominant lipid-laden macrophages in the gallbladder wall along with fibrosis. Clinical presentation, laboratory findings, and radiological analysis mimic gallbladder carcinoma. Ultrasonography usually shows diffuse wall thickening of the gallbladder, intramural hypoechoic nodules, unclear liver and gallbladder interface, and the presence of gallstones. The final diagnosis is made by histopathological analysis. Laparoscopic or open cholecystectomy, along with adjuncts as required, is performed for management with a low postoperative complication rate. Conclusion: XGC is a rare, benign disease that is often confused with gallbladder cancer before histological analysis. XGC can be managed with laparoscopic cholecystectomy with minimal postoperative complications.

Osler-Weber-Rendu syndrome: A case report on a rare vascular malformation presented with lower gastrointestinal bleeding.

Osler-Weber-Rendu syndrome is an uncommon vascular disorder inherited as an autosomal dominant trait with varying penetrance and expression. A multidisciplinary approach is used for a detailed diagnostic workup and management based on the patient's symptoms at presentation.

An institutional experience of hydatidosis and cysticercosis in Nepal: a retrospective chart review.

This study aimed to investigate the demographic characteristics, anatomical distribution, and histopathological features of hydatidosis and cysticercosis in a Nepalese population presenting to a tertiary care hospital. The study also aimed to provide a better understanding of the clinical and pathological aspects of these diseases in the local context. Methods: This retrospective study analyzed all cases of hydatidosis and cysticercosis reported in the Department of Pathology at Tribhuvan University Teaching Hospital between January 2013 and December 2019. Demographic, clinical, radiological, and histopathological data were collected and analyzed from hospital charts. Results: During the 7-year study period, the authors identified 112 cases of hydatid cysts and 26 cases of cysticercosis. The mean age of patients with hydatidosis was 33.86 years (range: 5-74 years), while the mean age of patients with cysticercosis was 25.39 years (range: 4-63 years). Females were more commonly affected with hydatidosis (68, 61.7%) than males (44, 39.3%), resulting in a male-to-female ratio of 0.6:1. In contrast, there was no significant sex difference in cysticercosis cases, with 14 (53.85%) males and 12 (46.15%) females affected. The most commonly affected site for hydatid cysts was the lung (47 cases, 42%), followed by the liver (41 cases, 36.6%). The study identified three cases of neurocysticercosis. The average diameter of hydatid cysts and cysticercosis was 8.7 cm and 1.7 cm, respectively. Conclusion: In conclusion, our study provides important insights into the clinical and pathological features of hydatidosis and cysticercosis in a Nepalese population. These zoonotic diseases pose a significant health burden, particularly among the poor and marginalized populations. Our findings highlight the need to integrate prevention and control measures into the healthcare system to decrease the overall burden of these diseases.

Obturator hernia (the little old lady's hernia) diagnosed via computed tomography: a case report.

Obturator hernia is an infrequent clinical entity of abdominal wall hernia, accounting for an incidence rate ranging from 0.073 to 2.2% of all hernias and being responsible for 0.2-1.6% of all cases of mechanical intestinal obstruction. The computed tomography (CT) scan, as an imaging modality, is critical in improving the diagnostic rate of obturator hernia. Case presentation: The authors herein report an 87-year-old thin male patient with a known history of chronic obstructive pulmonary disease who presenting with complaints of abdominal pain for 3 days and constipation for 2 days, as well as one episode of vomiting without any features of peritoneal irritation, which was diagnosed early as a right-sided obturator hernia via CT and managed with exploratory laparotomy with hernia reduction and polypropylene mesh repair. Discussion: Obturator hernia is a rare surgical phenomenon with a varied clinical spectrum, ranging from asymptomatic to presenting as intestinal obstruction. The CT scan plays a critical role in the detection of obturator hernias, which ameliorates the possible significant postoperative morbidity and mortality. Conclusion: This report demonstrates that a high index of suspicion combined with CT imaging aids in early diagnosis and management, thus overcoming the reluctant morbidity.

Acute Pancreatitis among Patients Visiting the Department of Surgery in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Acute pancreatitis is the inflammation of pancreatic parenchyma characterised by severe abdominal pain and nausea. It is a common gastrointestinal disease requiring hospital admission. The death rate for mild acute pancreatitis is low but severe acute pancreatitis can reach up to 40%. This study aimed to find the prevalence of acute pancreatitis among patients attending the Department of Surgery in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted from 1 October 2021 to 30 March 2022. The study was conducted after receiving ethical approval from the Institutional Review Committee (Registration number: 454). Patients with age more than 18 years were included and patients less than 18 years of age including those suffering from chronic pancreatitis, pancreatic malignancy or immunocompromised states were excluded. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 1560 patients, the prevalence of acute pancreatitis in our study is 120 (7.69%) (2.92-12.46, 95% Confidence Interval). Out of them, 57 (47.50%) were males and 63 (52.50%) were females. Out of total, hypertension found in 52 (43.33%) was the most common co-morbidity observed followed by diabetes mellitus 18 (15%). Similarly, 80 (66.67%) patients had mild pancreatitis whereas 40 (33.33%) had moderate pancreatitis and 8 (6.67%) had severe pancreatitis. Conclusions: The prevalence of acute pancreatitis among hospital admissions in the department of surgery in a tertiary care centre was found to be similar to other studies done in a similar setting. Keywords: acute pancreatitis; gastrointestinal disease; prevalence.

Intra-abdominal omental mass as a desmoplastic round cell tumor: A rare case report.

Key Clinical Message: Desmoplastic round cell tumor, though rare, must be taken into consideration as a differential diagnosis, thus aiding in early evaluation and changing the trajectory of the natural history of the disease condition, and improving the prognosis of patients. Abstract: Desmoplastic small round cell tumor is a rare, aggressive tumor of mesenchymal origin with an incidence of 0.74 cases per million. We present a young adult with a periumbilical mass who was diagnosed as a desmoplastic round cell tumor and later was treated with exploratory laparotomy and resection of the tumor with no recurrence during a 6-month follow-up period.

Appendicular actinomycosis: The first reported case of an uncommon finding of a common ailment from Nepal.

Key Clinical Message: Actinomycosis is a rare cause of appendicitis with an incidence of 0.3-1 incident per year per 100,000 people. A significant preoperative diagnostic challenge exists and is usually diagnosed incidentally on histopathological examination. Abstract: Appendicular actinomycosis, a rare, chronic granulomatous infection caused by actinomyces species, holds a significant preoperative diagnostic summons and is often diagnosed serendipitously during the regular histopathological examination. Herein, we present a case of a 36-year-old female who presented with features suggestive of acute appendicitis, underwent laparoscopic appendicectomy, and was diagnosed with appendicular actinomycosis from the histopathological examination.

Utilization rates of intravenous thrombolysis for acute ischemic stroke in Asian countries:: A systematic review and meta-analysis.

BACKGROUND: Despite intravenous thrombolysis (IVT) being used for the treatment of acute ischemic stroke (AIS) for over two decades, its accessibility remains limited in various regions of the world. The Asian region, which experiences the highest age-standardized incidence of AIS, currently lacks comprehensive data on the utilization of IVT. AIMS: This study aimed to provide precise estimates of IVT usage for AIS in Asian countries. METHODS: A literature search was conducted on PubMed and Google using appropriate search terms. English language, peer reviewed articles published after 2010 were included in the analysis. The pooled proportion was calculated utilizing the DerSimonian and Laird random-effects model. Additionally, a subgroup analysis was conducted, taking into account factors such as the study's country, the economic status of the country, specific Asian regions, publication year (before 2015 and from 2015 onwards), study location, study setting, hospital stroke protocol, and national stroke guidelines. RESULTS: 67 observational studies with 778,046 patients with AIS were included in the meta-analysis. The overall utilization rate of IVT was found to be 9.1%. High-income countries had a higher rate (11.3%) compared to lower-middle-income (8.1%) and upper-middle-income countries (9%). Central and North Asia had the highest rate (17.5%) and Southeast Asia had the lowest rate (6.8%). Studies conducted after 2015 had a higher thrombolysis rate (11.3%) compared to those before 2015 (1.5%). Presence of hospital stroke protocols (10.7%) and national stroke guidelines (10.1%) were associated with higher thrombolysis rates. CONCLUSION: The overall utilization rate of IVT for AIS in Asia stood at 9.1%, showcasing noteworthy disparities across countries, regions, and income brackets. To improve thrombolysis rates in the region, addressing prehospital delays, increasing public awareness, and implementing stroke protocols and national guidelines are key strategies.

Diagnostic dilemma in diagnosing rare cause of protein losing enteropathy: Waldmann's disease.

Waldmann's disease, or primary intestinal lymphangiectasia, is an unusual cause of protein-losing enteropathy primarily characterized by lymphopenia, hypoalbuminemia, and hypogammaglobulinemia. However, variable clinical presentations result dilemmas in diagnosis and effective management. We present a toddler diagnosed with Waldmann's disease managed with a high-protein diet and medium-chain triglyceride supplementation.

Acute recurrent pancreatitis in a child with pancreatic divisum- A case report.

Introduction and importance: In children, acute recurrent pancreatitis is attributed to pancreato-biliary anomalies, hereditary pancreatitis and cystic fibrosis. Pancreatic divisum is a common congenital ductal anomaly that leads to recurrence of pancreatitis. Case presentation: A 13 years old female presented with clinical features of acute recurrent pancreatitis. After ruling out common causes, magnetic resonance cholangiopancreatography was done which showed pancreatic divisum. Her symptoms resolved following duodenum preserving pancreatic head resection. Discussion: Acute recurrent pancreatitis is attributed to raised intrapancreatic dorsal ductal pressure due to ductal anomalies especially pancreatic divisum (PD). It is the embryological failure in the fusion of the dorsal and ventral ductal system. PD is further classified into a classical subtype where there is complete failure of ductal fusion and an incomplete subtype where there is partial fusion of the ductal system. The diagnosis is commonly done through abdominal imaging with secretin enhanced magnetic resonance cholangiopancreatography being the choice of imaging modality. The initial approach is endoscopic intervention unless patients present with signs of pancreatic fibrosis where a duodenum preserving pancreatic head resection can be carried out. Conclusion: A keen suspicion should be given towards anatomical or structural variants in absence of common etiologies. Early identification and management of pancreatic divisum prevents the recurrence of pancreatitis.

Ciprofloxacin induced toxic epidermal necrolysis with cholestatic hepatitis: A case report with literature review and revisit to the Naranjo adverse drug reaction probability scale.

Ciprofloxacin, among the many Fluoroquinolones, has been widely used as a broad-spectrum antibiotic due to its wide range of action and relatively safe adverse effect profile. However, among the cutaneous adverse drug reactions due to Ciprofloxacin, toxic epidermal necrolysis occurring along with cholestatic hepatitis is a rare one. Here, we present a case of a 22-year-old male patient who was diagnosed with toxic epidermal necrolysis with cholestatic hepatitis secondary to Ciprofloxacin. Naranjo adverse drug reaction probability scale was used for the causal association.

Cholecystopathia chronica calcarea (Porcelain gall bladder): A case report from Nepal.

Introduction and importance: Porcelain gall bladder is an uncommon end-stage modification of chronic cholecystitis, with an incidence ranging from 0.06 to 0.8% along with a plausibility of malignant transformation. Case presentation: We present a 55-year-old female presenting with complaints of epigastric and right hypochondriac region pain who underwent prophylactic laparoscopic cholecystectomy after making a provisional diagnosis of calcified gall bladder on a computed tomography workup. On histopathological examination, she was later diagnosed with a porcelain gallbladder devoid of features suggestive of malignant transformation. Clinical discussion: Porcelain gallbladder is a cholecystopathological condition in which the gallbladder wall gets calcified, either completely or partially. Though the exact pathomechanism of gallbladder calcification is unknown, it is believed to be due to chronic inflammation. Recent studies have shown that gallbladder calcification is associated with a lower risk of the development of gallbladder cancer. Imaging studies, followed by post-operative histopathological examinations, are used to diagnose the porcelain gallbladder. Though the management of asymptomatic patients is debatable, prophylactic cholecystectomy is the preferred treatment for symptomatic porcelain gallbladder patients. Conclusion: Individual porcelain GB patients should be addressed based on the presenting condition, whether surgically or via clinical monitoring and follow-up, taking into consideration the advantages and limitations of both treatment modalities.

Amyand hernia; a case report on serendiptous intra-operative diagnosis.

Introduction and Importance: Amyand hernia is an accidental finding that occurs in 0.19-1.7% of patients with inguinal hernia, with children being more commonly affected than adults. However, the management depends on the guidelines given by Losanoff and Basson. Case Presentation: A 62-year-old male presented with complaints of progressive swelling in the right inguinal region without any clinical spectrum of bowel obstruction or strangulation. Examination revealed a right-sided indirect inguinal hernia with positive Ziemann technique. Open hernioplasty revealed an appendix within a hernia sac and was found to be adhered to the surrounding structure with a fibrotic band. According to the Losanoff and Basson protocol, the patient had an appendectomy and an open mesh repair with polypropylene mesh without any post-operative complications. Clinical Discussion: Amyand hernia are often predominantly present in children, with a rare presence in the elderly. Pre-operative clinical diagnosis remains a challenge, and the management depends upon the Losanoff and Basson protocol. Appendectomy of the normal appendix within the hernia sac is often recommended to prevent the sequelae (appendicitis, rupture) following manipulation during hernioplasty. Conclusion: Amyand's hernia is a rare clinical entity and difficult to diagnose due to its uncomplicated presentation. Nevertheless, the progress of appendix inflammation, the possibility of abdominal sepsis, and co-morbidities should all be taken into consideration when deciding how to manage individual patients.

Sinistroposition: A case report on incidental finding of left sided gall bladder on laparoscopic cholecystectomy.

Introduction and importance: Left-sided gall bladder, a rare biliary abnormality with an incidence of 0.04-0.3%, is characterized by the presence of the gall bladder to the left of the ligamentum teres. However, they are often missed during pre-operative imaging and often encountered intraoperatively, thus challenging the surgical intervention for the surgeons. Case presentation: We herein present a 40-year-old male presented with colicky right hypochondriac pain and epigastric discomfort, diagnosed incidentally during laparoscopic cholecystectomy as a left-sided sided gall bladder without situs inversus, which was missed during pre-operative ultrasonography and was treated without any complications with conventional four-port technique without changes in the trocar placement. Clinical discussion: Gall bladder is normally found in the gall bladder fossa to the right of the ligamentum teres in the plane of the von Rex-Cantlie line; however, left-sided gall bladder is found to the left of the ligamentum teres and is frequently associated with inversus of the abdominal structures and associated vessels. They are frequently overlooked during preoperative diagnostic imaging, ultrasound for colicky discomfort, and encountered during intraoperative operations, confounding the treating surgeon's anatomic expertise. Intra-operative cholangiography is sometimes used as an adjunct, and operations can be accomplished with or without modifications in trocar position. Conclusion: Despite preoperative imaging, biliary abnormalities can be discovered accidently during laparoscopic cholecystectomy. Thus, diligent recognition of structures and related anomalies by the treating surgeon has a high value in the best possible outcome for the patient, and left-sided gall bladder can be done with minimum difficulty even without interposition of trocar placement.

A missed medial humeral epicondyle fracture with incarcerated fragment in the elbow joint and ulnar nerve palsy: A rare case report.

Medial epicondyle fracture associated with incarcerated intra-articular fragment and ulnar nerve palsy is uncommon and frequently missed. We report a case of 13-year-old boy with incarcerated medial epicondyle fracture fragment in ulnohumeral joint and ulnar nerve palsy, which was managed successfully by open reduction internal fixation and ulnar nerve transposition.