Dementia care landscape in Nepal: Understanding the context, barriers, and opportunities for the development of a national dementia care plan.

OBJECTIVE: This study was conducted to comprehensively understand the context, barriers, and opportunities for improving dementia care, treatment, and support. The objective is to guide the development of a national dementia care plan. METHODOLOGY: This document review was conducted by analyzing literature available in the public domain, including scientific publications, project documents/reports, media reports, and hospital records. Additionally, annual reports published by the Department of Health Services, national census and demographic and health survey reports, Old Age Homes, and other relevant government reports were examined. Firsthand information was gathered from relevant stakeholders based on the World Health Organization's situational analysis framework for dementia plans. This framework encompasses four domains: Policy context (national ministries, legislation, policies, strategies, plans related to dementia, mental health, aging, and disability), service delivery assessment (health and social care workforces, services, support and treatment programmes, and promotion of awareness and understanding), and epidemiological indicators (prevalence and incidence rates of dementia, risk factors). Ethical clearance was obtained from the Institutional Review Committee (IRC) of B.P. Koirala Institute of Health Sciences (IRC no.2658/023). RESULTS: Existing policies in Nepal inadequately address the needs of people with dementia and their caregivers. Concerning health services, the Government of Nepal provides financial subsidies to individuals diagnosed with dementia; however, numerous hurdles impede access to care. These obstacles include geographical and structural barriers, an inefficient public healthcare system, weak governance, financial constraints, low awareness levels, stigma, and inadequate workforce. Furthermore, the absence of robust nationally representative epidemiological studies on dementia in Nepal hampers the development of evidence-based plans and policies. Similarly, there are no interventions targeted at caregivers of people with dementia, and no initiatives for dementia prevention are in place. CONCLUSIONS: This review underscores the urgent need to formulate a comprehensive national dementia care plan to address the growing challenges. Key priority action areas include the integration of dementia care into primary healthcare services, training workforce to provide the care, increasing awareness, mitigating stigma, developing caregiver support programs, and initiating high-quality research to inform evidence-based policymaking.

Development and Validation of a Risk-Adapted Scoring Model for Metachronous Upper Tract Urothelial Carcinoma following Radical Cystectomy.

PURPOSE: The incidence and risk factors for metachronous upper tract urothelial carcinoma (UTUC) following radical cystectomy (RC) remain incompletely defined, which has limited the ability to individualize postoperative surveillance. MATERIALS AND METHODS: A retrospective review of 2 institutional registries was performed to identify patients undergoing RC for urothelial carcinoma. Multivariable Cox proportional hazard models for metachronous post-RC UTUC were developed in one institutional data set and validated in the second institutional data set. A post-RC UTUC risk score was then developed from these models. RESULTS: A total of 3,170 RC patients were included from the training cohort and 959 RC patients from the validation cohort. At a median followup after RC of 4.6 years (IQR 2.1-8.7), 167 patients were diagnosed with UTUC. On multivariable analysis in the training cohort, risk factors for metachronous UTUC were the presence of positive urothelial margin (HR 2.60, p <0.01), history of bacillus Calmette-Guérin treatment prior to RC (HR 2.20, p <0.01), carcinoma in situ at RC (HR 2.01, p <0.01) and pre-RC hydronephrosis (HR 1.48, p=0.04). These factors had similar discriminative capacity in the training and validation cohorts (C-statistic 0.71 and 0.73, respectively). A UTUC risk score was developed with these variables which stratified patients into low (0 points), intermediate (1-3 points), and high risk (4+ points) for post-RC UTUC, with respective 5-year UTUC-free survivals of 99%, 96%, 89% in the training cohort and 98%, 96%, and 91% in the validation cohort. CONCLUSIONS: We developed and validated a risk score for post-RC UTUC that may optimize UTUC surveillance protocols after RC.

The outcome of Radial Neck Fracture Treated with Closed/ Open Reduction and Retrograde Kirschner Wires Fixation in the Paediatric Age Group.

Background Radial neck fractures in children are rare injuries, representing 1 to 5% of all elbow pediatric fractures. Most of them are non-displaced or slightly displaced and treated conservatively. Severely displaced or angulated radial neck fractures (Judet type III and IV fractures or O'Brien type III radial neck fractures) requires surgical treatment. Objective To study the clinical and radiological outcomes of fractures following closed or open reduction and percutaneous intramedullary stabilization of the displaced radial neck fracture in children. Method There were 24 children with displaced radial neck fracture Judet type II, III and IV fractures O'Brien type II, III who underwent closed reduction and retrograde intramedullary stabilization with Kirschner wires. Functional outcomes were evaluated based on of Mayo Elbow Performance Score. Result The mean age of patients was 8.42 ± 1.82 years with boys 15(62.5%) and girls 9(37.5%) in number. An excellent result was seen in 5(20.8%) cases and good results in 15(62.5%) cases according to the Mayo elbow performance score. Analyzing a passive and active range of motion, 5 had excellent results, 15 had good results and 4 had fair results compared to the normal side. Radiological evaluation showed fracture healing in excellent or good alignment according to Ursei radiological evaluation classification. Conclusion Closed reduction and retrograde intramedullary Kirschner wires stabilization for the displaced radial neck fracture provide excellent clinical and radiological results with few complications.

Celiac Plexus Denudation in Triangle Dissection in Pancreatico Duodenectomy: Perioperative Anesthetic Implications.

This is a case report of inadvertent right celiac plexus denudation during triangle dissection during the surgery for carcinoma of pancreas under combined general epidural anaesthesia. Operative removal of the ganglia has its own autonomic effects, which are important to observe for anesthesiologists and perioperative critical care physicians alike.

Study of Two Different Volumes of 0.75% Ropivacaine for Ultrasound Guided Supraclavicular Brachial Plexus Block on Successful Blockade and Diaphragmatic Motility.

Background Use of ultrasound guidance during supraclavicular brachial plexus block allows the usage of a lower anesthetics dose and minimizing unwanted effects of the anesthesia. Objective To compare the success of sensory blockade and the incidence of hemidiaphragmatic dysfunction in patients receiving two different volume of 0.75% Ropivacaine for ultrasound guided supraclavicular brachial plexus block. Method A prospective randomized double-blinded comparative study was conducted. Group A patients (n=30) received 20 ml and Group B (n=30) received 25 ml of 0.75% Ropivacaine for ultrasound guided supraclavicular brachial plexus block. Hemodynamic parameters, oxygen saturation, diaphragmatic excursion, onset of sensory blockade and time for completion of blockade were measured. Independent t-test, Chi-square test and Mann-Whitney U test were used to analyze the data at p value of less than 0.05 using Statistical Package for Social sciences (version 11.5). Result At 30 minutes, 29 (96.67%) patients in group B and 27 (90.0%) patients in group A had no sensation in median, radial, ulnar, musculocutaneous and medial cutaneous nerves teritories; however, it was not significant statistically (p value > 0.05). At 30 minutes in Group A, 25 (83.33%) patients had no diaphragmatic hemiparesis and five (16.67%) patients had partial diaphragmatic hemiparesis. However, three (10%) patients had no diaphragmatic hemiparesis in Group B, 25 (83.33%) patients had partial and two (6.67%) patients had complete diaphragmatic hemiparesis and it was statistically significant (p < 0.05). Age and sex had no effect on diaphragmatic hemiparesis in both groups (p value > 0.05). Conclusion The patients receiving lower volume of Ropivacaine had less incidence of hemidiaphragmatic dysfunction with similar sensory blockade as compared to the patients receiving higher volume of Ropivacaine.

Prevalence and Associated Factors of Cesarean Section in Dhulikhel Hospital, Kathmandu University Hospital.

Background The Cesarean Section (CS) is a major obstetric life-saving procedure used to avoid pregnancy and childbirth complications. Cesarean sections are becoming more popular across the world, as well as in Nepal. Objective To assess the prevalence of cesarean section and its associated factors among women in Dhulikhel, Nepal. Method A cross-sectional study was conducted where 1246 pregnant women of age 15-45 years, admitted and delivered in hospital, were selected through purposive sampling technique and interviewed using structured questionnaires in Dhulikhel Hospital, Kathmandu University Hospital, Kavre, Nepal. Result The prevalence of cesarean section among women was 39.7% where the most common indication was previous cesarean section with scar tenderness, 27.9%. Half of the participants, i.e. 50.6%, were primigravida. Majority of women, 97.5% had done their antenatal checkup and among them 74.8% had their checkup in Dhulikhel Hospital, Kathmandu University Hospital. Most of them, i.e.76.2% had emergency cesarean section and 69.5% had primary cesarean section. Women of the age group 30-45 years (AOR=2.23) and women with higher secondary education level (AOR=2.03) were two times more likely to perform cesarean section. Women involved in service (AOR=1.37) and business (AOR=1.23) had greater odds of performing cesarean section than homemakers. Women giving birth to infants weighing 3.51- 5.00 kg were more likely to perform cesarean section (AOR=1.33). Conclusion The prevalence of cesarean section is noticeably high where the educated, employed and higher aged women are more inclined to cesarean section. More obstetric factors could be explored to determine the rise in cesarean section in Nepal which can help in decision making for clinicians.

Massive Hemoptysis and Pulmonary Thromboembolism in a Patient with Pulmonary Tuberculosis: A Therapeutic Conundrum Managed with Bronchial Artery Embolization.

Hemoptysis is a crucial entity taking into account its morbidity and mortality. Pulmonary tuberculosis is the leading cause for massive hemoptysis in our part of the world, which if left untreated may be life threatening. We present a case of a 37-year-old male patient with pulmonary tuberculosis with concurrent pulmonary thromboembolism presenting with massive hemoptysis, which was successfully managed with Bronchial Artery Embolization. This case represents that this measure can be a viable therapeutic choice for a patient with a severe lifethreatening hemoptysis, particularly when other treatment options are unavailable or ineffective.

A study of Deep Neck Space Infections at Kathmandu University Dhulikhel Hospital.

Background Enhanced recovery after surgery is a multimodal strategy, used to attenuate the loss and improve the restoration of functional capacity after surgery. Now widely used in elective surgery, the implementation of all of its components is not feasible in emergency surgery. Therefore, its tailored protocol is likely to give better outcome. Objective To investigate the feasibility and effectiveness of enhanced recovery after surgery in emergency surgery for Duodenal Ulcer Perforation. Method Hospital based study conducted at Nepalgunj Medical College, Kohalpur from September 2018 to 2020. Hundred patients underwent emergency laparotomy with Classical Graham's Patch Repair. Fifty patients in the enhanced recovery after surgery group were managed as per the protocol and the rest were managed conventionally. Both the groups were compared in terms of length of hospital stay, functional recovery parameters and complications. Result There were 48 (96%) males and 2 (4%) females in enhanced recovery after surgery group and 45 (90%) males and 5 (10%) females in non-enhanced recovery after surgery group. The mean length of hospital stay in enhanced recovery after surgery group was 4.9 ± 0.76 days together with early functional recovery compared to 9.06 ± 2.44 days in non-enhanced recovery after surgery group (p < 0.05). Complications as per Clavien-Dindo grading were more in the non- enhanced recovery after surgery group (p=0.03). Conclusion Enhanced recovery after surgery is feasible and effective strategy resulting in early recovery, reduced hospital stay and complications in patients undergoing emergency surgery for duodenal ulcer perforation.

Functional Outcomes of Arteriovenous Fistulas Created by Nephrologist.

Background Preoperative accurate staging of gallbladder cancer is still difficult. A number of patients with gallbladder cancer who undergo laparotomy for curative resection are ultimately found to have unresectable disease. The benifit of staging laparoscopy is its ability to find out the radilogical occult intraperitoneal metastasis and to spare from nontheraputic laparotomy. The role of staging laparoscopy has been extensively studied in hepatobiliary and pancreatic malignancies and found to be useful. But in recent time its utility in biliary cancers is sceptical probably because of the advent of positron emission tomography. However in gallbladder cancer it is still recommended. Objective To identify the utility of staging laparoscopy in gall bladder cancers. Method Hospital based study conducted at Nepalgunj Medical College, Nepal from October 2014 to June 2020. The patients with resectable gallbladder cancers on computed tomography were included. All patients underwent single stage staging laparoscopy. Staging laparoscopy was considered positive if the surface lesions (liver and/or peritoneal deposits) were detected. The surgery was terminated if positive. Patients with negative staging laparoscopy were proceeded with laparotomy. Result Staging laparoscopy was done in 47. The yield of staging laparoscopy was 14 (29.78%) and its accuracy was 58.33% (14/24). Out of 33 (70.21%) with negative staging laparoscopy, 10 (30.3%) had unresectable disease in laparotomy. The yield was higher in locally advanced in comparison to early disease (78.57% Vs 21.42%). Conclusion We recommend routine staging laparoscopy in gallbladder cancer, particularly when the disease is locally advanced.

Postoperative Analgesic Effect of Morphine Added to Bupivacaine for Transversus Abdominis Plane (TAP) Block in Appendectomy.

Background Transversus abdominis plane (TAP) block with local anaesthetics produces effective pain relief following lower abdominal surgeries. Although opioids have been found to have effects through peripheral receptors also, reports on their effect when used as additive to local anaesthetics for TAP block are lacking. Objective To assess the analgesic effect of peripherally administered morphine with bupivacaine for ipsilateral TAP block in patients undergoing emergency appendectomy under general anaesthesia. Method Sixty patients undergoing appendectomy were randomized to undergo ipsilateral TAP with 20 ml of 0.5% bupivacaine plus 2 ml of NS (total 22 ml) and 2 ml of intravenous (IV) saline (Group TB) or with 20ml of 0.5% bupivacaine plus 2 mg (2 ml) of morphine (total 22 ml) and 2 ml of NS IV (Group TBM) or with 20 ml of 0.5% bupivacaine plus 2 ml of NS (total 22 ml) and 2 mg (2 ml) IV morphine (Group TB-IVM). Pain severity was measured using Visual Analogue Scale (VAS) preoperatively (Baseline) and at 30 min, 6h, 12 h and 24 h postoperatively. Inj. tramadol 50 mg IV was used as rescue analgesic when postoperative VAS was 4 or more. The duration of analgesia (time to first analgesic) and the postoperative 24 h tramadol requirement was recorded. Result The mean duration of analgesia in Group TBM was significantly longer (801.50 ± 74.92 min, p=0.002) than in Group TB (720.00 ± 42.17 min) and Group TB-IVM (712.70 ± 40.94 min). The mean postoperative 24 h tramadol requirement was also less in Group TBM (69.23 ± 25.31mg) than in Groups TB (100.00 ± 38.34 mg) and TB-IVM (95.00 ± 39.40 mg) but did not reach the level of statistical significance (p=0.057). Significantly less ondansetron was required in Group TBM (3.80 ± 2.04 mg) than in Group TB (6.80 ± 2.93 mg) and TB-IVM (6.00 ± 2.75 mg) (p=0.002). Conclusion Morphine added to bupivacaine effectively prolongs the analgesic duration of TAP block in appendectomy.

Comparison of Initial Response of Nebulized Salbutamol and Adrenaline in Infants and young Children Admitted with Acute Bronchiolitis.

Background Acute bronchiolitis is common cause of hospitalization in infants and young children. There are widespread variations in the diagnosis and management. Despite the use of bronchodilators for decades, there is lack of consensus for the benefit of one above another. Objective To compare initial response of nebulized adrenaline and salbutamol. Method Children aged two months to two years admitted with acute bronchiolitis in the department of Paediatrics of Manipal teaching hospital, Pokhara, Nepal, from 1st March 2014 to 28th February 2015 were enrolled. Patients fulfilling inclusion criteria received either adrenaline or salbutamol nebulization. Data were collected in a predesigned proforma. Respiratory distress assessment instrument (RDAI) scores were considered primary outcome measure and respiratory rate at 48 hours, duration of hospital stay, requirement of supplemental oxygen and intravenous fluid were considered secondary outcome measure. Result A total of 40 patients were enrolled in each study group. Mean RDAI scores at admission was in 9.75 with (CI- 9.01, 10.49) in adrenaline and 9.77 (CI- 9.05, 10.50) in salbutamol group. There was gradual decline in mean RDAI scores in both the groups over 48 hours to 4.15 (CI- 3.57,4.73) and 4.13 (CI- 3.69,4.56) in adrenaline and salbutamol group respectively. Hospital stay was 5.32 days in adrenaline and 5.68 days in salbutamol group. Patients nebulized with adrenaline required oxygen for 33.30 hours compared with 36.45 hours in salbutamol. Intravenous fluid duration was also less in adrenaline group compared to salbutamol group (33.15 vs 37.80 hours). Conclusion Patients of acute bronchiolitis nebulized with either salbutamol or adrenaline experienced similar decline in RDAI scores in the first 48 hours. Duration of supplementary oxygen and intravenous fluid was less in adrenaline group compared with salbutamol group.

Compliance and its Determinants Regarding Iron and Folic Acid Supplementation during Pregnancy in Kathmandu, Nepal.

Background Iron deficiency anemia is one of the major public health problems mostly affecting pregnant women of developing countries like Nepal. Kathmandu, the capital city of Nepal, has considerably high prevalence of anemia, which is attributed to inadequate dietary iron and problems of compliance to iron and folic acid supplementation. Objective This descriptive study aimed to identify the levels of and determinants associated with compliance regarding Iron and folic acid supplementation among pregnant women in Kathmandu, Nepal. Method The study was conducted in Paropakar Maternity and Women's Hospital in Kathmandu. Systematic random sampling was done to select a total of 406 samples that were either handed questionnaire for self-administration or interviewed. The χ2 test and multiple linear regressions were used for statistical analysis. Result The findings showed 73.2% of the respondents had high compliance, 12.8% moderate compliance, and 14% low compliance to iron and folic acid supplementation. More than half of the respondents had insufficient knowledge regarding anemia, iron deficiency and iron and folic acid supplementation. Multiple linear regression revealed that perceived severity, perceived barriers and social support were determinants of compliance to iron and folic acid supplementation (p<0.05). Conclusion This study infers that there is a lack of knowledge and awareness regarding anemia, iron deficiency, and iron and folic acid supplementation among pregnant women, and improvement in social support and perception of severity of the disease, and minimization of associated barriers may lead to better outcome in terms of compliance to iron and folic acid supplementation among pregnant women.

Blue vitiligo following intralesional injection of psoralen combined with ultraviolet B radiation therapy.

A 23-year-old Chinese man presented with a 16-month history of white patches on his abdomen and neck. He had previously received an intralesional injection of psoralen along with narrowband psoralen ultraviolet B radiation (PUVB) therapy. Blue macules had appeared in and around the injection sites 1 week later. Dermoscopy revealed blue spots and reticular telangiectasia within the white patches. Histological examination revealed an absence of epidermal melanocytes and pigment in the basal layer, as well as deposition of melanophages between collagen bundles or surrounding blood vessels and appendages in the middle and lower parts of the dermis. A diagnosis of blue vitiligo was made. The blue colour faded gradually over time. Our case provides direct evidence to support the previous surmise that PUVB can contribute to blue vitiligo. To our knowledge, this is only the fourth reported case of blue vitiligo in the English literature.

Relation of Sociodemographics and Personal Hygiene on Different Childhood Dermatoses.

BACKGROUND: Skin diseases in children contribute to significant morbidity and psychological distress. Infective dermatoses are one of the major dermatoses in children. Low socioeconomic status, overcrowding and poor personal hygiene has been linked to skin diseases. OBJECTIVE: To find out the prevalence of infectious skin disease in children, rate of transmissible skin disease and association of sociodemographic factors and personal hygiene on infective childhood dermatoses. METHOD: This was a cross-sectional study conducted in the Pediatric and Dermatology Department, Manipal Teaching Hospital, Pokhara, Nepal. A total of 226 patients were examined over a period of one year. Relation of sociodemographics, crowding and personal hygiene on skin disease were assessed. RESULT: The most common category was Infections and Infestations (51.3%) followed by Dermatitis (27.9%). Transmissible skin disease was seen in 49.6%. Low socioeconomic status and overcrowding were associated with increased risk for infective dermatoses. CONCLUSION: Skin disease in children constitutes a public health problem. Improving the socioeconomic status and personal hygiene can help to reduce the incidence of skin disease in children.

Liver dysfunction in alcoholics in Western Nepal.

To estimate liver function tests in patients with alcoholic fatty liver disease, alcoholic hepatitis and alcoholic cirrhosis and to compare the levels of enzymes between the groups. A hospital based case control study was carried out at Nepalgunj Medical College, Nepal from January 2013 to June 2013. A total of 150 alcoholic associated liver disorders patients aged between 20-70 years and 50 sex age matched normal healthy controls were taken to assess liver function tests (LFTs) by measuring Aspartate aminotransferase (AST), Alanine aminotransferase (ALT), Alkaline phosphatase (ALP), Gamma glutamyltranspeptidase (GGT) & Albumin. The mean±SD of liver function tests (LFTs) of patients of alcoholic fatty liver disease is highest followed by alcoholic hepatitis patients. All the 3 groups of alcoholic associated liver disorders patients when compared to normal healthy control subjects showed statistically significant increase in the levels of AST (p<0.000), ALT (p<0.000), ALP (p<0.006), GGT (p<0.000), & Albumin (p<0.000). Liver function tests values for alcoholic associated liver disorders patients when compared to the healthy control subjects was significantly altered.

Delirium in critically ill patients in a tertiary care centre in western region of Nepal.

BACKGROUND: Delirium affects a significant proportion of critically ill patients admitted in hospital. It is associated with various adverse outcomes. Despite its enormous prognostic significance it tends to be underdiagnosed. There is a dearth of studies on risk factors of delirium in our setting. OBJECTIVES: The main objectives of this study was to find out the prevalence, rate of non recognition and risk factors associated with delirium in hospitalized critically ill patients. METHODS: A hospital based cross-sectional study was carried out. Data was collected using a predesigned semi-structured proforma and Intensive care delirium screening checklist was used to screen for delirium in patients admitted in various wards of Manipal teaching hospital, Pokhara, Nepal. RESULTS: Ninety five cases were included in the analysis. The mean age of study group was 58.9 ± 19.1 years. Delirium was present in 15/95 cases and it was not recognized by treating physician in about one third of cases. Odds ratio (OR) was statistically significantly increased in patients with history of stroke (OR=4.484 95% CI=1.0896;18.459), alcohol use (OR=10.792 95% CI=2.906;40.072), smoking (OR= 4.836 95% CI= 1.411;16.576), use of restraint (OR=17.143 95% CI=4.401;66.766), nasogastric tube placement (OR= 7.731 95% CI=2.348;25.452) and use of Foley's catheter (OR=12.000 95% CI= 3.072;46.877). CONCLUSION: About 16% of critically ill patients were found to be delirious. In about one third of the cases delirium was not recognized. Both patient related and iatrogenic factors may increase the risk of delirium in hospitalized critically ill patients.

Medication adherence to oral hypoglycemic agents among type II diabetic patients and their clinical outcomes with special reference to fasting blood glucose and glycosylated hemoglobin levels.

BACKGROUND: Oral hypoglycemic agents (OHAs) are the major treatment for people with type 2 diabetes mellitus (DM2). However, non-adherence to OHAs remains as one of the main reasons for poor glycemic control. OBJECTIVES: To assess the adherence pattern to OHAs and clinical outcomes with special reference to fasting blood glucose (FBG) level and glycosylated hemoglobin (HbA1c) levels. METHODS: Informed consent was obtained from patients fulfilling the criteria and from the patient party in case of incapacitated patients. Information was obtained by interviewing them and filled in the appropriate questionnaire. All the medical information of the patients was obtained from the medical case records and laboratory reports. RESULTS: OHAs had been discontinued by 25% of patients. Overall 38% had ever discontinued and/ or often missed OHAs. Intentional discontinuation of OHAs attributed for 72% of the patients, followed by forgetfulness (42.9%), carelessness (30.6%), and hypoglycemia, (24%). There were 50.50% patients who had uncontrolled FBG (>130 mg/dl) level and 39% had uncontrolled HbA1c (≥ 7%) level. Taking reference age group 51-60 years, control of FBG level was found to be statistically associated with the decreasing age group (p = 0.006, OR = 4.8) as well as increasing age group (p = 0.008, OR = 4.034). There was significant association between controlled HbA1c level and patients' knowledge about the precautions to be taken while using OHAs (p = 0.044, OR = 4). However, there was no significant association between glycemic control and OHAs adherence. CONCLUSION: Majority of the patients who had missed OHAs attributed it to forgetfulness. Hypoglycemia may also be one of the contributing factors for poor adherence to OHAs. However no association was found between adherence and various other factors like age groups, treatment complexity, health literacy and social or family support.

Initiating advanced laparoscopic surgery in a medical college hospital with basic laparoscopic set up: is it feasible and safe?

BACKGROUND: Laparoscopic surgery involves performing surgery through small incisions in abdominal wall to get access. Primary goal of this procedure is to achieve good cosmetic outcome, reduced post operative pain, early recovery and reduced hospital admission. OBJECTIVE: The main objective of this study is to see the feasibility and benefit of performing advance laparoscopic surgery in a place where basic laparoscopic surgery is done and to share my experience while performing it. MATERIALS AND METHODS: A retrospective study of case sheets and discharge summary from 1st May 2008 till 1st August 2009 was done. Altogether eight patients underwent different advanced laparoscopic procedure. Cases done for the fi rst time in the institute and those done by himself were only included. Technical feasibility, use of devices like harmonic scalpel, need for incision extension, operative time, blood product requirement, ambulation and enteral feed, post operative hospital stay and patients satisfaction regarding minimal scars were assessed. RESULT: Total eight patients underwent advance laparoscopic surgery. There were two common bile duct (CBD) exploration of which one was transcystic exploration, one total laparoscopic abdominoperineal resection (APR) for rectal cancer, one laparoscopic assisted right hemicolectomy for carcinoma ceacum, one laparoscopic assisted sigmoid colectomy for recurrent sigmoid volvulus, two laparoscopic right nephrectomy for non functioning right kidney, one retroperitoneal pyelolithotomy and one laparoscopic assisted splenectomy for massive splenomegaly with haemolytic anaemia. All procedures were technically feasible with basic laparoscopic instruments. However harmonic scalpel was required for splenectomy due to difficult hilum dissection. Ureteroscope was used as a choledochoscope in CBD exploration. Blood transfusion was required only in patient with low preoperative haemoglobin. Early ambulation and enteral feed was done within 24 hours in all and within 48 hours in patients who had bowel anastomosis. Post operative hospital stay was 5-8 days. Cosmetic scar was appreciated by all. Although long term oncological outcome is yet to come in malignancy case, biopsy report of laparoscopic APR identified 13 nodes which shows complete nodal dissection on oncological principal basis. CONCLUSION: Advanced laparoscopy is feasible, safe and effective in the hand of surgeons performing basic laparoscopic surgeries with guidance from surgeons who have long experience on same procedures but by open method.

Interesting Scenarios during Radiofrequency Ablation of Varicose Veins at University Hospital of Nepal.

A varicose vein is a common venous condition which affects the great saphenous vein and small saphenous vein causing symptoms of pain, edema, itchiness, pigmentation, and ulceration. There are various modalities of the treatment of varicose veins; however, radiofrequency ablation is among the tested and proven treatments for varicose veins. With every case, there can be some unexpected or interesting scenarios which can pose both technical and surgical difficulties. The main objective of this paper is to introduce these scenarios which can occur despite following the standard protocol and methods both preoperatively and intraoperatively. In these scenarios, the surgeon quickly need to decide how to deal with the aberrations. Based on extensive literature and consensus of a team of three vascular surgeons, lists of interesting scenarios were prepared along with their definition. Any occurrences of such scenarios were noted in the operation theatre note. Here, we describe 39 (6.38%) interesting cases among 611 cases of radiofrequency ablation that was performed in Dhulikhel Hospital, Kathmandu University Hospital, from January 2014 until December 2019. Despite following the proper protocol, we can face many unexpected challenges preoperatively, peroperatively, and postoperatively. From this article, we concluded that vigilance of all the factors and proper Doppler ultrasonography can help in identifying most of these scenarios and aid in making proper surgical planning.

Case report of eventration of diaphragm due to an unknown febrile illness causing phrenic nerve palsy and other multiple nerve palsies.

INTRODUCTION: Diaphragmatic eventration can be congenital or acquired. Diagnosis is delayed due to no symptoms or very mild ones and is generally done by imaging modalities. This condition is managed by plication of the affected part of diaphragm by various surgical approaches. PRESENTATION OF CASE: A forty seven years lady presented with one year long history of abdominal pain, bloating and fullness after meals who was being treated in line of peptic acid disorder. She had developed bilateral foot drop after typhoid fever at seventeen years of age. Clinical examination and imaging with chest x-ray, chest ultrasound and computed tomography scan suggested eventration of left hemidiaphragm. Plication of eventration of left hemidiaphragm was done via mini thoracotomy of the left thorax. There were no postoperative complications and she was discharged on the sixth postoperative day. DISCUSSION: Acquired eventration of diaphragm is commonly due to traumatic phrenic nerve palsy but rarely can be associated with a history of infection causing nerve palsies. Thoracic ultrasound is an emerging modality for diagnosis supporting X-rays and CT Scans. Plication of eventration with minimally invasive techniques has less number of hospital stay and less pain compared to open approaches. CONCLUSION: Non-traumatic diaphragmatic eventration due to acquired phrenic nerve palsy following an unknown febrile illness is a rare case to be reported in Nepal. The aim of treatment is expansion of intra-thoracic space which is done by plication of the diaphragm.