Surgical Outcome of Limberg's Flap Reconstruction in the Treatment of Pilonidal Sinus Disease in a Community Hospital.

Background Pilonidal sinus disease is an acquired condition that commonly arises in the hair follicles of the gluteal cleft with male predominance. Different treatment modalities have been described in the literature ranging from simple incision and drainage, wide local excision to complex plastic flaps. Objective To evaluate the efficacy and outcome of Limberg's flap reconstruction in a community hospital. Method This is a prospective study conducted over two-year duration in forty-two patients in the department of Surgery at Dhulikhel Hospital Kathmandu University Hospital from January 2017 till December 2018. Result Total of 42 patients were operated ranging from 16-31 years with mean of 22.86 years, male to female ratio was 7.5:1, 52% were students and 19% were drivers. Mean operative duration was 61.86±25.3 minutes, length of hospital stay was 2.83±1.68 days, mean duration of drain in situ was 4±1.34 days, mean days for return to work was 14.5±5.7. We had a complication rate of 9.52% out of which 4.76% had seroma, 2.38% hematoma, 2.38% wound infection, and there was no flap necrosis or recurrence. Conclusion It is a simple, easy to learn and safe procedure with good cosmetic results and low recurrence rate. It can be considered as an alternative to other flap and plasty procedures.

Microsurgical free flaps at Kathmandu Model Hospital.

BACKGROUND: Microsurgery is an emerging subspecialty in Nepal. Microsurgery was started at Kathmandu Model Hospital in 2007 with the support from Interplast Australia and New Zealand. This study will be useful for establishing a baseline for future comparisons of outcome variables and for defining the challenges of performing microsurgical free flaps in Nepal. METHODS: A retrospective cross sectional study was conducted using the clinical records of all the microsurgical free flaps performed at Kathmandu Model Hospital from April 2007 to April 2014. RESULTS: Fifty-six free flaps were performed. The commonest indication was neoplasm followed by post-burn contracture, infection and trauma. Radial artery forearm flap was the commonest flap followed by fibula, antero-lateral thigh, rectus, tensor facia lata, lattisimus dorsi, deep inferior epigastric artery perforator, and deep circumflex iliac artery flap. Radial artery forearm flaps and anterolateral thigh flaps were mostly used for burn contracture reconstructions. Twelve of the 13 (92%) fibulae were used for mandibular reconstruction for oral cancer and ameloblastoma. Rectus flaps were used mainly for covering defects over tibia. Hospital stay ranged from six to 67 days with an average of fourteen. Fifteen patients (26%) developed complications. The duration of operation ranged from six hours to 10.5 hours with an average of nine hours. The longest follow up was for four years. CONCLUSIONS: Microsurgery can be started even in very resource-poor center if there is support from advanced centers and if there is commitment of the institution and surgical team.

Extraventricular neurocytoma.

Extraventricular neurocytoma is a rare neuroepithelial tumor. Its propensity to occur in cerebral hemisphere is much higher. EVN has a histological resemblance to central neurocytoma but radiologically, it is more complex. Ganglionic differentiation is more common in EVN and tends to have more of a cystic component. Calcification is frequent but hemorrhage is only an occasional finding. Although it has been reported to occur in various regions, the propensity to occur in cerebral hemisphere is much higher. Herein, we report two cases which presented as a mass in the right frontal lobe and right parietal lobe. MRI showed hypointesity on T1, hyperintesity on T2-weighted images with moderate enhancement after contast injection. In short extraventricular neurocytoma should be considered indifferential diagnosis of complex intracranial masses.

Evolving experience in the management of empyema thoracis.

BACKGROUND: Empyema thoracis a disease of significant morbidity and mortality, especially in the developing world. However, the optimal management of empyema thoracis remains controversial. OBJECTIVE: To analyse evolving experience in clinical presentation, management, outcome and factors contributing to adverse morbidity in empyema thoracis. METHODS: This is hospital based retrospective study of patients who were diagnosed with empyema thoracis in cardiothoracic and vascular surgery (CTVS) unit, Bir Hospital, Kathmandu, Nepal over a period of one year (July 2009 to June 2010). A total of forty-six adult cases were categorized into two treatment groups: (i) thoracotomy for decortication (ii) segmentectomy, lobectomy and redo-thoracotomy for pneumonectomy. The median duration of illness prior to hospital admission was compared. The presence of loculated pleural fluid determined the need for thoracotomy. RESULTS: Out of forty-six cases, twenty- nine (63.04%) who had early thoracotomy (less than 22 days) had prompt symptomatic recovery. Fourteen out of seventeen (82.35%) of the patients who were initially treated with thoracocentesis or tube thoracostomy eventually needed thoracotomy. There was a positive shift in management towards early thoracotomy resulting in prompt symptomatic recovery. Significant complications were noted in eight patients who had delayed thoracotomy. Complications included recurrent empyema with lung abscess (n = 3), restrictive lung disease (n = 3), bronchopleural fistula (n = 1) and scoliosis (n=1). CONCLUSION: Early thoracotomy and decortication was found to be an excellent surgical procedure with good functional results and high patient satisfaction rate.

Quality assurance in the management of peritonitis: a prospective study.

The aim of this study was to assess the quality of care indicators in the management of peritonitis. A total of 124 cases with diagnosis of secondary and tertiary peritonitis were included. Detailed clinical history, examination, relevant investigations and details of operative findings were noted. The following quality indicators-surgical consultation time, waiting period for surgery, diagnostic accuracy, antibiotic utilization pattern, morbidity, mortality, length of hospital stay, and accessibility of service to patients were assessed. The mean age of patient was 37.4 years with male to female ratio of 4.4:1. More than half of the patients (51.6%) surgical consultation time was less than half an hour. Majority of patients (67.7%) were operated only after 6 hours. Duodenal ulcer perforation was the commonest etiology for peritonitis and the clinical diagnostic accuracy was 97.3%. The commonest bacteria isolated from peritoneal fluid culture was E. coli which was sensitive to Amikacin mostly. The overall morbidities were seen in 20.1% of patients and burst abdomen was the leading complication. A total of 8 patients (6.4%) died in this study and when Mannheim's peritonitis index (MPI) score was compared, score of more than 26 was found to be a significant predictor of mortality (p<0.0001). Most of the patients after reaching the tertiary care hospital were managed satisfactorily. Though there are lots of parameters that still need to be improved.

Epidemiological study of kala-azar by direct agglutination test in two rural communities of eastern Nepal.

We conducted a sero-epidemiological study of kala-azar in two endemic communities (Kasaini and Gidhaniya) situated in the Terai (plain) of eastern Nepal. Direct agglutination test (DAT) was used as a serological test for screening. Capillary blood samples were collected by filter paper method from 601 (96%) people of a total population of 628 in Kasaini and from 482 (94%) people of 515 in Gidhaniya. Positive DAT titres (1:2000) were found in 66 (6.09%) of 1083 sera tested. The male-female sero-prevalence ratio was 1.44:1 and the age group of 15 years and above was most affected. Among the bone marrow aspirates collected from 66 DAT seropositive cases, only 19 were positive for Leishmania donovani (LD bodies). Of the 47 DAT seropositive but LD bodies' negative cases, three were clinically active cases of kala-azar. Another nine developed clinical symptoms of kala-azar during 6 months follow-up and 23 were cases that had received prior treatment for kala-azar (within 1 year). The results of this study show the potential of the DAT on filter paper as a screening test for the surveillance of kala-azar at a community level.

Prospective evaluation and comparison of the direct agglutination test and an rK39-antigen-based dipstick test for the diagnosis of suspected kala-azar in Nepal.

The diagnosis of visceral leishmaniasis (kala-azar) remains difficult in rural endemic areas and practical and reliable tests are badly needed. Two serological tests, the Direct Agglutination Test (DAT) and an rK39-antigen-based dipstick test, were compared to parasitological diagnosis in a group of 184 patients presenting at a tertiary care centre in south-eastern Nepal with a history of fever > or = 14 days and splenomegaly; 139 patients had a parasitologically proven kala-azar and 45 patients had a negative parasitological work-up. The rK39 dipstick showed a sensitivity of 97% and a specificity of 71%. The DAT was up to 99% sensitive with a low cut-off titre (1:400) but its specificity did not exceed 82% even with a high cut-off titre (1:51 200). Both tests could be used for screening suspect patients in endemic areas. However, their use as confirmatory tests should be restricted to situations where the proportion of kala-azar among clinical suspect patients is high. The rK39 dipstick is cheaper and easier to use than the DAT and could be used widely provided that both its performance and production remain stable.