Bile duct injury following laparoscopic cholecystectomy in a patient with a trifurcated hepatic duct: A case report.

INTRODUCTION AND IMPORTANCE: Iatrogenic bile duct injury is a serious complication of laparoscopic cholecystectomy, often due to misinterpretation of biliary tree anatomy. Anatomical variations, patient condition, gallbladder pathology, and surgeon-related factors are key risk factors for bile duct injury. CASE PRESENTATION: A 68-year-old male with a history of hypertension and type 2 diabetes mellitus underwent Laparoscopic cholecystectomy for symptomatic gallstones. One-month post-surgery, he developed right upper quadrant pain, jaundice, and elevated liver enzymes. Magnetic resonance cholangiopancreatography (MRCP) showed a hilar confluence stricture affecting the right posterior and left hepatic ducts, with mild-to-moderate dilation of upstream intrahepatic bile ducts. CLINICAL DISCUSSION: Trifurcation of the hepatic duct is a rare but clinically significant anatomical variation that can predispose patients to common bile duct injuries. Preoperative MRCP can identify such variations, aiding in surgical planning. However, intraoperative recognition and management of these anatomical differences are crucial to prevent bile duct injuries. This is particularly important in low-resource settings where routine preoperative imaging may not be feasible. CONCLUSION: Accurate intraoperative identification of biliary tree anatomical variations is essential to prevent iatrogenic injuries during surgery. Preoperative imaging, when available, can provide valuable information to assist in surgical planning. Additionally, the use of intra-operative cholangiogram (IOC) should be considered to help identify and manage anatomical variations, thereby reducing the risk of bile duct injuries.

Adult with Coxsackie B virus-induced cardiomyopathy presents rare case of complicated acute embolic ischaemic stroke.

Introduction and importance: Stroke, a global health concern, often results from embolic events of cardiac origin. Coxsackie B virus (CBV) myocarditis, a common cause of viral heart infections, can lead to cardiac thrombi formation, subsequently causing devastating complications such as embolic stroke. The authors present a rare case of a 26-year-old male who experienced an embolic stroke following CBV myocarditis and cardiomyopathy. Case presentation: The patient exhibited left-sided weakness, facial droop, and respiratory distress. Laboratory findings indicated leukocytosis, hyponatremia, and elevated troponin I. Imaging revealed an acute right basal ganglia infarct and multifocal pulmonary embolism. The diagnosis involved positive CBV serology, severely reduced left ventricular function, and a large apical thrombus. Discussion: Cardioembolic strokes, often attributable to atrial fibrillation, can also result from intracardiac thrombosis associated with myocarditis. CBV, implicated in up to 40% of acute myocarditis cases, binds to cardiac myocytes, triggering inflammation and potential thrombus formation. Myocarditis-induced hypercoagulability increases the risk of thromboembolic events, complicating the clinical course. Conclusion: CBV myocarditis poses a risk of heart failure, cardiomyopathy, and thromboembolic complications such as embolic stroke. Vigilant monitoring for complications and prompt management is crucial, as primary disease treatment remains primarily supportive. This case highlights the need for increased awareness and further studies to understand the intricate relationship between viral myocarditis and embolic strokes.

Assessment of G10 Intraoperative Scoring System for Conversion in Patients Undergoing Laparoscopic Cholecystectomy: A Cross-Sectional Study From Nepal.

INTRODUCTION: Various preoperative risk factors for conversion in laparoscopic cholecystectomy (LC) have been well studied. However, the assessment of intraoperative factors for conversion in patients with cholecystitis is unclear. The G10 scoring system, which incorporates 10 parameters, has tried to fill this void by developing a scoring system for the most commonly encountered surgical illnesses. So, we aimed to assess the utility of the G10 scoring system among patients presenting for LC for symptomatic cholelithiasis (both acute and chronic cholecystitis) in the clinical setting of a low- and middle-income country. METHODS: All the patients undergoing LC were assigned a G10 value. Gallbladder surgery was considered easy if the G10 score was <2, moderate (2 ≦ 4), difficult (5 ≦ 7), and extreme (8 ≦ 10). All 10 risk factors were analyzed into a binary logistics model, and statistically significant risk factors were assessed. RESULTS: Among 177 patients, there were 36 males and 141 females. The median age of the patient was 42 years (range 11-79). There were 70 easy, 89 moderate, and 18 difficult cases. The overall mean G10 score was 2.32±1.5, which significantly increased as the severity progressed, with a mean value of 5.5±0.51 for difficult cases (P=0.0001). The mean G10 score for surgeries completed laparoscopically was 2.1±1.4, while it was 3.71±1.4 for open conversions [P=0.0001, AUC=0.79, CI=0.70-0.87]. There were 18 patients with G10 ≥5 with a conversion rate of 27.7%, while the overall conversion rate was 13.6%. Multivariate analysis showed free bile or pus outside the gallbladder [P=0.02, OR=5.1, CI=1.2-21.1] and fistula [P=0.01, OR=15.8, CI=1.9-129.8] as significant risk factors for conversion. CONCLUSION: Intraoperative risk factors for the prediction of conversion included the presence of free bile or pus outside the gallbladder and cholecystoenteric fistula. Based on the F1 score analysis, complemented with the Youden Index, the optimal cutoff value for conversion, based on the G10 score, lies around 4. Broader application and validation of the G10 scoring system are mandated to assess the utilization of this novel intraoperative scoring system.

Takayasu arteritis presenting as a stroke in young: a case report.

Introduction: Takayasu arteritis is a large-vessel vasculitis predominantly seen in young women. Lack of signs and symptoms in the early stage of the disease often delays the diagnosis and thus leads to significant morbidity and mortality. One severe complication that may arise is a significant narrowing of blood vessels, potentially leading to life-threatening ischemic repercussions. Case presentation: The authors present a case of a 29-year-old female who presented to our ER with features of left-sided hemiparesis and right-sided facial deviation. Computed tomography angiography and Carotid Doppler helped in making the diagnosis of Takayasu arteritis. She was managed with prednisolone and mycophenolate mofetil. She has been on a regular follow-up for the last year and is currently stable. Conclusion: Even being a rare scenario, stroke can be the initial presentation of Takayasu arteritis. Early diagnosis and management in young patients are vital in keeping the disease at bay and preventing physical, mental, and socio-economic adversities.

Extensive acute cutaneous graft versus host disease: A rare case report of survival.

Graft versus host disease (GVHD) is an immunologically mediated condition seen in allogeneic hematopoietic stem cell transplant (HSCT) recipients. Because of the rarity of the disease, nonspecific presentation, and lack of clinicopathological correlation, its diagnosis is often delayed and prompt treatment is deferred, with increased mortality.

Comparison of acute appendicitis before and within lockdown period in COVID-19 era: A retrospective study from rural Nepal.

INTRODUCTION: The world has been engulfed with the pandemic of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which have created significant impact in the emergency surgical health delivery including acute appendicitis. The main aim of this study was to compare the demographic and clinical parameters between two cohorts before the onset of lockdown and within the pandemic. METHODS: A retrospective analysis was performed between two groups A and B, who presented with acute appendicitis three months prior to and after initiation of lockdown on March 24 2020 respectively in one of the tertiary centers of Nepal. These two cohorts were compared in demographics, clinicopathological characteristics and surgical aspects of acute appendicitis. RESULTS: There were 42 patients in group A and 50 patients in group B. Mean age of the patients was 31.32±17.18 years with male preponderance in group B (N = 29). Mean duration of pain increased significantly in group B [57.8±25.9(B) vs 42.3±25.0(A) hours, P = 0.004] along with mean duration of surgery [51.06±9.4(B) vs 45.27±11.8(A) minutes, P = 0.015]. There was significant decrease in post-operative hospital stay among group B patients [3.04±1.1(B) vs 3.86±0.67(A) days, P = 0.0001]. Complicated cases increased in group B including appendicular perforation in 10 cases. Similarly, mean duration of presentation to hospital significantly increased in group B patients with perforation [69.6±21.01 vs 51.57±17.63 hours, P = 0.008]. CONCLUSION: During the adversity of the current pandemic, increased number of cases of acute appendicitis can be dealt with surgery as the chances of late presentation and complexity of the lesion exists.

Giant juvenile fibroadenoma in an adolescent female: A case report.

Giant juvenile fibroadenoma in adolescents should be dealt with utmost caution as this may be associated with anxiety, fear, and emotional factors. The treatment should aim for preserving the normal contour of the breast along with appealing scar.

Utilization of an Intraoperative Grading Scale in Laparoscopic Cholecystectomy: A Nepalese Perspective.

INTRODUCTION: Difficult geographic diversity and late presentation to medical attention often make the laparoscopic cholecystectomy difficult and chances of conversion and complication remains. Various preoperative grading scales have been developed for predicting the difficulty of surgery in cholecystitis patients; however, intraoperative assessment of anatomical status and inflammation of the gall bladder has not been assessed till date except for some guidelines like the Parkland grading scale (PGS). We aimed to utilise this guideline in patients undergoing laparoscopic cholecystectomy in rural community of the developing nation. METHODS: PGS was applied for all the patients undergoing laparoscopic cholecystectomy and laboratory and outcome factors like preoperative white blood cells (WBC), open conversion, subtotal cholecystectomy, length of surgery, and bile leaks postoperatively were assessed. RESULTS: Among 178 patients who underwent cholecystectomy, there were 40 grade one GBs, 90 grade two GBs, 26 grade three GBs, 16 grade four GBs, and six grade five GBs. With a conversion rate of 6.74%, eight patients underwent subtotal cholecystectomy. Among them, four patients were graded as 5th grade, two as 4th grade, and two as 3rd grade according to PGS system. Postoperative bile leak was seen in three patients among which two were grade five GBs and one was grade four. Preoperative WBC, conversion to open, subtotal cholecystectomy, length of surgery, and postoperative bile leak all significantly increased with increasing grades (p < 0.05). CONCLUSION: PGS can be applied in patients undergoing laparoscopic cholecystectomy in the rural setting of a developing nation. With its application, postoperative course could be predicted and adequate counselling can be done about the possibilities of the outcome.

Prostate tuberculosis complicated by huge prostatic abscess: A rare case report from Nepal.

INTRODUCTION: Prostatic tuberculosis is one of the rarest findings in clinical practice and associated prostatic abscess is even scarce, described in literatures. We present a rare case of prostatic tuberculosis complicated by huge prostatic abscess. PRESENTATION OF A CASE: A 68-year-old male with no any comorbidity presented with history of increased frequency of micturition along with poor flow, urgency and nocturia for 17 days. He was under medical treatment for benign enlargement of prostate for 2 years. Per rectal examination revealed a boggy cystic swelling anteriorly with enlarged prostate with mild tenderness. Ultrasonography abdomen and pelvis showed massive enlargement of prostate with central avascular necrotic area with moving internal echoes. Contrast enhanced computed tomography (CECT) showed 230 g of prostate with central liquefaction of approximately 101 mm3. Transurethral loop drainage along with resection of prostate was done. Histopathology revealed granulomatous prostatitis highly suggestive of prostatic tuberculosis. Prostatic abscess culture was negative. Patient is currently under category 1 anti-tubercular therapy. DISCUSSION: Prostatic tuberculosis is a rare clinical finding which is commonly seen in patients with disseminated tuberculosis with immunocompromised status. Prostatic abscess in setting of granulomatous tuberculosis of prostate is even rarer. Transrectal ultrasonography is the investigation of choice for diagnosis of abscess if available. Treatment includes drainage of abscess preferably transurethral, and antitubercular therapy. CONCLUSION: Trans-urethral loop drainage is a safe treatment modality for patients presenting with prostatic abscess followed by anti-tubercular therapy if histopathology findings are suggestive of granulomatous lesions.

Splenic abscess complicated by pleural empyema: A rare case report from rural Nepal.

INTRODUCTION: Splenic abscess generally occurs through hematogenous spread and typically follows endocarditis or seeding from contiguous sites of infection. This can be complicated by empyema thoracis. We present a rarer case of chronic alcoholic with splenic abscess along with empyema thoracis. PRESENTATION OF A CASE: A 39-year old alcoholic male presented with history of pain at left hypochondrium and difficulty breathing for 7 days. Abdominal examination revealed tenderness at left hypochondrium along with enlarged spleen and liver associated with decreased air entry of left chest. Chest X-ray showed complete white out lung field on left side. Contrast enhanced tomography abdomen and pelvis revealed splenic abscess involving lower pole of spleen along with peri splenic extension. Tube thoracostomy drainage on left chest was done followed by ultrasonography guided repeated aspiration of splenic entity. Pus culture sensitivity showed growth of Streptococcus pyogenes while splenic aspirate remained sterile. Patient got discharged on 8th day of admission with full recovery. DISCUSSION: Splenic abscess is the rare entity which is commonly seen in immunocompromised individuals that might get complicated as empyema thoracis and management includes broad spectrum antibiotics along with tube thoracostomy and percutaneous drainage of splenic abscess if possible, in view of spleen being salvageable. Pleural collection revealed growth of Streptococcus pyogenes in our case which itself is the rare finding. CONCLUSION: Splenic abscess can be managed with percutaneous aspiration/drainage if lesion is unilocular in the view of salvaging spleen. Complicated empyema can be managed with tube thoracostomy along with broad spectrum antibiotics.

Bilateral Hydrocele of the Canal of Nuck: A Rare Presentation in an Adult Female.

Hydrocele of the canal of Nuck is one of the rarest clinical entities in the female population. It occurs due to the failure of obliteration of the processus vaginalis, which is the extension of the parietal peritoneum. Hydrocele may be seen, along with associated inguinal hernia. It usually presents with painless inguinal unilateral or bilateral swellings, and is sometimes associated with features of intestinal obstruction if the hernia becomes incarcerated or obstructed. Ultrasonography of the abdomen and pelvis and magnetic resonance imaging provide the diagnosis, if these imaging modalities are available; however, definite diagnosis may only be made during surgery. Definitive treatment includes open/laparoscopic excision of the cyst with high ligation of the neck up to the peritoneal pouch, along with repair of the inguinal hernia, if present. We present a rare case of a 25-year-old woman who presented with bilateral inguinolabial swelling, clinically diagnosed as bilateral irreducible inguinal hernia. Intraoperatively, polycystic swelling with serous content was observed along with associated indirect inguinal hernia containing omentum on the left side. She was treated with removal of the cystic component of the bilateral canal and tissue repair of the left indirect inguinal hernia.

Ectopic Liver Tissue in the Gall Bladder: A Rare Entity.

Ectopic liver tissue (ELT) is a rare clinical entity that any surgeon faces in their career. Due to the association or propensity to develop hepatocellular carcinoma, this disease has gained clinical importance, and surgeons ought to be aware of the possible intervention and complications that can be associated with it. Incidence has been reported to be 0.24%-0.47%, with the gall bladder being the most common site. Anatomically, ELT in the gall bladder derives its blood supply either from the vascular pedicle arising with or without its own vein from the liver parenchyma or from branches of the cystic artery and, sometimes, through vascular structures embedded within the mesentery lying adjacent to the liver parenchyma. Surgically, it becomes important to delineate the blood supply because, often, the operating surgeon might encounter uncontrollable bleeding if the blood supply has been derived from the liver parenchyma itself. Complications that can be associated with ectopic liver are torsion, bleeding into the peritoneum, cirrhosis, and, sometimes, lead to malignant degeneration to hepatocellular carcinoma. It can be due to metabolic inactivity owing to less efficient vascular and biliary ductal systems, which sometimes might be confused for occult metastases from a primary hepatoma. Gall bladder-associated ELT is best managed by en bloc resection via laparoscopic cholecystectomy, which suffices if the biopsy comes out to be negative. However, as the risk of malignant degeneration still exists in about 3% of cases, some patients might need to undergo a second surgery for a negative resection margin and regional lymphadenectomy.