Accuracy of Frozen Section with Histopathological Report in an Institute.

INTRODUCTION: Frozen section helps in rapid intra-operative diagnosis. It is commonly used during surgical procedures to detect malignancy so that modifications of surgery can be decided at the time of surgery on the table. Frozen section is also performed for evaluation of surgical margins and detection of lymph node metastasis. In addition it is applied for detection of unknown pathological processes.The objective of this study was to assess the accuracy of frozen section diagnosis in comparison to gold standard histopathological diagnosis and to find concordance and discordance rate of frozen section with histopathological report. METHODS: This was a cross sectional study of 41 frozen section samples done in the department of pathology of BP Koirala Institute of Health Sciences from September 2014 to August 2015. All frozen section samples with their permanent tissue samples sent for final histopathological evaluation were included in the study. RESULTS: The overall accuracy of frozen section diagnosis was 97%. The sensitivity was 94%, specificity was 87%, positive predictive value was 90% and negative predictive value was 93%. The concordance rate was 90.2% and the discordance rate was 9.8%. CONCLUSIONS: The results of frozen section varied in different organ systems and the common cause of discrepancy in our study were the gross sampling error and the interpretational error.

Interrupted abdominal closure prevents burst: randomized controlled trial comparing interrupted-x and conventional continuous closures in surgical and gynecological patients.

Reduction in the risk of abdominal dehiscence with application of interrupted method of laparotomy closure and comparison with risk of burst with continuous method of closure. Three hundred forty eight patients undergoing laparotomy (114-elective gynecology, 114-emergency gynecology, 120-emergency surgery) were randomized into three arms to undergo closure with continuous, interrupted-X, and Modified Smead-Jones suturing techniques. Burst abdomen occurring up to 4 weeks of operation. Twenty-nine (8.33 %) of 348 patients developed burst in the post-operative period. 19 (15.70 %) of 121 patients in continuous arm developed burst. Five of 110 (4.55 %) patients in Interrupted-X arm and 5 of 117 (4.27 %) patients in Modified Smead-Jones arm developed burst. Interrupted suturing was associated with significant reduction in risk of burst when compared with continuous closure. Important predictors of burst were Intraperitoneal sepsis, cough, uremia, and surgical site infection.

Laparoscopic inguinal hernia repair: a prospective evaluation at Eastern Nepal.

INTRODUCTION: Inguinal hernias have been treated traditionally with open methods of herniorrhaphy or hernioplasty. But the trends have changed in the last decade with the introduction of minimal access surgery. METHODS: This study was a prospective descriptive study in patients presenting to Surgery Department of B. P. Koirala Institute of Health Sciences, Dharan, Nepal with reducible inguinal hernias from January 2011 to June 2012. All patients >18 years of age presenting with inguinal hernias were given the choice of laparoscopic repair or open repair. Those who opted for laparoscopic repair were included in the study. RESULTS: There were 50 patients, age ranged from 18 to 71 years with 34 being median age at presentation. In 41 patients, totally extraperitoneal repair was attempted. Of these, 2 (4%) repairs were converted to transabdominal repair and 2 to open mesh repair (4%). In 9 patients, transabdominal repair was done. The median total hospital stay was 4 days (range 3-32 days), the mean postoperative stay was 3.38±3.14 days (range 2-23 days), average time taken for full ambulation postoperatively was 2.05±1.39 days (range 1-10 days), and median time taken to return for normal activity was 5 days (range 2-50 days). One patient developed recurrence (2%). None of the patients who had laparoscopic repair completed complained of neuralgias in the follow-up. CONCLUSION: Laparoscopic repair of inguinal hernias could be contemplated safely both via totally extra peritoneal as well as transperitoneal route even in our setup of a developing country with modifications.

Prostate cancer screening in a healthy population cohort in eastern Nepal: an explanatory trial study.

BACKGROUND: Prostate cancer features a substantial incidence and mortality burden, similarly to breast cancer, and it ranks among the top ten specific causes of death in males. OBJECTIVE: To explore the situation of prostate cancer in a healthy population cohort in Eastern Nepal. MATERIALS AND METHODS: This study was conducted in the Department of General Surgery at B. P. Koirala Institute of Health Sciences, Dharan, Nepal from July 2010 to June 2011. Males above 50 years visiting the Surgical Outpatient Department in BPKIHS were enrolled in the study and screening camps were organized in four Teaching District Hospitals of BPKIHS, all in Eastern Nepal. Digital rectal examination (DRE) was conducted by trained professionals after collecting blood for assessment of serum prostatic specific antigen (PSA). Trucut biopsies were performed for all individuals with abnormal PSA/DRE findings. RESULTS: A total of 1,521 males more than 50 years of age were assessed and screened after meeting the inclusion criteria. The vast majority of individuals, 1,452 (96.2%), had PSA ≤4.0 ng/ml. Abnormal PSA (>4 ng/ml) was found in 58 (3.8%). Abnormal DRE was found in 26 (1.72%). DRE and PSA were both abnormal in 26 (1.72%) individuals. On the basis of raised PSA or abnormal DRE 58 (3.84%) individuals were subjected to digitally guided trucut biopsy. Biopsy report revealed benign prostatic hyperplasia in 47 (3.11%) and adenocarcinoma prostate in 11 (0.73%). The specificity of DRE was 66.0%with a sensitivity of 90.9% and a positive predictive value of 38.5%. The sensitivity of PSA more than 4ng/ml in detecting carcinoma prostate was 100% and the positive predictive value for serum PSA was 19.0% CONCLUSIONS: The overall cancer detection rate in this study was 0.73% and those detected were locally advanced. Larger community-based studies are highly warranted specially among high-risk groups.

Anterior resection for rectal cancer with mesorectal excision: institutional review.

This study aims to compare the operative results and oncological outcomes of patients with total mesorectal excision (TME) for mid and distal cancer and partial mesorectal excision (PME) for proximal cancer. Anterior resection has become the preferred treatment option for rectal cancer. TME with sharp dissection has been shown to be associated with a low local recurrence rate. Controversies still exist as to the need for TME in more proximal tumor. Resection of primary rectal and rectosigmoid cancer was performed in 298 patients from January 2003 to November 2010. These 298 patients (163 men and 135 women; median age, 67 years) underwent anterior resection. The curative resection was performed in 269 patients (90.3 %). TME was performed in 202 patients (67.8 %). Significantly longer median operating time, more blood loss, and a longer hospital stay were found in patients with TME. The overall operative mortality and morbidity rates were 1.8 % and 32.6 %, respectively, and there were no significant differences between those of TME and PME. Anastomotic leak occurred in 8.1 % and 1.3 % of patients with TME and PME, respectively (P < 0.001). Independent factors for a higher anastomotic leakage rate were TME, the malegender, the absence of stoma, and increased blood loss. The advanced stage of the disease and the performance of coloanal anastomosis were independent factors for increased local recurrence. By performing TME in patients with mid and distal rectal cancer, the local control and survival of these patients are similar to those of patients with proximal cancers where adequate clearance can be achieved by PME.

Rare location of primary non-Hodgkin's lymphoma in the rectum.

Lymphomas of the gastrointestinal tract are usually secondary. Primary rectal lymphoma is very rare by virtue of its location. We present here a 60 years old lady diagnosed as primary rectal diffuse large B-cell Non-Hodgkin's lymphoma managed operatively. The optimum management of this entity is still much debated.

Benign cystic mesothelioma of the peritoneum in a child-case report and review of the literature.

A 4-year old female child presented with clinical features of ascites that, on computed tomography, showed a huge thin-walled cystic lesion in the peritoneum. Laparotomy confirmed a unilocular cyst in the peritoneum adhered to the parietal wall and bowel but not originating from any internal organs. Histopathologic examination of the cyst wall was consistent with the diagnosis of benign mesothelioma. Benign cystic mesothelioma of the peritoneum has rarely been reported in children.

Type IV jejunal atresia with an unusual variation of enteric duplication: report of a case.

We report a rare case of type IV jejunal atresia with enteric duplication and multiple diverticuli, found in a 3-day-old baby girl. To our knowledge, this association has never been reported before.

Intussusception in adults: institutional review.

OBJECTIVE: The objectives were to review adult intussusception (AI), its diagnosis and treatment. BACKGROUND DATA: Intussusception is a different entity in adults than it is in children. AI represents 1% of all bowel obstructions, 5% of all intussusceptions. METHODS: The records of all patients, 18 years and older, with the postoperative diagnosis of intussusception at the B.P.K.I.H.S during the years 2003-2009 were reviewed retrospectively. RESULTS: In six years, there were thirty-eight patients of surgically proven AI. The patients' mean age was 49.6 years, M:F ratio was 1.3:1. Intestinal obstructions of various extents were the commonest presentation in twenty-seven patients (71%). There were 42% enteric, 32% ileocolic and 26% colonic AI. The diagnostic accuracy of the ultrasonography was 78.5%, CT scan was 90% and colonoscopy was 100%. The pathological lesions were found in 94% of AI. Among the pathological lesion, enteric have 62% benign, 38% malignant, ileocolic have 50% benign, 50% malignant, and in colocolic 70% malignant, 30% benign. In enteric AI, 68% were reduced successfully, 25% reduction was not attempted. Of ileocolic AI, 58.3% were reduced successfully, 41.6% had resection without reduction. Of colocolic AI, 30% of them were reduced successfully before resection, 70% had resection without reduction. CONCLUSIONS: AI is a rare entity and requires a high index of suspicion. CT scanning proved to be the most useful diagnostic radiologic method. Colonoscopy is most accurate in ileocolic and colonic AI. The treatment of adult intussusception is surgical. Our review supports that small-bowel intussusception should be reduced before resection if the underlying etiology is suspected to be benign or if the resection required without reduction is deemed to be massive. Large bowel should generally be resected without reduction because pathology is mostly malignant.

Caecal volvulus: a twisted tale.

Caecal volvulus is an uncommon cause of acute intestinal obstruction caused by axial twisting of the caecum along with the terminal ileum and ascending colon. Early diagnosis is essential in order to reduce the high mortality rate, though the condition is rarely diagnosed correctly at the time of presentation. We report a series of four cases describing their presentation, management and subsequent outcome.

Isolated pancreatic tuberculosis mimicking as carcinoma: a case report and review of the literature.

INTRODUCTION: Pancreatic tuberculosis is a rare disease even in endemic countries for tuberculosis. Here, we report a case of pancreatic tuberculosis from tuberculosis endemic zone presenting as obstructive jaundice mimicking pancreatic cancer. CASE PRESENTATION: A 41-year-old male presented with features of malignant obstructive jaundice. Ultrasonography and computed tomography scan showed mass in the pancreatic head and uncinate process. He underwent a pancreatoduodencetomy. Histological examination showed typical features of tuberculosis. Antitubercular drugs were started and he remains well six months after surgery. CONCLUSION: Tuberculosis should be considered as a differential diagnosis to an obscure pancreatic mass in younger or middle aged patient residing in tuberculosis endemic zone.

Initial experience with Soave's transabdominal pull-through: an observational study.

PURPOSE: The purpose of this study was to evaluate the clinical profile and outcome of patients with Hirschsprung's disease undergoing Soave's transabdominal pull-through. METHODS: The study is a prospective study in neonates, infants and children presenting to Surgery Department of B. P. Koirala Institute of Health Sciences, Dharan, Nepal with a diagnosis of Hirschsprung's disease who underwent a Soave's transabdominal pull-through from 2006 to 2008. RESULTS: There were 20 patients, including 10 neonates (50%), 8 infants (40%) and 2 children (10%). There were 18 males and 2 females. Mean age at presentation was 9.2 months (range 7 days-7 years). Mean time of passing stool postoperatively was 49.5h (range 15-72h). Mean time to orally allowing was 97.2h postoperatively (range 36-120h). Mean hospital stay was 14.4 days (range 11-19days). One patient died due to uncontrollable hyperthermia (5% mortality). Other complications noted were 1(5.2%) anastomotic leak, 1(5.2%) cuff abscess and 1(5.8%) anastomotic stricture. Mean stool frequency at 1st month of follow-up was 6.8 per day, which later decreased to 4.5 per day at 3rd month, 3.1 per day at 6th month and 1.7 at 1 year. Two patients (11.7%) have constipation at 1 year follow-up. CONCLUSION: The rate of complications like mortality, cuff abscess, anastomotic leak and constipation are comparable to other series. The short-term results of Soave's transabdominal pull-through have been satisfactory; however long-term results are still awaited.

Transhepatic perforation of the gallbladder: rare complication of a common disease.

Acute cholecystitis leading to gallbladder perforation is relatively common. However, transhepatic perforation of the gallbladder leading to biliary peritonitis is very rare. We present a rare case of biliary peritonitis caused by transhepatic perforation of the gallbladder.

Intussusception due to non Hodgkin's lymphoma; different experiences in two children: two case reports.

In children, non-Hodgkin's lymphoma has been found to be the lead point in intussusception involving the terminal ileum. We present here two cases of ileal primary non-Hodgkin's lymphoma which presented as intussusception, highlighting the differing presentations of these children and their outcome, with a brief review of the literature.

Comparison of aspiration-sclerotherapy with hydrocelectomy in the management of hydrocele: a prospective randomized study.

BACKGROUND: Hydrocelectomy is practiced as the gold standard technique for the treatment of hydrocele worldwide. Aspiration and sclerotherapy is cheap, less invasive and safe compared to hydrocelectomy. However, the outcomes are inconsistent because of lack of uniformity in methods and sclerosing agents used. MATERIALS AND METHODS: This was a randomized controlled study conducted in a university hospital for a period of one year. Sixty symptomatic adult males without fertility concern or coexisting scrotal pathology were enrolled. Aspiration and sclerotherapy and hydrocelectomy were performed in 30 each. PRIMARY OUTCOME MEASURES: incidence of complications, loss of working days, cost involved, recurrence rate and patient's satisfaction. Patients were followed up till 6 months after the procedures. RESULTS: Eight patients (26.7%) after hydrocelectomy developed fever which was significantly more (p<0.05) than 2 patients (6.7%) following sclerotherapy. Four patients (14%) with hydrocelectomy had infection (p<0.05). The incidence of pain and haematocele between the two groups were comparable. Nine patients (34.6%) after sclerotherapy developed recurrence at 3 months. All patients developed recurrence after repeat aspiration and sclerotherapy. The level of satisfaction was more in hydrocelectomy 19 (95%) versus 13 (61.9%) patients in sclerotherapy (p<0.05). The cost involved was fivefold and the loss of working days sevenfold in hydrocelectomy (p<0.01) as compared to sclerotherapy. CONCLUSION: Although aspiration and sclerotherapy had less complications, morbidity and was cheaper, it had lower success rate and less patient's satisfaction than hydrocelectomy.

Anorectal tuberculosis coexisting with adenocarcinoma: an unusual association.

INTRODUCTION: Tuberculosis affecting the anorectum is an uncommon extra-pulmonary form of the disease, and its association with malignancy is highly unusual. CASE REPORT: A 35 year lady presented with lower gastrointestinal bleed, altered bowel habit and significant weight loss. On examination, she had nodular stricture in the lower rectum, with friable mucosa, bleeding easily on touch. With the diagnosis of carcinoma lower rectum, she underwent abdomino-perineal resection of the growth. The histopathological examination revealed carcinoma rectum with coexisting tuberculosis. CONCLUSION: The aetiological association between the tuberculosis and anorectal cancer is a matter of debate. However, the treating surgeon should be aware of this association, to avoid confusion and delay in the management.

A report of a rare congenital malformation in a Nepalese child with congenital pouch colon: a case report.

Congenital pouch colon is one of rare congenital anomalies. We report a 3-day-old male child with congenital pouch colon who underwent a window colostomy but died because of overwhelming sepsis. Due to its rarity, many surgeons in our part of the world may not be aware of it, hence increasing the potential to its mismanagement. However, with simple keen observations, we can safely come to its diagnosis. The aim of this report is to bring attention to congenital pouch colon associated with anorectal malformation in our country, with a brief emphasis on an approach to its diagnosis and initial management.

One year of neurosurgery in the eastern region of Nepal.

BACKGROUND: This article briefly discusses about the present status, future strategies, and perspectives of neurosurgery in the eastern region of Nepal. METHODS: B.P. Koirala Institute of Health Sciences, Dharan, Nepal, is the only tertiary referral center responsible for patient care as well as training of postgraduate students and paramedical staff including health care workers in the eastern region of Nepal. We analyzed the data from January 2006 to January 2007 regarding patient care and their outcomes. At the same time, we also evaluated our limitations regarding resources and their impact on patient care. Strategies are suggested to overcome the barriers to establish effective neurosurgical centers in developing countries. RESULTS: At present in the BPKIHS, neurosurgical facilities are being provided as a specialty unit in the department of surgery. From January 2006 to January 2007, a total 1120 patients were treated for different neurological and neurosurgical conditions. At present, there are 8 beds allotted to neurosurgical services in the general surgery ward. In addition, there are 8 ICU beds catering to the needs, including neurosurgery, of the hospital. No vascular, epilepsy surgery or functional neurosurgery has been performed due to lack of resources. The only imaging facility for neurosurgery that is available in the hospital is CT scan. CONCLUSIONS: The study concludes that in a developing country, the neurosurgical unit can be structured in a manner that will fulfill most of the objectives required for better clinical outcome. This structured program may also benefit substantially in training health professionals as well.