Acute splenic hematoma: A rare complication of snake bite.

Splenic hematoma secondary to snake bite is a potential complication due to snake envenomation and poses a significant risk to the health of the patients. Although relatively rare, this complication once diagnosed, should be initiated with timely anti-venom administration and supportive care. Clinicians must be aware of any signs of hematological abnormalities in snakebite patients, as the development of splenic hematoma can have serious implications for patient outcomes. Awareness of this potential complication and multidisciplinary collaboration among medical teams are crucial to ensuring effective management and optimal patient care in these clinical scenarios. Understanding this concern can improve patient prognosis and advance the overall approach to snakebite management in healthcare settings.

Prevalence of autism spectrum disorder among children in Southeast Asia from 2002 to 2022: An updated systematic review and meta-analysis.

Background and Aims: Autism spectrum disorder (ASD) is a neurodevelopmental condition that impacts the brain, characterized by challenges in social communication and interaction, often accompanied by repetitive behaviors or focused interests. This study sheds light on the prevalence of ASD within the Southeast Asian region. Methods: The study protocol was registered in PROSPERO (Registration No: CRD42023413915). Appropriate search terms and Boolean operators were employed to explore electronic databases for relevant articles. Data thus extracted were prepared in Excel and analyzed in Comprehensive Meta-Analysis Software. The effect measure utilized in the study was represented by the proportion, and the choice between a fixed or random-effect model depended on the observed heterogeneity. Visual feedback was provided through the use of forest plots and funnel plots. Results: A total of 14 studies were included in the qualitative and quantitative synthesis after screening the imported studies. The prevalence of ASD was six per 1000 population (proportion: 0.006; CI: 0.002-0.017; I 2: 99.263%). Among the ASD cases, 64.4% (proportion: 0.644; CI: 0.590-0.693; I 2: 9.937%) were males and 35.6% (proportion: 0.356; CI: 0.307-0.410; I 2: 9.937%) were females. Conclusion: The prevalence of ASD in Southeast Asia was estimated to be six cases per 1000 individuals, with a higher prevalence among males. This study contributes to our understanding of ASD prevalence in the region, although it is essential to note certain limitations in estimating prevalence.

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.

An uncommon cause of sub-acute intestinal obstruction in young adult: Wilkie's syndrome.

Abstract: Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare disease presenting as an acute abdomen. It has a clinical presentation similar to intestinal obstruction and is often missed during diagnosis. Reduced weight leading to loss of fat pad between SMA and aorta is the main pathophysiology. Diagnosis is made through barium meal and CT scan. Conservative management remains the treatment of choice; however, surgery is opted for in refractory cases. Key Clinical Message: Superior mesenteric artery (SMA) syndrome, also known as Wilkie's syndrome, is a rare disease presenting as an acute abdomen with clinical features similar to intestinal obstruction. This is a case of SMA syndrome in an adult male with a decrease in aortomesenteric angle, with no predisposing condition.

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.

Ergonomics in the operation-theatre: a healthcare provider-based cross-sectional study.

Background: Performing surgery is a task that demands mental stability, precision, and vigilant eyes, along with resilient physical strength, as surgeons and those who assist the surgeons have to assume a sustained, difficult posture that can go on for hours. About 23-100% of surgeons report musculoskeletal discomfort that originates from poor ergonomics. Methods: Ethical clearance for the study was obtained. This cross-sectional study, conducted in a tertiary centre among the healthcare providers working inside the operating room, spanned from 1 March 2023, to 26 June 2023. Systematic sampling was applied, and consent was obtained before data collection. A structured questionnaire was used as the study tool, and the collected data was analysed in SPSS 20. Results: A total of 98 personnel responded, among which 67.3% were males and 32.7% were females, with a median age of 36 (32-42) years. Only 6.1% of the workers had received training on ergonomics. The prevalence of work-related musculoskeletal disorders was 82.7%, and more than two-thirds of the participant's life outside of work was affected by this. More than two-thirds (69.4%) felt their work environment was not safe, and surgeons performing open surgery were at lower odds of feeling that their work environment was safe. Conclusion: There is a high prevalence of work-related musculoskeletal disorders among healthcare providers working inside the operating room, and the majority had their body position deviated from neutral most of the time during the surgery. There is a deficiency in ergonomic practices, which demands an effective intervention.

Postoperative surgical site infection after preoperative use of razor versus clipper for hair removal in inguinal hernia surgery: A quasi-randomized clinical trial.

Trail Design: Quasi-randomized clinical trial. Methods: Participants: This study includes adult patients (≥18 years) who gave written consent for preoperative site preparation using razors or clippers. Exclusions comprised individuals <18 years, bilateral hernias, prior laparoscopic hernia repair, steroid/chemotherapy use, diagnosed chronic obstructive pulmonary disease, and incomplete medical documentation. Intervention: Patients who underwent hernia surgery during the initial week of the study underwent site preparation using a razor, while in subsequent weeks underwent site preparation using a clipper. This randomization was maintained throughout the study. Uniform site preparation was done by consistent staff. Postpreparation interviews, follow-up interviews of the patients, and unbiased evaluation of digital photographs were conducted by nonoperating surgeon panels. Outcome: Preoperative, patient response, degree of skin trauma, quality of hair removal, and association between site preparation-like parameters were compared and analyzed between two groups using Statistical Package for Social Sciences-25. Blinding: In this study, blinding was not done and the primary investigator was aware of the two groups. Results: The total number of participants was 320. The mean age of the Razor group was 45.36 ± 14.68 years and that of Clipper was 44.42 ± 13.77 (p < 0.98). The incidence of surgical site infection (SSI) was 23 (14.4%) in the razor group and 8(5%) in the clipper group, (p = 0.01). Skin trauma was found more in the razor group as compared to the clipper group. Also, the analysis of the provided data revealed that 65% of participants who experienced sustained cuts developed SSI. Conclusion: In summary, the practice of preoperative hair removal on-site preparation using a razor is associated with the incidence of skin trauma but overall shave quality at the operative site was better in the razor group with an apparent increased risk of SSI. Based on these findings, it would be better for surgeons to decide on an operation for either razors or clippers for preoperative preparation.

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.

Surviving the perilous: A case report on an urgent approach to necrotizing fasciitis.

Necrotizing fasciitis is a rare, fatal, and rapidly progressing bacterial infection of fascia and subcutaneous tissues. Skin necrosis, pain, bullae, and erythema are the common manifestations. Early diagnosis and prompt treatment can improve outcome.

Endovenous laser ablation versus conventional surgery (ligation and stripping) for primary great saphenous varicose vein: a systematic review and meta-analysis.

Background: The great saphenous varicose vein was managed with high ligation and stripping conventionally, but with the development of minimally invasive surgical techniques like endovascular laser ablation (EVLA), they have become popular. This systematic review and meta-analysis of randomized controlled trials aim to compare the short-term and long-term outcomes of these two modalities on headings like procedural time, technical success, recovery time, recurrences, cost-effectiveness, and complications. Materials and methods: The protocol followed in this study was registered prospectively in the Registry of Systematic Reviews/Meta-analyses. Electronic databases were searched with appropriate search terms for relevant studies, and after their screening, data was extracted. The odds ratio was used for dichotomous data, and the mean difference or standardized mean difference was used for continuous variables. Results: This study identified 18 publications (10 randomized controlled trials) with a total of 1936 patients. There was no difference in procedural time, recovery time, recurrences at 1, 2, and 5 years, or clinical severity score. The surgery group had 4.35 times higher statistically significant odds of being technically successful at 2 years, while pooling data on bruising, hematoma, sensory disturbance, infection, and phlebitis showed that the EVLA group was less likely to develop postoperative complications. Conclusion: Technical failures were more common in the EVLA, whereas postoperative complications were more common in the surgery group. Both have comparable clinical effectiveness, and neither modality has clear superiority over the other. Parameters like cost-effectiveness must be assessed at the hospital level before choosing the right procedure for the patients.

Comparison of outcomes of open and laparoscopic appendectomy: A retrospective cohort study.

Background: Open appendectomy has been the conventional choice of treatment for acute appendicitis. However, nowadays laparoscopic approach is emerging for the benefits it provides, like lesser postoperative pain and lesser duration of hospital stay, but at the cost of higher expenses and longer operative duration. Methods: A retrospective cohort study was done at Shree Birendra Hospital from January 2018 to December 2021, with a total study population of 450 participants (300 in open appendectomy and 150 in laparoscopic appendectomy). Preoperative. Intraoperative and postoperative parameters were compared and analyzed between two groups using SPSS-25. Results: The mean age was 26.72 ± 9.70 in the open appendectomy (OA) and years 23.89 ± 6.32 in the laparoscopic appendectomy (LA) group. (p = 0.010) There was a significant difference between the mean operative time (46.08 ± 13.10 min in OA and 56.86 ± 11.70 min in LA, p = 0.000), length of hospital stay (1.28 ± 0.80 days in OA and 1.07 ± 0.25 days in LA, p = 0.000), course of oral analgesics (3.55 ± 0.68 days in OA and 3.00 days in LA p = 0.000) between OA groups and LA groups, while the total number of complications was less in the LA group however there was no statistically significant difference postoperative complications (p = 0.124) between the two groups in the surgical findings. Conclusion: All in all, the laparoscopic approach is a better option for uncomplicated appendicitis due to its less postoperative pain and shorter duration of hospital stay.

How informed is informed consent?-Evaluating the quality of informed consent among surgical patients in a tertiary care hospital in Nepal.

BACKGROUND: Informed consent-taking is a part of clinical practice that has ethical and legal aspects attached to it. This protects the autonomy of the patients by providing complete information regarding the rationale, modality, potential risks, benefits, and alternatives of the planned procedure to the patients. This enables the patients to make the right decision for themselves and their care. This study aims to find out if the informed consent-taking process has ensured the active participation of the patients or the next of kin in the decision-making. MATERIALS AND METHODS: This is a prospective cross-sectional study conducted in a military healthcare institution among patients undergoing major surgical procedures from July 2022 to October 2022. Ethical clearance was obtained before the commencement of this study. A structured questionnaire was prepared, and the collected data was refined in Excel and imported into SPSS for analysis. RESULTS: A total of 350 individuals of mean age 47.95 ± 16.057 years were part of this study. The majority of the respondents were married, literate, and family by beneficiary category. All of the respondents received and signed the consent form. About 77% of the respondents read it completely, and 95.4% of them reported that it was understandable. The majority of the patients did not know who was going to perform the surgery, the alternatives to the planned treatment, the benefits of the surgery, or the outcome of non-treatment. On the patient satisfaction scale, 16.28% of the participants agreed that they were satisfied with the informed consent-taking process. CONCLUSION: Deficiencies in the informed consent-taking process were the lack of dissemination of adequate information on the nature, duration, pros and cons, post-operative state, and alternative of the planned procedure. A well-structured format of the consent form that is specific to a particular procedure should be adopted, and various alternatives to it must be disseminated to the patient or the next of kin to improve the quality of the informed consent-taking process.

Perforated marginal ulcer following Whipple procedure: A case report.

Marginal ulcers are rare complications of pancreatoduodenectomy. Patient can present with varying symptoms such as epigastric discomfort, pain, dysphagia, or can present in emergency department with complications like bleeding and perforation.

Small bowel intussusception in an adult secondary to gastrointestinal stromal tumor: a rare case report.

Intussusception is a rare surgical condition in adults less commonly confined to small bowel. Adult intussusception is an indication of surgical resection due to possibility of ischemia and malignant pathological cause like gastrointestinal stromal tumor (GIST) as in this case. Case presentation: A 32-year-old male presented with abdominal pain and vomiting for 3 days. Vitals parameters and abdominal examinations were normal. Abdominal ultrasonography revealed target sign suggesting ileoileal intussusception in right lower quadrant. Abdominal contrast-enhanced computed tomography of abdomen showed features suggestive of ileoileal intussusception. Diagnostic laparoscopy was done which was later turned to laparotomy for segmental resection and anastomosis of ileum for ileoileal intussusception. Polypoidal growth noted in the resected section of ileum was found to be GIST (CD117 and DOG-1 positive) which was considered to be the lead point. Patient recovered well during postoperative period and later referred to oncology clinic for chemotherapy. Clinical discussion: Intussusception and subsequent obstruction are very uncommon presentation in a patient with GIST because of their tendency to grow in an extraluminal fashion. As intussusception is rare in adult, high level of suspicion and proper imaging technique plays important role in diagnosing the condition. Conclusion: Ileoileal intussusceptions due to GIST are a rare clinical entity in adult intussusceptions and generally have a vague variable clinical presentation thus requiring high index of clinical judgement and suspicion with judicious use of imaging.

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.

Diaphragmatic rupture secondary to trauma from falling sacks: A case report.

Key Clinical Message: Diaphragmatic hernia does not only occur during high velocity impact or penetrating injury, but also can occur when heavy loads impact the torso. Diaphragmatic hernia must be ruled out in a patient with polytrauma with a chest X-ray at the least. Abstract: Trauma-induced diaphragmatic hernia is a protrusion of abdominal contents through the defect in diaphragm and is an uncommon and less heard of injury. This case report conveys that diaphragmatic hernia should be ruled out in any polytrauma case presenting with shortness of breath with the chest X-ray at the least.

Case of giant appendicolith: A common ailment with a rare finding.

Giant appendicoliths are rare appendicoliths with the largest diameter of more than 2 cm. It can increase the risk of complications such as perforation or abscess formation. This is a case of an uncommon definitive pathology diagnosed for a right iliac fossa calcification with a rare transoperative finding.

Gallstone among Patients Presenting to the Department of Surgery in a Tertiary Care Center: A Descriptive Cross-sectional Study.

Introduction: Gallstone is the most common biliary pathology. Once thought of as a disease of the western world, the incidence and burden of cholelithiasis are increasing in Asia. Its literature from Nepal is however still primitive. The study aimed to find out the prevalence of gallstone among patients presenting to the Department of Surgery in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients presenting to the Department of Surgery after receiving ethical approval from the Institutional Review Committee (Registration number: 625). The study was conducted from 1 June 2022 to 1 November 2022. Patients with age more than 18 years were included and patients less than 18 years of age, having common bile duct stones, suffering from biliary malignancy or having an immunocompromised state were excluded. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 1700 patients, gallstone was seen in 200 (11.76%) (10.23-13.29, 95% Confidence Interval). Among the 200 patients, 133 of them (66.50%) were females. Multiple gallstones were present in 118 (59%) cases whereas 82 (41%) cases had a single stone. Conclusions: The prevalence of gallstone was found to be similar as compared to other reported literature. Keywords: cholelithiasis; gallbladder; prevalence.

Spontaneous splenic hematoma secondary to dengue infection: a rare case report.

Dengue infection may have various surgical complications. Splenic hematoma is a rare complication of dengue hemorrhagic fever and may be life-threatening. Case Presentation: A 54-year-old male, diagnosed with dengue infection detected at another hospital, presented on the 10th day of fever with left upper abdominal pain for 7 days without history of trauma. Urgent ultrasonography of the abdomen revealed findings suggestive of a splenic subcapsular hematoma, which was confirmed by computed tomography scan. The grade II splenic hematoma was being managed conservatively. Unfortunately, the patient developed hospital acquired pneumonia and died from septic shock. Clinical Discussion: Hemorrhagic manifestations are seen in the febrile and critical phase of dengue, but the spleen is infrequently involved. Splenic hematoma can lead to splenic rupture, which can be rapidly fatal. Specific treatment guidelines of such hematomas are needed in the context of dengue infection, as the treatment modality is controversial. Conclusion: Patients must be carefully evaluated for the complications and surgical manifestations of dengue as abdominal pain and hypotension from splenic hematoma may be misinterpreted as components of dengue hemorrhagic fever and dengue shock syndrome.

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.