Laparoscopic Adrenalectomy: Two Years Experience at Bangabandhu Sheikh Mujib Medical University.

Laparoscopic surgery has become an efficient tool for many complex surgical procedures. In last decades, laparoscopic adrenalectomy has become a more viable option for removal of adrenal pathology, with many surgeons preferring it to the conventional open technique. This study was done to evaluate the outcomes of lateral transperitoneal adrenalectomy (LTA) in our department and evaluate the feasibility of lateral transperitoneal adrenalectomy (LTA) in our perspective. This study is case series observational study carried out at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from March 2015 to May 2017. Suspected primary adrenal malignancies were excluded. Seventeen (17) patients (10 male and 7 females with mean age of 35.29 years) underwent 18 adrenalectomy (one bilateral). Seventeen (17) adrenal tumours were resected through laparoscopy and one adrenal tumour is resected through open approach due to conversion. All the patients underwent hormonal evaluation, ultrasonogram and computed tomography of whole abdomen. Ten (10) patients (58.82%) had hormonal active adrenal mass. Seven (7) patients (41.18%) were asymptomatic of which 2 had associated cholelithiasis, 7 patients had generalized weakness, 3 had weight gain with Cushing syndrome (one drug induced) and one had Hirsutism with musculanizing effect. Nine (9) patients had hypertension and 6 patients had diabetes mellitus. Eight (8) right, 8 left and 1 bilateral LTA were performed. The mean age of the patients were 35.29 years, adrenal tumour size ranges from 15-65mm and operation time ranges from 75-120 minutes for unilateral adrenalectomies and 220 minutes for bilateral adrenalectomy. Estimated blood loss ranges from 30 to 130 ml in 16 cases and in one case it was 220 ml in which conversion was done. Mean post operative stay in hospital was 3.94 days. In 16 cases no major or minor complications were observed but in one case due to haemorrhage and infiltration of the tumour to kidney conversion are done in the form of right adrenalectomy with upper partial nephrectomy (Histopathology revealed angiomyolipoma). In pathological examination 9 patients (52.94%) had adrenocortical adenoma, 2 patients (11.76%) had phaeochromocytoma including bilateral one, 2 patients (11.76%) had myolipoma of which one converted to open, 2 patients (11.76%) had adrenocortical hyperplasia, one patient (5.88%) had adrenal cyst and one patient (5.88%) had haemorrhagic cyst. LTA is a safe and efficient minimally invasive treatment options for both secreting and non secreting adrenal masses. The procedure has a learning curve and should be performed by a surgeon experienced in both open and laparoscopic adrenal surgery.

Nodular Mucinosis of Male Breast: A Rare Case Report.

Multinodular accumulation of stromal mucin in breast known as nodular mucinosis is an extremely rare condition of breast. Alternatively it is known as myxoma or nerve sheath myxoma of breast. This benign lesion is confined to only nipple and areola region presenting as slow growing, soft and non tender lobulated mass. Histopathologically it reveals well circumscribed non-encapsulated myxoid/mucinous lesion with few infiltration of spindle cells within a collaginized stroma. The mucinous substance is stained positively with Alcian blue. Mucinous carcinoma or phylloids tumour are important differential diagnosis of nodular mucinosis of breast. Here we report a case of nodular mucinosis of male breast with clinical, radiological and pathological findings with differential diagnosis and treatment modalities.

Carcass characteristics, chemical and fatty acid composition and oxidative stability of meat from broiler chickens fed black cumin (Nigella sativa) seeds.

A study was conducted to investigate the dietary supplementation of black cumin seeds (BCS) on carcass characteristics, chemical and fatty acid (FA) composition and antioxidant properties of thigh and breast meat of broiler chickens at 42 days of age. Three hundred sixty 1-day-old broiler chickens were allocated to five dietary treatment groups (each group containing eight replicate pens with each pen containing nine broiler chickens): basal diet (control; CON), CON + 0.05 g/kg of bacitracin methylene disalicylate (AB), CON + 5 g/kg of BCS (low dose of BCS), CON + 10 g/kg of BCS (medium dose of BCS) and CON + 20 g/kg of BCS (high dose of BCS). Weight (g) of slaughtered birds (p = .03), hot carcass (p = .007), breast (p = .03), thigh (p < .001), wing (p = .06), neck (p = .01), liver (p = .09), abdominal fat (p = .01) and total edible parts (p = .01) increased or tended to increase due to BCS supplementation compared with the CON. The concentrations of dry matter, crude protein and ether extract in chicken thigh and breast meat increased (p = .038 to <.001) with increasing doses of BCS in diets. The ferric reducing antioxidant activity in blood and meat increased linearly with increasing doses of BCS in the diets. However, peroxide values in meat were not affected by BCS and AB on both days 1 and 7 of storage at 4°C. Supplementation of BCS increased the concentrations of C14:1, C18:3n-6, C20:1, C20:2 FA and PUFA linearly (p < .05) and tended to increase (p = .098) the concentration of C18:2cis linearly. However, the concentrations of C16:0 and C16:1 FA decreased linearly with increasing doses of BCS in the diets. In conclusion, dietary supplementation of BCS at 20 g/kg diet may improve slaughter body weight, beneficial FA concentrations and antioxidant properties of broiler chicken meat.

Irritable Bowel Syndrome: Prevalence and Dietary Factors in the Sylhet District of Bangladesh.

Irritable bowel syndrome (IBS) is a common functional bowel disorder. Along with other factors diet plays an important role in the causation of IBS. This population-based study was done to find out the prevalence of IBS and to find out the dietary factors associated with IBS from August 2011 to December 2011 in Sylhet district of Bangladesh. Nineteen hundred apparently healthy subjects selected by cluster sampling methods were interviewed by a validated bowel disease questionnaire. Dietary history of the subjects was also taken. Irritable bowel syndrome was diagnosed according to Rome III criteria. The prevalence of IBS was found 14.2% (n=269, M=15%, F=13.4%, p=0.365). Mean age of the IBS patients were higher than the study population (41.35 years vs. 34.74 years, p=0.000). Irritable bowel syndrome was found more in low education group (16.3%) with lower socioeconomic status (16.5%) and in single person (16.7%). IBSD was the most prevalent subtype (48.7%), IBSM was the next common subtype. Abdominal pain relieved by defecation (81%) and abdominal pain associated with loose stools (81%) were the two commonest symptoms. Age (OR 1.023, p=0.000), less intake of meat (OR 2.281, p=0.000) and pulses (OR 1.648, p=0.001) and more intake of tea (OR 1.524, p=0.009) and spices (OR 0.452, p=0.000) were found as independent predictor of IBS. Irritable bowel syndrome is a common disorder in our community. IBSD is the most prevalent subtype. Less intake of meat, pulses and more intakes of tea and spices are important associated factors for IBS.

Incidental Thyroid Carcinoma in Patients Treated Surgically for Presumably Benign Thyroid Disease.

Incidental Thyroid Carcinoma (ITC) is quite high as been reported in the world's Journal. This study reviews the frequency of the ITC in patients treated surgically for otherwise benign Thyroid disease in one of the Endocrine surgery unit of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh. This study was developed by the investigating the outcome of one hundred and twenty seven patient who underwent partial or total thyroidectomy for benign thyroid pathology in a single Endocrine Surgery Unit of BSMMU from January 2011 to July 2015. This observational study was done to find out the actual incidence of thyroid malignancy among the patients admitted for surgical management with thyroid pathology. All patients underwent at least FNAC and Ultrasonography of the Neck before surgery. Patients with undetermined cytology and follicular nodules were excluded from the study. Overall 19(14.96%) incidental thyroid carcinoma was recorded. Among the ITC 11(8.66%) Papillary Carcinoma, 7(5.51%) Follicular Carcinoma & 1(0.79%) is poorly differentiated carcinoma. The Overall incidence of papillary carcinoma is higher among the incidental carcinoma of Thyroid. Increased incidence associated with follicular adenoma present as an isolated thyroid nodules or multifocal lesion and should be considered malignant potential and total thyroidectomy would be the right choice as surgical management of the both cases. In case of multinodular goiter, total thyroidectomy is currently practiced in majority of the centers and our observations reinforced the attitude further.

Morbidity and Mortality after Pancreatoduodenectomy: A Five Year Experience in Bangabandhu Sheikh Mujib Medical University.

Mortality and morbidity was assessed after adoption of a systematic care for patient with pancreatoduodenectomy starting from patient selection and preparation, operative technique, and postoperative care. In this prospective study seventy patients who underwent pancreatoduodenectomy for periampullary carcinoma with curative intent between January 2010 and December 2014 were carefully analyzed prospectively. Patients were selected those who had ampullary carcinoma, lower bile duct carcinoma and small size carcinoma head of pancreas without local invasion and distant metastasis, and the patient who did not have any major disabling comorbid diseases. All patients were assessed uniformly before surgery and deficiency were corrected up to normal level before operation. Pancreatoduodenectomy and standard lymphadenectomy was performed meticulously with minimum blood loss. The pancreatojejunal reconstruction was performed using duct-to-mucosa method mostly. A nasojejunal feeding tube was placed in most patients for starting postoperative early oral feeding. Broad spectrum antibiotics and the epidural analgesia were mostly prescribed for good control infection and pain. Proper nutrition was maintained in calculative way through central venous line and nasojejunal feeding tube in the early postoperative period. General care, early mobilization and chest physiotherapy were given routinely in each patient. Seventy-seven percent (n=54) patients did not have any postoperative complications and they were discharged from hospital within 12-14 postoperative days. The morbidity occurred in 16 patients (23%) and most common complication was wound infection (18%, n=9). The rest complications were pancreatojejunal anastomotic leakage - 2, hepaticojejunal anastomosis leakage - 1, melaena - 1, intra-abdominal abscess - 1, intra-abdominal hemorrhage - 1, and renal dysfunction - 1. The mortality rate was 5.7% (n=4), causes of death were massive myocardial infarction; 1, failure of reversal from anesthesia; 1, massive intraabdominal bleeding; 1 and CV catheter related severe sepsis; 1. Review of recent published literature revealed that mortality and morbidity our series is better than low volume center and almost similar with high volume center of pancreatoduodenectomy surgery. Our systematic management policy of careful patient selection, planned approach in the form of proper work up, meticulous conduction of the procedure, appropriate postoperative care provides an acceptable morbidity and mortality after pancreatoduodenectomy.

Correlation between Clinical and Arthroscopic Findings in Meniscal Tear of Knee.

The meniscus is the most commonly injured structure in the knee joint. Carefully performed clinical examination can give better diagnosis of meniscal tear. The aim of this study was to find out the correlation between clinical and arthroscopic findings in meniscal tear of knee. This cross sectional observational study was conducted in the Department of Orthopaedic Surgery, BSMMU, Dhaka from July 2012 to June 2014. Thirty patients of meniscal tear were selected as per inclusion and exclusion criteria. After proper evaluation and clinical examination of these patient arthroscopic examinations was done under spinal anesthesia. A total number of 30 patients were recruited in this study. Twenty seven (90%) patients were male and only 3(10%) were female. Mean±SD of age was 26.00±5.55 and range was 17-34 years. Out of 30 patients 19(63.3%) had right knee affected and the rest 11(36.7%) had left knee affected. It was found from clinical diagnosis that most of the patients had MM injury (73.4%) and LM injury was in 26.6% patients. From arthroscopic diagnosis we found most of the patients had multiple types of injury (40.0%) followed by 26.7% patents had isolated MM injury, 16.6% patients had isolated LM injury, 10.0% patients had other injuries like ACL, PCL or MCL and rest 6.7% patients had no injury at all. Sensitivity, specificity, PPV, NPV and accuracy of clinical diagnosis in diagnosis of MM injury were 94.4%, 58.3%, 77.3%, 87.5% and 80.0% respectively. Sensitivity, specificity, PPV, NPV and accuracy of clinical diagnosis in diagnosis of LM injury were 85.7%, 91.3%, 75.0%, 95.5% and 90.0% respectively. Clinical evaluation may diagnose meniscal tear accurately.

Huge Perineal Tumour: A Rare Presentation of Gastrointestinal Stromal Tumour of Rectum.

Gastrointestinal stromal tumour (GIST) is a relatively rare neoplasm of gastrointestinal tract of which Rectal GIST is uncommon. It produces symptoms of per rectal bleeding or change in bowel habit. Recurrences following curative resection are predominantly intraabdominal, hepatic metastasis occurring at a median 20-25 months following the primary surgery. A 42 years old male presented a huge mass in hypogastrium, the size of which was reduced ofter neoadjuvant therapy for period of 1.5 years. He underwent abdominoperineal resection. He developed recurrences in perineum three times and in thigh at short intervals after primary resection. He also developed liver metastasis. He died two and half years after primary diagnosis. Rectal GIST should be included in differential diagnosis of intraabdominal mass and preoperative diagnosis based on histopathological as well as the immunohistochemical feature of the CD(117) and CD(34). Although complete surgical resection with negative tumour margin is the principal curative procedure for primary and non metastatic tumours, further studies are still needed for the determination of the most effective treatment strategy for patients of rectal GIST.

Pigtail Catheter in the Management of Liver Abscess.

Amoebic liver abscess is a common condition in Bangladesh. Though conservative treatment plays a major role, refractory patients can be successfully treated with minimally invasive approach. This prospective study was carried out to evaluate the prospect of sono-guided percutaneous catheter drainage for liver abscess patients not responding to conservative treatment. This study was done at Dhaka Medical College Hospital from January 2005 to June 2006 among patients with liver abscess that were treated conservatively outside and got admitted in different surgery and medicine units. Included 35 patients were evaluated clinically and through relevant investigations. Sono-guided percutaneous pigtail catheter was introduced for drainage and patients were followed up for two weeks on average at hospital indoor by amount of drainage, clinical improvement and serial follow up USG. After discharge from the hospital, all patients were followed up monthly and assessed clinically and ultrasonographically up to two months on outdoor basis. Thirty five patients underwent pigtail catheter drainage that was refractory to conservative treatment or needle aspiration. Following insertion of catheter patients who were pyrexic, fever subsided in two to three days and never back during the postoperative period and follow up. Antimicrobials were changed according to the report of the culture and sensitivity of the aspirate that was done routinely. Maximum total (4300 ml) amount of pus was drained in a patient. Average duration of catheter drainage in this study was 8 days. With a very low morbidity and zero mortality rates, minimum treatment costs and early return to regular life style proved this minimally invasive procedure to be a rational treatment option for amoebic liver abscess in selective cases.

Serum adiponectin in patients with coronary heart disease.

Adiponectin is an adipocyte derived hormone, a modulator of lipid metabolism and systemic inflammation. It has potential anti-atherogenic property. Adiponectin is present in low concentration in patients with obesity, insulin resistance (IR), Type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD). In this case control study, we studied the association of Serum adiponectin with CHD. Sixty-four subjects were enrolled. Consecutive 31 CHD patients (Group I) and 33 healthy controls (Group II) were included. Serum adiponectin & lipid profile were estimated in all. Serum adiponectin was significantly lower in CHD patients (3.90±2.21µg/ml) in comparison with controls (5.09±2.13µg/ml)(P<0.05). There was no significant difference of any fraction of lipid profile between cases and controls. Significant negative correlation was observed between Serum adiponectin and Serum triacylglyceride (STG) in cases (P<0.01). It may be concluded that low serum adiponectin may have some important role in development of CHD and probably low adiponectin and dyslipidemia are linked in the development of atherosclerosis. Further study is recommended with larger sample size to explore the role of hypoadiponectinemia in the causation of CHD.

Relationship of blood and semen lead level with semen parameter.

Lead has for long been known to affect multiple organs and can affect reproduction in male and female as well as the offspring. The study was done to find out the level of lead in blood and semen of infertile men and to find its effect on the semen parameters, as well as the minimum level of lead in blood and semen that can have negative impacts on semen parameters. The study was cross sectional in design. Male partners of 57 infertile couples attending a tertiary infertility center in Dhaka, Bangladesh were recruited for the study. Blood lead was measured by the Graphite Furnance Atomic Absorption Spectrophotometer and semen analysis was done according to the WHO recommendation (1999). With increasing blood lead concentration there was corresponding increase in the mean semen lead concentration. Reduction of mean semen volume started at level of mean blood lead level of >40mugm/dl. Mean total count of sperm (x106/ml) started decreasing at blood lead level of >30mugm/dl with very significant reduction of the count at level >40mugm/dl. At mean blood lead level >35mugm/dl there was decrease in mean values for total motility and rapid linear motility of sperm. In 12.3 % of the patients mean blood lead level was above >35mugm/dl. Higher mean blood and semen lead level was associated with significant declining semen parameters.