Laparoscopic Cholecystectomy and Common Bile Duct Exploration in Situs Inversus Patients.

Situs inversus is a congenital condition in which the major visceral organs are reversed from their normal positions, estimated to occur in 1 in 5000-20,000 births. Incidence of gallbladder stone disease is same in these patients and normal patients. Laparoscopic cholecystectomy remains the treatment modality, and performing it successfully in these patients even rarer. We report a 54 years gentleman with gall stone, and 63 years lady who had both gall stone and common bile duct stone along with situs inversus. The mirror image reversibility of the abdominal viscera was seen in both cases. Ports were placed on the opposite side as the liver and the gallbladder were on the left side. Dissection was difficult because being a righthanded surgeon, the non-dominant hand would be the working hand. However, no perioperative complications occurred. It is technically challenging and requires a proper orientation of the left upperquadrant of abdomen.

Where is the Perforation ? Rare Complication of Endoscopic Retrograde Cholangio Pancreatography.

Perforation is one of the most feared complications of Endoscopic Retrograde Cholangio Pancreatography (ERCP). ERCP has become important method for treating biliary-pancreatic diseases. Perforation related with Endoscopic Retrograde Cholangio Pancreatography is an infrequent, but if happens is a severe complication. Reported incidence of Edoscopic Retrograde Cholangio Pancreatography related perforation is 0.3-6%. Its mortality is as high as 37.5%. In our hospital since 2010 AD, There were 6 Perforations related to Endoscopic Retrograde Cholangio Pancreatography done in 4787 cases. This is a case of Endoscopic Retrograde Cholangio Pancreatography related perforation with no site of perforation recognized during surgical management.

Laparoscopic Cholecystectomy: Conversion Rate and Associated Factors for Conversion.

Background Laparoscopic cholecystectomy is the standard surgical treatment of gall bladder disease. However, conversion to open cholecystectomy is inevitable in certain cases. Different centers has reported different conversion rate and factors associated with conversion. Objective To identify the conversion rate, postoperative complication and factors associated with conversion. Method This retrospective study included all laparoscopic cholecystectomy cases attempted in Dhulikhel hospital during the year 2015 and 2016. Records of all patients were reviewed to find out demography of the patients, indications of laparoscopic cholecystectomy, rate of conversion to open, underlying reasons for conversion and postoperative complications. Result Out of 644 cases of laparoscopic cholecystectomy, 452 (70.18%) were female and 192 (29.81%) were male with the mean age of 39 years. Over all conversion rate to open cholecystectomy was 1.86% with the frozen calot's triangle as the most common reason for conversion. The overall postoperative complication was found to be 1.24% with no major bile duct injury. Acute cholecystitis is a significant preoperative predictor for the conversion into open cholecystectomy. Conclusion Laparoscopic cholecystectomy can safely be done with low conversion rate and complication. Appreciation of the predictor factors help the patient and surgeon for appropriate treatment plan.

The Trend and Outcomes of Laparoscopic Appendectomy for Complicated Appendicitis in Nepal: A retrospective study from 2014 to 2018 in a University Hospital.

Background Globally, appendicitis is the most frequent emergency surgical procedure. Laparoscopic Appendectomy (LA) is recommended as a standard surgical procedure to remove appendix. In Nepal, studies showed improved outcomes of Laparoscopic Appendectomy than Open Appendectomy (OA) in treating acute appendicitis. However, effectiveness of in Complicated Appendicitis (CA) has not yet studied in Nepal. Objective This study aims to assess the temporal trend of Laparoscopic Appendectomy in management of Complicated appendicitis and to compare outcomes with Open Appendectomy. Method The study is a retrospective descriptive study. The outcome measures in the study are age, sex, ethnicity, length of postoperative stay (LOS), and conversion rate. Secondary data of 174 patients with complicated appendicitis were extracted and reviewed from the operation theater records and the discharge summary from the period of 2014 to 2018. Result The mean age of the patients is 33.2 (SD ±19.4). Predominantly increased incidence is observed among male patients (66%). Mean Length of stay was 4.07(SD±2.1) days. Laparoscopic Appendectomy had shorter hospital stays than open and converted cases. The conversion rate was 10.92% for the observation period, and it was in a decreasing trend with the latest of 4.54%. The temporal trend for the percentage of patients who underwent Laparoscopic Appendectomy was increasing in the observation period. Conclusion The utilization of laparoscopic appendectomy in complicated appendicitis is growing in Nepal, and has decreasing conversion rate.

Validation of host-specific Bacteroidales quantitative PCR assays and their application to microbial source tracking of drinking water sources in the Kathmandu Valley, Nepal.

AIMS: To validate host-specific Bacteroidales assays to identify faecal-source contamination of drinking water sources in the Kathmandu Valley, Nepal. METHODS AND RESULTS: A total of 54 composite faecal-source samples were collected from human sewage, ruminants, pigs, dogs, chickens and ducks, which were analysed by quantitative polymerase chain reaction using human-specific (BacHum, HF183 SYBR, gyrB and HF183 TaqMan), ruminant-specific (BacCow and BacR), pig-specific (Pig2Bac and PF163) and dog-specific assays (BacCan SYBR). The BacHum, BacR and Pig2Bac assays were judged the best performing human-specific, ruminant-specific and pig-specific assays respectively. The BacCan SYBR assay highly cross-reacted with other species, resulting in poor performance. Furthermore, these validated assays were applied to microbial source tracking (MST) of 74 drinking water samples. Out of these, 20, 12 and 4% samples were judged contaminated by human, ruminant and pig faeces respectively. Detection ratios of human and ruminant faecal markers were relatively higher in built-up and agricultural areas respectively. CONCLUSION: BacHum, BacR and Pig2Bac assays were found suitable for MST and both, human and animal faecal contaminations of drinking water sources were common in the valley. SIGNIFICANCE AND IMPACT OF THE STUDY: MST could be an effective tool for preparing the faecal pollution strategies as these are site specific.

Magnetoencephalographic imaging of ictal high-frequency oscillations (80-200 Hz) in pharmacologically resistant focal epilepsy.

OBJECTIVE: Specificity of ictal high-frequency oscillations (HFOs) in identifying epileptogenic abnormality is significant, compared to the spikes and interictal HFOs. The objectives of the study were to detect and to localize ictal HFOs by magnetoencephalography (MEG) for identifying the seizure onset zone (SOZ), evaluate the cortical excitability from preictal to ictal transition, and establish HFO concordance rates with other modalities and postsurgical resection. METHODS: Sixty-seven patients with drug-resistant epilepsy had at least 1 spontaneous seizure each during MEG acquisition, and analysis was carried out on 20 seizures from 20 patients. Ictal MEG data were bandpass filtered (80-200 Hz) to visualize, review, and analyze the HFOs co-occurring with ictal spikes. Source montages were generated on both hemispheres, mean fast Fourier transform was computed on virtual time series for determining the preictal to ictal spectral power transition, and source reconstruction was performed with sLORETA and beamformers. The concordance rates of ictal MEG HFOs (SOZ) was estimated with 4 reference epileptogenic regions. RESULTS: In each subject, transient bursts of high-frequency oscillatory cycles, distinct from the background activity, were observed in the periictal continuum. Time-frequency analysis showed significant spectral power surge (85-160 Hz) during ictal state (P < .05) compared to preictal state, but there was no variation in the peak HFO frequencies (P > .05) for each subgroup and at each source montage. HFO source localization was consistent between algorithms (k = 0.857 ± 0.138), with presumed epileptogenic zone (EZ) comparable to other modalities. In patients who underwent surgery (n = 6), MEG HFO SOZ was concordant with the presumed EZ and the surgical resection site (100%), and all were seizure-free during follow-up. SIGNIFICANCE: HFOs could be detected in the MEG periictal state, and its sources were accurately localized. During preictal to ictal transition, HFOs exhibited dynamic augmentation in intrinsic epileptogenicity. Spatial overlap of ictal HFO sources was consistent with EZ determinants and the surgical resection area.

Midline depressed skull fracture presenting with quadriplegia: A rare phenomenon.

BACKGROUND: Midline depressed skull fractures (MDSFs) deserve a special mention among skull fractures and should always be treated with caution. Here, an extremely unusual clinical presentation of a case of MDSF is highlighted along with its successful surgical management. CASE DESCRIPTION: A 26-year-old male presented with quadriplegia following assault on the head with sharp weapons. The patient had multiple lacerated wounds on the scalp with underlying cranial fractures. On evaluation, computerized tomography (CT) of the brain showed a midline depressed skull fracture compressing the superior sagittal sinus (SSS) causing bilateral frontoparietal venous infarction. CT venogram showed a filling defect of the SSS due to the penetrating bone fragment. He underwent elevation of the depressed fracture and repair of the sinus with pericranial graft. Patient improved neurologically, and follow-up magnetic resonance venogram showed a patent SS. CONCLUSION: MDSF can present with quadriparesis/quadriplegia due to middle one-third SSS obstruction/thrombosis leading to bilateral motor cortical venous infarction. Such MDSFs may require emergent surgical elevation of the depressed bone fragment for restoration of the patency of the sinus.

Clinico-Pathological Correlation of Colorectal Diseases by Colonoscopy and Biopsy.

Background Colonoscopy is a simple, safe and well tolerated procedure, the visualization of the mucosa of the entire colon and terminal ileum to detect intestinal abnormalities and obtain biopsy leads to the early detection of the pathologic process and institution of appropriate therapy. Objective To find out the correlation between clinical and histopathological diagnosis of colorectal diseases. Method A cross-sectional study was conducted at Department of Pathology, Dhulikhel Hospital, Kathmandu University Hospital from Jan. 2015 - Jan. 2016. Altogether, 95 colonoscopic biopsies were examined and recorded clinical data using pre-designed pro forma. The specimens were grossed, processed and embedded using standard procedures, stained with Hematoxylin and Eosin stain and were analyzed using light microscope. Special stains Ziehl Neelsen, and Periodic Acid-Schiff were used whenever necessary. Result Analyses of 95 cases of colonoscopic biopsies were done. The most common clinical diagnosis was polyp in 49 cases (51.57%) and the common histopathological diagnosis was non-neoplastic polyps 31(32.63%). There was no correlation in cases for suspected infectious colitis, microscopic colitis and hemorrhoids. Conclusion Colonoscopy is incomplete without biopsy and histopathology is the gold standard for the diagnosis of colorectal lesions. The clinico-pathological correlation for neoplastic lesions was excellent. However, correlation was poor in non-neoplastic lesion.

Effect of omega-3 and omega-6 polyunsaturated fatty acid enriched diet on plasma IGF-1 and testosterone concentration, puberty and semen quality in male buffalo.

The objective of the present study was to evaluate the effect of omega-3 and omega-6 PUFA enriched diet on plasma IGF-1 and testosterone concentrations, puberty, sperm fatty acid profile and semen quality in male buffalo. Eighteen male buffalo calves were distributed randomly in three different groups and fed concentrate mixture along with green fodder and wheat straw in 50:40:10 ratios as per requirements. Basis ration of animals in group I was supplemented with 4% of prilled fat (PFA), while in group II and group III were added 4.67% of Calcium salt from Soybean (CaSFA) and Linseed oil (CaLFA), respectively. Male buffalo fed omega-3 PUFA high diet significantly increased concentrations of IGF-1 and testosterone in plasma as compared to two other diets (p<0.05). The age of puberty and scrotal circumference significantly increased by dietary fat effect (p<0.05) of which n-3 PUFA enriched diet (CaLFA) had the largest influence as compared to other diets (PFA and CaSFA). Feeding of n-3 PUFA rich diet significantly increased the DHA (C22:6n-3) content in sperm (p<0.05), which contributed to increased fluidity of plasma membrane, elevated quality of sperm (motility, viability) and in vitro fertility (plasma membrane integrity, acrosome integrity) in both fresh and post-thawing semen. These findings indicate that feeding of n-3 PUFA enriched diet increased IGF-1 and testosterone secretion, reduced pubertal age and improved both fresh and post-thawing semen quality in male buffalo.

Kinnow madarin (Citrus nobilis lour × Citrus deliciosa tenora) fruit waste silage as potential feed for small ruminants.

AIM: Study was conducted to ascertain the quality of Kinnow mandarin waste (KMW) silage and its utilization by adult male goats. MATERIALS AND METHODS: KMW was collected, dried to 30% dry matter level and ensiled in silo pit after addition of disodium hydrogen orthophosphate as source of phosphorus as KMW is deficient in phosphorus. Oat was collected at milking stage, chopped finely and ensiled in a silo pit for 2 months. Twelve nondescript local adult male goats of about 8-10 months age and mean body weight of 23.00±0.90 kg were selected. The goats were randomly allotted on body weight as per randomized block design into two equal groups, six animals in each group (n=6) namely "oat silage (OS)" and "Kinnow silage." Goats were offered weighed quantities of respective silage on ad libitum basis. The silages were evaluated for proximate principles and silage quality attributes. RESULTS: Differences were found between chemical composition of both silages with higher organic matter, ether extracts, nitrogen free extract (p<0.05) and lower (p<0.01) crude fiber, neutral detergent fiber and acid detergent fibre concentration in KMW silage as compared to OS. However, silages were isonitrogenous (8.20 vs. 8.17; p>0.05 for CP) and possess comparable (2.23 vs. 2.06; p>0.05) calcium content. The pH, ammonia nitrogen (percent of total nitrogen) and soluble carbohydrate content were lower (4.20 vs. 3.30; 4.14 vs. 3.80; 2.73 vs. 1.86; p<0.05) in KMW silage, whereas, lactic acid concentration was higher (6.23 vs. 8.14; p<0.05) in KMW silage indicating its superior quality as compared to OS. Body weight (kg) of goats and silage intake (g/day), were comparable (p>0.05) among the two dietary groups. CONCLUSION: It can be concluded that KMW can be used to prepare good quality silage for feeding of goats.

In vitro utilization of lime treated olive cake as a component of complete feed for small ruminants.

AIM: The current in vitro study was carried out to determine the chemical composition and inclusion level of lime treated olive cake on acid detergent fiber (ADF) replacement basis in adult male goats. MATERIALS AND METHODS: Crude olive cake was collected and evaluated for proximate composition and protein fractionation. It was treated with 6% lime and incubated for 1 week under room temperature in 2 kg sealed polythene bags and was evaluated for proximate composition after incubation. Different isonitrogenous complete diets containing 0-50% of lime treated olive cake on ADF replacement basis were formulated as per the requirement of adult male goats. In ADF replacement, fiber and concentrate sources were replaced by lime treated olive cake by replacing the 0-50% ADF percentage of the total 40% ADF value of complete feed. The formulated complete diets were tested for in vitro degradation parameters. RESULTS: Treatment of olive cake with 6% slaked lime increased availability of cellulose and alleviated digestibility depression caused by high ether extract percentage. Organic matter, nitrogen free extract, ADF and neutral detergent fiber were significantly lowered by lime treatment of olive cake. The cornell net carbohydrate and protein system analysis showed that non-degradable protein represented by acid detergent insoluble nitrogen (ADIN) was 21.71% whereas the non-available protein represented by neutral detergent insoluble nitrogen (NDIN) was 38.86% in crude olive cake. The in vitro dry matter degradation (IVDMD) values were comparable at all replacement levels. However, a point of inflection was observed at 40% ADF replacement level, which was supported by truly degradable organic matter (TDOM), microbial biomass production (MBP), efficiency of MBP and partitioning factor values (PF). CONCLUSION: In our study, we concluded that there is comparable difference in composition of Indian olive cake when compared with European olive cake. The most important finding was that about 78% of nitrogen present in Indian olive cake is available to animal in contrary to that of European olive cake. We concluded from in vitro studies that Indian olive cake can be included in complete feed at 30% level (w/w; 40% ADF replacement) for feeding in small ruminants without compromising in vitro degradability of the feed.

Comparison of Tzanakis score vs Alvarado score in the effective diagnosis of acute appendicitis.

BACKGROUND: Acute appendicitis is the most frequent surgical emergency encountered worldwide. This study was conducted to compare the efficacy of Tzanakis score and Alvarado score in diagnosing acute appendicitis. OBJECTIVES: The aim of this study is to compare the efficacy of Tzanakis scoring system with Alvarado scoring system in diagnosing AA. METHODS: This was a retrospective and nonrandomized observational study conducted in Dhulikhel hospital. It included 200 clinically diagnosed cases of acute appendicitis who underwent emergency open or laparoscopic appendectomy during the year 2012. Final diagnosis of acute appendicitis was based on histological findings given by pathologist. RESULTS: The sensitivity, specificity, positive predictive value and negative predictive value of Tzanakis score was 86.9%, 75.0, 97.5% and 33.3% respectively. The sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score was 76.0%, 75.0%, 97.2% and 21.4% respectively. Negative appendectomy was 8.0%. CONCLUSION: Tzanakis scoring system is an effective scoring system in diagnosing acute appendicitis.

Safety profile and patient satisfaction of the routine use of propofol in gastrointestinal endoscopy.

BACKGROUD: Routine use of sedation in upper gastrointestinal endoscopy is uncommon in Nepal. There is no study on use of propofol sedation in routine endoscopy examination in Nepal. This study was conducted in order to assess the patient satisfaction and safety profile in patient undergoing routine upper GI endoscopic examination on outpatients. OBJECTIVE: To study safety profile and patient satisfaction of use of propofol in patients undergoing upper GI endoscopy. METHOD: A prospective, observational study was conducted in the endoscopy unit of Dhulikhel hospital, Kathmandu University Hospital from July 2011 to 2012 July. Patients who were referred to upper GI endoscopy were offered to sedation under propofol. Informed consent was taken after explaining side effects, advantages and risk-benefit to the clients. The propofol was administered by the endoscopy nurse under guidance and supervision of the endoscopy performing physician. Data were collected and analyzed using SPSS version 16.0 with 0.05 level of significance. RESULT: Total of 203 patients included in the study. Among 203 patients, 21.2% were males and 78.8% were females; 83.7% were of less than of 60 years age and 16.3% above 60 years of age. The mean total dose of propofol required was 136.08 ± 48.82 mg. Total of 29.1 % of cases required O2 administration during the procedure time due to transient drop in O2 saturation. Total of 4.4% of cases required fluid administration due to transient fall in blood pressure. Total of 68.0% of cases were completely sedated; 28.6% had minor restless and 3.4% showed agitation during induction period of propofol sedation. Total of 99.5% of patients reported pleasant experience while 0.5% reported unpleasant. Among 203 respondents, 98.5% responded they would prefer to do the procedure under propofol sedation in the future; 1.5% responded they did not want sedations in the future. CONCLUSION: Upper GI endoscopy can safely be performed under propofol sedation administered by registered trained nurse under the supervision of endoscopist.

Clinical practice recurrent severe obscure gastro intestinal-bleeding in a 20 year old man.

Morbus Osler-Weber-Rendu syndrome also known as Hereditary hemorrhagic telangiectasia (HHT) and Meckel's diverticulum is a rare combination disorder. Our case presented with the recurrent obscure gastrointestinal (GI) bleeding for several years. He came with a massive active lower gastrointestinal bleeding. Ultimatively, he underwent an exploratory laparotomy along with intraoperative colonoscopy. A Meckel's diverticulum in combination with multiple erosions was found as a probable cause of the massive gastrointestinal bleeding. An ileo-caeacal resection had been performed and by the pathologist multiple telangiectasias in the resected ileum were established. Blood was sent for genetics and was negative for ENG, ALK-1, and SMAD-4 genes. The patient was discharged after 10 days from time of admission and is under regular follow up without any further bleeding. In this case, despite sophisticated techniques for investigations the cause of the GI-bleeding with several esophagogastroduodenoscopies and colonoscopies, mesenteric angiography and finally an oral double balloon enteroscopy was misdiagnosed till the intra operative endoscopy showed a middle GI-bleeding. The management for obscure GI-bleeding is discussed for countries with lower medical facilities like Nepal in our case with Morbus Osler-Weber-Rendu syndrome.

The predictive value of pre-operative symptoms including upper gastrointestinal endoscopy before laparoscopic cholecystectomy for elective symptomatic cholecystolithiasis.

BACKGROUND: It has always been a challenge to distinguish between upper gastrointestinal symptoms due to gall stones or any other causes. The persistence of abdominal symptoms even after cholecystectomy is highly discouraging for surgeons. OBJECTIVE: To evaluate the value of preoperative (UGE) as a routine investigative tool in patients with gall stone disease and to assess the outcome of cholecystectomy in patients with gallstones on preoperative abdominal symptoms. METHODS: This is a prospective study conducted on 96 cases at the Department of Surgery, Dhulikhel Hospital among ultrasonographically proven gall bladder stones irrespective of age and sex. After the examination, all the patients were subjected to UGE, and biopsy were obtained for histopathology if required. The statistical analysis were performed using spss version 16. RESULTS: Out of total patients, 84(87.5%) were females and 12(12.5%) were males with a M: F ratio of 1:7. Both the sexes were comparable in age groups. Out of total 96 patients, 53(55.2%) presented with typical pain and 43(44.8%) presented with atypical pain. All the patients were subjected to upper gastrointestinal endoscopy (UGE) and 53(55.2%) had normal findings and 43(44.8%) had various lesions. Patients with typical pattern of pain had normal endoscopic findings and those with atypical pain had pathology in upper gastroendoscopy (p<0.001). Serious pathology resulting to change of the planned treatment was found in three cases (3.12%). Among them two had gastric carcinoma and one had active peptic ulcer disease. The relief rate after the cholecystectomy was significant in patients with typical pain than among those with atypical pain (p<0.001). The commenest post cholecystectomy symptoms were heart burn (10%), abdominal discomfort (9%) and dyspepsia (7%). CONCLUSION: Presence of atypical pain in patients with gall stones is highly likely to have other coexisting upper gastrointestinal pathologies. Hence, upper gastrointestinal endoscopy prior to elective cholecystectomy in patients with gall stones can be clinically helpful.

Role of ultrasound as compared with ERCP in patient with obstructive jaundice.

BACKGROUND: The diagnosis of obstructive jaundice relies on proper history taking, clinical examination, laboratory investigations and different non invasive imaging modalities like Ultrasonography (USG), Cholangio Computed Tomography (CCT), Magnetic resonance Imaging (MRI) with Magnetic Resonance Cholangio Pancreatography (MRCP) and invasive modalities like endoscopic retrograde cholangiography (ERCP) and percutaneous trans hepatic cholangiography (PTC). OBJECTIVE: To compare the role of ultrasound with endoscopic retrograde cholangiography and to determine the major causes of obstructive jaundice in our prospect. METHODS: This was a prospective, analytical study conducted on 88 patients presenting to Department of Radiodiagnosis and Imaging at Dhulikhel Hospital-Kathmandu University hospital from March 2011 to August 2012 with clinical diagnosis of obstructive jaundice. Sonographic evaluation was performed in Siemens acusion x-150 and x-300. The final diagnosis was made by endoscopic retrograde cholangiography and /or surgery and confirmed histopathologically. RESULTS: The most common benign causes of obstructive jaundice were choledocholithiasis (63%), CBD stricture (12.3%), cholangitis (8%) and pancreatitis (6.85%) whereas cholangio carcinoma (6.85%) and carcinoma head of pancreas (4%) comprised of the malignant causes . Ultrasonography had sensitivity of 100% and specificity of 89% in detecting choledocholithiasis. It was found to be 98.78% sensitive and 83.33% specific in cholangiocarcinoma. Similarly in pancreatitis, the sensitivity of ultrasonography was 97.59% and sensitivity was 66.67%. CONCLUSION: Ultrasonography acts as a valuable diagnostic imaging modality in detecting the causes of obstructive jaundice. Due to its easy availability, non invasive nature and cost effectiveness, it can be considered as the first line imaging technique/ tool. ERCP is the invasive imaging tool and can be used for both diagnostic and therapeutic purpose.

Laparoscopic cholecystectomy complication and conversion rate.

BACKGROUND: Laparoscopic cholecystectomy has become standard method for treating gallstone. However, different centres have reported different complications and conversion rate. The objective of this study was to evaluate complications and conversion of laparoscopic cholecystectomy into open cholecystectomy in Dhulikhel Hospital, Kathmandu University, Nepal. METHODS: Files of all patients who had laparoscopic cholecystectomy from January 2005 to December 2009 were reviewed. Out of 119 laparoscopic cholecystectomy cases, 102 were included in the study as complete information was lacking in the rest. RESULTS: Out of 102 cases, 80 were female. Symptomatic cholelithiasis were 76.47%. The mean hospital stay was 2.48 days. Postoperative complications occurred in 5.88% patients. Conversion rate to open cholecystectomy was 3.92%. CONCLUSIONS: Laparoscopic cholecystectomy is a reliable and safe surgery. With growing experience in laparoscopic technique, it is possible to bring complications and conversion rate to minimum. However, there will be no significant improvements once learning curve is reached. Rather, the nature of biliary injury may become more severe.

Intrauterine condom tamponade in management of post partum haemorrhage.

BACKGROUND: Uterine tamponade is often used to control post partum hemorrhage. Among various methods, condom Foley's catheter tamponade is simple, easy to use and is believed to be effective. The study evaluates outcome of condom Foley's catheter tamponade. METHODS: In this prespective observational study, condom tamponade was applied to fourteen cases with varying degrees of PPH, not controlled with pharmacologic measures. The efficacy on control of bleeding was assessed along with the total amount of blood loss and any complications. RESULTS: The condom tamponade stopped bleeding in all the cases. Average amount of blood loss was 1221 ml. No complications were noted. CONCLUSIONS: Thus, condom tamponade is an effective method to control intractable PPH. It's simple and does not require expertise to use, so, it can have a wide application even in resource poor settings.

Haemorrhoidectomy: Ferguson's (closed) vs Milligan Morgan's technique (open).

This study was done to compare the efficacy of closed Vs open haemorrhoidectomy. The study design was unblinded randomised control trial at Dhulikhel Hospital, Kathmandu University Hospital. Total number of patients was 56 all with 3rd and 4th degree haemorrhoids. Post operative pain was taken as main outcome measures. Operation time varied from 200 seconds for each haemorroidal cushion with open technique to 626 seconds by closed technique. The blood loss was not quantifiable in closed technique. Pain was scored on visual analogue scale. In closed group, the pain score was 4.9 immediate post operative period and 2.3 (24 hours later). In the other group, the scores were 7.8 and 6.9. These differences were significant. At the end of study we came to a conclusion that haemorrhoidectomy using closed technique has more advantages.