Evaluation of Mannheim's Peritonitis Index in Prediction of Mortality in Patients with Non-traumatic Hollow Viscus Perforation Peritonitis.

BACKGROUND: Hollow viscus perforation peritonitis is one of the commonest surgical emergencies with high mortality and morbidity. The objective of this study was to evaluate the effectiveness of Mannheim's peritonitis index in prediction of mortality in these patients. METHODS: This is a retrospective, observational cohort study in these patients managed in a single-center from January 1, 2013 to December 30, 2019. Total index scores were plotted in the receiver operating characteristic curves to find out the cut-off point. Sensitivity, specificity, relative risk, positive and negative predictive values were calculated. The individual risk factors were analyzed for mortality as well. RESULTS: Case records of 395 cases of non-traumatic hollow viscus perforation peritonitis were available, there were 33 mortalities (8.2%), mean score was 22.96 (+7.6) points (range 10-43 points). The sensitivity and specificity with score cut-off of 25 came to be 75.8% and 56.35%; positive and negative predictive value being 13.7% and 96.2%. Risk of patients for mortality with scores >25 was 3.62 times those with scores <25 for mortality. Mortality rate was 2.4% with scores <21, 8.9% with 21-29 and 20.9% with >29 respectively (p-value <0.05). Univariate analysis showed age >50 years, presence of organ dysfunction, diffuse peritonitis, non-colonic origin and character of exudates were significant factors; multivariate analysis showed only organ failure as significant. CONCLUSIONS: Mannheim peritonitis index is very useful in stratification of severity of the disease and prediction of mortality in patients with peritonitis, and should be included in management of all these patients.

e-TEP Retromuscular Repair for Recurrent Incisional Hernias: Report of Three Cases.

INTRODUCTION: Recurrent incisional hernias are difficult to treat. There are many factors involved in the recurrence, and due to extensive dissections, the planes are fused with adhesions, and we may need a new plane for dissection and placement of meshes. CASE REPORT: We report here three cases of recurrent incisional hernias which were dealt by a relatively new method to laparoscopy: the enhanced view totally extraperitoneal repair (e-TEP) retromuscular technique. There were three patients: one after an open onlay repair of lower midline incision, another after an onlay mesh repair of a subcostal incision for open cholecystectomy followed by an intraperitoneal onlay mesh hernioplasty (IPOM) repair, and another after IPOM repair of epigastric hernia. They were treated with the abovementioned technique with satisfying short-term results. CONCLUSION: The e-TEP technique is a relatively new method of providing minimal access surgery to these patients utilizing the previously unaccessed retromuscular (Rives and/or preperitoneal) space for the repair of these recurrent incisional hernias.

Challenges and Results of Laparoscopic Splenectomy for Hematological Diseases in a Developing Country.

INTRODUCTION: Though, in developed countries, laparoscopy is now a gold standard for splenectomy, we are lacking in this aspect in the eastern world. Splenectomy has mostly been performed by open surgery in our region. This is our effort to introduce laparoscopic splenectomy in our country. METHODS: This is a retrospective cohort study done in patients presenting to hematology and surgery department of our hospital who underwent laparoscopic splenectomy for hematological diseases from January 2013 to December 2016. RESULTS: There were 50 patients (38 females, 12 males). The diagnoses were idiopathic thrombocytopenic purpura in 31, (steroid/azathioprine-resistant, steroid dependent), hereditary spherocytosis in 9, alpha-thalassemia in 3, beta-thalassemia in 2, autoimmune hemolytic anemia in 4, and isolated splenic tuberculosis in 1. Average platelet counts preoperatively were 62000 ± 11000/mm3 (range 52000-325000/mm3). The mean operative time was 130 ± 49 minutes (range 108-224 min). The mean postoperative stay was 4 ± 2.11 days (range 3-9 days). Laparoscopic splenectomy could be completed in 45 (90%) patients. CONCLUSION: Laparoscopic splenectomy could be successfully contemplated in patients with hematological diseases, especially if spleen is normal or only mildly enlarged, and is an advantageous alternative to open splenectomy. Absence of ideal resources has not limited our progress in minimal access approach.

Solid pseudopapillary tumor in an ectopic pancreas: an unusual presentation.

Pancreatic solid pseudopapillary tumor is a rare neoplasm. Very rarely, it may arise from an ectopic site. Solid pseudopapillary tumor occurring in the root of mesentery has not been described in the literature. This report summarizes a case of an adult male having the tumor arising from the mesenteric root. He underwent complete resection of the tumor followed by six cycles of adjuvant chemotherapy and remains asymptomatic till date.

Chilaiditi's sign secondary to Richter's hernia or Chilaiditi's syndrome?

Chilaiditi's sign and syndrome seem similar but are actually different entities, difficult to distinguish from each other. A 60-year-old female presented with a clinical scenario of intestinal obstruction, which was thought to be Chilaiditi's syndrome because of the unusual impression of gas under the diaphragm, but was confirmed as Chilaiditi's sign after laparotomy. The interposition of dilated small bowel loops below the diaphragm due to distal obstruction somewhere else can also produce a Chilaiditi's sign.

Simultaneous laparoscopic management of Morgagni hernia and cholelithiasis: two case reports.

BACKGROUND: Morgagni hernia is a rare type of diaphragmatic hernia. Though in the past, it has been dealt with an open approach, nowadays laparoscopic management is a favored approach. However, there are few controversies in this scenario. CASE PRESENTATION: We present here two females of Aryan ethnicity, one 55 and another 45 years old, who presented with pain at upper abdomen and retrosternal chest pain; on investigations were found to have cholelithiasis along with Morgagni hernia which were managed via the laparoscopic approach in the same sitting. CONCLUSION: Repair of Morgagni hernia also via the minimally invasive technique can be offered to the patients like that for cholelithiasis.

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.

An alarming but self-limited case of isolated large spontaneous liver hematoma in pregnancy.

Spontaneous subcapsular liver hematoma is rare but potentially life-threatening complication of pregnancy usually associated with severe preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). We present here a case of such a large spontaneous liver hematoma presenting in pregnancy, but without other known associated abnormalities, which has not been described before and it resolved on itself without any intervention.

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.

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.

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.