An analysis of surgical complications; a tool to improve surgical outcome.

Complications in surgery are an important cause of morbidity and mortality. Complications may result in an increased length of stay in hospital, repeat surgery, additional medical treatment, legal issues and increased costs. Classification and regular audit of complications is a useful tool to improve patient safety and surgical outcome. The purpose of this study is to identify and classify surgical complications and evaluate the various contributing factors. The complications were categorized by Clavein Dindo system as Grade 1:52 (29.1%), Grade II :45 (25.1%),Grade IIIa:26 (14.5%), Grade IIIB:25 (14%), Grade IVa:5 (2.8%), Grade IVb:0 and Grade V:26 (14.5%) . The complication rate was 5.3% and mortality rate was 0.8% in total 3336 surgical procedures. There was significantly higher mortality in complications due to patient related factors 23.4% (11/47), compared to technical factors 4.2% (2/48) and other factors 15.4% (13/84) (p value = 0.024). The mortality was significantly higher in the patients who required ICU care, 54% (20/37), in class B surgical procedures 22.4% (22/98) and those who developed complications after emergency procedures were 31% (14/45). The mortality was significantly higher in the patients who required medical intervention for various medical complications 30.1% (19/63) compared to those who required surgical intervention 8.4% (5/59) or were managed conservatively 3.5% (2/57) (p value = 0.0001).

Stapled haemorrhoidectomy in the operative treatment of grade III and IV haemorrhoids.

Stapled haemorrhoidectomy (SH) is a minimally invasive intervention that uses a stapling device which avoids the need for wounds in the sensitive anal area and reduces the pain after surgery. This study was undertaken in Nepal Medical College Teaching Hospital from January 2010 to December 2012 to evaluate the efficacy of this modality of treatment among patients (32) who presented in the Surgery OPD with grade III and grade IV haemorrhoids. The results of SH were evaluated by the relief of symptoms, severity of post operative pain, and complications of SH. Twenty five (78.1%) patients had grade III and 7 (21.9%) presented with grade IV hemorrhoids. The most frequent presentation reported in our study was bleeding per rectum with perianal prolapse. Mean operating time was 40-60 minutes whereas mean hospital stay was 1.9 days. Urinary retention was the most common complication found in 12 (37.5%) patients in the immediate post operative period. SH is a safe, rapid, and convenient surgical remedy for grade III and grade IV hemorrhoids with low rate of complications, minimal postoperative pain, and shorter hospital stay.

Study on responses after splenectomy for idiopathic thrombocytopenic purpura patients, Kathmandu, Nepal.

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by accelerated destruction of platelets due to the presence of platelet (Plt) auto antibodies and impaired production of platelets. Splenectomy is still the standard salvage therapy in cases refractory to corticosteroid therapy. Retrospectively we analyzed 34 patients with ITP that underwent splenectomy in the period May 2010 to March 2012 and have been followed for at least 12 months. All patients met the diagnostic criteria for ITP. The median age at diagnosis was 26 years (range: 14-55 years). Overall response rate to splenectomy after 1 year of follow up was 94.1%, with Complete response in 32 and no response or relapse in 2 (5.8%). Sex didn't influence the outcome after splenectomy in our group of patients. Only preoperative response to steroids (P value = 0.018) and post-operative platelet count (P value = 0.013) were found to be significant statistically. Splenectomy considered as safe and effective treatment for patients with ITP who failed to respond to firs-line treatment with corticosteroids. Management of patients who do not respond or relapse after splenectomy represent an important problem for further treatment due to low response rate to other treatment options.

Choledochoduodenostomy in the management of dilated common bile duct due to choledocholithiasis.

Choledochoduodenostomy (CDD) is the operative procedure for Choledocholithiasis in the presence of a dilated common bile duct (CBD). It has been reported as a most effective treatment of CBD stones than T-tube drainage but is regarded as a obsolete therapeutic method due to fears of higher morbidity, cholangitis, "sump" syndrome etc. This study was done prospectively to assess the aforementioned issues analyzing our two years (July 2009 - June 2011) experience.CDD was performed in 31 patients (22 females and 9 males) with aged 18 - 72 years. CBD stones were the only indications in all patients with 18 (45.1%) patients had cholangitis, 8 (35.4%) had cholecystitis and 5 (19.3%) had biliary colic. Abdominal sonogram revealed dilated CBD with single or multiple calculi. The diameter of CBD varies from 14 - 29mm with stone size being ranged from 10- 26mm.Early post operative complications were seen in 4 (12.9%) patients. Only one patient had recurrent cholangitis presented lately due to intrahepatic stones.CDD is a highly effective treatment for choledocholithiasis in all age group with low morbidity and mortality provided a wide anastomosis is accomplished.

Comparative study of post operative wound infection following emergency lower segment caesarean section with and without the topical use of fusidic acid.

The study was undertaken to see the infection rate of wound following emergency caesarean section with and without the use of topical fusidic acid. The study was carried out at Himal Hospital from April 2006 to Jan. 2008. A total of 70 child bearing patients who underwent emergency caesarean sections were included. All of the patients were given absorbable subcuticular stitches. Out of the 70 patients, 35 patients had topical fusidic acid immediately after subcuticular stitches followed by dry dressing. The other 35 patients had simple dressing with povidone- iodine. Six patients (17.1%) out of the 35 patients who had dressing with povidone-iodine developed wound infection at the surgical site and only 1 patient (2.8%) out of the 35 patients with fusidic acid developed wound infection. The use of fusidic acid reduced the infection rate by six times. The relation of fusidic acid to wound infection was statistically significant (p = 0.0460).