Journal of Society of Surgeons of Nepal

A Novel Technique For Enterocutaneous Fistula Closure- Local Transposition Flap

Sudhir Kumar, Aakansh Jain — Mon, 28 Aug 2023 00:00:00 +0000

Enterocutaneous fistulae are one of the most dreaded complications of abdominal surgeries which may be due to the result of multiple causes like anastomotic failure, poor blood supply, or iatrogenic bowel injuries. These fistulae are classified based on their output. Most Low output fistulae usually close spontaneously but few remain patent and may require surgical intervention. We are presenting two of our cases where we have used the local transposition flap to cover the enterocutaneous fistulae successfully. It can serve as a good armour in the armamentarium of plastic surgeon.

Gallstone Ileus: A Stone In The Way

Bárbara Neto Castro, Ana Rita Ferreira, Susana Graça, Manuel Oliveira — Mon, 28 Aug 2023 00:00:00 +0000

Gallstone ileus, a rare complication of cholelithiasis, is caused by an impaction of gallstones within the gastrointestinal tract leading to mechanical intestinal obstruction. Here in, we describe a case of gallstone ileus in a 62-year-old woman successfully treated with enterolithotomy. The patient was discharged home after an uneventful post-operative period. Gallstone ileus is an uncommon complication of gallstones and a rare cause of intestinal obstruction, with often delayed presentation and non-specific symptoms. The preferred approach is enterolithotomy. Elective cholecystectomy after the acute episode is controversial.

Adenomyoma As A Lead Point For Jejunal Intussusception In An Adult: A Rare Case

Rajiv Nakarmi, Muza Shrestha, Sundar Maharjan, Deliya Paudel, Himanshu Regmi — Mon, 28 Aug 2023 00:00:00 +0000

Adenomyoma of small intestine causing intussusception in adults is a rare condition. The small intestine is the second most frequent location, usually in the periampullary area, but the lesion also occurs in the jejunum and ileum.We present a case of 76 years old female who presented with pain abdomen and was diagnosed to have jejunal intussusception. She underwent surgery with segmental resection and anastomosis of jejunum and the histopathological examination revealed jejunal adenomyoma as the pathological lead point. Adenomyoma of jejunum as a lead point should be taken into consideration while dealing with a patient with jejunal intussusception.

Pelvi-Ureteric Junction Obstruction In A Malrotated Ectopic Kidney With Concomitant Lithiasis – A Rare Clinical Scenario

Mohammed Ayub Siddiqui, Shashank Sharma, Vivek Shaw — Mon, 28 Aug 2023 00:00:00 +0000

Kidney lying outside renal fossa is referred as ectopic kidney. Hereby we are presenting a rare case of Pelviureteric junction obstruction in a malrotated ectopic kidney with concomitant lithiasis in a 16 year male. He presented with pain in lower abdomen intermittently. On CT scan, a left malrotated ectopic kidney was located in the pelvis near the midline with a 10 mm stone in the lower pole, and having obstructed pattern drainage with moderate hydronephrosis. Open Anderson-Hynes dismembered pyeloplasty was done.

Thorough clinical approach with delineating aberrant anatomy of ectopic kidneys and their vascular supply with consideration of unusual functional data on conventional functional renogram is necessary for intervening in malrotated ectopic kidney with concomitant lithiasis.

Colonic Mucormycosis In A Post Covid Patient: A Case Report

Amrita Patkar, Neha Kalwadia, Shailja Dadhich, Ojas Potdar, Manoj Mulchandani — Mon, 28 Aug 2023 00:00:00 +0000

Mucormycosis is rare infection caused by fungi of order Mucorales which frequently involves rhino-cerebral or respiratory system with involvement of gastrointestinal (GI) tract being rare.

Classically majority of patients with invasive mucormycosis are immunocompromised and/or have poor glycemic control. This happens especially during recovery phase of COVID-19 when patients are immunocompromised and simultaneously having poor glycemic control. While gastrointestinal (GI) mucormycosis is rare, stomach and colon are most commonly affected organs, and mortality can be as high as 85%.

Diagnosis is difficult since signs and symptoms, imaging and intraoperative gross appearance may not suggest mucormycosis. Diagnosis is usually by histopathologic identification of fungal hyphae in biopsy specimen. A high index of suspicion is therefore necessary in post-COVID-19 patients presenting with mesenteric ischemia or bowel perforation especially if they were immunocompromised. Here we present a case of post COVID disseminated mucormycosis in a 59-year-old diabetic male patient.

An Interesting Case Of A Horseshoe Kidney With Unilateral Single Ureter And Associated Anorectal Malformation

Mon, 28 Aug 2023 00:00:00 +0000

Horseshoe kidney (HSK) has an incidence of about 1 in 400 or 0.25% of the general population and is seen more commonly in males as compared to women in a ratio of 2:1. Usually, Horseshoe kidney would have two normal ureters each draining separately into the bladder. We present a rare and interesting case of Horseshoe kidney with unilateral single ureter and associated anorectal malformation.

Surgeon Burnout: An Alarming Issue

Rupesh Mukhia, Smriti Pokharel — Mon, 28 Aug 2023 00:00:00 +0000

No abstract available.

Transverse Eponychial Flap For Nail Lengthening And Fingertip Reconstruction

Krishna Manadhar — Mon, 28 Aug 2023 00:00:00 +0000

Introduction: Fingertip injuries are frequented with loss of pulp and nail complex. Most reconstructive procedures provide either the soft tissue defect coverage or lengthen the nail.

Methods: Patients included were more than 10 years of age with fingertip injury of Allen type III and IV with intact eponychium. Transverse Eponychial Flap was used to lengthen the nail lost as well as provide defect coverage. Paired t test, chi square test and Pearson correlation and Mann Whitney test were used for statistical analysis.

Results: Seventeen digits were analyzed. The average lengthening of the nail achieved was 142.4%. The average nail length during follow up was 59.1% of contralateral, with average final nail lengthening achieved was 31%. Reconstruction with Transverse Eponychial flap alone was performed in 58.8% of digits. Four patients (23.52%) had complete near normal nail. Sixteen digits had satisfactory and higher results. With Transverse Eponychial Flap alone it was possible to completely cover 10 fingertips (58.8%), requiring local flaps or skin graft for the remaining cases. Obliquely orientated injuries (76.47%) were more likely to undergo the procedure.

Conclusion: The flap significantly lengthens the nail, and provides satisfactory results. We recommend the use of this flap in defects with Allen type III and IV fingertip injuries.

A Prospective Study To Evaluate Medical Management Vs Surgical Intervention In Pain Relief And Healing Of Anal Fissure

Mon, 28 Aug 2023 00:00:00 +0000

Introduction: Anal fissure is a commonly encountered problem for surgeons. It is a longitudinal tear in distal anal canal with or without an ulcer. It causes significant changes in quality of life. This study was done to compare the efficacy of medical management and surgical intervention in cases of anal fissures.

Methods: 50 patients were divided into two groups of 25 each. Group A patients were treated with topical application of 2% diltiazem gel and Group B patients were treated with Lateral sphincterotomy. Both groups were examined weekly for 4 weeks for pain using VAS score and at 12 weeks for healing.

Results: 21(84%) patients were pain free after 4 weeks under Group A, 24 (96%) patients were pain free after 4 weeks under Group B. 22(88%) patients were completely healed at 12 weeks under Group A, 25(100%) patients were completely healed at 12 weeks under Group B.

Conclusion: Lateral sphincterotomy can be advocated as treatment of choice for anal fissures. It has better pain relief and healing rates compared to topical application of 2% diltiazem gel. Medical Management can be used in patients refusing surgery or unfit for surgery

Comparison Of Inter-Appointment Pain Between Calcium Hydroxide Mixed With Normal Saline And Calcium Hydroxide Mixed With 2% Chlorhexidine During Root Canal Treatment

Puja Lamichhane, Bandana Pathak, Jwolan Khadka — Mon, 28 Aug 2023 00:00:00 +0000

Introduction: Pain is one of the major and common symptoms a patient goes through during root canal treatment (RCT). Calcium hydroxide [Ca(OH)₂] combined with normal saline (NS) is commonly used as an intracanal medicament against root canal pathogens, but combination of Ca (OH)₂ with chlorhexidine (2% CHX) is not routinely used. Aim of this study is to compare the combination of Ca(OH)₂ +NS and Ca(OH)₂ +2% CHX to reduce the interappointment pain in RCT.

Methods: A comparative, prospective, qualitative study was conducted in the Department of Conservative Dentistry and Endodontics, KIST Medical College and Teaching Hospital from September 2022 to March 2023. Total of 60 patients aged 16-70 years were included in the study. Group I received Ca(OH)₂+NS and group II received Ca(OH)₂ +2% CHX. Pain score was recorded using visual analogue scale (VAS) from baseline to 6,12,24 and 48 hours.

Results: The mean pain score after 6 hours for Group I was 0.93(±0.83) and Group II was 1.43 (±0.63); P=0.011. The mean pain score after 12 hours for Group I was 0.40(±0.56) and Group II was 0.90(±0.66); P=0.003. 24 hours, mean pain score for Group I was 0.27(±0.45) and Group II was 0.60(±0.56); P=0.014. Patients reported reduction of pain after 24 hours, with Ca(OH)₂ +NS (Group I) than Ca(OH)₂ +2% CHX (Group II).

Conclusion: The combination of Ca(OH)₂ +NS was more effective in reducing interappointment pain than Ca(OH)₂ +2%CHX.

Efficacy Of 18FDG-PET/CT In Predicting Response After Neoadjuvant Chemoradiation In Rectal Cancer

Narendra Pandit, B R Mittal, Nandita Kakkar, G R Verma — Mon, 28 Aug 2023 00:00:00 +0000

Introduction: Neoadjuvant chemoradiation (NACRT) may result in significant response in rectal cancer. Conventional imaging may not be accurate. ¹⁸FDG-PET/CT scan has shown promising results for monitoring the response to NACRT. The aim of this study is to evaluate the role of ¹⁸FDG-PET/CT scan in predicting pathological response after NACRT in carcinoma rectum.

Methods: Thirty-two consecutive patients with locally advanced rectal cancer were enrolled. Patients underwent NACRT comprising of external beam radiotherapy and concomitant infusional 5-FU based chemotherapy. It was followed 6 weeks later by total mesorectal excision. All patients underwent FDG-PET/CT before and minimum 6 weeks after the completion of NACRT. Maximum standardized uptake (SUV_max) value was calculated. The tumor regression grade (TRG) in resected specimen was scored according to the Mandard criteria. TRG 1-2 was considered as responders and TRG 3-5, non-responders. The SUV_max within the tumor was correlated to differentiate pathological responders from non-responders.

Results: Fourteen of 30 patients were excluded due to protocol deviation. Following NACRT, 7 (50%) patients were classified as responders (TRG 1-2) and 7 (50%) non-responders (TRG 3-5). There were no significant differences in pre NACRT SUV_max between responders (12.05±2.81) and non-responders (17.65±7.20) (p=0.079). The mean post-NACRT SUV_max was significantly lower in responders than non-responders (6.4 vs 10.8; p=0.024). To compare the response using ROC curve analysis (AUC=0.83), and considering a cut-off post SUV_max as 7.0, the sensitivity was 57.14%, specificity 71.43%, positive predictive value (PPV) 66.67%, negative predictive value (NPV) 62.50%, and the overall accuracy was 64.28% to differentiate pathological responders from non-responders.

Conclusion: These preliminary results suggest that ¹⁸FDG-PET/CT could be a potentially useful tool in predicting response after NACRT in locally advanced rectal cancer. Post SUV_max of 7.0 appears to be the best predictor tumor response following NACRT.

Outcome Of Totally Extra-Peritoneal (TEP) Mesh Repair Among Patients With Unilateral Primary Inguinal Hernia: A Single Center Experience

Kunda Bikram Shah, Sunil Basukala, Barurendra Raj Yogi, Srijan Malla — Mon, 28 Aug 2023 00:00:00 +0000

Introduction: Inguinal hernias were conventionally treated with open methods like hernioplasty and herniorrhaphy. However, with the development in minimal access surgery, the trends have changed and surgeons are also performing the TEP and TAPP laparoscopic hernia repair routinely. Hence, a retrospective study was performed to assess the safety, feasibility, and associated complications of the TEP laparoscopic hernia repair.

Methods: A single institution, single unit retrospective study of all TEP hernia repair was performed at the department of surgery from May 2020 to April 2021. Data of all patients undergoing TEP were obtained from a proforma attached to the case file during patients’ admission and was analyzed.

Results: A total number of 30 patients underwent the TEP laparoscopic hernia repair during the study period. Age group ranged from 25 years to 80 years and a male preponderance was noted with all patients being male. Per operative findings of indirect hernia was noted in 27, and direct hernia in 3 patients. The mean operating time was 76.23 ± 13.53 minutes. Complications encountered in the post-operative period were seroma in one patient, and wound erythema in two patients. The mean hospital stay was 1.6 ± 0.72 days.

Conclusion: Totally Extra-peritoneal (TEP) laparoscopic repair can be performed and has all the established benefits of minimal access surgery among patients with primary unilateral inguinal hernia.

Topography Of Short Hepatic Veins And Interface Veins For Safe Tunneling During Hanging Maneuver Of Liver

Mon, 28 Aug 2023 00:00:00 +0000

Introduction: During hanging maneuver liver resection, a tunnel is created at the interface of the liver and Inferior venacava (IVC). Gap between the middle and right hepatic vein is known as Fossa venacava. A gap between the Inferior right hepatic vein and the Caudate vein is known as a Vein gap. The Fossa venacava and Vein gap provide a safe plane for the insertion of forceps during tunneling. The aim of this study is to determine the topography of this safe plane.

Methods: A cross-sectional study was done. Twenty livers were used in our study. Major hepatic veins, distance of Vein gap, Fossa venacava, and each vessel present at the interface between liver and IVC was measured by a Vernier caliper. All the collected data was entered and analyzed by using Statistical Package for Social Sciences version 20 (SPSS-20).

Results: The average length of retro hepatic IVC was 49.5±10.5 mm and the diameter of 25.6±4.4 mm. The inferior right hepatic vein was present in 60% of cases while the Caudate vein was present in 85% of cases. Fossa venacava had an average distance of 12.3±3.46 mm and the Vein gap was 18.9±7.1 mm.

Conclusion: While tunneling between IVC and the liver, Fossa venacava could be as small as 4.6 mm. The shortest distance of the Vein gap could be as small as 5.8 mm. The intermediate course of forceps insertion is safer than the right or left course.