A 55 years lady presented with dull aching right upper abdominal pain with intermittent episodes of diarrhea following cholecystectomy which she underwent fourteen years back. Ultrasound and computed tomography findings were suggestive of foreign body in right subhepatic space. Exploratory laparotomy revealed circumvented loop of ileum with intra luminal mass sized 5x10 cm, resection anastomosis of the segment of ileum was performed. When opened it contained a surgical sponge with no external communication but an internal fistulous tract was present between the proximal and distal loops beyond the mass. Though intraluminal migration of retained surgical sponge has often been reported, complete intraluminal migration without features of obstruction or external opening is rarely seen.JNMA J Nepal Med Assoc. 2008 Jul-Sep;47(171):136-138.
Introduction: Gastric cancer (GC) is the second most common cause of cancer-related deaths causing about 800,000 deaths worldwide/year. In Nepal gastric cancer is the second common cancer among males after the lung cancer. Gastric cancer shows a wide variation in incidence worldwide, being highest in Korea and Japan. It is detected early due to the low threshold for upper gastrointestinal endoscopy and screening programs. In the rest of the world and particularly in developing countries, GC is advanced in most of the cases. Inspite of controversies in extent of resection and lymphadenectomy, surgery remains the gold standard treatment. The study was conducted to determine the outcome of the patients with gastric cancer. Methods: The study was conducted in the department of surgery at Nepalgunj Medical College and Teaching Hospital Kohalpur from November 2015 to Dec 2018. Patients diagnosed with GC were studied. The patients with resectable disease underwent radical resection followed by adjuvant chemo-radiation as indicated. Patient’s demography, clinical presentation, stage of disease, types of surgery performed and survival were analysed. Results: 58 patients were diagnosed with gastric cancer. The age ranged from 20-83 years with the mean of 61.26±11.28. Male to female ratio was 2.41: 1. The common clinical presentations were weight loss, anorexia and anemia, 17 (29.31%) had gastric outlet obstruction at initial presentation and 4 (6.89%) presented with perforation peritonitis. Antropyloric region was the commonest site of tumor location seen in 41 (70.68%). 7 (12.06%) patients had distant metastasis and 5 (8.62%) had ascites at presentation. Out of 58 patients, 43 (74.13%) were operated. Only 18 (41.86%) patients underwent R0 resection. 14 (24.13%) underwent palliative gastrojejunostomy. Two (3.44%) patients underwent primary repair for perforation and in 9 (15.51%) the procedure was abandoned due to and presence of metastasis. There was one post-operative mortality. The histology of gastric cancer was found to be adenocarcinoma in all patients. There was no patient in stage I. 3(16.66%) patients were in stage II and 15 (83.33%) in stage III. 17 (29.31%) had stage IV disease. Out of 43 operated patients, 13 lost follow up. All 17 resected patients and those with metastatic disease were followed up. There was no death and no local recurrence in stage II. In stage III, 78.57% were alive and in stage IV 35.29% were alive. Conclusion: Gastric cancer is one of the common gastrointestinal malignancies affecting predominantly male gender. Stage of the disease is one of the major prognostic factors related with the survival. Adenocarcinoma is the commonest histology. Radical resection followed by adjuvant chemotherapy is the standard of care. Palliative chemotherapy can prolong the overall survival in patients with metastatic disease.
Introduction: Acute Calculous Cholecystitis is a condition in which the gallbladder becomes inflamed due to cholelithiasis. Early diagnosis, severity grading and appropriate intervention reduce both morbidity and mortality. The aim of this prospective study is to correlate the severity with the outcome of acute calculous cholecystitis according to Tokyo Guidelines. Methods: This was a hospital based prospective study conducted in the Department of Surgery, Nepalgunj Medical College Teaching Hospital for a period of two years from April 2017 to March 2019. The patients were classified into three groups according to the severity grading in the Tokyo guidelines (TG18/ TG13). Clinical characteristics among these patients were analyzed for comparison. Results: Among all diagnostic criteria, right upper quarter (RUQ)h abdominal pain (94%) Murphy's sign (94%) and thickened gallbladder wall (80%) had the highest sensitivity rates (p<0.032), whereas elevated white cell count (32%) and RUQ abdominal mass (32%) had the lowest sensitivity rates (p<0.035). Higher sensitivity rates of diagnostic criteria were related to severe cholecystitis, except for Fever (46%) and elevated white blood cell (WBC) count (32%). All the 28 patients in grade I and selected patients 3 out of 6in grade II underwent early laparoscopic cholecystectomy (LC) without any conversion and increased morbidity and mortality. Out of16 patients in grade III there was 2 mortalities due to ARDS, 1 needed Ultrasonography (USG) guided cholecystostomy, 1 underwent emergency cholecystectomy. 16 patients, 3 in grade II and 13 in grade III underwent interval laparoscopic cholecystectomy safely. There were no major postoperative morbidities except for superficial surgical site infection (SSI) in 1 patient in grade III who underwent emergency cholecystectomy Higher grade of severity was associated with increased morbidity and mortality (p<0.03). Conclusion: A combination of diagnostic criteria with different path physiologic findings, as noted in the Tokyo guidelines, can help clinicians make the correct diagnosis for patients with acute cholecystitis and there was strong correlation between the severity and outcomes of acute cholecystitis.
Background Enhanced recovery after surgery is a multimodal strategy, used to attenuate the loss and improve the restoration of functional capacity after surgery. Now widely used in elective surgery, the implementation of all of its components is not feasible in emergency surgery. Therefore, its tailored protocol is likely to give better outcome. Objective To investigate the feasibility and effectiveness of enhanced recovery after surgery in emergency surgery for Duodenal Ulcer Perforation. Method Hospital based study conducted at Nepalgunj Medical College, Kohalpur from September 2018 to 2020. Hundred patients underwent emergency laparotomy with Classical Graham’s Patch Repair. Fifty patients in the enhanced recovery after surgery group were managed as per the protocol and the rest were managed conventionally. Both the groups were compared in terms of length of hospital stay, functional recovery parameters and complications. Result There were 48 (96%) males and 2 (4%) females in enhanced recovery after surgery group and 45 (90%) males and 5 (10%) females in non-enhanced recovery after surgery group. The mean length of hospital stay in enhanced recovery after surgery group was 4.9 ± 0.76 days together with early functional recovery compared to 9.06 ± 2.44 days in non-enhanced recovery after surgery group (p < 0.05). Complications as per Clavien-Dindo grading were more in the non- enhanced recovery after surgery group (p=0.03). Conclusion Enhanced recovery after surgery is feasible and effective strategy resulting in early recovery, reduced hospital stay and complications in patients undergoing emergency surgery for duodenal ulcer perforation.
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