Pancreatic injury following blunt trauma abdomen is presentation with significant morbidity and m... more Pancreatic injury following blunt trauma abdomen is presentation with significant morbidity and mortality. Our first case here is the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade V pancreaticoduodenal injuries following penetrating injury managed with pancreaticoduodenectomy and the second case is blunt trauma to the abdomen with pancreatic tail transection which is American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade III that was managed with Endoscopic Retrograde Cholangiopancreaticography (ERCP) and pancreatic duct stenting. The outcome depends on early diagnosis and needs a high index of suspicion due to subtle clinical and radiological findings initially. Hemodynamically unstable patients may have other associated visceral and vascular injuries, and damage control strategy will be a suitable option. Same sitting resection procedures like pancreaticoduodenectomy are rarely performed. Pancreatic injuries can ofte...
Background: Roux-en-Y Hepaticojejunostomy (RYHJ) is the most common form of reconstruction of the... more Background: Roux-en-Y Hepaticojejunostomy (RYHJ) is the most common form of reconstruction of the biliary pathway. It is a time honoured, durable, less resource intensive and a definitive procedure. Objectives: The aim of this study was to evaluate the indications of Hepaticojejunostomy and to assess the outcome of surgery following change in surgical technique of Hepaticojejunostomy. Methods: All patients who underwent RYHJ from Magh 2067 (January 2011) till Ashad 2071 (July 2014) in a single surgical unit at the Department of Surgery, Kathmandu Medical College Teaching Hospital were included. Demographics of the patient, indications for surgery, type of surgery, hospital stay and duration of drain placement were evaluated. Since, this is a prospective descriptive study, only mean value was calculated for age, hospital stay and duration of drain placement using SPSS Statistics 17.0 for statistical analysis. Results: Twenty patients underwent RYHJ during the study period. Fifteen pe...
Introduction: Blunt abdominal trauma bears significant morbidity and mortality worldwide and need... more Introduction: Blunt abdominal trauma bears significant morbidity and mortality worldwide and needs careful evaluation and management for a better outcome, where the resources are limited and the impact of the financial burden is very important. Previously, many cases used to be managed with operative procedures, and now the trend has been shifting to non-operative management. This study aimed to determine the prevalence of blunt abdominal trauma among patients admitted to the Department of Surgery of a tertiary care centre. Methods: This was descriptive cross-sectional study done between 1 February 2022 to 31 January 2023 after taking ethical approval from the Institutional Review Committee (Reference number: 2312202103). The decision of non-operative versus operative treatment was decided with dynamic clinical evaluation and severity of intraabdominal injuries. Demographic data, the mechanism of injury, and both conservative and operative management were studied. All the patients w...
Background: Gallbladder adenocarcinoma is the most common malignant tumor of the biliary tract. M... more Background: Gallbladder adenocarcinoma is the most common malignant tumor of the biliary tract. Most of gall bladder cancers are detected incidentally only after pathological examination of the excised surgical specimens. In this study we investigated the characteristics of incidental gallbladder cancers in our center. Material & methods: We retrospectively reviewed all of the cholecystectomy specimens in sent for histopathology following laparoscopic cholecystectomy in the study period from January 2015 to October 2019. Clinicopathological characteristics were extracted from the patients' clinical charts, which included symptoms, radiological findings, laboratory data, and surgical procedures as well as outcome. Results: We identified 6 cases of incidental gall bladder cancer, consisting of 4 women and 2 men ranging in age from 28 to 77 years (mean age 60.5 after pathological study of 1530 resected gall bladders. Out of the 6 cases, 1 case was carcinoma in situ of gall bladder...
Background: Acute pancreatitis is a common and challenging disease that can develop both local an... more Background: Acute pancreatitis is a common and challenging disease that can develop both local and systemic complications. According to the Atlanta classification, local complications include peri-pancreatic collection, acute necrotic collection, pseudocyst and walled-off necrosis.Methods: A hospital-based retrospective study was conducted in the department of surgery at Kathmandu medical college teaching hospital. Patients were recruited using purposive sampling method and those who underwent laparoscopic, retroperitoneal or open surgical procedures for the management of local complications of acute pancreatitis from June 2017 to July 2021. The indication, perioperative outcome and associated complications were evaluated in all the cases.Results: Between June 2017 to July 2021, 432patients were admitted to the surgery department with acute pancreatitis or with complications of acute pancreatitis. Twenty-one patients required surgical intervention in the form of external drainage, c...
Introduction: Pancreatoduodenectomy with vascular resection is performed in locally advanced peri... more Introduction: Pancreatoduodenectomy with vascular resection is performed in locally advanced periampullary malignancies. In our practice, early oral feeding is initiated in patients undergoing pancreatoduodenectomy. This study aims to find the prevalence of early oral feeding with vascular resection among patients undergoing pancreatoduodenectomy. Methods: This was a descriptive cross-sectional study conducted among hospital records of 152 patients who underwent pancreatoduodenectomy in the department of surgery of a tertiary care hospital from 2016 to 2020. Ethical approval was taken from the Institutional Review Committee (Reference number: 0812202102). Convenience sampling was done. Patients clinical and sociodemographic data were collected and analyzed using Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency, percentage, mean, and median. Results: Among 152 patients undergoing pancreatoduodenectom...
Introduction: Superior mesenteric artery first pancreaticoduodenectomy is being increasingly used... more Introduction: Superior mesenteric artery first pancreaticoduodenectomy is being increasingly used for pancreatic head and peri-ampullary tumors. The aim of our study was to determine the frequency of various approaches of superior mesenteric artery pancreaticoduodenectomy along with its postoperative complications in a tertiary care center. Methods: This is a descriptive cross-sectional study of patients undergoing superior mesenteric artery first pancreaticoduodenectomy with different approaches conducted at Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal, from May 2018 to April 2020. Ethical approval was taken from the Institutional Review Committee (reference no: 310520193). The whole sampling method was adopted. Thirty-four patients undergoing a superior mesenteric artery first pancreaticoduodenectomy at our center with different approaches were included in the study. The data analysis was done in the Statistical Package for the Social Sciences version ...
Introduction: Management of patients with suspected bile leak or bile duct injury after laparosco... more Introduction: Management of patients with suspected bile leak or bile duct injury after laparoscopic cholecystectomy is challenging. Early laparoscopy in these groups of patients will benefit in terms of diagnostic as well therapeutic purpose. Objective: This study is done to assess utility of early re-laparoscopy in suspected bile duct injury in early postoperative period following laparoscopic cholecystectomy. Methodology: It is a descriptive study of all consecutive patients who underwent diagnostic as well therapeutic re-laparoscopy when required in suspected bile duct injury in early postoperative laparoscopic cholecystectomy that is within 72 hours of presentation. Study was conducted over a period from June 2019 to December 2020 at Kathmandu medical College, Sinamangal, Kathmandu, Nepal. Relaparoscopic operative findings and therapeutic intervention done were recorded. Result: The mean age at presentation was 34.6 years and male to female ratio was 1:1.8. During the study per...
Background: R0 surgical resection with D2 lymphadenectomy has been the cornerstone treatment in m... more Background: R0 surgical resection with D2 lymphadenectomy has been the cornerstone treatment in major gastric cancer guidelines for resectable locally advanced gastric cancer. The extent of D2 lymphadenectomy may vary among surgeons because of technical difficulty and lack of anatomical definition of individual lymph node (LN) stations. Objective: To standardize our surgical quality of D2 lymphadenectomy and improve surgical proficiency using checklist method. Method: In this retrospective analysis of a prospective cohort, all consecutive resectable gastric cancer patients who underwent curative gastrectomy with D2 lymphadenectomy in Kathmandu medical college and teaching hospital (KMCTH) were analyzed. A complete unedited video of our surgical procedure was recorded and evaluation was done for completeness of D2 lymphadenectomy. Surgical compliance (removal of indicated lymph node stations) and surgicopathological compliance (removal of > 15 lymph nodes) were recorded and assess...
Background: In pancreatic ductal adenocarcinoma, standardised concepts of radical surgical cleara... more Background: In pancreatic ductal adenocarcinoma, standardised concepts of radical surgical clearance have not been universally applied. Objectives: The main objective of this study is to reveal the status of circumferential resection margin of the apical tissue of the triangle namely the confluence of SMA and coeliac trunk in relation to circumferential resection margin of triangle tissue bounded by superior mesenteric artery, common hepatic artery and portal vein when performing the TRIANGLE operation. Methodology: This was a hospital-based cross-sectional study conducted at Kathmandu Medical College and Teaching Hospital, from September 2020 to December 2020. The study was done after ethical clearance from the Institutional Review Committee of Kathmandu Medical College. All consecutive patients who were subjected for Whipple’s operation for pancreatic head and uncinate process were included. Results: Fifteen patients underwent the “TRIANGLE” operation during a four months period. ...
Elderly population is growing because of increasing life expectancy. Decision-making for major su... more Elderly population is growing because of increasing life expectancy. Decision-making for major surgery like pancreaticoduodenectomy in this group is challenging. Therefore, we evaluated the feasibility of this procedure by comparing perioperative outcomes in Septuagenarians and Octogenarians patients. From August 2017 to December 2019, 18 consecutive patients who underwent pancreaticoduodenectomy were enrolled. These patients were divided into two groups (group1 – septuagenarians and group 2 – octogenarians). A comparative study between two groups was done regarding perioperative outcome and early complications. 18 patients were enrolled, 10 patients (55.6%) were septuagenarians (70-80 years) and 8 (44.4%) patients were Octogenarians (>80 years). There was no significant difference in the rate of surgical and medical complications between the two groups. Furthermore, there were no significant differences in risk factors, blood loss and operating time between the groups. Overall m...
Groove pancreatitis is uncommon form of chronic pancreatitis common in patients with history of s... more Groove pancreatitis is uncommon form of chronic pancreatitis common in patients with history of smoking and alcohol abuse. High index of suspicion is required as it may masquerade pancreatic ductal adenocarcinoma and both of these conditions are difficult to differentiate preoperatively. Pancreaticoduodenectomy has good outcome in patient with Groove pancreatitis. Hence, we are reporting a case report of Groove pancreatitis in 40 years gentleman, who was being managed by multiple endoscopic dilatations, later underwent pancreaticoduodenectomy for persistent symptoms. He had no perioperative morbidity and doing well in 24 months follow up.
Background: Several studies have proposed en bloc resection with major hepatectomy to achieve neg... more Background: Several studies have proposed en bloc resection with major hepatectomy to achieve negative margin in hilar cholangiocarcinoma. These major hepatectomy have morbidity in some subgroups of patients with limited functional hepatic reserve. Methodology: Patients with Bismuth type III and IV hilar cholangiocarcinoma with underlying early cirrhosis that underwent liver parenchymal preserving bilobar wedge liver resection between July 2017 to June 2020 were included in the study. Results: Twelve patients underwent liver parenchymal preserving bilobar wedge liver resection between July 2017 to June 2020. Mean age of the study population was 70.83±3.58 years. Reconstruction of biliary tree was done with intrahepatic cholangiojejunostomy in Roux en Y fashion in multiple segmental hepatic stomas. Conclusion: Liver parenchymal preserving surgery should be considered in hilar cholangiocarcinoma in selected cases to prevent suspicion increasing morbidity and mortality due to post-ope...
Pancreatic injury following blunt trauma abdomen is presentation with significant morbidity and m... more Pancreatic injury following blunt trauma abdomen is presentation with significant morbidity and mortality. Our first case here is the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade V pancreaticoduodenal injuries following penetrating injury managed with pancreaticoduodenectomy and the second case is blunt trauma to the abdomen with pancreatic tail transection which is American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS) Grade III that was managed with Endoscopic Retrograde Cholangiopancreaticography (ERCP) and pancreatic duct stenting. The outcome depends on early diagnosis and needs a high index of suspicion due to subtle clinical and radiological findings initially. Hemodynamically unstable patients may have other associated visceral and vascular injuries, and damage control strategy will be a suitable option. Same sitting resection procedures like pancreaticoduodenectomy are rarely performed. Pancreatic injuries can ofte...
Background: Roux-en-Y Hepaticojejunostomy (RYHJ) is the most common form of reconstruction of the... more Background: Roux-en-Y Hepaticojejunostomy (RYHJ) is the most common form of reconstruction of the biliary pathway. It is a time honoured, durable, less resource intensive and a definitive procedure. Objectives: The aim of this study was to evaluate the indications of Hepaticojejunostomy and to assess the outcome of surgery following change in surgical technique of Hepaticojejunostomy. Methods: All patients who underwent RYHJ from Magh 2067 (January 2011) till Ashad 2071 (July 2014) in a single surgical unit at the Department of Surgery, Kathmandu Medical College Teaching Hospital were included. Demographics of the patient, indications for surgery, type of surgery, hospital stay and duration of drain placement were evaluated. Since, this is a prospective descriptive study, only mean value was calculated for age, hospital stay and duration of drain placement using SPSS Statistics 17.0 for statistical analysis. Results: Twenty patients underwent RYHJ during the study period. Fifteen pe...
Introduction: Blunt abdominal trauma bears significant morbidity and mortality worldwide and need... more Introduction: Blunt abdominal trauma bears significant morbidity and mortality worldwide and needs careful evaluation and management for a better outcome, where the resources are limited and the impact of the financial burden is very important. Previously, many cases used to be managed with operative procedures, and now the trend has been shifting to non-operative management. This study aimed to determine the prevalence of blunt abdominal trauma among patients admitted to the Department of Surgery of a tertiary care centre. Methods: This was descriptive cross-sectional study done between 1 February 2022 to 31 January 2023 after taking ethical approval from the Institutional Review Committee (Reference number: 2312202103). The decision of non-operative versus operative treatment was decided with dynamic clinical evaluation and severity of intraabdominal injuries. Demographic data, the mechanism of injury, and both conservative and operative management were studied. All the patients w...
Background: Gallbladder adenocarcinoma is the most common malignant tumor of the biliary tract. M... more Background: Gallbladder adenocarcinoma is the most common malignant tumor of the biliary tract. Most of gall bladder cancers are detected incidentally only after pathological examination of the excised surgical specimens. In this study we investigated the characteristics of incidental gallbladder cancers in our center. Material & methods: We retrospectively reviewed all of the cholecystectomy specimens in sent for histopathology following laparoscopic cholecystectomy in the study period from January 2015 to October 2019. Clinicopathological characteristics were extracted from the patients' clinical charts, which included symptoms, radiological findings, laboratory data, and surgical procedures as well as outcome. Results: We identified 6 cases of incidental gall bladder cancer, consisting of 4 women and 2 men ranging in age from 28 to 77 years (mean age 60.5 after pathological study of 1530 resected gall bladders. Out of the 6 cases, 1 case was carcinoma in situ of gall bladder...
Background: Acute pancreatitis is a common and challenging disease that can develop both local an... more Background: Acute pancreatitis is a common and challenging disease that can develop both local and systemic complications. According to the Atlanta classification, local complications include peri-pancreatic collection, acute necrotic collection, pseudocyst and walled-off necrosis.Methods: A hospital-based retrospective study was conducted in the department of surgery at Kathmandu medical college teaching hospital. Patients were recruited using purposive sampling method and those who underwent laparoscopic, retroperitoneal or open surgical procedures for the management of local complications of acute pancreatitis from June 2017 to July 2021. The indication, perioperative outcome and associated complications were evaluated in all the cases.Results: Between June 2017 to July 2021, 432patients were admitted to the surgery department with acute pancreatitis or with complications of acute pancreatitis. Twenty-one patients required surgical intervention in the form of external drainage, c...
Introduction: Pancreatoduodenectomy with vascular resection is performed in locally advanced peri... more Introduction: Pancreatoduodenectomy with vascular resection is performed in locally advanced periampullary malignancies. In our practice, early oral feeding is initiated in patients undergoing pancreatoduodenectomy. This study aims to find the prevalence of early oral feeding with vascular resection among patients undergoing pancreatoduodenectomy. Methods: This was a descriptive cross-sectional study conducted among hospital records of 152 patients who underwent pancreatoduodenectomy in the department of surgery of a tertiary care hospital from 2016 to 2020. Ethical approval was taken from the Institutional Review Committee (Reference number: 0812202102). Convenience sampling was done. Patients clinical and sociodemographic data were collected and analyzed using Statistical Package for the Social Sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency, percentage, mean, and median. Results: Among 152 patients undergoing pancreatoduodenectom...
Introduction: Superior mesenteric artery first pancreaticoduodenectomy is being increasingly used... more Introduction: Superior mesenteric artery first pancreaticoduodenectomy is being increasingly used for pancreatic head and peri-ampullary tumors. The aim of our study was to determine the frequency of various approaches of superior mesenteric artery pancreaticoduodenectomy along with its postoperative complications in a tertiary care center. Methods: This is a descriptive cross-sectional study of patients undergoing superior mesenteric artery first pancreaticoduodenectomy with different approaches conducted at Kathmandu Medical College Teaching Hospital, Sinamangal, Kathmandu, Nepal, from May 2018 to April 2020. Ethical approval was taken from the Institutional Review Committee (reference no: 310520193). The whole sampling method was adopted. Thirty-four patients undergoing a superior mesenteric artery first pancreaticoduodenectomy at our center with different approaches were included in the study. The data analysis was done in the Statistical Package for the Social Sciences version ...
Introduction: Management of patients with suspected bile leak or bile duct injury after laparosco... more Introduction: Management of patients with suspected bile leak or bile duct injury after laparoscopic cholecystectomy is challenging. Early laparoscopy in these groups of patients will benefit in terms of diagnostic as well therapeutic purpose. Objective: This study is done to assess utility of early re-laparoscopy in suspected bile duct injury in early postoperative period following laparoscopic cholecystectomy. Methodology: It is a descriptive study of all consecutive patients who underwent diagnostic as well therapeutic re-laparoscopy when required in suspected bile duct injury in early postoperative laparoscopic cholecystectomy that is within 72 hours of presentation. Study was conducted over a period from June 2019 to December 2020 at Kathmandu medical College, Sinamangal, Kathmandu, Nepal. Relaparoscopic operative findings and therapeutic intervention done were recorded. Result: The mean age at presentation was 34.6 years and male to female ratio was 1:1.8. During the study per...
Background: R0 surgical resection with D2 lymphadenectomy has been the cornerstone treatment in m... more Background: R0 surgical resection with D2 lymphadenectomy has been the cornerstone treatment in major gastric cancer guidelines for resectable locally advanced gastric cancer. The extent of D2 lymphadenectomy may vary among surgeons because of technical difficulty and lack of anatomical definition of individual lymph node (LN) stations. Objective: To standardize our surgical quality of D2 lymphadenectomy and improve surgical proficiency using checklist method. Method: In this retrospective analysis of a prospective cohort, all consecutive resectable gastric cancer patients who underwent curative gastrectomy with D2 lymphadenectomy in Kathmandu medical college and teaching hospital (KMCTH) were analyzed. A complete unedited video of our surgical procedure was recorded and evaluation was done for completeness of D2 lymphadenectomy. Surgical compliance (removal of indicated lymph node stations) and surgicopathological compliance (removal of > 15 lymph nodes) were recorded and assess...
Background: In pancreatic ductal adenocarcinoma, standardised concepts of radical surgical cleara... more Background: In pancreatic ductal adenocarcinoma, standardised concepts of radical surgical clearance have not been universally applied. Objectives: The main objective of this study is to reveal the status of circumferential resection margin of the apical tissue of the triangle namely the confluence of SMA and coeliac trunk in relation to circumferential resection margin of triangle tissue bounded by superior mesenteric artery, common hepatic artery and portal vein when performing the TRIANGLE operation. Methodology: This was a hospital-based cross-sectional study conducted at Kathmandu Medical College and Teaching Hospital, from September 2020 to December 2020. The study was done after ethical clearance from the Institutional Review Committee of Kathmandu Medical College. All consecutive patients who were subjected for Whipple’s operation for pancreatic head and uncinate process were included. Results: Fifteen patients underwent the “TRIANGLE” operation during a four months period. ...
Elderly population is growing because of increasing life expectancy. Decision-making for major su... more Elderly population is growing because of increasing life expectancy. Decision-making for major surgery like pancreaticoduodenectomy in this group is challenging. Therefore, we evaluated the feasibility of this procedure by comparing perioperative outcomes in Septuagenarians and Octogenarians patients. From August 2017 to December 2019, 18 consecutive patients who underwent pancreaticoduodenectomy were enrolled. These patients were divided into two groups (group1 – septuagenarians and group 2 – octogenarians). A comparative study between two groups was done regarding perioperative outcome and early complications. 18 patients were enrolled, 10 patients (55.6%) were septuagenarians (70-80 years) and 8 (44.4%) patients were Octogenarians (>80 years). There was no significant difference in the rate of surgical and medical complications between the two groups. Furthermore, there were no significant differences in risk factors, blood loss and operating time between the groups. Overall m...
Groove pancreatitis is uncommon form of chronic pancreatitis common in patients with history of s... more Groove pancreatitis is uncommon form of chronic pancreatitis common in patients with history of smoking and alcohol abuse. High index of suspicion is required as it may masquerade pancreatic ductal adenocarcinoma and both of these conditions are difficult to differentiate preoperatively. Pancreaticoduodenectomy has good outcome in patient with Groove pancreatitis. Hence, we are reporting a case report of Groove pancreatitis in 40 years gentleman, who was being managed by multiple endoscopic dilatations, later underwent pancreaticoduodenectomy for persistent symptoms. He had no perioperative morbidity and doing well in 24 months follow up.
Background: Several studies have proposed en bloc resection with major hepatectomy to achieve neg... more Background: Several studies have proposed en bloc resection with major hepatectomy to achieve negative margin in hilar cholangiocarcinoma. These major hepatectomy have morbidity in some subgroups of patients with limited functional hepatic reserve. Methodology: Patients with Bismuth type III and IV hilar cholangiocarcinoma with underlying early cirrhosis that underwent liver parenchymal preserving bilobar wedge liver resection between July 2017 to June 2020 were included in the study. Results: Twelve patients underwent liver parenchymal preserving bilobar wedge liver resection between July 2017 to June 2020. Mean age of the study population was 70.83±3.58 years. Reconstruction of biliary tree was done with intrahepatic cholangiojejunostomy in Roux en Y fashion in multiple segmental hepatic stomas. Conclusion: Liver parenchymal preserving surgery should be considered in hilar cholangiocarcinoma in selected cases to prevent suspicion increasing morbidity and mortality due to post-ope...
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