Outcome of diaphragmatic herniation and eventration repair in adults

Introduction: Diaphragmatic hernia and eventration are amongst the less commonly encountered thoracic surgical problems in Nepal. Unlike, the cases of traumatic herniation, adults with congenital hermination  and eventration seek medical attention very late.Methods: It is a retrospective observational study of patients presenting with diaphragmatic hermiation  and eventration at Manmohan Cardiothoracic Vascular and Transplant Center, Kathmandu, Nepal. Medical records of five years (May, 2010 to April, 2015) were reviewed. Analysis of the demographic profile, clinical features, management and outcome was done.Results: There were a total of 15 patients who were diagnosed to have diaphragmatic hermiation  and eventration. There were eight cases of hermiation and seven cases of eventration. There were three cases of acute diaphragmatic hermiation. Thoracic trauma was found to be associated in three cases of herniation only. The mean age at presentation was 46.5 years. Thoracic trauma was seen in Younger age (mean age being 34 yrs). There were two cases of morgagni hernia and one of these was diagnosed incidentally. Mean duration of symptoms was two months. The most common presenting symptoms were shortness of breath and cough. Twelve cases were repaired via thoracotomy. Mean size of diaphragmatic defect was six centimeters. The most commonly herniated organ was stomach followed by momentum. Placation was the most commonly performed procedure in eventration and primary repair was done in six cases of hermiation and mesh repair in two cases. Only two patients had superficial surgical site infection. Mean duration of hospital stay was eight days. The patients were doing good up to mean follow up period of four months.Conclusion: Diaphragmatic hermiation and eventration in symptomatic patients should be managed surgically. Surgical approaches can be thoracotomy, laparotomy and Video Assisted Thoracoscopic Surgery. Outcome following surgery is good with minimal postoperative complications. JSSN 2015; 18 (1), Page : 1-4

Laparoscopic antireflux surgery - our initial experience

Introduction: Laparoscopic antireflux surgery (LARS) currently represents the gold standard in the surgical management of gastrointestinal reflux disease (GERD) with minimal morbidity and mortality. Routine fundoplication following laparoscopic Heller’s cardiomyotomy is also being recommended to reduce the incidence of pathological gastro-oesophageal reflux after surgery. The aim of the current study was to evaluate patients receiving LARS and to assess their surgical outcomesMethods: Prospective data of all patients admitted in our department with these diseases and undergoing LARS, from May 2014 to November 2015 were reviewed. Patients with Achalasia cardia underwent Laparoscopic Heller’s cardiomyotomy with Dor’s fundoplication and those with GERD with hiatus hernia underwent Laparoscopic Toupet’s fundoplication. Age, sex, duration of surgery, surgical morbidity and hospital stay were recorded. Results: Eleven patients underwent LARS. Females were 5(45.5%) and males were 6 (54.5%). Mean age of patients was 36.18 ± 15.79 years (range 18-68 years). 6 patients (54.5%) underwent Laparoscopic Heller’s cardiomyotomy with Dor’s fundoplication for Achalasia cardia while 5 patients (45.5%) underwent Laparoscopic fundoplication. The median operating room time was 133.64 ± 15.66 minutes (range, 110–160). There were no conversions. The median hospital stay was 3.45±0.522 days (range, 3-4 days). No postoperative complications or preoperative deaths occurred. No patient had a perforation revealed on the postoperative contrast swallow when performed. Gastro esophageal reflux symptoms were significantly improved and severity of dysphagia was also reduced after surgery. The average follow-up period is 5.45 ± 2.67 months (range, 3- 12).Conclusion: LARS is well established technique and becoming more popular over conventional open surgery in view of its equal safety and efficacy with added advantage of less morbidity and mortality. However larger case series and long term follow up would be warranted.

Transbronchial needle aspiration cytology of endobronchial abnormalities: does it increase the positivity rates of bronchoscopy

Background: Negative results in bronchoscopic sampling techniques increase costs and delay treatment. We analyzed if addition of transbronchial needle aspiration (TBNA) increases the diagnostic yield of bronchoscopy. Materials and Methods: Patients with endobronchial abnormalities in whom a full set of sampling techniques (lavage, TBNA, biopsy and brushing) were done and had a confirmed diagnosis of lung cancer by one or more methods were included. The positivity rates of each of the sampling techniques and their various combinations were studied. We compared the positivity rates of bronchoscopy with and without TBNA. We also studied if TBNA was more valuable in any specific type, histology or position of endobronchial abnormalities. Results: The overall positivity rate of TBNA was 56%. It was higher than lavage and brushing but lower than biopsy. The addition of TBNA to the routine combination of sampling tachniques (lavage, biopsy and brushing) increased diagnostic yield from 76% to 86.6%. Contrary to previous reports, the increase in diagnostic yields did not differ significantly between types (exophytic vs submucosal), side or location of the endobronchial lesions. TBNA was found to have a significantly better positivity rates in small cell carcinoma than in non-small cell carcinoma cases. Conclusion: TBNA is a safe sampling technique for endobronchial abnormalities during bronchoscopy. It increases the diagnostic yields of bronchoscopy and this increase seems to be uniform amongst different types, histologies and locations of endobronchial abnormalities. DOI: http://dx.doi.org/10.3126/jpn.v4i7.10324 Journal of Pathology of Nepal (2014) Vol. 4, 565-569

Breast cancer knowledge, attitudes and practices among Nepalese women

Although Nepal has an epidemic of early-onset, aggressive, advanced breast cancer, breast cancer knowledge and screening practices of Nepalese women have not been assessed. This paper summarises the results of a physician-administrated survey of gynaecologic inpatients (n= 100) admitted between 1 December 2009 and 31 January 2010 at a Nepalese University. Mean knowledge score of the participants was 65%, significantly higher among highly educated women (P= 0.008), professionals (P= 0.014) and women counselled during medical visits (P= 0.030). Study participants, including highly educated women, had many misconceptions. This included lack of awareness of painless nature and non-lump symptoms of breast cancer as well as the belief that traditional health care can be curative. The majority of participants were unaware of clinical breast examination (68%) and mammography (56%). Only 10% of the participants had undergone breast evaluation in the last 2 years. The practice of breast evaluation was more common among Buddhists (P= 0.043), and women counselled during medical visits (P < 0.001), with high economic status (P= 0.022), higher education (P= 0.013) and a family history of breast cancer (P= 0.049). Counselling during medical visits and higher education level were associated with better knowledge of and screening practices for breast cancer in the studied population.

Management of Breast Cancer in Nepal

Breast cancer is the second most common malignancy among women in Nepal. It is more commonin young premenopausal women. Breast cancer continues to increase in incidence due to lifestylechanges in Nepalese women despite constant remarkable development in the management of thisdisease over the past three decades. Breast cancer was diagnosed solely clinically and surgery wasthe only treatment option until fi fty years ago. Multidisciplinary approach has been adopted fordiagnosis and treatment of breast cancer in Nepal. Imaging is required for the diagnosis, appropriatetreatment decision and proper follow up. Treatment modality depends upon the extent of thedisease and tumor biology. However, there is a strong need for standard guidelines for the propermanagement of breast cancer in Nepal so that surgeries, chemotherapy, hormone therapy andradiotherapy are standardized in the country. Palliative care has been initiated to provide to somepatients with metastatic breast cancer recently.The breast cancer management in Nepal is a little different when compared with the centers in thedeveloped countries. The reasons are socioeconomic status, lack of education and lack of facilities.Although cancer care is on the rise in Nepal, the optimal facility for centers managing breast cancerhas to be improved signifi cantly.Cancer education, screening and early detection are the keyelements to infl uence the diagnosis, treatment and prognosis of breast cancer in Nepal. Breast cancerawareness and clinical breast examination are important tools for early detection in our resourcelimited context. Breast cancer can be cured in majority of the cases if diagnosed in early stages.This review will focus on relevant patient data along with future recommendation regarding breastcancer treatment in Nepal.Key Words: Breast cancer, cancer education, chemotherapy, imaging, radiotherapy, surgery

Management of breast cancer in Nepal

Breast cancer is the second most common malignancy among women in Nepal. It is more common in young premenopausal women. Breast cancer continues to increase in incidence due to lifestyle changes in Nepalese women despite constant remarkable development in the management of this disease over the past three decades. Breast cancer was diagnosed solely clinically and surgery was the only treatment option until fifty years ago. Multidisciplinary approach has been adopted for diagnosis and treatment of breast cancer in Nepal. Imaging is required for the diagnosis, appropriate treatment decision and proper follow up. Treatment modality depends upon the extent of the disease and tumor biology. However, there is a strong need for standard guidelines for the proper management of breast cancer in Nepal so that surgeries, chemotherapy, hormone therapy and radiotherapy are standardized in the country. Palliative care has been initiated to provide to some patients with metastatic breast cancer recently. The breast cancer management in Nepal is a little different when compared with the centers in the developed countries. The reasons are socioeconomic status, lack of education and lack of facilities. Although cancer care is on the rise in Nepal, the optimal facility for centers managing breast cancer has to be improved significantly.Cancer education, screening and early detection are the key elements to influence the diagnosis, treatment and prognosis of breast cancer in Nepal. Breast cancer awareness and clinical breast examination are important tools for early detection in our resource limited context. Breast cancer can be cured in majority of the cases if diagnosed in early stages. This review will focus on relevant patient data along with future recommendation regarding breast cancer treatment in Nepal.

Accuracy of Triple Test Score in The Diagnosis of Palpable Breast Lump

Breast lump is a very sensitive issue for the patient so a reliable, non invasive and prompt diagnosishelps to lessen the associated anxiety and leads to early definitive treatment. The aim of this studywas to evaluate the acuracy of Triple Test Score (TTS) as a clinical tool for the diagnosis of a palpablebreast lump. This diagnostic test study was carried out in the Department of Surgery of TribhuvanUniversity Teaching Hospital. Of the 117 patients admitted with breast diseases from the breastclinic over thirteen months, 87 had breast lump. Fifty patients underwent Triple Test Score ( physicalexamination, mammography and fine needle aspiration cytology) and were categorized into benign,suspicious and malignant. This was later correlated with the histopathological findings. Nineteenpatients with breast lumps interpreted by TTS as benign correlated with the histopathologicalfindings whereas of 31 malignant lumps, 30 turned out to be malignant and one benign. This givesTTS an over all accuracy of 98% with 100% sensitivity, 95.2% specificity and positive predictive valueof 96.7%. Carcinoma was seen in 29 (58%) cases in the age group of 35 to 70 years. The mean age atdiagnosis of benign and malignant disease was 41.8 and 45.1 years respectively. In conclusion, TTS isan accurate and least invasive diagnostic test based on which definitive treatment can be initiated.Key words : breast lump, carcinoma breast, triple test score

Accuracy of triple test score in the diagnosis of palpable breast lump

Breast lump is a very sensitive issue for the patient so a reliable, non invasive and prompt diagnosis helps to lessen the associated anxiety and leads to early definitive treatment. The aim of this study was to evaluate the accuracy of Triple Test Score (TTS) as a clinical tool for the diagnosis of a palpable breast lump. This diagnostic test study was carried out in the Department of Surgery of Tribhuvan University Teaching Hospital. Of the 117 patients admitted with breast diseases from the breast clinic over thirteen months, 87 had breast lump. Fifty patients underwent Triple Test Score ( physical examination, mammography and fine needle aspiration cytology) and were categorized into benign, suspicious and malignant. This was later correlated with the histopathological findings. Nineteen patients with breast lumps interpreted by TTS as benign correlated with the histopathological findings whereas of 31 malignant lumps, 30 turned out to be malignant and one benign. This gives TTS an over all accuracy of 98% with 100% sensitivity, 95.2% specificity and positive predictive value of 96.7%. Carcinoma was seen in 29 (58%) cases in the age group of 35 to 70 years. The mean age at diagnosis of benign and malignant disease was 41.8 and 45.1 years respectively. In conclusion, TTS is an accurate and least invasive diagnostic test based on which definitive treatment can be initiated.

Mammographic diagnosis of breast carcinoma: an institutional experience

Mammogram is a common diagnostic modality for breast carcinoma. Diagnostic mammogram is available at only few centers in Nepal. The aim of this study was to determine the accuracy of diagnostic mammogram in Nepalese women suffering from breast carcinoma. A retrospective analysis of the breast carcinoma was carried out in the Department of Surgery, Tribhuwan University Teaching Hospital from October 1995 to October 2007. Out of 556 patients with histologically proven breast carcinoma, 378 patients (68%) had undergone mammography. Breast carcinoma was identified on mammography in 328 (87%) cases while 50 cases (13%) were reported as normal or benign lesions. Diagnostic mammogram had a sensitivity of 86.8%, a specificity of 98.6% with a positive predictive value of 68.8% and a negative predictive value of 99.5%. In mammographically missed breast carcinoma, 34% were less than 40 years of age (P<0.05), 60% were premenopausal (P<0.05) and 88% patients presented with a painless lump. The study shows that the diagnostic accuracy of the mammogram is very high. However, there is a chance of missing the breast carcinoma in young and premenopausal women.

Mammographic Diagnosis of Breast Carcinoma: An Institutional Experience

Mammogram is a common diagnostic modality for breast carcinoma. Diagnostic mammogramis available at only few centers in Nepal. The aim of this study was to determine the accuracy ofdiagnostic mammogram in Nepalese women suffering from breast carcinoma. A retrospectiveanalysisofthebreast carcinomawas carriedoutintheDepartmentof Surgery,TribhuwanUniversityTeaching Hospital from October 1995 to October 2007. Out of 556 patients with histologically proven breast carcinoma, 378 patients (68%) had undergone mammography. Breast carcinoma was identified on mammography in 328 (87%) cases while 50 cases (13%) were reported as normal or benign lesions. Diagnostic mammogram had a sensitivity of 86.8%, a specificity of 98.6% with a positive predictive value of 68.8% and a negative predictive value of 99.5%. In mammographically missed breast carcinoma, 34% were less than 40 years of age (P<0.05), 60% were premenopausal (P<0.05) and 88% patients presented with a painless lump. The study shows that the diagnostic accuracy of the mammogram is very high. However, there is a chance of missing the breast carcinoma in youngand premenopausal women.Key words: breast carcinoma, diagnostic mammogram, premenopausal women

Predictive value of ultrasonography in the diagnosis of palpable breast lump

A lump is the first symptom in over 80 percent of all patients with cancer of the breast. Consequently, the finding of any lump in the breast is a highly significant sign and warrants a thorough investigation. The present study was undertaken to study the predictive value of ultrasonography in the diagnosis of palpable breast lumps. Fifty-two female patients with palpable breast lumps that were unilateral underwent ultrasonography of the breast. Thirty-six of these patients who had solitary, unilateral, solid lumps were followed up with FNAC/biopsy/mammography and the findings were compared. The mean age group was seen to be 41 years. The youngest patient was 17 years old and the oldest was 80 years. The validity of USG in the diagnosis of palpable breast lumps was calculated. A sensitivity value of 95%, specificity of 94.10%, positive and negative predictive values of 95.50% and 93.75% were noted and were comparable to other similar studies. The sensitivity, specificity, positive and negative predictive values were statistically significant (p=0.0000006) and were comparable to the values obtained by different studies conducted elsewhere. Among the multiple USG parameters, shape, margins, vascularity, surrounding tissue character, sound transmission through the lump were more significant in the diagnosis of benign vs. malignant lumps. Echogenicity and echotexture were of less significance.

The Role of Feeding Jejunostomy in the Surgical Treatment Of Oesophageal Carcinoma

Abstract

Closed Mitral Valvotomy During Pregnancy

Abstract

Empyema Necessitatis Presented as Breast Abscess

abstract

[A case of omental pedicle flap plombage for fungus ball type pulmonary aspergillosis]

The usual surgical treatment for fungus ball type pulmonary aspergillosis is lobectomy, but in cases of aspergillosis located in a post-lobectomy space a second lobectomy is difficult because of the accompanying inflammatory process. A 53-year-old male underwent left upper lobectomy for pulmonary tuberculosis eight years ago. Six year postoperatively, he developed fungus ball type aspergillosis in the post-lobectomy space with bronchopleural fistula and recurrent hemoptysis. We performed an omental pedicle flap plombage via the post-sternal route to resect the pleural cavity fungus ball. The post operative course was uneventful and clinically the bronchopleural fistula was closed.

Achalasia Cardia: Experience With Trans-Thoracic Heller's Cardiomyotomy

Abstract