Analysis of Lung Cancer Cases Presenting in Outpatient Department of University Hospital of Nepal

Background Lung cancer is one of the leading cause of cancer related death. Most common histopathology of lung cancer is non-small cell carcinoma of which adenocarcinoma is the most common. There are limited number of studies done in Nepal to know different aspects of lung cancer. Objective To know demographic parameters of patients diagnosed as lung cancer in a university hospital. The study also aims to know the different histopathological diagnosis of lung cancer. Method All the patients presenting to outpatient department (Cardio Thoracic and Vascular unit) of Dhulikhel Hospital, if are diagnosed as cancer of lung/bronchus will be included in the study. The duration of the study was January 2017 to December 2021. The details on age, gender, presenting symptoms, histopathology of lung cancer, operability will be included in database and will be analyzed. Result There were total of 127 patients diagnosed as lung cancer. Male:female ratio was 1.7:1. Overall mean age was 63.23 years (SD 13.5 years, Range 19-89 years). Non small cell carcinoma was the most common type of lung cancer with 83.7%. In non small cell carcinoma, most common type was Squamous cell carcinoma followed by undifferentiated and Adenocarcinoma. Only five (3.93%) cases were in operable stage. Conclusion Despite the fact that lung cancer is one of the most common cancer, patients usually present late and moslty are not in operable stage. This study shows that squamous cell carcinoma is the most common histopathology in lung cancer cases.

Solving the Mystery of Giant Intrathoracic Mass

Intrathoracic schwannoma are highly vascular nerve sheath benign tumors arising from neural crest derived schwann cells of the intercostal nerves. Common clinical presentation is palpable mass but in our case patient presented with shortness of breath which is rare presentation in Schwannoma. Imaging studies of the patient showed the lesion in left lung, however surgical finding showed mass to arise from chest wall and it was confirmed to be schwannoma by histopathological examination.

Open Surgical Management of Abdominal Aortic Aneurysm at a Community Based University Hospital in Nepal

Aortic aneurysms are abnormal dilatation of aorta. The risk factors include male sex, age > 65, smoking, coronary artery disease and hypertension. Here we report a case of infra-renal abdominal aortic aneurysm (AAA) of diameter 6 cm. The patient sucessfully underwent aorto-biiliac bypass surgery using Dacron Y graft. During abdominal aortic aneurysm surgery anesthetic challenge is also of paramount importance and should be considered.

A case of thymoma in myasthenia gravis: Successful outcome after thymectomy

INTRODUCTION

Thymic abnormalities occur as hyperplasia and thymoma. Myasthenia gravis is commonly present in thymoma. Thymectomy possesses risk due to anatomical proximity with vital thoracic structures and myasthenia crisis.

PRESENTATION OF CASE

Forty five years female with complaints of difficulty swallowing and weakness of upper limb muscles upon investigation showed mass in mediastinum and antibody test for myasthenia gravis positive. Medical management was done for a month followed by thymectomy. There were no intra and postoperative complications. Medical management was stopped one month after surgery and she is symptom free.

DISCUSSION

Thymectomy is the standard of care where median sternotomy is the mainstay approach to surgery. Various other surgical approaches and complications revolving around surgery has been discussed.

CONCLUSION

Surgical removal of thymoma cured myasthenia gravis in our case. We focused on proper preoperative optimization of myasthenia gravis symptoms before thymectomy.

Factors Affecting Recanalisation after Optimal Management of Deep Vein Thrombosis; A single institution based study

Background Presence of recanalisation will favour for better physiological recovery after medical management of Deep Vein Thrombosis (DVT) along with lesser chances of post thrombotic syndrome. Rate of recanalisation is varied and can range from 43-57% and the factors that affect recanalisation are still a dilemma. Objective To know the factors for recanalisation following Deep Vein Thrombosis. Method This is a single institution based retrospective-prospective analytical study encompassing all ultrasonologically diagnosed cases of Deep Vein Thrombosis in adults from January 2015 to November 2017. All the cases were admitted with oral warfarin bridged by Heparin/ Enoxaparin and were discharged once International Normalization Ratio was in therapeutic range. The patients were followed up for three months with minimal of three outpatient followup. Best finding in the doppler ultrasonography (done by Acuson P500, Seimens) in relation to recanalisation was taken for the study. Result There were 67 cases of Deep Vein Thrombosis. Of these cases male to female ratio was 0.91. The mean age was 48.07. Most common extent was up to common femoral vein (47.8%) followed by upto popliteal vein (40.3%). Remaining 11.9% had extension upto iliac veins. There was no recanalisation in 2 cases (3%). Partial recanalisation was seen in 23 cases (34.3%) while complete recanalisation was seen in 42 cases (62.7%). Recanalisation is more in DVT involving popliteal vein while it decreases as the extension goes up. In contrast to 79.4% complete recanalisation in popliteal vein, that in common femoral vein is 62.5% while in iliac vein is only 37.5%. Mean age in no recanalisation group is much younger than partial or complete recanalisation groups. Conclusion Recanalisation following Deep Vein Thrombosis distal to popliteal vein is more than that in proximal Deep Vein Thrombosis. The information on recanalization can be considered to use to decide upon the duration of medical management of Deep Vein Thrombosis.

Chest Trauma Requiring Admission: Differences in Earthquake Victims and other Modes of Injury

Background The April 25, 2015 Nepal earthquake (7.8 Richter scale) followed by May 12, 2015 major aftershock (7.3 Richter scale) killed more than 9,000 people and injured more than 23,000 people. Dhulikhel Hospital situated at Kavre district of Nepal encountered major bulk of Earthquake victims residing at Sindhuplanchowk, Kavre and Dolakha districts during subsequent earthquake events. Objective To distinguish any significant differences in hospital admitted Earthquake and nonEarthquake chest trauma cases. Method Retrospective study was done comparing earthquake with non-earthquake chest trauma cases admitted in Dhulikhel Hospital. Study included parameters like mode of injury, time taken to reach health center, symptoms at presentation, involvement of chest area, presence and site of rib fracture, presence of hemothorax or pneumothorax, spectrum of treatment required, hospital admission days. Result There were total 23 earthquake victims of which 14 (61%) were female and rest of 9(39%) were male whereas out of total 95 non earthquake cases 23(24%) were female and 72 (76%) were male (p< 0.01). Mean age in earthquake victims was 53.73 (SD 18.33, range 19-84) while non earthquake cases was 46.83(SD 16.53, range 11-90), (p >0.05). Major mode of injuries in earthquake victims was hit by objects (82.60%) followed by fall (17.4 %). Incidence of rib fractures was 69.56% in earthquake victims and 85.26 % in non earthquake cases with average of 2-3 ribs in both cases (p>0.05). There was higher rates of pneumothorax in earthquake victims (52.17%) compared to non earthquake cases (30.52%), (p<0.05). There wasn't evidently major differences in incidence of pulmonary contusion, hemothorax and surgical emphysema. The mean duration of hospital admission days in earthquake victims was 7.78 days while non earthquake cases was 5.04 days (p >0.05). The total number of patients requiring chest tube insertion in earthquake victims was 16(69.56%) while that was 29(30.52 %) in non earthquake patients (p <0.01). Conclusion There was preponderance of female gender in earthquake related cases compared to non earthquake cases. Incidence of rib fracture was higher in earthquake victims. In earthquake victims, higher proportion of patient required chest tube drainage compared to non earthquake cases.

Abnormal Venous Dilatation other than Typical Varicose Vein, Rare Encounters

Varicose vein, one of the common vascular illnesses is usually a disease in lower limb. This is due to reflux of blood from deep venous system to superficial venous system. Rarely, this disease can also happen in veins in different location. Four such rare encounters are mentioned in this case series.

Optimal Starting Dose of Warfarin for Treatment of Deep Vein Thrombosis in Nepalese Context, A Retrospective- Prospective Institutional Review

Background Deep vein thrombosis (DVT) requires an early establishment of effective anticoagulation in order to reduce harms and cost of concomitant treatments. Selection of the right warfarin dose at the start of treatment is important. Objective To know ideal starting dose of warfarin in adult with Deep Vein Thrombosis of our population. Method This is a retrospective-prospective single institution based analytical study including Deep Vein Thrombosis in adults from January 2015 to November 2017. On the first half (January 1, 2015 to July 31, 2016) of the study period, the cases were given 3mg of warfarin as initial dose (Group 1); while in the second half (August 1, 2016 to November 31, 2017) cases were given 5mg as the initial dose (Group 2). Two sequential International Normalisation Ratio (INR) within therapeutic range is considered as target attained. Result There were total of 63 patients (M:F=1:1.03) of which 85.7% (n=54) cases were acute deep vein thrombosis and 14.3% were chronic cases. Mean final dose of warfarin was 6.03 mg; where it was 6.50 mg in group 1 and 5.63 mg in group 2, p=0.11. Difference between final dose and starting dose it was found to be 3.5 mg in Group 1 while that was only 0.63 mg in Group 2 (p<0.01). Conclusion Lesser change in dose of warfarin from its initial starting dose (5 mg) was noticed in group 2. Warfarin 6 mg as ideal starting dose can be recommended but larger, multicentric and follow up studies are essential to substantiate the findings.

Initial Experience of Complex Peripheral Bypass Surgery at Dhulikhel Hospital, Kathmandu University Hospital

Peripheral arterial disease is seemingly silent yet is a major pubic health problem with limb threatening and life threatening consequences. This condition can initially be asymptomatic and gradually may progress to intermittent claudication and finally to critical ischemia. When conservative management is not sufficient and there is option of surgical management, peripheral bypass surgery is an established modality of treatment of peripheral arterial disease. We present our initial cases of peripheral arterial bypass surgery all of which are technically demanding surgeries. All the cases have resulted into limb salvage until current follow-up.

Short Term Fate of Great Saphenous Vein after Radiofrequency Ablation for Varicose Veins

Background Radiofrequency ablation of varicose vein have gained popularity compared to conventional surgery due to comparable long term results in addition to definite immediate superiorities. This modality has been started in Nepal since August 2003 and the study on short term fate of ablated vein segment confirms the anatomical benefit in addition to the clinical benefit. Objective To analyze short term fate of segment of great saphenous vein that has been treated by Radiofrequency ablation in terms of occlusion of saphenofemoral junction and absence of recanalisation on Doppler ultrasonography finding done at 3-6 months postoperative period. Method Total 81 cases subjected for radiofrequency ablation of great saphenous vein in thigh segment during August 2013 - September 2014 were followed up in between 3 to 6 months by Doppler ultrasonography. The findings were classified into type 1 to 4 results based on the anatomic closure of saphenofemoral junction and absence of recanalisation on treated segments. Result There were total 81 cases with 54.3% female and 45.7% male patients. Mean short term follow up duration was 4.9 months (S.D. 1.1 months). Great Saphenous Vein was cannulated most frequently in between 5 cm above knee to 5 cm below knee. Mean number of Radio Frequency Ablation (RFA) segments were 6.6 (SD=3.1). There was complete occlusion (Type 1 results) in 51 cases (63.0%). In 24 cases (29.6%) there was competent saphenofemoral junction with partial recanalisation in distal part of Great Saphenous Vein (GSV) (Type 2 results). In six cases (7.4%) there was incompetent saphenofemoral junction with partial recanalisation in distal part of Great Saphenous Vein (Type 3 results). There were no cases with incompetent saphenofemoral junction with complete recanalisation in distal part of Great Saphenous Vein (Type 4 results). Conclusion Radio Frequency Ablation for varicose vein, besides making clinical improvements, is also associated with good anatomical results.