bluuebunny/crossref_metadata_2025 huggingface dataset:
The Deductibility of Fines, Penalties, and Restitution Related to Illegal Activities
Authors: Schnee Edward J. , Seago W. Eugene
Published: July 2016

Determining the deductibility of fines, penalties, settlements, and other forms of restitution paid by taxpayers as a result of violations of criminal and civil law fall under a number of sometimes conflicting code sections, IRS pronouncements, and case law.

In this article, we discuss the deductibility of fines, penalties, and other forms of restitution under the provisions of IRC Section 162(f) and the violation of public policy doctrine. Since some taxpayers attempt to capitalize the expenditures rather than deduct them, we also discuss the application of Sections 263 and 263A to these payments. If a taxpayer incurs expenditures in a transaction not part of a trade or business, then the deduction of the expenditure is controlled by Section 165. The application of the violation of public policy doctrine and Section 162(f) to Section 165 are also evaluated.

Following the discussion of the current cases and rulings, we recommend several changes in tax law that will clarify and simplify when expenditures related to illegal activities are deductible.
Ceramic Inlays: Effect of Mechanical Cycling and Ceramic Type on Restoration-dentin Bond Strength
Authors: Trindade FZ , Kleverlaan CJ , da Silva LH , Feilzer AJ , Cesar PF , Bottino MA , Valandro LF
Published: July 2016

This study aimed to evaluate the bond strength between dentin and five different ceramic inlays in permanent maxillary premolars, with and without mechanical cycling. One hundred permanent maxillary premolars were prepared and divided into 10 groups (n=10) according to the ceramic system (IPS e.Max Press; IPS e.Max CAD; Vita PM9; Vita Mark II; and Vita VM7) and the mechanical cycling factor (with and without [100 N, 2 Hz, 1.2×106 cycles]). The inlays were adhesively cemented, and all of the specimens were cut into microbars (1×1 mm, nontrimming method), which were tested under microtensile loading. The failure mode was classified and contact angle, roughness, and microtopographic analyses were performed on each ceramic surface. The mechanical cycling had a significant effect (p=0.0087) on the bond strength between dentin and IPS e.max Press. The Vita Mark II group had the highest bond strength values under both conditions, with mechanical cycling (9.7±1.8 MPa) and without (8.2±1.9 MPa), while IPS e.Max CAD had the lowest values (2.6±1.6 and 2.2±1.4, respectively). The adhesive failure mode at the ceramic/cement interface was the most frequent. Vita Mark II showed the highest value of average roughness. IPS e.max Press and Vita Mark II ceramics presented the lowest contact angles. In conclusion, the composition and manufacturing process of ceramics seem to have an influence on the ceramic surface and resin cement bond strength. Mechanical cycling did not cause significant degradation on the dentin and ceramic bond strength under the configuration used.
Preparedness of health care of older people
Authors: Bhattarai B
Published: July 2016

Not available.Health Renaissance 2014;12(3): 147-148
Circumstances of the First Drink among Problem Drinkers Seeking Help from a Psychiatric Service of a Teaching Institute In Eastern Nepal
Authors: Shakya Dhana Ratna
Published: July 2016

Background: Alcohol use and problem are common in Nepal.Objective: To investigate into the circumstances of alcohol use among problem drinkers, focusing mainly the first drink.Methods: It is a descriptive study among total of 200 consecutive consenting patients: 100 male and 100 female (gender balance emphasized), with alcohol use disorders seeking help from psychiatric service of a teaching institute in eastern Nepal in 2006-08. Alcohol use disorders were diagnosed with the ‘International classification of diseases and infirmities’ (ICD)- 10th edition. Related information about socio-demography and circumstances of alcohol use were collected by using a ‘semi-structured proforma’Results: Average (minimum, maximum) age of the subjects was 39.29 (17, 84) years. The age at the first drink was 17.31 (infancy, 59) years: 15.96 (infancy, 45) for males and 18.68 (infancy, 59) for females. As a whole, the most common circumstances of first use were custom of using alcoholic beverage as food, peer pressure/company, stressful situation and easily available at home. Custom of using alcohol as food, stressful situation, making in home and for health reason like during breast feeding were most common circumstances for first drink among females; and peer pressure and the custom were among males. A perceived stressor was associated more among females.Conclusion: Most problem-drinkers first drink in the pretext of the custom of alcoholic beverage as food, peer pressure, stressful situation and easy availability in eastern Nepal. Males start drinking at younger age and the first drink was more associated with stressors among females.Health Renaissance 2014;12(3): 154-161
Prevalence of Histologically Proven Acute Appendicitis And Incidental Carcinoid Tumour in the Practice of Surgical Pathology at BPKIHS
Authors: Upadhyaya P , Agarwal C S , Karak A K , Karki S , Pradhan A , Subba T N
Published: July 2016

Background: Appendicitis is the most common cause of acute abdominal pain requiring surgical intervention. Objective: To determine the relative prevalence of histologically proven acute appendicitis in surgically respected specimens with clinical diagnosis of acute appendicitis and also to find out the rate of occurrence of characinoid tumour as an incidental histologic finding.Methods: It is a retrospective study involving all gross specimens received in the department of pathology over a period of twenty months (1.1.2006 to 31.8.2007). Histologic data on 515 appendicectomy samples (clinically diagnosed as appendicitis) of the total 7295 specimens received over a period of twenty months were retrieved from the archives of department of pathology, with exclusion of appendectomy incidental to another surgical procedure.Results: Appendectomy specimens constituted 7.0% (n=515; M:F 1.1:1) of all surgical pathologic specimens (n=7295) at B.P.K.I.H.S. The breakups of histologic diagnoses are: acute appendicitis with or without periappendicitis and gangrenous change (93.6%, n=482), “receding appendicitis” (5.4%, n=28), and normal histology (1.0%, n= 5). Carcinoid tumours were detected incidentally in three cases (0.58%) out of all appendectomy specimens.Conclusion: Analysis of data revealed a prevalence of 6.99% of histologically proven acute appendicitis in this tertiary health care set up. The rate of occurrence of carcinoid tumour was 0.58%.Health Renaissance 2014;12(3): 197-203
Effect of Oral Clonidine Premedication on Propofol Consumption for Patient Undergoing Laparoscopic Cholecystectomy
Authors: Prasad Jagat Narayan , Singh S N , Pokhrel K , Khatiwada S
Published: July 2016

Background: Various goals of premedication includes anxiolysis, sedation, amnesia, analgesia, attenuation of autonomic reflexes, and reduction of anaesthetic dose requirement. Preanaesthetic oral clonidine has been shown to produce anxiolysis, sedation and attenuation of hemodynamic stress response to tracheal intubation.Objective: To investigate the clinical efficacy of oral clonidine on propofol consumption in patients undergoing laparoscopic cholecystectomy.Methods: This was a prospective, randomized, double-blind placebo controlled study conducted in ninety consecutive patients randomly divided into three equal groups (placebo, tab. clonidine 150 mcg and tab. clonidine 300 mcg) meeting inclusion and exclusion criteria who underwent laparoscopic cholecystectomy. Study drug was given 60 minutes before induction of anaesthesia. Anaesthesia was induced with intravenous pethidine 1mg/kg followed by propofol . The dose of propofol for loss of verbal command was recorded. Anaesthesia was maintained with propofol at the rate of 10 mg/kg/h for 10 minutes then to 8 mg/kg/h for 10 minutes and ultimately decreased to 6 mg/kg/h after tracheal intubation. The rate of propofol infusion was adjusted by 2mg/kg/h to obtain adequate depth of anaesthesia (maintaining hemodynamic parameters within 20% of baseline).Results: The propofol induction dose was less in clonidine 150 mcg (1.2±0.2 mg/kg) and clonidine 300 mcg (1.08±0.24 mg/ kg) groups as compared to placebo group ( 1.4±0.3 mg/kg) (p=˂0.001). The rate of propofol infusion in mg/kg/h and in mcg/kg/h was lower in clonidine 150 mcg (6.7±1.6 and 121.3±11.37) and clonidine 300 mcg (7±1.4 and 120.0±9.8) groups as compared to placebo (10±3.2 and 148.0±32.53) group (p =˂ 0.001).Conclusion: oral clonidine premedication reduces propofol requirement for induction and maintenance of anaesthesiain patients undergoing laparoscopic cholecystectomy.Health Renaissance 2014;12(3): 204-208
Presentation, Prescription Pattern and Time Taken To Discharge From An Emergency Department Of Eastern Nepal
Authors: Yadav A K , Bhandari R , Rai B , Giri S , Baral D D , Mandal M
Published: July 2016

Background: It is a great challenge for a doctor to give proper care and discharge because of overcrowding in emergency units like ours. The clinical records in emergency are an essential document that reflects the quality of care which is given to the patient.Objectives: To find out the time taken for discharge from emergency and to find out the current trend of problems presenting to emergency and their prescription pattern.Methods: A retrospective descriptive hospital based study was carried out using all emergency discharged patients’ case sheet records from 14th April to 14th May 2013. A number of 1022 files were analyzed. Results: Out of 1022 discharge files, majority (72%) of the patients included Australian Triage Score (ATS) 3. Patients with ATS 5 had a mean duration of stay of 24 hours whereas ATS 2, 3, 4 patients had mean duration of stay of 10.10 hours, 8.75 hours and 5.48 hours respectively. Most common clinical presentation was trauma (31.3%). Out of 1022 patients, 504 (49%) were treated with antibiotics. Cefixime was the most frequently administered antibiotics (24.7%). Of all 506 patients received analgesic, mostly diclofenac (30.8%), 79 received antispasmodic drugs, mostly hyoscine butyl bromide (6.2%), and antipyretics mostly paracetamol. Proton pump inhibitors (PPI) were used in 594 (58.1%) patients mostly pantoprazole (47.2%). Conclusion: Sicker patients had longer duration of stay in the emergency unit. Trauma is the most common presentation, analysis, antibiotics and PPL are the most commonly prescribed which show in the emergency unit.Health Renaissance 2014;12(3): 209-214
Varenicline for Smoking Cessation: a Review
Authors: Rauniar G P , Mishra A , Sarraf D P
Published: July 2016

Tobacco use is the leading cause of preventable death and disability in the world. Although gradually declining in most developed countries, the prevalence of tobacco use has increased among developing countries. Nicotine is an addictive chemical that is inhaled from the tobacco present in the cigarettes. It acts on neuronal nicotinic acetylcholine receptors within the ventral tegmental area of the brain, causing dopamine release in the nucleus accumbens which reinforces nicotine-seeking behavior. Reward through the dopaminergic system is a common thread among many drugs of addiction. According to the National Anti-Tobacco Communication Campaign Strategy for Nepal smoking prevalence in Nepal is higher (38.4%) than the smoking prevalence in the world (29%). Smoking attributable annual deaths in Nepal is estimated at nearly 14,000 (9,000 male deaths and 5,000 female deaths) for population aged 35 and over. First-line pharmacotherapies for smoking cessation are varenicline, sustained-release bupropion and various forms of nicotine replacement therapy (i.e., patch, gum, lozenge, inhaler, nasal spray). These drugs can be used as monotherapy or combination therapy for the treatment of smoking cessation. After studying the outcome of many clinical trials and meta-analysis, it is concluded that cigarette smokers taking varenicline have the most success quitting smoking as compared with those taking other first-line pharmacotherapies for treating smoking cessation.  Health Renaissance 2014;12(3): 215-220
A Case of Bipolar Affective Disorder Not Otherwise Specified Or Cyclothymia
Authors: Adhikari B R , Sapkota N , Gautam R , Basnet M , Koirala P , Rajbhandari N
Published: July 2016

The symptoms of mood disorders can be highly variable from person to person, and there are some differences in the present systems of classification to view some of the presentations of Bipolar Disorder Not Otherwise Specified (BPAD-NOS) and cyclothymia. This case highlights one of such presentations.Health Renaissance 2014;12(3): 221-223
Laparoscopic antireflux surgery - our initial experience
Authors: Pradhan S , Ghimire Bikal , Kansakar P , Singh YP , Vaidya P , Sayami P
Published: July 2016

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.
Comparative study between 3-ports and 4-ports laparoscopic cholecystectomy for the cases of gall stone disease
Authors: Tamrakar KK , Khwaunju P , Sah K
Published: July 2016

Laparoscopic cholecystectomy is currently accepted approach for the management of patients with cholelithiasis. The standard method for removal of gall bladder in laparoscopic cholecystectomy is by using four ports. Although other techniques such as by using 3 ports or only single port are being practiced, their safety and efficacy has not been established. This study was done to assess the efficacy and safety of the use of only three ports for laparoscopic cholecystectomy.Methods: Between August 2013 and February 2014, 78 patients with the diagnosis of cholelithiasis were operated. Patients were randomized into 3-ports group and 4-ports group using random number. Operative time taken for the procedure and operative findings were noted. Postoperative pain and complications were noted in both groups. The two groups were compared using student-T test and chi square test. Results: There was no significant difference in the operating time taken for the 3-ports laparoscopic cholecystectomy and 4-ports laparoscopic cholecystectomy. However operating time was significantly higher when the cases that had dense adhesions present were compared with those who did not have. Conversion from 3-ports technique to 4-ports technique was determined mainly by the degree of adhesions and to some degree by the BMI of the patient. Postoperative wound infection rate was similar among the two groups. There was no incidence of biliary injury in both the groups.Conclusion: 3-ports laparoscopic cholecystectomy is safe and efficient approach for the selected patients who seek for lesser invasive method of laparoscopic cholecystectomy.
Advanced laparoscopic surgery: our initial experience at Nepal Medical College
Authors: Nishes Dr , Subash Dr , Pranil Prof
Published: July 2016

If we consider the last century of history of surgery, few advances can be compared to the changes engendered by the introduction of minimally invasive surgery, which in the last decade has represented a revolution in surgical practice and patient care. Since 1987, when the first laparoscopic cholecystectomy was performed, laparoscopic procedures have been the standard of care for many routine diagnostic and therapeutic procedures. Laparoscopic techniques have become an integral part of the operative management in virtually every realm of general surgery. The success of the laparoscopic technique has been due mainly to patient demand, which has contributed to a rapid expansion in the number of laparoscopic procedures performedThe benefits conferred to patients by less invasive procedures like decreased pain, and shorter recovery time have to be weighed against overzealous application and the problems created by the lack of familiarity with new techniques and instruments. Basic laparoscopic procedures include laparoscopic cholecystectomy, laparoscopic appendectomy, and diagnostic laparoscopy. All other laparoscopic operations are defined as “advanced”. Learning curve and added expenses have been prohibitative in development of advanced laparoscopic surgery in resource poor setting like ours. However, advance laparoscopic surgery is here to stay. We must therefore have a concentrated effort to move towards offering these facilities to our patients.Despite the initial hiccups, some advanced laparoscopic surgeries are being performed and at Nepal Medical College, moving a step closer towards the gold standards in surgical management. Surgeons from various units and subspecialties work together and help each other and utilize each other’s limited experience. This spirit has been a great help to reach our way to develop ourselves despite our technical limitations. Our experience is limited but the outcomes so far are encouraging and we have tried to highlight the significance of framework. There is a long road ahead but a hood beginning is more than half done.
Cancer of esophagus and GE junction– a long-term follow-up results
Authors: Thakur Binay , Yonghui Di , Devkota Mukti , Baral Paribartan , Shrestha Sudhir , Upreti Janaki , Kandel Nirmala
Published: July 2016

Background:  Esophageal and GE Junction malignancies are diagnosed late and the long-term outcome is still suboptimal. We present our experience.Methods: 421 patients with mean age of 57.6 years with cancer of esophagus and GE Junction were evaluated with physical examination, CT chest and abdomen, gastroduodenoscopy and bronchoscopy. 254 (60.4%) patients underwent surgical treatment only and 167 (39.6%) underwent multimodality treatment. 295 patients underwent transthoracic approach, 88 – transhiatal approach and 58 patients underwent – abdominal approach only.Results: Upper, middle, GEJ type – I, GEJ type – II, GEJ type – III tumors were present in 5.7, 28.5, 36.8 and 1.9% cases, respectively. Anastomosis was placed at neck in 73.2% and in chest in 26.8% cases. Final stages were 0 (0.2%), Ia (0.5%), Ib (1.9%), IIa (10%), IIb (8.8%), IIIa (15.7%), IIIb (14.3%), IIIc (41.6%) and IV (7.1%). R0 resection was achieved in 91.5% cases. Postoperative mortality, recurrent laryngeal nerve injury, anastomotic leak and pneumonia were observed in 4.8%, 5.7%, 11.6% and 22.1%, respectively. Median overall survival was 28 months with 5-year overall survival of 21%. A subgroup of 70 patients (16.6%) who were subjected to preoperative chemoradiation followed by surgery showed response in 64.3% cases with a median and 5-year survival of 49 months and 30% in responders, and 15 months and 15% in non-responders.Conclusion: Patients presented mostly in stage III (78.7%), therefore a multimodality approach should be considered as a standard practice in Nepalese context in order to achieve better survival results.
Red cell distribution width as a predictor of severity of acute pancreatitis
Authors: Aafee Ali , Pokharel Rameshwar Prasad
Published: July 2016

Introduction and Objective: Acute Pancreatitis (AP) is one of the most common surgical emergencies, a third of which becomes severe. Mortality rate of severe AP can reach up to 40%. Identification of those at risk of severe AP would allow early intervention to improve outcome Red cell distribution width (RDW), an indicator of systemic inflammation has been show to be effective at predicting mortality in AP. The objective of this study was to determine whether admission RDW can predict severity of AP.Materials and Methods: A total of 74 patients admitted to Surgery Department in TUTH were included in this prospective study. Demographic data, admission time and laboratory parameters including RDW--?CV were obtained from each patient at admission. Reassessment was done at 48 hours. The patients were followed up till discharge. Severity of AP was classified by the 2012 revised Atlanta criteria.Results: A positive correlation between admission RDW - CV and severity of AP was found (Spearman’s rho 0.246, p value 0.034). ROC analysis revealed that admission RDW was accurate at predicting severe AP (AUC 0.733, 95% CI 0.612 to 0.854, p value 0.001) but was not accurate at differentiating mild from moderate AP ( AUC 0.510, 95% CI 0.291 to 0.729, p value 0.932). The cut off value for detecting severe AP was 13.7% with sensitivity of 66.7%, specificity 68.1%, PPV of 54.5 and NPV of 78.Conclusion: Admission RDW is as predictor of severe acute pancreatitis
Early identification of patient at risk of acute severe pancreatitis with systemic inflammatory response
Authors: Laudari U , Parajuli TP , Parajuli A , Rupakheti SR , Joshi MR
Published: July 2016

Introduction and Objective: Clinically, the Systemic Inflammatory Response Syndrome (SIRS) is identified by two or more symptoms including fever or hypothermia, tachycardia, tachypnoea and change in blood leukocyte count. The relationship between SIRS symptoms at the time of presentation and severity of pancreatitis is yet to be determined though progression of SIRS in subsequent days has been already correlated. The aim our study was to determine the severity of pancreatitis with SIRS score at the time of admission.Materials and Methods: We conducted prospective cohort study of consecutive patient admitted to emergency of KMCTH, with diagnosis of Acute Pancreatitis (AP) from December 2014 to January 2016. Clinical, biochemical and imaging data from the patients were collected to diagnose pancreatitis. Acute Pancreatitis was diagnosed as per Revised Atlanta Classification 2012. SIRS was evaluated at the time of admission and was correlated with Modified Marshall scoring system for organ dysfunction and sensitivity, specificity and predictive value of SIRS score at admission for organ failure was calculated.Results: Among 41 patients admitted with diagnosis of Acute pancreatitis irrespective of cause the sensitivity of SIRS score at admission in predicting Severe pancreatitis was 28 %, specificity was 80%, Positive predictive value was 60 % and NPV was 51 %, with P value of 0.52 and odds ratio of 1.6 ( CI- 0.376-6.808).Conclusion: This study showed that SIRS score at admission is not sensitive in predicting severe pancreatitis however it is specific for severe pancreatitis.
SMA first approach Pancreaticoduodenectomy for cancer – should it be standard approach?
Authors: Thakur Binay , Devkota Mukti , Yonghui Di , Regmi Yogesh , Khanal Durga , Khadaka Kopila
Published: July 2016

Background: pancreaticoduodenectomy (PD) has become the standard treatment for cancer of head of pancrease and periampullary malignancies. Recently superior mesenteric artery (SMA) first approach has shown to have several advantages over the conventional superior mesenteric vein (SMV) first approach. We present our initial experience with SMA first approach for PD.Methods: Thirteen patients undergoing SMA first PD during year 2014-2015 (1 year) were prospectively studied. A posterior approach with “hanging maneuver” was used to identify SMA first and the resectibility was confirmed. Inferior pancreaticoduodenal artery (IPDA) was ligated before the division of pancreatic neck. Duct to mucosa pancreaticojejunostomy followed by hepaticojejunostomy and gastrojejunostomy was performed.Results: patients with mean age of 53 years presented with abdominal pain and jaundice (100%). Tumors were of periampullary region in 10 cases and of head of pancrease in three cases. Two patients required partial SMV wall resection with tangential repair. Mean operating time, blood loss and postoperative stay was 304 minutes, 380 ml and 14 days, respectively. Replaced/ aberrant right hepatic artery from SMA was observed in 38% cases. Mean number of dissected nodes was 16. R0 resection was achieved in 100% cases. There was one postoperative mortality (7.7%) and minor complications were noted in 46% cases.Conclusion: SMA first PD helps to properly identify and control anomalous or accessory right hepatic artery arising from SMA, minimizes intraoperative bleeding due to proper control.
Evaluation of complications of PTBD using Hull’s Risk Stratification Index
Authors: Jha Prabhat , Lakhey Paleswan
Published: July 2016

Introduction: Obstructive jaundice is a common surgical problem. Percutaneous transhepatic biliary drainage (PTBD) is one of the effective treatments in the management of biliary obstruction. Hull Risk stratification index has been proposed to identify which patients are more likely to suffer from immediate and early complications and procedural mortality.Materials and Methods: This is a descriptive observational study conducted at the department of surgery TUTH over a period of 1 year between october 2014 and october 2015. Hull risk stratification index was used to predict the complications of the procedure.Results: 79 patients who underwent PTBD were included during the study period of one year. Among them 39(49%) were male and 40(51%) were female. The median age of patients undergoing the procedure was 59yrs (range 35-90yrs). Twenty nine patients (36%) were in the medium Hull risk group, 50 (64%) of patients were in the low risk group and there were no patients in the high risk group. Six patients (7.5%) died after the procedure. Seven patients (8%) developed sepsis following the procedure. One patient (1.2%) developed hemobilia. Two patients (2.4%) developed pneumonia following the procedure. The sensitivity, specificity, positive predictive value, negative predictive value of the index for complications of PTBD were 81%, 74%, 44% and 94% respectively. Patients with medium Hull’s risk were 3 times more likely to develop complications of PTBD than those with low risk.Conclusion: Hull’s Risk Stratification Index can be utilized as a marker for predicting the early, immediate complications as well as procedure related mortality.
Role of alanine aminotransferase in determining the biliary etiology in acute pancreatitis
Authors: Simkhada Shailesh , Mishra Parashuram
Published: July 2016

Background: Acute pancreatitis (AP) is a common surgical presentation and a leading cause of morbidity and mortality worldwide. Gallstones and excessive alcohol consumption are the most frequent causes of AP. Aim of this study was to investigate the predictive value of raised ALT (Alanine aminotransferase) in determining biliary etiology in patients presenting with acute pancreatitis.Materials and Methods: All patients admitted in the surgical ward of Tribhuvan University Teaching Hospital with the diagnosis of AP were studied prospectively over a period of 1 year between 2014and 2015. Peak ALT within 48 h of presentation was recorded. Etiology was determined on the basis of history, Abdominal Ultrasound (AUS) and other relevant investigations.Results: A total of 80 patients of AP were included in the study. Among them, 46 (57.5%) patients had biliary pancreatitis, 18(22.5%) had alcoholic pancreatitis, 4(5%) patients had drug induced pancreatitis and 12(15%) patients had idiopathic pancreatitis. 46(57.5%) were male and 34(42.5%) were female. Mean ALT for biliary pancreatitis was 212.5U/L, for alcoholic was 58 U/L, for drug induced was 71 U/L and for idiopathic was 43 U/L. When compared between biliary and non-biliary pancreatitis, it was statistically significant( p value < 0.00). Biliary was the most common etiology followed by alcoholic. The sensitivity, specificity, positive predictive value(PPV) and negative predictive value(NPV) of alanine aminotransferase with cut off of 100 U/L for biliary pancreatitis was 65%, 94%, 91.5% and 72.8% respectively.Conclusion: An elevated ALT strongly supports a diagnosis of gallstones in Acute Pancreatitis.
Laparoscopic management of Hydatid cyst
Authors: Pangeni Anang , Shakya Vikal Chandra
Published: July 2016

Introduction and Objective: Hydatid cyst of the liver is a fairly common parasitic condition. We present here a series of 9 patients with hydatid cyst of the liver managed by minimally invasive surgeryMaterials and Methods: It was a prospective study in patients presenting with hydatid cyst of the liver to Surgery Department who were managed laparoscopically from January 2013 to November 2015.Result: There were 9 patients (5 males and 4 females). The mean operative time was 124+32 minutes. One patient developed mild allergy in the form of skin rashes on 3rd postoperative day, and another patient developed cholangitis which resolved on conservative management. There was no conversion.Conclusion: Laparoscopic management of hydatid cysts is possible, and looks promising provided we have advanced energy sources.
Clinicopathological study of gall bladder cancer and its relationship with gall stones
Authors: Poudel R , Singh SK , Basnet S , Devkota H , Adhikari SK
Published: July 2016

Introduction: Gall bladder cancer is the most common cancer of the biliary tree and one of the highly malignant tumors with poor prognosis. Although its incidence is low in west, it is common in our part of the world. There are very few studies regarding gall bladder cancer in Nepal. The incidence of gallstones in patients with gall bladder cancer is high. The aim of the study was to evaluate the clinicopathological aspect of the disease in patients with gallbladder cancer and to Asses the incidence of gallstones in patients with gall bladder cancer.Material and Methods: This was a retrospective study carried out in GI Surgery unit of National Academy of Medical Science, Bir Hospital, Kathmandu, Nepal. All patients diagnosed as gallbladder carcinomas during 12 years period from 2002 to 2014 were included in this study. Their clinical characteristics, laboratory data, tumor histopathology reports were obtained and analyzed using SPSS17.Results: Total of 47 patients who met inclusion criteria were included in the study. Male to Female ratio was 1:1.8. Age ranged from 32 to 72 years with mean age of 54. Most common presenting symptom was Pain abdomen (93.6%) followed by weight loss (51.1%) and Jaundice (46.8%). Most common finding on examination was Icterus (42.6%) followed by palpable gall bladder (34%) and Hepatomegaly (29.8%). Gall Stones were seen in 37 (72.3%) patients. Most common histopathology was Adenocarcinoma (93.6%).Conclusion: Most of the patient with gall bladder cancer remained asymptomatic until late. Pain abdomen was most common presenting symptom and icterus was most common findings. There was strong association between gall bladder cancer and gallstones. There should be high index of suspicion if patient with gallstones has constant pain in right hypochondrium and has jaundice.
Laparoscopic management of hydatid cyst of liver
Authors: Pradhan Sumita , Ghimire Bikal , Kansakar Prasan , Bhandar RAMESH Singh , Lakhey Paleshwan Joshi , Singh YP , Vaidya P , Mishra P , Singh KP
Published: July 2016

Background and Objectives: The surgical treatment of liver hydatid disease has evolved dramatically and laparoscopic treatment has shown encouraging results with the advantages of minimally invasive surgery. We conducted this study to determine the outcome of laparoscopic management of hydatid disease of the liver.Methods: Consecutive patients with this disease reporting to our department from July 2014 to July 2015 were offered laparoscopic management. All patients received pre- and postoperative albendazole. The laparoscopic technique consisted of aspiration of the cyst fluid, sterilization, suction and drainage of the cavity, deroofing and addition of omentoplasty. Age, sex, duration of surgery, surgical morbidity, hospital stay and evidence of hydatid cyst recurrence were measured.Results: Twenty six patients had laparoscopic treatment for hepatic hydatid cysts. Females were 18 (69.2%) and males were 8 (30.8%). Mean age of patients was 37.46 ± 15.96 years (range 17-74 years). Pain was the commonest presentation occurring in 21 (80.8%).The right lobe of the liver was most commonly involved in 20 patients (76.9%). The mean cyst size was 6.77 cm (range, 5 cm to 12 cm). Minor spillage of cyst contents occurred in 5 patients (19.23%) and major spillage occurred in 1 patient (3.8%). The mean duration of surgery was 84.81 ± 28.93 minutes (range 50 – 150 minutes). Conversion was needed in 2 (7.7%). Complications included portsite infection in 2 (7.7%), bile leak in 3 (11.5 %), fever in 5 (19.2%) and chest infection in 2 (7.7%) cases. Mean hospital stay is 4.58 ± 3.40 days (range 3-16). There was no mortality in the series. The average follow-up period is 7.81 ± 2.57 months. There have been no recurrences to date however 1 patient was lost to follow up.Conclusion: Laparoscopic management of hydatid cysts of the liver is a safe and effective option with advantage of minimally invasive surgery in properly selected patients.
Laparoscopic splenectomy: case series of 24 patients
Authors: Shakya Vikal Chandra , Paudyal Bishesh
Published: July 2016

Introduction and Objective: Splenectomy has mostly been performed by open surgery. Laparoscopy seems to be a meaningful alternative to open technique.Materials and Methods: This study was done in patients presenting to hematology and surgery department of Civil Service Hospital who underwent laparoscopic splenectomy from January 2013 to November 2015Results: There were 24 patients (16 females, 8 males). The diagnoses were idiopathic thrombocytopenic purpura in 19, hereditary spherocytosis in 2, @hemolytic anemia in 2, b-hemolytic anemia in 1. The mean operative time was 130+49 minutes. The mean postoperative stay was 5+2.11 days. Laparoscopic splenectomy could be completed in 21 patients. Rest 3 needed conversion to open (causes being excessive bleeding form splenic vein, splenic tear, and excessively low platelet counts). Three patients needed additional pfanneinsteil/lumbar incision to retrieve the spleen.Conclusion: Laparoscopic splenectomy could be successfully contemplated in patients with hematological diseases, more so if spleen is of normal or mildly enlarged; and could be an advantageous alternative to open splenectomy.
Early experience in pediatric hepatic resection at IOM, TUTH
Authors: Shah S , Kansakar P , Vaidya P
Published: July 2016

Total 5 pediatric hepatectomy were performed at IOM TUTH during last 2 years. Three children were cases of hepatoblastoma and two were cases of symptomatic focal noduler hyperplasia (FNH). Two left hepatectomy for left hepatoblastoma, one right hepatectomy for right hepatoblastoma were performed and 2 non-anatomical resection of mass with 2 cm margin for focal nodular hyperplasia were performed. Median hospital stay was 7 days. Post operative period at hospital was uneventful. Three cases of hepatoblastoma received neoadjuvant and adjuvant chemotherapy. Among 3 cases of hepatoblastoma, there was one mortality due to severe sepsis when he was on adjuvant chemotherapy. Other 4 cases are living without recurrence.
Total extraperitoneal approach in large inguino-scrotal hernias: an institutional approach
Authors: Shah Tuhin , Shah S , Joshi BR , Karkee RJ , Gupta RK
Published: July 2016

Introduction: Since 2 decades laparoscopichernia repair has gained key role in uncomplicated inguinal hernia surgery with advantages showed by several trials and guidelines. However, its role in complicated inguinal hernia such as incarcerated, obstructed and inguino-scrotal is debatable. Cases of large inguino-scrotal raises objection to laparoscopic procedure because of anticipated problems and complications in dissecting extended hernia sac even though posterior approach is advocated as repair of choice for complicated cases. Here, we reviewed our series of patients undergoing TEP in a limited time frame.Method: Between March 2013 and June 2014, 50 consecutive patients underwent TEP repair for inguinoscrotal hernia. Patient demographics, hernia characteristics, operating time, surgical technique, conversion rate, intraoperative, postoperative complications and recurrence was recorded and analyzed using MS Excel.Results: 50 patients were recorded, 26 had unilateral and 24 had bilateral hernias. Mean age was 52 (22-72) years. The mean operation time was 70 (50-140) min. Bilateral repairs took 45% (18 min) longer than for unilateral repairs (52 + 12 min). Two (12.5%) patients required combined open surgery to transect the incarcerated omentum. There was no mortality. Morbidity was limited to asymptomatic seroma formation in 2 (12.5%) patients; 1 patient of combined open-TEP approach had wound infection, both treated conservatively. Mean follow up was 6.3 months; we recorded 2 recurrences (12.5%). The mean length of hospital stay was 1.8 days.Conclusion: We conclude that TEP can be safely employed for complicated inguinal hernias repair. Surgical experience in mandatory with tailored technique to reduce morbidity and achieve good clinical outcome with acceptable recurrence rates.
Cystic lesions of pancreas: challenges in diagnosis and management
Authors: Bohara S , Tamang TY , Maharjan DK , Shrestha SK , Thapa PB
Published: July 2016

Introduction: Pancreatic cysts are common (2.5%). Cystic neoplasms represent 10% of cystic lesions and 1% of pancreatic tumors. However, it is difficult to differentiate benign cyst from malignant cystic lesions preoperatively.Objective: To study the cases of pancreatic cystic lesion who underwent various forms of pancreatic resection.Materials and Methods: Nine cases of pancreatic cystic lesion who presented to Kathmandu Medical College Teaching Hospital, Surgical Unit 3 within December 2014- November 2015 were evaluated. Four pancreatic cysts who underwent resection are discussed whereas not managed with resection are excluded.Results: There were 4 cases of pancreatic cyst who underwent pancreatic resection. First case underwent pancreaticoduodenectomy for pancreatic mucinous cystadenoma. However histopathological examination revealed a serous cystadenoma. In second case, pancreatic neck lesion suspected to be mucinous cystadenoma or pseudocyst in MRCP, with negative malignant cells in EUS guided FNAC underwent Central pancreatectomy and was found to be serous cystadenoma. The third case with suspected pseudocyst underwent Pancreaticoduodenectomy after a 3X2 cm2 cystic mass was felt at the posteroinferior side of pancreatic head and malignancy was suspected intraoperatively . HPE report was mucinous cystadenoma. The fourth case with pancreatic pseudocyst at tail with duct calculi and chronic pancreatitis underwent distal pancreatectomy with splenectomy with Frey’s procedure.Conclusion: Management of pancreatic cystic lesion is challenging. Though radiological imaging has limited role in accurate diagnosis, endoscopic ultrasound may be of some benefit.
Minimal invasive endoscopic neurosurgery
Authors: Thapa Amit , KC Bidur , Shakya Bikram
Published: July 2016

Introduction and Objective: If microscope heralded a new era in delicate and precise neurosurgical procedures, endoscope introduced an element of minimal invasiveness and supplemented microscope where they could not reach. We introduced and have been improving this art in brain and spine surgery and here present our experiences.Materials and Methods: We retrospectively studied patients who underwent endoscopic neurosurgery since July 2014 till January 2016 for brain and spine diseases. Endpoints for the audit were feasibility, reliability, cost effectiveness, extra time taken and morbidity.Results: We used endoscope in 42 cases. Ventriculoscopy was done for endoscopic third ventriculostomy, septoplasty, cyst aspiration and excision and biopsy. Nasal endoscopy was used to excise pituitary tumor and repair skull base CSF leaks. Spinal endoscopy was performed to remove herniated discs and canal stenosis. Endoscope helped in microscopic excision of acoustic schwannoma as well as craniopharyngioma. We did not have any mortality however CSF leaks were seen which was successfully managed. Since endoscopic procedures involve minimal incision and retraction, patients could be discharged early and mobilised. We discuss our learning phase and limitations of the endoscope with videos and case scenarios.Conclusion: A continuous phase of learning and problem solving is required to master the art of minimal invasive neurosurgery. Use of endoscope not only supplemented microscope but in cases of ventricular surgery is beyond comparison. It has minimised morbidity as well as hospital stay and is cosmetically acceptable to patients.
Management of gun shot injury in a tertiary hospital
Authors: Joshi A
Published: July 2016

Introduction: Gun shot injury is an uncommon surgical emergency . A timely and multidisciplinary management by surgical team is an essential factor in decreasing mortality and morbidity . This study highlights the multidisciplinary management of gun shot injury.Methodology: Bir hospital is a postgraduate teaching hospital under National Academy of Medical Sciences and tertiary referral center in Kathmandu. A prospective cohort study of gunshot injury was conducted during Septemeber 2015 and early outcome analysis was done.Results: There were thirteen cases of gunshot wound. The mean age of casualty was 31 years and all were male.Injury                 Number (n)    Intervention                             Outcome Large intestine            3            Laparotomy                             Ileostomy/wound infection Perineum                   1            Exploration/Debridement           Loop ileostomy Bone- fracture            3            Traction/Enternal fixation/                                               Open reduction Internal Fixation Vertebra                     1                                                          Right hip power 3/5 Vascular- AV fistula      1           stenting                                   Referred Brachial plexus            1                                                         Sensory/motor deficit Neck                           2           Exploration                              Marginal mandibular                                                                                              nerve palsy Elbow                          1           Debridement/Split                                                thickness skin graftThere were no mortality and one case was referred.Discussion: With the multidisciplinary team approach, all the gunshot injury cases were managed with good outcome. The timely intervention by a surgical team is an essential factor for proper management of gun shot injury.
Centchroman versus Tamoxifen in the management of mastalgia: a randomized controlled clinical trial
Authors: Khadka S , Rajbanshi S , Khaniya S , Agrawal CS , Adhikary S
Published: July 2016

Introduction and Objective: Mastalgia is defined as painful nodularity for more than 1 week of menstrual cycle. The long list of drugs highlights the ongoing debate about the drug of choice for the management of mastalgia. So in this study, we compared the effectiveness and cost of Centchroman and Tamoxifen in the management of mastalgia.Materials and methods: A total of 106 female patients with the clinical diagnosis of mastalgia were enrolled in the study and randomized to 1:1 ratio into Centchroman and Tamoxifen group for a period of 1 year. The duration of therapy was 3 months. All patients completed the study and follow up. The response of therapy was assessed on 1, 2, 3 and 6 months by using a Visual Analogue Scale (VAS).Results: Baseline mean VAS score was 6.25 in Tamoxifen and 6.49 in Centchroman group.There was marked improvement in VAS score after the treatment in both the groups, which was statistically significant with greater reduction in Centchroman group(p= 0.001).The number of patients who achieved VAS less than 3 were 51(96.2%) in Centchroman and 49(92.5%) in Tamoxifen group at the end of treatment. Tamoxifen was found to be statistically significant and cost-effective (p <0.001) in comparison to Centchroman.Conclusion: We conclude that Centchroman is not inferior to Tamoxifen and both the drugs effectively reduced pain, however Centchroman reduced the pain more than Tamoxifen.
Laparoscopic inguinal hernia repair (total extra-peritoneal): tips and tricks
Authors: Bhattarai SM , Simkhada G , Shah T , Gupta RK
Published: July 2016

Introduction: Inguinal hernia is one of the major problems at B.P. Koirala Institute of Health Sciences (BPKIHS), a tertiary referral center. We perform Laparoscopic hernia repair as a routine procedure for groin hernias. This technique is highly demanding and complex. In our country the development of laparoscopic technique is still in a developing phase.Aims and objective: To present technical tips and trick in LIHR, which we experienced, as lead to preventing intra/post operative complication.Results: We have performed a total of 129 groin hernia repairs in 105 patients with M: F= 26:1 and mean age 41.97±20 (16-85). The mean length of hospital stay was 1.14 ± 0.35 days. Eight patients were converted to TAPP and 1 converted to open hernia repair due to operative difficulty. The complications encountered are pain (20), seroma(8) and epididymitis(2).Conclusion: In our experience LIHR (TEP) is safe method for routine management of groin hernias.