COVID-19 Pandemic: What is Known Till June 2020 and What is Yet to Know?

Since first cluster of unknown pneumonia from China reported in December 2019 to World Health Organization, more than 10.5 million new cases and more than 0.513 million deaths have been reported till June 30, 2020 in six months' time. World got to know lot of facts about COVID-19 within short period of six months and success stories too concerning its containment. The situation has constantly been unfolding every moment educating people regarding public health and clinical aspects of the infection and disease and its impact on countries and communities. But still lot of information and evidences are required with regard to pharmacological interventions including effective drugs and efficacious vaccine to mitigate the impact of COVID-19 pandemic at all levels. It seems that we have to live with COVID-19 months-years as the virus is going to stay for longer period of time. The option is to continue practice of effective non-pharmacological interventions as to minimize spread of COVID-19 and ensure adequate provision of PPE to healthcare workforce and testing of health-care workers (HCWs) as to alleviate the anxiety of HCW and lessen their depletion by unnecessary quarantine thereby protect their health and reduce in hospital transmission.

The demise of a wonder: Evolutionary history and conservation assessments of the Wonder Gecko Teratoscincus keyserlingii (Gekkota, Sphaerodactylidae) in Arabia

Effective biodiversity conservation planning starts with genetic characterization within and among focal populations, in order to understand the likely impact of threats for ensuring the long-term viability of a species. The Wonder Gecko, Teratoscincus keyserlingii, is one of nine members of the genus. This species is distributed in Iran, Afghanistan, and Pakistan, with a small isolated population in the United Arab Emirates (UAE), where it is classified nationally as Critically Endangered. Within its Arabian range, anthropogenic activity is directly linked to the species’ decline, with highly localised and severely fragmented populations. Here we describe the evolutionary history of Teratoscincus, by reconstructing its phylogenetic relationships and estimating its divergence times and ancestral biogeography. For conservation implications of T. keyserlingii we evaluate the genetic structure of the Arabian population using genomic data. This study supports the monophyly of most species and reveals considerable intraspecific variability in T. microlepis and T. keyserlingii, which necessitate broad systematic revisions. The UAE population of T. keyserlingii likely arrived from southern Iran during the Pleistocene and no internal structure was recovered within, implying a single population status. Regional conservation of T. keyserlingii requires improved land management and natural habitat restoration in the species’ present distribution, and expansion of current protected areas, or establishment of new areas with suitable habitat for the species, mostly in northern Abu Dhabi Emirate.

An integrative assessment of the diversity, phylogeny, distribution, and conservation of the terrestrial reptiles (Sauropsida, Squamata) of the United Arab Emirates

In the present study we use an unprecedented database of 5,535 distributional records to infer the diversity, ecological preferences and spatial distribution of the 60 species of terrestrial reptiles of the United Arab Emirates (UAE), and use the 57 native species to test the effectiveness of the protected areas’ network in conserving this unique vertebrate fauna. We infer a time-calibrated phylogeny with 146 species of squamates and 15 genes including all UAE terrestrial reptile species to determine the phylogenetic diversity (PD) and evolutionary distinctiveness (ED) of the native species and to compare it with the distribution of the hotspots of native species richness. The results of this study indicate that the sampling effort is remarkable, covering 75% of the country’s territory representing nearly the entire climatic space of the UAE defined by the mean annual temperature and the total annual precipitation, as well as the multivariate climatic space defined by a principal component analysis (PCA). Species richness is highest in the northeast of the country, in a transitional area from sandy desert to the mountainous terrain of the Hajar Mountains. The highest PD of a single square cell of 10 arc-minutes grid is of 2,430 million years (my) of accumulated evolutionary history and the strong correlation between PD and species richness suggests that the raw number of species is a good surrogate to quantify the evolutionary history (i.e., PD). The species with the highest values of ED are those in families represented by only one species in the UAE. Finally, the assessment of the UAE protected areas shows that, despite their relevance in protecting the terrestrial reptiles, they do not offer adequate protection for some threatened species. Therefore, a reassessment of some of the protected areas or the creation of species specific conservation action plans are recommended in order to ensure the preservation of the unique diversity of UAE terrestrial reptiles.

Admitting Deserving Medical Students from Rural and Disadvantaged: Patan Academy of Health Sciences' Approach

BACKGROUND

Patan Academy of Health Sciences (PAHS) aims to produce physicians who would be able and willing to serve in the rural areas. Recognizing the critical importance of student selection strategy, among others, in achieving the program goals, it has adopted an innovative scheme for selecting medical students. This paper describes PAHS medical student selection scheme that favors enrollment of deserving applicants from rural and disadvantaged groups so as to help improve distribution of physicians in rural Nepal.

METHODS

A student admission committee comprising a group of medical educators finalized a three-step student selection scheme linked with scholarships after reviewing relevant literatures and consultative meetings with experts within and outside Nepal. The committee did local validation of Personal Quality Assessment (PQA) that tested cognitive ability and personality traits, Admission OSPE (Objective Structured Performance Examination) that assessed non-cognitive attributes of applicants. It also provided preferential credits to applicants' socio-economic characteristics to favor the enrollment of deserving applicants from rural and disadvantaged groups through Social Inclusion Matrix (SIM). Three different categories of scholarship schemes namely Partial, Collaborative and Full were devised with Partial providing 50% and other two categories each providing 100% coverage of tuition fee.

RESULTS

PAHS student selection scheme succeeded in enrolling more than half of its students from rural areas of Nepal, including about 10% of the students from that of the most backward region of the country. About one third of students were female and about the same were from public and community school. Sixty percent of students receive different categories of scholarships.

CONCLUSIONS

Limited findings indicate the success of the selection scheme in enrolling high proportion of applicants from rural and disadvantageous groups and enable them to pursue study by providing scholarships.

Presence of choledocholithiasis in patients undergoing cholecystectomy for mild biliary pancreatitis

Background: Standard recommendations for patients recovering from an episode of biliary pancreatitis include cholecystectomy with intra operative cholangiogram or ERCP during the same hospital admission as it is believed that the instigating factor is the passage of stones through the common bile duct. As ERCP is not widely available and expensive, cholecystectomy with IOC is routinely performed to rule out choledocholithiasis. However detection of common bile duct stones is challenging. Whether these patients undergoing cholecystectomy require direct common bile duct evaluation is controversial.Objectives: To see the presence of common bile duct stones in patients with resolving acute mild biliary pancreatitis.Materials and Methods: Patients admitted in the surgical ward in Patan and Bir hospital with the diagnosis of mild acute biliary pancreatitis that underwent cholecystectomy with intra operative cholangiography from August 2010 to July 2011 were studied. The outcome of cholangiogram was analyzed together with findings of Common bile duct exploration.Result and Conclusion: A total of 52 patients with acute mild biliary pancreatitis were operated during this period. The Common bile duct stone was found in 1.9%. Out of four patients with abnormal cholangiogram, only one patient (25%) had stone on exploration, rest of the three cases (75%) had negative exploration. The presence of common bile duct stone in case of mild acute biliary pancreatitis undergoing cholecystectomy is very low (1.96%), and thus policy of selective IOC should be applied for cases with mild biliary pancreatitis.Bangladesh Journal of Medical Science Vol.15(4) 2016 p.517-521

Presence of choledocholithiasis in patients undergoing cholecystectomy for mild biliary pancreatitis

Introduction: Standard recommendations for patients recovering from an episode of biliary pancreatitis include cholecystectomy with intra operative cholangiogram or ERCP during the same hospital admission as it is believed that the instigating factor is the passage of stones through the common bile duct. As ERCP is not widely available and expensive, cholecystectomy with IOC is routinely performed to rule out choledocholithiasis. However detection of common bile duct stones is challenging. Whether these patients undergoing cholecystectomy require direct common bile duct evaluation is controversial. Objective of the study was to see the presence of common bile duct stones in patients with resolving acute mild biliary pancreatitis. Methods: Patients admitted in the surgical ward in Patan Hospital and Bir Hospital with the diagnosis of mild acute biliary pancreatitis who underwent cholecystectomy with intra-operative cholangiography from August 2010 to July 2012 were studied. The outcome of cholangiogram was analyzed together with findings of common bile duct exploration. Results: A total of 52 patients with acute mild biliary pancreatitis were operated during this period. The common bile duct stone was found in 1.9%.  Out of four patients with abnormal cholangiogram, only one patient (25%) had stone on exploration, rest of the three cases (75%) had negative exploration.Conclusion: The presence of common bile duct stone in case of mild acute biliary pancreatitis undergoing cholecystectomy is very low (1.96%), and thus policy of selective IOC should be applied for cases with mild biliary pancreatitis.Journal of Society of Surgeons of Nepal Vol.17(1) 2014: 11-15

Taking Specialist Surgical Services to the Rural District Hospitals at One Forth Cost: A Sustainable 'Return on Investment' Public Health Initiative of Patan Hospital, Patan Academy of Health Sciences, Nepal

The inequitable distribution and centralization of resources and services in urban area persists around the world, more so in developing countries. The challenge to meet the health needs of rural population requires health policy makers, government and concerned organization to put extra efforts. Such efforts require innovative, feasible and sustainable strategies to address the social justice of people living in districts away from capital and urban cities. At Patan Academy of Health Sciences, the medial school curriculum is designed to address these issues. Together with health professionals from Patan Hospital, the main teaching hospital on which the academy evolved, have initiated strategies to bring specialist services, starting with surgical services to remote district hospitals to serve the need of rural population. This initiative is 'desirable, doable and feasible'. Further more, this can be modified for replication and promotion by other academic institutions, central hospitals and government health system.

Recurrence of subsquamous dysplasia and carcinoma after successful endoscopic and radiofrequency ablation therapy for dysplastic Barrett's esophagus

Barrett's esophagus with dysplasia is commonly treated with radiofrequency ablation (RFA). Despite its effectiveness, a concern of any ablative technique is the development of subsquamous intestinal metaplasia, which could have potential for future neoplastic progression. To date, 34 cases of subsquamous neoplasia have been described in the literature after various ablation therapies. However, only three cases of subsquamous neoplasia have been reported after successful RFA treatment of dysplastic Barrett's esophagus. In this case series, we report on four additional cases of subsquamous neoplasia detected after successful endoscopic resection and RFA for neoplastic and dysplastic Barrett's esophagus. All four patients were treated successfully with endoscopic resection of their recurrent subsquamous neoplastic and dysplastic lesions. This case series highlights the need for continued surveillance following successful treatment of dysplastic Barrett's esophagus with RFA.

Is routine hospital visit after day case inguinal hernia surgery in children necessary?

BACKGROUND

To observe the prospects of day case inguinal hernia surgery in children without routine postoperative hospital visits. The aim was to access the advantages, acceptability and safety of this change in practice in low resource country like Nepal.

METHODS

This was a cross-sectional study in a tertiary care general teaching hospital. Thirty children aged 6 months to 14 years who had elective day case Inguinal Hernia surgery from May 2011 to Oct 2011 were prospectively observed. Children with obstructed hernia, un-descended testis were excluded. Parents were counseled for omission of routine hospital visit after surgery. Main outcome measures were to observe unplanned hospital visit, reasons for visit, post-operative pain, wound infection and overall satisfaction of parents interviewed by telephone. Study was approved by institutional review committee.

RESULTS

There were 28 boys and two girls. Average age was five years. Right Inguinal Hernia patients were 19 in number while 11 patients had left sided hernia. None of the children visited health facility for pain or wound problem. Two children were brought to outpatient because they were mistakenly given appointment slip. Mother noticed recurrence and brought one child to surgical outpatient. All 30 parents responded to telephone enquiry and were satisfied.

CONCLUSIONS

Routine follow up visit after day care Inguinal Hernia surgery in children is not necessary. This practice is safe, economic and well accepted by children and parents.

Endoscopic ultrasound-guided drainage of pancreatic fluid collections with indeterminate adherence using temporary covered metal stents

Transenteric drainage of a pancreatic fluid collection (PFC) with poor adherence to the bowel wall risks leakage and perforation. Elimination of tract dilation and the use of a fully covered self-expanding metal stent (FCSEMS) may improve safety. We evaluated endoscopic ultrasound (EUS)-guided drainage of PFCs using a one-step access device followed by placement of a FCSEMS. Eighteen patients (12 males; median age 50) with PFCs (median size 135 mm) meeting the criteria for indeterminate adherence were enrolled. After 7 - 10 days, the FCSEMSs were removed and exchanged for double-pigtail stents. When indicated, tract dilation and endoscopy-guided cyst debridement was performed. FCSEMS placement was technically successful in all patients without complications. Median procedure time was 37.5 minutes. Cystgastrostomy dilation resulted in dehiscence in one patient and was treated with repeat FCSEMS placement. Cyst resolution was achieved in 78 % of patients. FCSEMS placement without tract dilation enables safe initial drainage of PFCs with indeterminate adherence.

Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study

BACKGROUND AND STUDY AIMS

Surgical gastroenterostomy is associated with appreciable morbidity and mortality. We evaluated the technical feasibility and outcomes of a new method of endoscopic ultrasound (EUS)-guided gastroenterostomy using novel tools designed for transluminal therapy.

METHODS

In one acute and four survival female pigs, a gastroenterostomy was created under EUS guidance. Novel tools used included: (i) an anchor wire; (ii) an access device; (iii) a fully covered metal stent with bilateral lumen-apposing anchors. The anchor guide wire was inserted through a standard 19-G fine needle aspiration (FNA) needle to appose the small-bowel and stomach walls. The access device created a 3.5-mm fistula opening for insertion of the stent delivery catheter. The stent lumen was dilated to 10 mm to pass a gastroscope into the small bowel.

RESULTS

The procedure was technically successful in all animals. No bleeding occurred. In one acute animal, necropsy showed good stent position and no tissue injury. In four survival animals, the stents remained fully patent and all animals showed normal eating behavior without signs of infection. Stents were easily removed without tissue trauma at 4.5 weeks (n = 3) or 5.5 weeks (n = 1). After stent removal, the tracts appeared mature and were easily intubated with the gastroscope. Necropsy and histopathology showed complete fusion of the stomach and small-bowel wall layers at the site of gastroenterostomy.

CONCLUSIONS

EUS-guided gastroenterostomy is feasible using novel tools with no adverse outcomes in a survival porcine model. Further study of this is indicated as an alternative to surgical bypass for the palliation of malignant gastric outlet obstruction in appropriately selected patients.

Need of Improvement in Timing of Prophylactic Antibiotic in Elective Surgery

Objective: Infections in surgery are major concern of morbidity, mortality, and costs. Timely antibiotic prophylaxis (AP) before incision ensures optimum concentration of AP in blood and tissues to prevent surgical site infections (SSIs). However, proper timing of AP remains problematic as reported by various studies, though none so far from  local institutions in Nepal. Aim of this cross sectional observation study was to assess and address the issues of timing of AP and need for improvements. Material & Methods: Convenient sample target of 100 cases of preoperative AP were studied from Oct 1 to Oct 30, 2010. Data were prospectively entered in predesigned ‘AP form’ for all major elective surgeries, except obstetric cases, who received AP of intravenous Cefazoline 1 g as per existing hospital protocol. Time of AP administration in respect to incision time was analyzed. Results: There were 125 cases during study period. Majority, 81% received AP before incision, while 19% had AP after the incision. Only 1% of patients received AP within recommended period within 60 to 30 minutes before incision. Conclusion: Current practice of antibiotic prophylaxis (AP) at our institutions needs improvement as per standard guidelines of AP within 60 to 30 minutes before incision. DOI: http://dx.doi.org/10.3126/ajms.v2i3.5610 Asian Journal of Medical Sciences 2 (2011) 207-211 

Early feeding and discontinuation of intravenous fluid after laparoscopic cholecystectomy

BACKGROUND

Common practice at most centers in the country is to continue intravenous (i.v.) fluid till morning round next day following laparoscopic cholecystectomy (LC), assess patient and gradually allow oral diet. However this seems unnecessary in view of fast recovery after minimal invasive LC. The aim of this study was to observe the prospects and assess the acceptability, safety and benefit of early oral feeding and discontinuing i.v. fluid after LC.

METHODS

This cross-sectional observational study was carried out prospectively from Oct 1, 2009 to Sep 31, 2010 at Patan Hospital, a university teaching hospital. All elective LC patients were included. Oral liquid was introduced after four hours and i.v. fluid was stopped after six hr of LC. I.v. cannula was kept locked in situ. Vomiting, abdomen distension and reasons for continuation or resumption of i.v. fluids were recorded.

RESULTS

During one year period 294 LC patients fulfilled study criteria. Average age was 40.8 years. Female accounted for 78.2%. Oral fluid was started in average of 5.5 hrs in 97%. In 3% (9/294) i.v. was continued. Postoperative nausea and vomiting was observed in 25.9% (76/294), of which 6.6% (5/76) required i.v.. There was no untoward affect after i.v. fluid was stopped.

CONCLUSIONS

Early oral feeding and discontinuing of intravenous fluid in laparoscopic cholecystectomy is safe, economic and well accepted by patients, family and nursing staff in Patan hospital.

Endoscopic ultrasound-guided anterograde treatment of biliary stones following gastric bypass

Endoscopic treatment of bile duct stones in gastric bypass patients is challenging. We describe a novel method involving endoscopic ultrasound (EUS)-guided anterograde interventions. After prior experience with EUS-guided rendezvous endoscopic retrograde cholangiopancreatography (ERCP) and direct EUS-guided anterograde stenting for malignant biliary obstruction, we have attempted EUS-guided treatment of biliary stones as first-line therapy following gastric bypass. Our approach involves: (i) EUS-fine needle aspiration (FNA) puncture into an intrahepatic bile duct; (ii) EUS-guided cholangiography; (iii) guide wire advancement across the ampulla; (iv) catheter dilation of the transhepatic-transgastric access tract; (v) anterograde balloon sphincteroplasty; and (vi) anterograde advancement of stones across the ampulla using a balloon catheter. We reviewed outcomes and complications of this technique. Six patients with previous Roux-en-Y gastric bypass were referred for treatment of symptomatic choledocholithiasis. EUS-guided transhepatic puncture and cholangiography was successful in 100 %, and revealed choledocholithiasis in all patients. Tract dilation, anterograde balloon sphincteroplasty, and stone extraction were successful in four (67 %). Anterograde sphincteroplasty failed in two patients due to inability to advance the transhepatic dilation catheters. In both cases, wires were advanced down the afferent limb, and rendezvous ERCP using double-balloon enteroscopy was successful. Five patients experienced no complications. One patient in whom EUS anterograde therapy failed due to difficulty in advancing the transhepatic dilation catheter, developed a subcapsular hepatic hematoma. This was managed conservatively. Direct EUS-guided treatment of biliary stones after gastric bypass appears safe and feasible. Further studies are needed to confirm the safety and efficacy of this technique.

A five years review intra-operative cholangiogram

BACKGROUND

Intra-operative cholangiogram is often performed to detect concurrent common bile duct stones in cholecystectomy patients. Routine cholangiogram add to cost and exposes patients to unnecessary exploration of common bile duct due to frequent false positive results. Thus, there is need of better indicators for cholangiogram in order to minimize unnecessary procedure and its morbidity.

METHODS

A retrospective analysis of patients undergoing intra-operative cholangiogram during open or laparoscopic cholecystectomy was done at Patan Hospital from Oct 1, 2005 to Sep 31, 2009. Indications and outcome of cholangiogram were analyzed together with findings of common bile duct exploration.

RESULTS

A total of 68 (2.8%, 68/2400) intra-operative cholangiogram were done in 2400 cholecystectomy patients during five years period. Eight (11.8%, 8/68) patients had abnormal findings. Two (3%, 2/68) patients with abnormal cholangiogram had stones in common bile duct. There was no mortality in this series.

CONCLUSIONS

Existing indications of intra-operative cholangiogram detects only small percentage of patients with bile duct stones and has high false positive results. This unnecessarily increases bile duct exploration, cost and morbidity. Thus, there is need to redefine indications for intra-operative cholangiogram.

Outcomes of endoscopic papillectomy in elderly patients with ampullary adenoma or early carcinoma

Outcomes for 14 elderly (age ≥ 70 years) patients (79.4 ± 1.0 years) who underwent endoscopic papillectomy for ampullary tumors were compared with those of 22 younger (age < 70 years) patients (52.5 ± 1.9 years). There were no differences in procedural success (100%), bleeding (5/14 vs. 6/22), adenoma recurrence (0/14 vs. 2/22) and median survival (24.0 vs. 25.5 months) between the elderly and younger patients. In younger patients, although adenoma recurrences (n=2) were managed endoscopically, invasive adenocarcinomas (n=3) were treated by pancreatoduodenectomy. All elderly patients with invasive (T2) tumors (n=5) were not surgically fit and underwent successful palliation with further endoscopic resection and stenting. Whilst all younger patients survived, five elderly patients died but three of these deaths were not cancer-related. Advanced age, therefore, did not adversely influence the outcomes of endoscopic papillectomy, suggesting it may be a treatment of choice for elderly patients with ampullary tumors or early cancer who are deemed unfit for surgery.

Need of improvement in timing of prophylactic antibiotic in elective surgery

INTRODUCTION

Infections in surgery are major concern of morbidity, mortality, and costs. Timely antibiotic prophylaxis before incision ensures optimum concentration of AP in blood and tissues to prevent surgical site infections . However, proper timing of AP remains problematic as reported by various studies, though none so far from Nepal. Aim of this prospective observational study was to assess and address the issues for improvements in timing of AP.

METHODS

The pattern of antibiotic prophylaxis were prospectively collected in respect to time of induction, and incision time were recorded on predesigned 'AP form'. The study included all the elective major cases who received AP of intravenous Cefazoline 1 g as per our existing protocol. The emergency surgeries and obstetric cases were excluded from the study.

RESULTS

There were 125 cases of which 89% received AP before incision (63% within 5 minutes before incision), while 11% had AP after the incision and 1% within the recommended time period of 2 hour to 30 minutes before incision.

CONCLUSIONS

Current practice of antibiotic prophylaxis (AP) needs improvement as per standard guidelines of AP within 2 hour to 30 before incision.

Animated brain: a functional neuroimaging study on animacy experience

Previous research used animated geometric figures to investigate social cognitive processes involved in ascribing mental states to others (e.g. mentalizing). The relationship between animacy perception and brain areas commonly involved in social cognition, as well as the influence of particular motion patterns on animacy experience, however, remains to be further elucidated. We used a recently introduced paradigm for the systematic variation of motion properties, and employed functional magnetic resonance imaging to identify the neural mechanisms underlying animacy experience. Based on individual ratings of increased animacy experience the following brain regions of the "social neural network" (SNN), known to be involved in social cognitive processes, were recruited: insula, superior temporal gyrus, fusiform gyrus, parahippocampal gyrus and the ventromedial prefrontal cortex bilaterally. Decreased animacy experience was associated with increased neural activity in the inferior parietal and inferior frontal gyrus, key constituents of the human "mirror neuron system" (hMNS). These findings were corroborated when analyses were based on movement patterns alone, irrespective of subjective experience. Additionally to the areas found for increased animacy experience, an increase in interactive movements elicited activity in the amygdala and the temporal pole. In conclusion, the results suggest that the hMNS is recruited during a low-level stage of animacy judgment representing a basic disposition to detect the salience of movements, whereas the SNN appears to be a high-level processing component serving evaluation in social and mental inference.

Clipless laparoscopic cholecystectomy--a prospective observational study

In laparoscopic cholecystectomy (LC), cystic duct and artery are normally secured with titanium clips. Intracorporeal ligation is normally superior to extra corporeal knotting. Most studies report of separate and multiple ligations of cystic duct and artery, which are viewed as technically demanding and time consuming. Similarly the harmonic scalpel and 'LigaSure' are prohibitory expensive for resource limited country like Nepal. After several modifications, we observed the success of intracorporeal "single ligation of cystic artery and duct" with free silk tie. From Jul to Oct 2009, after a pilot study and several modifications ofintracorporeal ligation, we successfully used single ligation of cystic artery and duct (SLAD) with free silk 2/0 in symptomatic cholelithiasis patients.80 cases undergoing elective laparoscopic cholecystectomy. There were 80 patients, females 71.0% (n=57). Average age of patients was 39 yr (14-65). We had no bile leak or other complications related to ligature. The time taken for tie varied from 2 to 7 minutes (average 3 min). In 3 cases, a 5th port was made to grasp and ligate the bleeding vessels. There were 19 (25.0%) acute calculus cholecystitis, including mucocele, empyema, gangrenous cholecystitis. Two patients (2.0%) had inflammation of umbilical port which healed spontaneously. This technique of intracorporeal single ligation of cystic artery and duct (SLAD) in LC is simple, safe and economical. SLAD do not increase operative time as only single tie is used. This no clip laparoscopic cholecystectomy (NCLC) eliminates the clip related complications.

Endoscopic ultrasound (EUS)-guided transhepatic anterograde self-expandable metal stent (SEMS) placement across malignant biliary obstruction

Endoscopic retrograde cholangiopancreatography (ERCP) with placement of self-expandable metal stents (SEMS) for palliation of malignant obstruction may not be possible in patients with an inaccessible biliary orifice. Endoscopic ultrasound (EUS)-guided drainage methods may be useful in this setting. This study aimed to determine the outcomes of EUS-guided anterograde SEMS placement across malignant strictures in patients with an inaccessible biliary orifice. Over a 2-year period, procedural and outcomes data on all patients undergoing EUS-guided anterograde SEMS drainage after failed ERCP were prospectively entered into a database and reviewed. Five patients underwent EUS-guided anterograde SEMS. Indications included: advanced pancreatic cancer (n = 3), metastatic cancer (n = 1), and anastomotic stricture (n = 1). The biliary orifice could not be reached endoscopically due to duodenal stricture (n = 4) or inaccessible hepaticojejunostomy (n = 1). EUS-guided punctures were performed transgastrically into left intrahepatic ducts (n = 4) or transbulbar into the common bile duct (n = 1). Guide wires were passed and SEMS were successfully deployed across strictures in an anterograde fashion in all patients. Jaundice resolved and serum bilirubin levels decreased in all cases. No procedure-related complications were noted during a mean follow-up of 9.2 months. EUS-guided anterograde SEMS placement appears to be a safe and efficient technique for palliation of biliary obstruction in patients with an endoscopically inaccessible biliary orifice. The procedure can be performed at the time of failed standard ERCP, and provides an alternative drainage option to percutaneous or surgical decompression and to EUS-guided creation of bilioenteric fistulae.

Endoscopic management of biliary tract disease

New investigations, evaluation of controversial issues, and advances in technology continue to shape the endoscopic management of biliary disorders. This article discusses recent literature related to the diagnosis and therapy of biliary tract disease. Specifically, the diagnosis and management of choledocholithiasis, complications of biliary endoscopy and potential preventive measures, roles for endosonography in the evaluation of biliary disease, and endoscopic therapy of postoperative liver transplantation complications are reviewed. Recent advances in biliary stents and the use of cholangioscopy in biliary disorders are also assessed.

Paediatric Day Care Inguinal Hernia Surgery in a General Hospital: A Prospective Study on Change in Practice

Introduction: This prospective study was undertaken to observe the prospects of daycare inguinal hernia surgery in general hospital setup in a developing country like Nepal and to assess the advantages, acceptability and safety of this approach. Methodology: The study was carried out prospectively for one year from March 2009- Feb 2010. Before surgery, children were examined in surgical referral clinic (SRC). Parents were given verbal and written instructions for pre-operative fasting. Operations were carried out under intravenous anesthesia without intubation by experienced consultant general surgeon or by registrar under supervision. Children were observed in recovery area till conscious. Once awake, the children were handed over to parents for further observation till fully conscious and could tolerate liquid. Oral Paracetamol and homecare instructions were given to parents. Appointment slip was given for follow up visit in SRC within 3-5 days. Results: There were 90 children, male 81 (89%), age 2 months to 13 years. Right inguinal hernias were 62 (70%). There were no major complications, mortality or readmission. Saving in terms of less disruption of routine work at home and office was more appreciated by parents. Conclusion: We conclude that day care inguinal hernia surgery in children in our setup is safe, economic well accepted by child and parent's both. Key words: Children; Day case hernia surgery; Paediatric inguinal hernia DOI: 10.3126/jnps.v30i3.3913J Nep Paedtr Soc 2010;30(3):128-131

JEJUNO-JEJUNAL INTUSSUSCEPTION DUE TO LIPOMA

Sixty eight year old lady from Kathmandu presented to Emergency Department, Patan Hospital with painand abdomen distention associated with vomiting and constipation. Abdomen examination revealed a massin infraumblical region. Emergency laparotomy for acute intestinal obstruction revealed jejuno-jejunalintussusception due to multiple lipoma of jejunum intestine. Resection anastomosis was done. Postoperativeperiod was uneventful.Key Words: Intussusception, Intestinal obstruction, Jejunum, Lipoma.