jssn vol 17 no1_final to print copy.pdf jssn journal of society of surgeons of nepal jssn 2014; 17 (1) early warning score in predicting the severity of acute pancreatitis poudyal s, singh yp correspondence: abstract introduction: warning score and severity of pancreatitis. methods: results: conclusion: complications of acute pancreatitis. keywords: introduction and mortality worldwide. severe pancreatitis may develop in approximately a third of the patients resulting in progressive organ dysfunction which is usually caused 1 important to determine the severity of the disease to anticipate complications and to manage them.3 organ 3 disease and avoidance of complications. so various scoring it has its role in wards to evaluate the severity of any disease process and indirectly measures sirs and helps in predicting the severity of the disease. original article jssn journal of society of surgeons of nepal jssn 2014; 17 (1) methods 3 managed at other centers were excluded. informed temperature, neurological status and urine output were recorded four hourly and as per necessary from the time of as per need of the patient. severity of acute pancreatitis 3 results table 1. early warning score score 3 2 1 0 1 2 3 heart rate ((beats/min) 111-129 systolic blood pressure (mmhg) respiratory rate (/min) <9 temperature (°c) level of consciousness sponse pain response urine output nil 2 hours 2 hours 2 hours 18jssn journal of society of surgeons of nepal jssn 2014; 17 (1) any time was regarded as a predictor of severe pancreatitis. st, 2nd and 3rd table 2). fig. 1). similarly there . and npv of ews in our study for predicting severity of acute pancreatitis ews24hr ews48hr ews72hr ews* sensitivity 98.38 figure 1: receiver operating characteristics curve of ews on day 1, 2 and 3 discussion continuous as complications may occur at any time during admission. mediated. group of late deaths, the presence of organ dysfunction mortality. according to severity3 high dependency unit timely. is normally voiding the urine. in our study, severity increased with the age of the patient. similar to previous studies, our study showed that males had more severe course of the disease than the females.8, 9 etiology and severity of the disease. other studies have 19jssn journal of society of surgeons of nepal jssn 2014; 17 (1) even in most cases of moderately severe pancreatitis from figure 1). in-patients.12 13 similarly, smith et al operations, and severe complications in surgical patients. considering the unprecedented nature of the disease process itself. they have pancreatitis in terms of severity, critical care admission and patient need. when compared to various scoring systems (table 3). the early component that determines the severity in early the complications and helps in early management. with categorized severity into three grades-mild, moderately study. npv for different scoring systems in various studies predicting severity of acute pancreatitis sensitivity ppv npv apache ii (at admission)18-19 apache ii (at 48 hours)18-19 balthazar18-19 glasgow18-19 ranson18-19 ews24 garcea et al.14 91.60 85.00 71.00 96.36 ews24 current study 87.50 95.38 95.45 95.30 ews* current study conclusion pancreatitis. this will not replace the currently accepted jssn journal of society of surgeons of nepal jssn 2014; 17 (1) in assessing repeatedly without any further cost and every case of acute pancreatitis to assess its evolution and complications. references 1. 2. for acute pancreatitis. summary of the international 3. . 8. infections and death in severe acute pancreatitis. 9. and severity. scandinavian journal of surgery 11. 12. 13. of patients. postgrad med j. warning scores predict outcome in acute pancreatitis.j 18. necessity of re evaluation of scoring systems according 19. severity and progression of acute pancreatitis. best jssn vol 17 no1_final to print copy.pdf 31jssn journal of society of surgeons of nepal jssn 2014; 17 (1) management of cysto-biliary communication in hydatid cyst of liver bhattarai a, kandel bp, ghimire b, kansakar p, lakhey pj, vaidya p, singh kp correspondence: abstract introduction: biliary communication of hepatic hydatosis is one of the important complications. it mortality. methods: th th results: during operation and managed with suture plication and omentopexy. out of the eight major communications, seven were diagnosed preoperatively and all had cholangitis, and one had hydatid evacuation of cyst content and stenting. one case was managed with pigtail drain as the patient had conclusion: therapeutic options are related to size and location of the cyst and size of communication. keywords introduction literature, only four species are clinically important. involvement is seen in two third of the cases. it is one communication of the hydatid cyst is one of the most common and serious complication of the hydatid cyst of the liver. communications either due to increased intracystic duct due to cyst.1 rarely hydatid cyst ruptures into the peritoneal cavity, pleural cavity and pericardial cavity. 1 2 original article 32jssn journal of society of surgeons of nepal jssn 2014; 17 (1) 2 duodenum, present as cbc, whereas after surgery the 2,3 3 cbc pre-operative ultrasound, ct scan and mri may of the cases. if cbc remains undetected or unrepaired during is important to diagnose and treat cbc in the preoperative and intraoperative period. there are several factors that can predict cbc. these other factors cm, cyst located at the center of the liver and near hilum, advance stage of the cyst, multivescicular cyst are also independent predictor of cbc. surgery is the mainstay of the treatment for the hepatic the management of hepatic hydatid cyst and cbc. several site of communication, size of communication, experience of the surgeon, general condition of the patient and status in this study we review the demography, clinical feature, communication (cbc) in our institute. methods and patients who were diagnosed and treated for hepatic hydatid cyst with cbc were included in this study. result hydatid cyst. thirteen patients were diagnosed as cbc. were minor cbc. presentation and it was present in all cases. seven patients jaundice and cholangitis whereas one patient with hydatid patients with major cbc whereas only mild derangement infection was present in 3 cases. complex surgery and need of repeated intervention. one table 1.surgical procedure done for major cbc interventions done no of patients exploration 2 1 stenting 2 1 1 pigtail drain 1 33jssn journal of society of surgeons of nepal jssn 2014; 17 (1) surgical site infection (ssi) was the most common table 2.total no. of complications types of complications no of patients ssi 3 chest infection 2 1 cect abdomen shows hydatid cyst of gall bladder cect hydatid cyst with cbc discussion hydatid cyst surgery.3 cbc after surgery. literature. pre-operative diagnosis of minor cbc was rest was normal during clinical and radiological examination whereas in major cbc most of the patients presented with hydatid cyst of liver with right sided hypochondrial pain suspected to have cbc.2 in our study, whereas in some literature shows involvement 8 but in contrast to other studies, incidence of major cbc is high this is due to most of the cases were referred from the other center for further management. 3, 11 2 sphincterotomy is considered the procedure of choice to decrease the rate of surgical reinterventions.8 in a study to heal.12 jssn journal of society of surgeons of nepal jssn 2014; 17 (1) conclusion of hydatid cyst of liver. therapeutic options are related to size and location of the cyst, size of communication and more complex procedures. references 1. langenbecks arch surg. 2012 aug;397(6):881-7. 2. in the treatment of controversial complication of 3. hepatic hydatid cyst surgery in basrah. bas j surg. of hydatid cysts into the liver with reference to 8. cholangiopancreatography in the management of 9. c. management of liver hydatid cysts with a large 11. 12. 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at nepjol.info port 443 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at nepjol.info port 443 page 1-64_bw output.pdf issn 1815 -3984 volume 18 jssn supplimental issue 29 correspondence: abstract materials and methods: results: conclusion: jssn vol 17 no1_final to print copy.pdf 11jssn journal of society of surgeons of nepal jssn 2014; 17 (1) presence of choledocholithiasis in patients undergoing cholecystectomy for mild biliary pancreatitis pradhan s1, shah s2, maharjan s2, shah jn3 1 2 2 3 professor, patan hospital correspondence: introduction: methods: patients admitted in the surgical ward in patan hospital with the diagnosis of mild acute results: negative exploration. conclusions: keywords: biliary pancreatitis; choledocholithiasis; intra operative cholangiogram. introduction clinical course of pancreatitis is usually self-limited and 1 times higher than in comparison to the general population.2 because of this, treatment usually includes cholecystectomy evaluation and treatment of persistent choledocholithiasis. original article 12jssn journal of society of surgeons of nepal jssn 2014; 17 (1) 3 who form the larger group, after recovering from an episode intra-operative cholangiogram (ioc) is a widely used performing routine ioc. addressed in literature however it is well accepted that exploration. methods with intra-operative cholangiography during the study period were included in the study. patient who underwent than threefold rise in serum amylase, visualization of mild acute pancreatitis associated with minimal dysfunction, uneventful recovery with prompt normalization of physical local complications. pancreatitis was considered resolved repeated in the immediate preoperative period and surgery was performed only if they were in decreasing trend to considered dilated. underwent open cholecystectomy with ioc. the ioc was head up and left lateral position. films were immediately performed. ioc was repeated if dye did not reach the duodenum in spite of injection buscopan as one or more of the following th post operative day. 13jssn journal of society of surgeons of nepal jssn 2014; 17 (1) microsoft excel software.8 results open cholecystectomy with ioc was performed in the same acute pancreatitis and eight had past history of jaundice. there was no failed ioc. table 1: surgical management of patients with resolving mild acute biliary pancreatitis (n=52) name of surgery numbers percentage (%) cholecystectomy with ioc 92.31 open cholecystectomy with ioc and total 52 100 cases the cystic duct was opened directly into the right th post nd symptoms of retained stones were found post-operatively. reoperation in 12 months follow up period. discussion pancreatitis cases annually. traditional teaching indicates ioc in all patients undergoing cholecystectomy following stones remain in the common duct.9 facilities for immediate study and the patients in our setting are usually from low which is expensive in comparison to routine ioc. thus as a part of the usual treatment of gallstone pancreatitis, routine ioc at the time of cholecystectomy was performed choledocholithiasis. gallstone pancreatitis who underwent ioc does not differ acute gallstone pancreatitis undergoing cholecystectomy stone.11 our study shows that patients recovering from acute gallstone pancreatitis who undergo cholecystectomy after increases with increases in the preoperative time interval, 12 the mean length of hospitalization from admission to cholecystectomy was around seven jssn journal of society of surgeons of nepal jssn 2014; 17 (1) 13 and his team who reviewed the diagnostic accuracy of ioc in cases highly suggestive of choledocholithiasis. there were three false positive cases and one case of false patients with a history of pancreatitis. they concluded that in to identify one case of choledocholithiasis. suits et al patients with symptomatic gallstone disease. these data pass spontaneously and thus ioc for every case of mild of ioc, past history of pancreatitis was associated with of detection. a previous history of jaundice, elevated liver function test, limitations of this research conclusion pancreatitis. references 1. 2. pancreatitis and relationship with cholecystectomy or 3. cholangiopancreatography in gallstone-associated 9 . jssn journal of society of surgeons of nepal jssn 2014; 17 (1) 8. 9. the incidence of cholangitis and clinical predictors 11. intraoperative cholangiogram in the management of 12. 13. korman j, cosgrove j, furman m, nathan i, cohen j. the role of endoscopic retrograde cholangiopancreatography and cholangiography in the jssn vol 17 no1_final to print copy.pdf 1jssn journal of society of surgeons of nepal jssn 2014; 17 (1) editorial jssn online journal of society of surgeons of nepal (jssn) is an on peer reviewed research materials of surgical interests; jssn has served as a prominent form of communication among surgeons of nepal with great effort from previous editors and eminent surgeons of the country. we are grateful to them for guiding us to arrive at present volume of the journal. of indexing and impact factor, going digital is a must. print edition. on the process of digitization, jssn has started to archive all past issues into electronic versions. standard of the journal and enhance the readership response. our main goal is to meet the norms of getting our journal the journal in future. most of us would agree that digital revolution has made can’t ignore the feel of the touch of paper in your hands the journal to promote research, a platform to communicate among professional colleagues, to raise a voice to change dr.rupesh mukhia page 1-64_bw output.pdf issn 1815 -3984 volume 18 jssn supplimental issue 33 serious? correspondence : abstract materials and methods: results: conclusion: page 1-64_bw output.pdf issn 1815 -3984 volume 18 jssn supplimental issue 43 correspondence abstract materials and methods: results: conclusion: 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at nepjol.info port 443 page 1-64_bw output.pdf issn 1815 -3984 volume 18 jssn supplimental issue 30 role of alanine aminotransferase in determining the biliary correspondence: abstract materials and methods: results: conclusion: 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at nepjol.info port 443 jssn vol 17 no1_final to print copy.pdf 2jssn journal of society of surgeons of nepal jssn 2014; 17 (1) original article oral contraceptive consumption and cerebral venous sinuses thrombosis jha gupta kukum1, jha rajiv2 1 2 correspondence: abstract introduction: consumption of ocps, treated in the department of neurosurgery, bir hospital and om hospital, methods results found included papilloedema, fever, slurring of speech and focal neurological signs. conclusion key words: introduction potentially deadly condition. known conditions that states, dehydration, adjacent infectious processes, replacement therapy, pregnancy, and puerperium.1,2 3jssn journal of society of surgeons of nepal jssn 2014; 17 (1) untreated, the intracranial pressure continues to rise and the vascular supply is compromised, leading to ischemia. indicated depending on the person’s neurological status and diagnostic results.1 with systemic anticoagulation therapy with heparin and 2 retrieval for rapid recanalization of the affected sinus can interventional neuroradiology. with consumption of ocps, its presentation, and early outcome. methods this was a retrospective case series carried out in the department of neurosurgery, bir hospital and om hospital analyzed and complications associated with anticoagulation for. follow up was made at three months. results oral contraceptive pills. majority of the patients were from 3rd th table 1: presenting symptoms (no of patients) presenting symptoms no of patients headache 9 vomiting loss of conciousness 1 seizure 1 (paresis) 1 fever 1 neck pain 1 papilloedema 6 paresis 1 1 hemianopia 1 slurring of speech 2 (fig. 1). one patient had straight sinus involvement and managed conservatively and recovery was uneventful. month’s follow up. figure 1: preand post treatment ct scan jssn journal of society of surgeons of nepal jssn 2014; 17 (1) figure 2: mr venogram showing obliteration of left transverse and sigmoid sinus discussion varied clinical presentation usually affecting middle-aged healthcare cost and utilization project, estimated that deliveries, and that increased maternal age was a major of the estrogenic component irrespective of the route of administration. more recent data showed a higher incidence and gestodene) rather than second-generation progestins (e.g. levonorgestrel and norgestrel), with an estimated generation preparations. the procoagulant effect of oral contraceptive pills (ocps) is due to the resultant increase in the levels of coagulation factors and decreases in the levels 9 than women who do not. 11 concomitant oral contraceptive use had an increased odds women that did not carry this defect.13 it is generally accepted a graded scheme of precautions when considering which patients should not use hormonal contraception. women given ocp.13 history of headache with focal neurological symptoms, concomitant vascular disease), patients with liver disease, intracranial hypertension. benign intracranial hypertension jssn journal of society of surgeons of nepal jssn 2014; 17 (1) references 1. 2. 3. contraceptives with differing progestagen components. 8. in low dose oestrogen oral contraceptives on venous 9. of levonorgestreland desogestrel-containing low 11. 12. 13. venous mr angiography for diagnosis and follow-up. jssn 2018; 21 (2) 1 jssn journal of society of surgeons of nepal editorial sick surgeon: problem and the panacea! bikal ghimire department of gi and general surgery, maharjgunj medical campus, instute of medicine, tribhucan university. editor in chief, jssn email: drbikalghimire@iom.edu.np gautam buddha has rightly said ‘to keep the body in good health is a duty... otherwise we shall not be able to keep our mind strong and clear’. we need clear minds as a clinician and more so as surgeon to plan the course of treatment and to physically execute it. however, apart from clear minds a surgeon should also be physically capable to withstand strenuous activities for long periods of time. daily exertion for prolog periods for surgeons leads to poor quality of life especially in our subcontinent where health institutions and the government do not prioritize the health of clinicians. the problem the surgeon faces a myriad of health issues related to musculoskeletal disorders, cardiovascular diseases, sleep deprivation, burn out and mental health issues apart from the risks involved in the operation theater. a review of ill health in 574 doctors associated with nhs revealed skin related disease, psychiatric illness and musculoskeletal diseases and alcohol and drug abuse to be very common.1 with the advent of laparoscopy, focus has always been on patient safely and cost but compared with open surgery, laparoscopic surgery imposes greater ergonomic constraints on surgeons. there is 73% to 88% prevalence of physical complaints among laparoscopic surgeons, which is greater than in the general working population. prevalence of musculoskeletal disorder (mds) has been observed to be 73 to 88% among specialists in minimal invasive surgery where as in general occupational population the prevalence of backache was 24.7%, muscular pain 22.8%, and neck and shoulder pain 23%. symptoms associated with these msds mainly include fatigue, pain, stiffness, and numbness and such symptoms can affect task accuracy. 2, 3 a surgeon in pain may not be able to give the best possible treatment to their patients. in a review of various approaches to prostatectomy, 25% surgeons complained that musculoskeletal pain considerations impacted their choice of operative approach and 32% considered open most painful followed by laparoscopic and robotic to be the least. 4 apart from the strain of physical exertion, surgeons are exposed to certain occupational hazards like cuts, needle pricks and infections. on average, surgeons report a rate of approximately 11 injuries over a 3-year time period. infections due to the exposure to blood, body fluids or tissue specimens possibly leading to blood-borne diseases such as hiv, hepatitis b and hepatitis c and use of co2 laser risk infection with hpv (human papilloma virus). in the us, of the four million health care workers at risk for infection with blood borne pathogens, 25% are surgeons. 5 though hiv, hepatitis b virus (hbv) and hepatitis c virus (hcv) pose the highest risk of morbidity and mortality, there are over 20 blood borne pathogens identified as transmissible through sharps injuries. 4b though hiv is dreaded; the risk of seroconversion following exposure to hiv from a needle-stick injury is approximately 0.3%, and even lower when the exposure is confined to mucous membrane or cutaneous exposures. 6 it supports the need to address the physical health issues of surgeons with eagerness. 7 apart from physical health, mental health is also an important issue. since time immemorial, surgeons have always been stereotyped as brash, arrogant with little in the way of human compassion. for many, this may be a way of shielding away from the pain they suffer so that they can operate with the level of confidence that is required for each and every patient and for a few it may be just what they are. it has been rightly said that each surgeon carries within him burden of a graveyard. (“every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.’ rené leriche, la philosophie de la chirurgie, 1951” ) the sheer mental stress imposed trying to save a dying mailto:drbikalghimire@iom.edu.np jssn 2018; 21 (2) 2 jssn journal of society of surgeons of nepal patient and the inevitable failures can be depressing. all clinicians are at risk of developing mental health problems but surgeons have been found to be the ones least likely to seek help.8 in the uk where the quality of life of surgeons is lot better than most developing countries, 10 to 20% become depressed at some point in their carrier.9 suicide is a common issue among doctors, and relative to the general population female doctors have a 3.7-fold to 4.5-fold increased risk of death from suicide, and male doctors have a 1.5-fold to 3.8-fold increased risk.10, 11 in a review of doctors presenting to the practitioner health program (php), a confidential london based health service for doctors and dentists, it was observed that surgeons had myriads of health issues mainly 55% depression and anxiety, 30% complex mental health issues and 16% with addiction. though this was lower than that observed with other health professionals it could be because surgeons are tailored to cope better with stress due to their rigorous training or they tend to underreport due to the stigmata attached that might risk their career. 12 violence against medical professionals is a global phenomenon as it involves emotional issues for the patients and their families and surgeons are more prone to suffer from it. there has been increase in such incidences in resent years with a survey amongst doctors by indian medical association, reporting 75% observing such incidences at work. 13 this adds to the level of stress associated with the occupation. the panacea! the practitioner health program (php) is a confidential london based health service for doctors and dentists. practitioners presenting to the service have considerable, often severe, mental health problems, similar to patients who present to nhs mental health services.6 most developing countries lack a system to take care of health workers by assessing the problems and working towards the solution. it is high time various societies and the government work together to have a system to address the issue before it is too late. burnout has been characterized by, overwhelming physical and emotional exhaustion; feelings of cynicism and detachment from the job, a sense of ineffectiveness and lack of accomplishment; over identification with work to the exclusion of other activities and irritability and hyper vigilance. it is imperative that all surgeons are aware of the features and seek help at the earliest. 14 a systematic literature review of pubmed, embase and cochrane library in spring 2015 for comparative data on surgeons’ physical workload with robotic-assisted laparoscopy and conventional laparoscopy which involved 2685 records were screened and 15 articles suggested that robotic-assisted laparoscopy is less strenuous compared with conventional laparoscopy. however, the widespread use of robotics is limited by the high cost involved and availability especially in our subcontinent. prevention of spread of sharp injuries and transmission of infection during surgeries requires following universal precaution and using safety guidelines. however, the compliance amongst surgeons is less, most blaming lack of safe devices, urgency of the procedure and lack of dexterity and blunted sensation associated with double gloving and other safety systems though studies have not provided any evidence to support it.15 in the american college of surgeons (acs) report, “being well and staying competent: challenges for the surgeon” created in 2012, acknowledges that healthcare systems and hospitals don’t have an incentive to limit surgeons’ working hours and the burnout to be reversible and addresses methods to tackle burnout.16 they advice for promoting a culture of medicine that values work-life balance, promote the “just culture” paradigm during training and most importantly, give ourselves permission to be sick and to accept good medical care. we should also nurture the religious/spiritual aspects of ourselves and get involved in non-patient care activities (e.g., research, education, administration). in the us, work-hour limitations have been implemented by the ‘accreditation council for graduate medical education’ (acgme) in july 2003 in order to minimize fatigue related medical adverse events.17 in nepal, the remuneration for doctors is one of the lowest amongst other developing countries. hence, doctors tend to work for extended hours and are exposed to mental and physical exhaustion, which is seen more commonly in surgeons. with the need to keep updated with rapidly progressing advances in medicine, doctors are in the need of attending continuing medical education (cme) programs, workshops and courses. the government is also working on making these activities mandatory. in this context, health professionals should be allocated a 5 days work day with a day dedicated to perusing these activities so that their social life is not compromised. jssn 2018; 21 (2) 3 jssn journal of society of surgeons of nepal conclusion to safe guard the health of doctors, we need to study their present status including physical and mental health, timing of work hours and the morbidity and mortality in the community. societies should work to promote health and working conditions of the clinicians and lobby the legislature to make rules and regulation to safe guard it. a healthy clinician will only be capable of delivering quality care to their patients that translates into improved health care in the country. references 1. ananth vijendren, matthew yung , jose sanchez. the ill surgeon: a review of common work-related health problems amongst uk surgeons. langenbeck’s archives of surgery december 2014, volume 399, issue 8, pp 967–979 2. huysmans ma, hoozemans mj, van der beek aj, et al. fatigue effects on tracking performance and muscle activity. j electromyogr kinesiol. 2008;18:410–419. 3. huysmans ma, hoozemans mj, van der beek aj, et al. position sense acuity of the upper extremity and tracking performance in subjects with non-specific neck and upper extremity pain and healthy controls. j rehabil med. 2010;42:876–883. 4. bagrodia a, raman jd. ergonomics considerations of radical prostatectomy: physician perspective of open, laparoscopic, and robot-assisted techniques. j endourol. 2009;23:627–633. 5. jennifer f. waljee, md, ms1, sunitha malay sharps injuries: the risks and relevance to plastic surgeons. plast reconstr surg. 2013 apr; 131(4): 784–791. 6. zanni gr, wick jy. preventing needle stick injuries. consult pharm. 2007; 22:400–402. 4–6, 9. [pubmed: 17658957] 7. chantal c. j. alleblas, anne marie de man, lukas van den haak. prevalence of musculoskeletal disorders among surgeon; performing minimally invasive surgery. annals of surgery volume xx, number xx, month 2017 8. clare gerada, richard jones. surgeons and mental illness: a hidden problem? bmj 2014; 348 doi: https:// doi.org/10.1136/bmj.g2764. 9. brooks s, gerada c, chalder t. review of literature on the mental health of doctors: are specialist services needed? j mental health 2011;1-11:i. 10. frank e, biola h, burnett ca. mortality rates and causes among us physicians. am j prev med 2000;19:155-9. 11. lindeman s, laara e, hakko h, lonnqvist j. a systematic review on gender-specific suicide mortality in medical doctors. br j psychiatry1996;168:274-9. 12. gerada, c. surgeons and mental illness: a hidden problem? bmj 2014;348:g2764 13. [last accessed on 2018 jan 10]. available from: http://www.timesofindia.indiatimes.com/ india/75-percentof-doctors-have-been-attackeda t wor k bydi sgr un t l eda t t en da n t s -st ud ysa ys/ articleshow/49533759cms . 14. kearney mk. self-care of physicians caring for patients at the end of life. jama. 2009; 301:1155 1164). 15. fry de, harris we, kohnke en, twomey cl. influence of double-gloving on manual dexterity and tactile sensation of surgeons. journal of the american college of surgeons. 2010; 210:325–330. [pubmed: 20193896] 16. pape h c, pfeifer r, patient safety in surgery 2009, 3:3 restricted duty hours for surgeons and impact on residents quality of life, education, and patient care: a literature review, bmc, doi:10.1186/1754-9493-3-3 17. governor’s committee on physician competency and health, being well and staying competent: challenges for the surgeon; 2013 (accessed on 2nd dec, 2018 at https://www.fa cs.or g/~/media/files/member%20 services/being_well_and_staying_competent.ashx. ) http://www.timesofindia.indiatimes.com/ http://www.facs.org/~/media/files/member http://www.facs.org/~/media/files/member jssn vol 17 no1_final to print copy.pdf 21jssn journal of society of surgeons of nepal jssn 2014; 17 (1) correlation of d-dimer level with outcome in traumatic brain injury pradip prasad subedi 1 , sushil krishna shilpakar 2 email: abstract introduction immense. the major determinant of outcome following tbi is the severity of the primary injury. management of tbi. methods results conclusion key words original article 22jssn journal of society of surgeons of nepal jssn 2014; 17 (1) introduction mechanical force applied to the cranium and the intracranial contents, leading to temporary or permanent impairments, 1,2 according to specialities and circumstances. often the inclusion criteria.3 in patients with multiple trauma, head is the most common are treated and discharged from the emergency department. 8 9 the incidence in china is 11 for multiple reasons, including inconsistencies and complexities of diagnostic coding and inclusion criteria, hospital admissions versus door-to-door surveys), transfers to multiple care facilities (for example, patient admissions practices.12 the true data of the incidence of head injury in nepal and its 13 centres outside the capital, most cases are either referred many as two thirds of those with moderate head injury will this cost of head injury is a besides, head injury involves the younger productive age community. adults and fall injury in children. injury. the prognosis of head injury depends on various factors. individual after tbi. the major determinant of outcome from tbi is the severity of the primary insult, which hypotension, hypoxia, hyperpyrexia, and hypoglycaemia tbi.11 coagulopathy has major impact on the outcome of the patients.18 this study is done to see the correlation of 23jssn journal of society of surgeons of nepal jssn 2014; 17 (1) figure 1: formation of d-dimer 45 objectives primary objective secondary objectives hypothesis null hypothesis (h0) alternate hypothesis (h1) materials and methods ninety four patients were admitted with the diagnosis of met the inclusion criteria were included in the study. inclusion criteria exclusion criteria patients on anticoagulants polytrauma indication of admission vomiting and seizure patients presenting to the emergency department with of the injury. patients were followed up and evaluated record of mortality were collected in a preset proforma. jssn journal of society of surgeons of nepal jssn 2014; 17 (1) outcome variables primary outcome: secondary outcome: 1. gcs: gcs score was determined using following guidelines: 48 points best eye opening best verbal response best motor response oriented spontaneous confused withdraws to pain 3 to speech inappropriate words flexion to pain (decorticate) 2 to pain 1 none none none glasgow coma scale (recommended for age < 4 yrs) 48 points best eye opening best verbal response best motor response smiles, oriented to sound, spontaneous crying interaction withdraws to pain inappropriate 3 to speech moaning flexion (decorticate) 2 to pain restless 1 none none none none 2. severity of head injury : severity of head injury was graded based on gcs score. severity gcs mild moderate 9-12 severe 1-8 3. glasgow outcome scale: the glasgow outcome scale is a 5 level score:49 jssn journal of society of surgeons of nepal jssn 2014; 17 (1) 4. duration of illness: time period between trauma and measured in hours in this study. 5. duration of hospital stay: number of days the patient is in hospital. staying for a night is taken as one day. 6. normal d-dimer level: < 200ng/ml statistical analysis the data were analyzed using the statistical program for used to study the correlation of mode of injury and grade of results one hundred and ninety four patients were admitted with study after meeting the inclusion and exclusion criteria. twenty one to forty years of age. the mean duration of figure 2 : bar diagram showing distribution of patients according to age figure 3: figure showing the frequency of patients in different sexes the most common cause of tbi was fall injury which figure 4: figure showing frequency of patients with different modes of injury sustained moderate head injury and twenty six patients jssn journal of society of surgeons of nepal jssn 2014; 17 (1) table 1: lesions in ct scan of the head number percentage 22.9 28.3 28 18.9 contusion 12 8.1 pneumocephalus 12 8.1 hemorrhage 19 12.8 1 1 table 2: number of patients with normal and elevated d-dimer level d-dimer level frequency percentage (%) 31.1 table 3: man-whitney test showing correlation between d-dimer and duration of hospital stay, duration of icu stay and gos man-whitney test (ranks) d-dimer n mean rank hospital stay total 39.82 total total test statistics duration of hospital stay gos icu stay mannwilcoxon w z -3.312 (2-tailed) jssn journal of society of surgeons of nepal jssn 2014; 17 (1) table 4: chi-square test showing correlation of d-dimer with grade of injury grade of injury total mild moderate severe 82 22 total 92 chi-square tests value df asymp. sig. (2-sided) a 2 2 table 5: chi-square test showing correlation of d-dimer with mode of injury mode of injury total fall others physical 38 19 2 total 11 value df asymp. sig. (2-sided) a 3 3 discussion institution of resuscitative measures with simultaneous the early management to improve outcome in head injury. the severity of the primary injury generally dictates the outcome; nevertheless secondary injuries have a profound the secondary phenomenons after a tbi is the hemostatic that of the international mission on prognosis and analysis age of maximum economic productivity. thirty six patients . in our study the most common cause of head injury was sustained mild head injuries similar to other injuries as facilities within the capital only. the most common intracranial lesion in our study was naseri et al out of et al . limitations of the study 28jssn journal of society of surgeons of nepal jssn 2014; 17 (1) institute conclusion and early treatment may help in recovery. references 1. development and international validation of 2. 3. medscape.com th department visits, hospitalizations, and deaths. prevention, national center for injury prevention national center for injury prevention and control. 8. 9. 11. 12. 13. surgeons of nepal. th ed. 18. level with poor outcome in traumatic intracranial 19. klein mj. post head injury endocrine complications; medscape.com 29jssn journal of society of surgeons of nepal jssn 2014; 17 (1) 21. 22. in warfarinised patients. singapore med j 23. and recommendations for return to activity. clinical 28. macpherson bcm, macpherson p, jennett b. ct incidence of intracranial contusion and hematoma 29. extra dual hematoma of delayed onset is not a rarity. 31. 32. 33. and recommendations for return to activity. clinical surgery. 18th consortium survey of head injuries. neurosurgery 38. axonal injury and traumatic coma in the primate. 39. with closed head injuries and their role in predicting jssn journal of society of surgeons of nepal jssn 2014; 17 (1) attended the emergency department with head comparisons of analysis of the condition in children pb 27jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2017; 20 (1) jssn 2017; 20 (1) original article comparison of clinical course of acute biliary and nonbiliary pancreatitis abishek bhattarai1 , pragya devkota2 , bishnu prasad kandel3 , bikal ghimire3 , prasan bir singh kansakar3, ramesh singh bhandari3 , kishor kumar tamrakar4 , palaswan joshi lakhey3, parshuram mishra 3, yogendra prasad singh3, pradeep vaidya3 , keshaw prasad singh3 1department of surgery, maharajgunj medical campus, tribhuvan university teaching hospital, nepal 2resident, department of pharmacology, maharajgunj medical campus, tribhuvan university teaching hospital, nepal 3department of surgery, maharajgunj medical campus, tribhuvan university teaching hospital, nepal 4chitawan medical college, bharatpur chitawan correspondence: dr abhishek bhattarai, department of surgery, maharajgunj medical campus, tribhuvan university teaching hospital email: abhishekbhattarai@gmail.com abstract introduction: incidence of acute pancreatitis (ap) varies in different parts of the world. the published data are mainly based on retrospective analysis of hospital admissions, which show that there are considerable geographical differences in the incidence rate. there are also regional divergences with regard to the etiology, and its impact on morbidity and mortality. therefore, we compare the clinical course of acute biliary and non-biliary pancreatitis at the tribhuvan university teaching hospital (tuth) as well as we compare the morbidity and mortality and duration of hospital stay in these groups. methods: this prospective study included the patients with a diagnosis of ap over a period of one year. eighty-five patients with the diagnosis of ap were included in the study. revised atlanta classification system (2012) was used to diagnose and define the severity of disease. the occurrence of local and systemic complications, median duration of hospital stay and mortality in ap was studied. results: among 85 patients, 34 patients were females and 51 were males. among them, 46 patients belonged to the biliary group and 39 belonged to the non-biliary group. alcohol intake was the major etiology in the non-biliary group (n = 26) and all of them were male. the majority of the gallstone induced ap patients were female (n = 29). twenty-nine patients developed severe acute pancreatitis (sap: 16 in biliary and 13 patients in non-biliary group). complications were mostly seen in sap. the acute fluid collection was the most common local complication (15 patients in biliary and 15 patients in non-biliary group, p > 0.05) and respiratory failure was the most common systemic complication (18 patients in biliary and 16 patients in non-biliary group, p > 0.05) in both groups. three patients in biliary group and four patients in non-biliary group died due to multi-organ failure (p > 0.05). there was no statistical significant difference in the median duration of hospital stay in these groups. conclusion: though pathogenesis vary for different etiologies, once the disease process has started, local complications, systemic complications, duration of hospital stay and mortality in ap depends on the severity of the disease irrespective of the etiology. key words: acute pancreatitis; biliary pancreatitis; non-biliary pancreatitis. 28 29jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2017; 20 (1) jssn 2017; 20 (1) introduction acute pancreatitis (ap) is a common cause of acute abdomen with variable risk factors, and wide range of severity from mild self-limiting disease to a severe rapidly progressive illness leading to multi organ failure and death.1 about 15-20% of the patients with a history of ap can progress to severe acute pancreatitis associated with local and systemic complications.2 there are no actual prevalence data available in our country. however hospital based data showed an annual incidence of 60 to 90 patients per year at tertiary care center in kathmandu. 3, 4 two major etiological factors responsible for ap are gallstone and alcohol. 5 other risk factors include endoscopic retrograde cholangiopancreatography (ercp), trauma, drugs, surgery, malignancy, viral infection, hyperlipidemia, and biliary tract anomalies.1 idiopathic pancreatitis (ip) is described as pancreatitis in which the etiological factor cannot be diagnosed.6 the incidence of ip ranges from 4.21 per 100 000 to as high as 45.33 per 100 000.6 there was no universally accepted definition, classification and severity grading of the ap in the past. atlanta symposium was first convened in 1992 attempted to provide the common terminology and define the severity of the disease with a uniform classification for the first time and it was revised & updated in 2012. this new definition and classification system addresses the diagnosis, types and severity of ap, and definition of pancreatic and peripancreatic collections.7 in spite of numerous advances in diagnosis and treatment of ap in the recent years, ability to predict outcome remains challenging. several scoring systems have been proposed for the assessment of the severity, including ranson score, glasgow score, bisap score and apache, sirs score by different authors to predict the severity and outcome following ap.8 none of them are accurate to predict morbidity and mortality. generally, it is believed that, though the pathogenesis is different for different etiology, once the disease process has started mortality depends on the severity of the disease. there are several publications regarding the impact of etiology on the outcome of the ap. the published data are mainly based on retrospective analysis of hospital admissions, which showed that there are considerable geographical differences in the incidence rate as well as etiology, and its impact on morbidity and mortality. some authors deny a relationship of mortality and morbidity with etiology whereas others describe the relation.9-17 therefore, we compare the clinical course of acute biliary and nonbiliary pancreatitis at the tribhuvan university teaching hospital (tuth) as well as we compare the morbidity, duration of hospital stay and mortality in these groups so that we could detect difference in characteristics that could be relevant for the prognosis and therapy. methods patients with a diagnosis of ap admitted in the surgical ward of tribhuvan university teaching hospital over a period of one year (2070/05/01 to 2071/04/30) were studied. patients of age less than 18 years, post ercp pancreatitis, recurrent acute pancreatitis were excluded. diagnosis of acute pancreatitis, its severity, local and systemic complications were defined as per revised atlanta classification 2012. modified marshall score was determined at admission, and at 48 hours of hospital admission. biliary etiology was confirmed as the cause of ap in patients with a history of cholecystectomy or with cbd exploration or detection of gall bladder of bile duct stone on imaging. combination of age, sex and laboratory markers (system 4) was used in case of difficulty to predict a biliary etiology. 18 alcoholic etiology was defined on the basis of a history of chronic alcohol intake or recent alcohol intake in the week prior to admission while ap of other etiologies were excluded. 15, 19 other etiologies were diagnosed on the basis of the history and examination of the patients. when a diagnosis could not be made through a history, physical examination, laboratory studies, and imaging modalities those cases were designated as idiopathic pancreatitis. the data were analyzed using statistical package for social sciences (spss) for windows version 19. chi square test was used for categorical variables, and t-test was used for continuous variables. p-value <0.05 was considered clinically significant. result within the study period, a total of eighty five patients were included in the study. forty six (54%) patients were admitted with biliary etiology and 39 (46%) with nonbiliary etiology. (table 11) among non-biliary patients, alcohol induced pancreatitis was the most common (n=26). in 5% of the cases etiology could not be identified (n=4). 28 29jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2017; 20 (1) jssn 2017; 20 (1) table 1: etiology of acute pancreatitis total no. of pts. n=85 biliary 46 (54%) non biliary 39 (46%) alcohol 26 (31%) drug induced 3 (3.5%) trauma 3 (3.5%) malignancy 2 (2%) mumps 1 (1%) others 4(5%) age and gender the age of the patients ranged from 21 to 85 years. the mean age was 46.15 ± 15.75 years for biliary and 40.23±15.65 years for non-biliary group (p value >0.05). biliary pancreatitis was predominantly seen in female (n = 29), whereas non biliary was mostly seen in male (n=34). (table 2) table 2: age and gender distribution of the patients biliary (n = 46) non biliary (n = 39) p value male 17 (37%) 34 (87%) 0.001 female 29 (63%) 5 (13%) 0.001 mean age (year) 46.15±15.75 40.23±15.65 0.087 severity about 53% of the patients belonged to the mild group, 13.0 % in moderate group and 34.0% in severe group. there was no statistical difference in the incidence of severity among the biliary and non-biliary groups. (table 3) table 3: distribution of patients, according to severity severity biliary (n = 46) non biliary (n = 39) total mild (52.94%) 26 (56.5%) 19 (48.7%) 45 moderate (12.94%) 4 (8.6%) 7 (17.9%) 11 severe (34.11%) 16 (34.7%) 13 (33.3%) 29 total 46 39 85 patients with map had a median duration of hospital stay of 4 days (range of 4-6 days for biliary and 4-5 days for non-biliary group). whereas in moderate group it was 6 days (6-9 days) for biliary and 7 days (6-17days) for non biliary group. for severe group it was 10 (9-60) days for biliary and 13 (7-30) days for non-biliary pancreatitis. diagnostic criteria twenty nine out of forty six (63.0%) in biliary group and 22 out of 39 (56.4%) had a history of a typical pancreatic type of pain. the pancreatic enzymes amylase and lipase were significantly raised in both groups. whereas usg was less reliable to diagnose acute pancreatitis during an emergency. (table 4) table 4: diagnostic criteria of ap biliary (n = 46) non biliary (n =39) p value typical pain 29 (63%) 22 (56.4%) 0.534 raised amylase /lipase 38 (82.6%) 35 (87.7%) 0.533 usg 16 (34.7%) 14 (35.8%) 0.914 local complications fifteen (32.60%) out of 46 patients in biliary group and 15 out of 39 (38.46%) patients in non-biliary group developed local complications. eleven patients (23.91%) in biliary group and 8 patients (20.51%) in non-biliary group developed pancreatic necrosis (p value >0.05). (table 5) there was no statistical difference in the incidence of peri-pancreatic collection, infected and sterile pancreatic necrosis, pancreaticoperitoneal fistula and vascular aneurysm in biliary and non-biliary groups. table 5: incidence of local complications in biliary and non-biliary pancreatitis local complications biliary (n = 46) non biliary (n = 39) p value acute fluid collection 15 (32.6%) 15 (38.4%) 0.574 necrosis 11 (23.9) 8 (20.5%) 0.233 sterile 7 (15.2%) 7 (17.9%) 0.753 infected 4 (8.6%) 1 (2.5%) 0.231 pseudo aneurysm 1 (2.1%) 0 0.231 pancreatico-peritoneal fistula 1 (2.1%) 3 (7.6%) 0.231 30 31jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2017; 20 (1) jssn 2017; 20 (1) systemic complications respiratory failure was the most common organ failure followed by renal and cardiovascular failures with the similar incidence rate (p value >0.05) in both groups. (table 6) table 6: incidence of systemic complications in biliary and non biliary pancreatitis biliary (n = 46) non biliary (n = 39) p value cardiovascular failure 6 (13%) 4 (10.2%) 0.691 renal failure 6 (13%) 4 (10.2%) 0.691 respiratory failure 16 (34.7%) 16 (41%) 0.554 transient organ failure 2 (4.3%) 4 (10.2%) 0.289 persistant organ failure 16 (34.7%) 13(33.3%) 0.915 single organ failure 9 (19.5%) 11 (28.2%) 0.349 multi organ failure 9 (19.5%) 6 (15.3%) 0.614 similarly, there was no statistical difference in the incidence of other complications like pleural effusion, chest infection, however, there is a higher proportion of cholangitis and cholecystitis in biliary group, whereas, variceal bleeding and stress ulcer in non biliary group (table: 7). table 7: incidence of other complications in biliary and non biliary pancreatitis complications biliary n=46 non biliary n=39 p value pleural effusion 20 (43.4%) 18 (46.1%) 0.805 chest infection 11 (23.9%) 7 (17.9%) 0.502 stress ulcer 0 3 (7.6%) 0.055 variceal bleed 0 3 (7.6%) 0.055 cholangitis 6 (13%) 0 0.80 cholecystitis 4 (8.6%) 0 0.231 diabetes 6 (13%) 3 (7.6%) 0.424 intervention some form of intervention was done in 3 patients with biliary etiology and 4 patients with non-biliary etiology. necrosectomy, percutaneous drainage and ptbd were done for one patient in each group, whereas ercp and stenting was done in one patient with alcoholic pancreatitis with pancreatic ascites. (p value >0.05) (table 8) table 8: total no. of interventions done in biliary and non biliary pancreatitis biliary (n =46) non biliary (n=39) p value necrosectomy 1 1 0.906 percutaneous drainage 1 1 0.906 ptbd 1 1 0.906 ercp + stenting 0 1 0.275 total 3(6.52%) 4(10.25%) mortality three patients in biliary group and four patients in the nonbiliary group died due to mods. (p value >0.05) discussion worldwide biliary and alcohol are the most common etiologies of pancreatitis. these account for almost 80% of the cases of acute pancreatitis. 20 but their incidence varies in different parts of the world. but their incidence varies in different parts of the world. some of the hospitalbased studies from australia, america and india showed that incidence of non-biliary pancreatitis is more common than that of biliary pancreatitis in their institute, whereas, from nepal, it showed a higher incidence of the biliary pancreatitis than non-biliary pancreatitis. 3, 4, 20 21 22 in our study, incidence of biliary pancreatitis is higher than that of non -biliary pancreatitis. the exact cause of this geographical variation is not well known, but growing evidence suggests that environmental and possibly genetic cofactors may also play a role in the development of ap. in the present study, it was found that ap is more common in males than females and can affect any age, which is comparable with other studies. 23 it was also found that alcohol was the main etiology in non-biliary pancreatitis and all alcoholic pancreatitis were seen in male patients, while biliary pathology was the main cause of ap in females. it is due to hormonal influence, especially estrogen, which plays an important role in gallstone formation in females, hence increases the risk of pancreatitis. 23 30 31jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2017; 20 (1) jssn 2017; 20 (1) map accounts more than 50% of the cases in most of the literature, but there is a wide range of variation in the incidence of msap ( ranges from 25.39% to 35.6%) and sap ( ranges from 4% to 25.39%) respectively. 21, 24, 25 in this study, there was a higher incidence of sap in both groups, as compared to other study, because most of the severe cases were referred cases from primary and secondary health care centers. the result we obtained also did not match with the result obtained from another tertiary care center from kathmandu with a higher proportion of severe acute pancreatitis in both groups3. literature shows 30-57% of patients with ap have fluid collections with 39% of the patients having two areas involved and 33% having three or more and about 5–21% of patients develop necrosis of the pancreatic parenchyma or peri-pancreatic tissue or both.7, 21, 26 up to 30% of patients with necrotizing pancreatitis develop infection and its incidence may increase to 70% in the third week. 2 in our study, the incidence of acute fluid collection was 32.60% and 38.46% and incidence of necrosis was 23.91% and 20.51% in biliary and non-biliary group and there was no statistical difference in the incidence of infective and non-infective local complications in between these groups, which is also comparable with the data in the published literature. however, some of the studies also show that alcoholic pancreatitis tends to have more prominent peripancreatic changes than biliary pancreatitis, and higher incidence of necrotizing pancreatitis.11, 27 hemorrhagic complications are frequently encountered in routine practice following ap. the incidence of fatal haemorrhagic complications accounts for 1.2-14.5% and incidence of pseudoaneurysm is about 3.5-10%.28 in our study there was a patient with pseudoaneurysm of gastroduodenal artery with infected pancreatic necrosis in biliary group, causing massive bleeding, which was managed with laparotomy, necrosectomy and suture ligation of gda, later patient devlop colocutaneous fistula. pancreatic ascites or pancreatico peritoneal fistulas are the rare complications of acute pancreatitis.29 these are mostly seen in the patients with traumatic, chronic and alcohol induced pancreatitis, cystic duplications of biliopancreatic ducts, ampullary stenosis or ductal lithiasis. 30, 31 all together 4 patients developed pancreatic ascites in our study, one in biliary and 3 in non-biliary group. incidence of local complications in our study is comparable with that of others in the literature. pulmonary dysfunction was the most important systemic manifestation of acute pancreatitis ranging from hypoxia to ards. 32, 33 it is seen in 30-50% of the patients with severe pancreatitis and is regarded as one of the major factors of mortality in 22-25% of the patients and a contributing factor in an additional 30% morbidity during the course of disease.33 it is because lung involvement is the integral part of (third phage) of the ap characterized by progression of the pancreatic injury and involvement of extrapancreatic change including sirs and ards. these complications are due to production of noxious cytokines, leading to increased lung capillary permeability and decreased level of lung surfactant. 32 respiratory dysfunction precedes heart, liver and kidney failure and is responsible for the early deaths in severe pancreatitis. the prevalence of acute renal failure (arf) in ap ranges from 6-16% and carries a bad prognosis, especially in elderly and in those with multi-organ failure in presence of local complications.34, 35 similar to a respiratory dysfunction arf is due to toxic injury to the kidney by release of variety of vasoactive peptides, enzymes, cytokines and other inflammatory mediators from the necrosed pancareas. hypovolemia, decreased renal blood flow, intravascular clotting and infection also contributes to arf35. the mechanism of circulatory failure is poorly understood in ap. failure in the physiological equilibrium between vasodilator (e.g. nitric oxide) and vasoconstrictor (endothelin and angiotensin) mediators have been proposed.36 respiratory failure was the most common systemic complication in our study and there was also no significant difference in the incidence of systemic complications in both biliary and non-biliary groups, but there was some variation in the incidence systemic complications as compared with other studies.21 the need of intervention depends on the type of complications that develops after an episode of ap. overall 12.8% ap patients required intervention. for msap and sap this was 12.3% and 38.5% respectively. 21 in this study, intervention was required only in sap. for biliary etiology it was 6.52% and for non-biliary it was 10.25%. the overall incidence of mortality is 5%.37 but this also depends on the type and severity of the disease. for msap mortality is < 8%, whereas for sap it can go up to 62%.37, 38 mortality is directly proportional to the incidence of infective complications.37 in present study mortality rate was 6.52% and 10.25% for biliary and non-biliary etiologies respectively, and there was no mortality in mild and moderate group. 32 33jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2017; 20 (1) jssn 2017; 20 (1) duration of hospital stay varied according to the severity of the disease. there was difference in the median duration of hospital stay among map, msap and sap group.4, 21 in our study there was no significant difference in length of hospital stay in between the biliary and non-biliary groups. but as compare with the similar kind of study, there was a significant difference in the median duration of hospital stay in the severe group which is 24 (16-39) days, this is because of less number of interventions done in sap in our study.21 conclusion though pathogenesis vary for different etiologies, once the disease process has started, local complications, systemic complications, duration of hospital stay and mortality in ap depends on the severity of the disease irrespective of the etiology. references 1. carroll jk, herrick b, gipson t, lee sp. acute pancreatitis: diagnosis, prognosis, and treatment. american family physician 2007; 75(10): 1513-20. pmid:17555143 2. beger hg, rau bm. severe acute pancreatitis: clinical course and management. world journal of gastroenterology : wjg 2007; 13(38): 5043-51. h t t 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acute pancreatitis in a prospective cohort: have all loose ends been tied? pancreatology : official journal of the international association of pancreatology 2014; 14(4): 257-62. 26. whitcomb dc. clinical practice. acute pancreatitis. the new england journal of medicine 2006; 354(20): 2142-50. h t t p s : / / d o i . o r g / 1 0 . 1 0 5 6 / n e j m c p 0 5 4 9 5 8 pmid:16707751 27. kim ys, kim y, kim sk, rhim h. computed tomographic differentiation between alcoholic and gallstone pancreatitis: significance of distribution of infiltration or fluid collection. world journal of gastroenterology : wjg 2006; 12(28): 4524-8. h t t p s : / / d o i . o r g / 1 0 . 3 7 4 8 / w j g . v 1 2 . i 2 8 . 4 5 2 4 pmid:16874865 pmcid:pmc4125640 28. mallick ih, winslet mc. vascular complications of pancreatitis. jop : journal of the pancreas 2004; 5(5): 328-37. 29. erich h jensen db-c, waddah b.al-refaie, selwyn m vickers. sabiston textbook of surgery. in: courtney m. townsend rdb, b. mark evers, kenneth l. mattox, editor. exocrine pancreas. 19th ed. usa: elsevier saunders; 2012. p. 1515-47. 30. kozarek ra. management of pancreatic ascites. gastroenterology & hepatology 2007; 3(5): 362-4. 31. kalyan kanneganti ss, bijay acharya, venkatram sindhaghatta, sridhar chilimuri. successful management of pancreatic ascites with both conservative management and pancreatic duct stenting. gastroenterology research 2009; 2(4): 245-7. https://doi.org/10.4021/gr2009.08.1306 32. browne gw, pitchumoni cs. pathophysiology of pulmonary complications of acute pancreatitis. world journal of gastroenterology : wjg 2006; 12(44): 7087-96. h t t p s : / / d o i . o r g / 1 0 . 3 7 4 8 / w j g . v 1 2 . i 4 4 . 7 0 8 7 . pmcid:pmc4087768 34 35jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2017; 20 (1) jssn 2017; 20 (1) 33. raghu mg, wig jd, kochhar r, et al. lung complications in acute pancreatitis. jop : journal of the pancreas 2007; 8(2): 177-85. 34. tran dd, oe pl, de fijter cw, van der meulen j, cuesta ma. acute renal failure in patients with acute pancreatitis: prevalence, risk factors, and outcome. nephrology, dialysis, transplantation : official publication of the european dialysis and transplant association european renal association 1993; 8(10): 1079-84. pmid:8272219 35. b avinash nk, ay lakshmi, s padmanabhan, v siva kumar. acute renal failure in acute pancreatitis -role of pancreatic computed tomography severity index (ctsi). indian journal of nephrology 2005; 15: 14-6. 36.garcia m, calvo jj. cardiocirculatory pathophysiological mechanisms in severe acute pancreatitis. world journal of gastrointestinal pharmacology and therapeutics 2010; 1(1): 9-14. h t t p s : / / d o i . o r g / 1 0 . 4 2 9 2 / w j g p t . v 1 . i 1 . 9 pmid:21577289 pmcid:pmc3091142 37. banks pa, freeman ml, practice parameters committee of the american college of g. practice guidelines in acute pancreatitis. the american journal of gastroenterology 2006; 101(10): 2379-400. https://doi.org/10.1111/j.1572-0241.2006.00856.x pmid:17032204 38. sarr mg. 2012 revision of the atlanta classification of acute pancreatitis. polskie archiwum medycyny wewnetrznej 2013; 123(3): 118-24. https://doi.org/10.20452/pamw.1627 24 25jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2016; 19 (1) jssn 2016; 19 (1) 3t mr imaging evaluation of perianal fistulas: an initial experience in nepal ghanshyam gurung department of radiology and imaging, tribhuvan university teaching hospital, maharajgunj, kathmandu, nepal correspondence: dr. ghanshyam gurung email: ghanshyam_gurung@yahoo.com abstract introduction: fistula–in–ano is an abnormal perianal tract that connects anal canal to the perianal skin. improper visualization of primary fistulous tract and the associated abscesses or secondary tracts a r e the causes of recurrence. earlier imaging modalities like conventional fistulography, endosonography and ct scan have had limited role. even without endorectal coils, 3t mri has multi-planar imaging capability and excellent soft tissue differentiation to show perianal anatomy, primary and secondary tracts with associated abscesses in relation to sphincter complex. it provides excellent road map to surgeons for preoperative evaluation. the objective of the study was to evaluate the role of 3t mr in imaging of perianal fistulas. methods: a retrospective study was done among 32 patients who were referred for mr fistulogram for suspected perianal fistula at jeebanta advanced kathmandu imaging, durbar marg, kathmandu, nepal. all images and findings were obtained and recorded with the help of philips ingenia 3t digital broadband mr scanner. imaging was performed in oblique coronal and oblique axial plane. mr images were studied and grading system was applied according to the st james’s university hospital classification. the data were entered in a performa and was analyzed using ibm spss v21. results: male to female ratio was 7:1. according to st. jame’s university hospital mr imaging classification of perianal fistulas, most of the patients (25%) had grade 4 followed by (12.5% each) grade 0, grade 1 and grade 2 and (6.3% each) grade 3 and grade 5 fistulas. mean age was 37.28 y e a r s (std. deviation 11.9). common internal opening in axial image was found at 5 0’ clock positions (31.3%). mean length of the fistulous tract was 3.9 cm (std. deviation 2.3). conclusion: perianal fistulas are more common in males and grade 4 fistulas are the commonest. mri is well-tolerated, painless and noninvasive technique and has multiplanar capabilities with excellent tissue differentiation of pelvic muscle along with sphincter complex. keywords: abscess; fistula; mri; secondary tract. introduction fistula–inano is an abnormal perianal tract lined with epithelialized surface that connects anal canal to the perianal skin.1 fistula-in-ano is not a very common disease of the gastrointestinal tract. the prevalence rate is approximately 0.01% and more common in men than in women. male female ratio is 2:1.2 on and off perianal discharge, itching, discomfort, fever and local pain are the common symptoms.3,4 even though being an uncommon disease, fistula-in-ano was first described in hippocrates. in 1835, frederick salmon treated 131 patients for fistula st mark’s hospital in london.5 in 1900, david henry goodsall described the course of fistulous tract original article 26 27jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2016; 19 (1) jssn 2016; 19 (1) and developed goodsall’s rule for fistulous tract. 6 “parks’ initial classification of perianal fistula was presented in 1976. it was based on surgical anatomy.7 morris modified the parks classification system in 2000. this on the basis of radiologic anatomy on pelvic mri, which is known as the st. james university hospital classification.5 obstruction by trauma or fecal material to the outlet duct of the mucous anal gland leads to stasis, infection and first stage of perianal abscess. pus then follows the least resistance path between the internal and external anal sphincter and through the external anal sphincter into the skin or ischioanal fossa or both. multiple secondary tracts is also developed.8 postoperative recurrence rate of perianal fistula is very high. this is not due to surgical hands. the main cause is due to poor or lack of demonstration of anatomical details, primary fistulous tract and it’s multiple branches with abscess.5, 9 three tesla magnetic resonance imaging has excellent multiplanner imaging capability and provides excellent anatomical details (especially sphincter anatomy) in relation with primary, secondary tracts with abscess and can be performed without endorectal coils.10, 11 the objective of the study was to evaluate 3t mr imaging of perianal fistula. high tesla mri is very important in the evaluation of perianal fistulas including simple vs. complex fistulas along with secondary tracts and abscess in relation with anal sphincter complex. it will provide excellent road map for surgeon for preoperative evaluation for management.12 methods a retrospective study was done among 32 patients who were referred for mr fistulogram for clinically suspected perianal fistula with perianal discharge at jeebanta advanced kathmandu imaging pvt. ltd., durbar marg, kathmandu, nepal from 11th january, 2015 to 9th march, 2016. the mri protocol for all of the sequences was standard. all images were obtained with a philips ingenia 3t digital broadband mr scanner. patient was placed in supine position with head first body coil was placed over the pelvis region placing center at the level of symphysis pubis. t1 3d gre sequences in 3 planes were taken as localizer. for all sequences, distal rectum and subcutaneous tissue was included in imaging volume. imaging plane was also included supralevator space to ensure no extension. imaging was performed in oblique coronal and oblique axial planes. the plane for oblique coronal plane was parallel to anal canal and plane for oblique axial plane was perpendicular to oblique coronal. following sequences were taken as standard sequences. 1. t1w oblique axial tr/te 450/8ms, field of view (fov) 18-20 cm, slice 3mm with 0.9 mm gap and matrix 348x298. 2. t2w oblique axial tr/te 2400/90ms, field of view (fov) 18-20 cm, slice 3mm with 0.9 mm gap and matrix 328x267 3. t2w spair in oblique axial and oblique coronal tr/ te 3400/65ms, field of view (fov) 18-20 cm slice 3mm with 0.9 mm gap and matrix 276x254 4. 3dt2w spair in sagital plane tr/te /8ms 1500/145, field of view (fov) 20 cm, continuous slice of 1mm with isometric voxel having matrix of 200x198.these 3d data were sent to philips intellispace portal and further analyzed in different planes (mpr/ mip) to see the extension of fistula to other area and to project the lesion better. image analysis mr images were interpreted by a single radiologist with more than 13 years of experience in abdominal imaging with experience in perianal fistula imaging. mr imaging was described and grading was done according to the st james’s university hospital classification. according to this grading system, normal findings is grade 0 (figure 1), simple linear intersphicteric fistula is grade 1 (figure 2), intersphicteric fistula with intersphicteric abscess or secondary tract is grade 2 (figure 3), transphicteric fistula is grade 3 (figure 4), transsphicteric fistula with abscess or secondary tract within the ischioanal or ischiorectal fossa is grade 4 (figure 5) and tract extending to supralevator region of translevator region is grade 5 (figure 6). figure 1. normal findings 26 27jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2016; 19 (1) jssn 2016; 19 (1) figure 2. grade 1 figure 3. grade 2 figure 4. grade 3 figure 5. grade 4 figure 6. grade 5 the fistulous internal opening was described as clockwise fashion. 12 o’clock position is anterior and 6 o’clock position is posterior. length of the track was measured from internal opening to skin surface, and number of secondary tract and tract direction was also mentioned. fistulous tract associated with presence or absence of abscess in the ischioanal, ischiorectal or supralevator spaces were carefully evaluated. the data was entered in a predesigned performa. data analysis was done by commercially available software package (using ibm spss v21). numeric variables were presented as mean and standard deviation and categorical variables were presented as number and percentage. results out of 32 patients, 4 (12.5%) were normal while 28(87.5%) were abnormal mri findings. amongst the abnormal findings, 8 (25%) of the patients had intersphincteric fistulas followed by 10 (31.3%) transsphincteric fistulas, 6 (18.8%) sinus tract, 2 (6.3%) supralevator/translevator and pilonidal sinus (figure 7). figure 7. mri findings 28 29jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2016; 19 (1) jssn 2016; 19 (1) associated ischianal/ ischiorectal abscess and secondary tracts were found in 5(15.6%) and 17(53.1%) patients respectively. abnormality was seen maximum in male patients 28(87.5%) rather than female patients 4 (12.5%) and male female ratio was 7:1. minimal age was 18 years and maximum age was 63 years. mean age was 37.28 (std deviation 11.9). external fistulous opening at anal region were found right side 13(40.6%), left side 14(43.8%) and inferiorly 3(9.4%) associated with multiple opening in 5(15.6%), single opening in 25(78.1%) and no external opening seen in 2(6.3%) patients. common internal opening (sphincteric) in axial mr image was found in 5 0’clock position in 10(31.3%) patients while least common 1(3.1%) of the patients had 1, 4, 11 0’clock position. maximum length of the tract was found 9cm while minimum length was 1cm. mean tract length was 3.9 (std. deviation 2.3) and anterosuperior direction of the tract was found in maximum patients 9(28.1%). in our study, st. jame’s university hospital mr imaging classification of perianal fistulas identified grade 4 (transsphincteric fistula with secondary tract/abscess) in most of the patients 8 (25%), grade 0 (normal), grade 1 (simple linear intersphicteric fistulas) and grade 2 (intersphicteric fistula with secondary tract/abscess) in 4(12.5%) patients and grade 3 (transsphincteric fistula) and grade 5 (supralevator and translevator) in 2(6.3%) patients (table 1). table 1. st. jame’s university hospital mr imaging classification of perianal fistulas grade frequency percent grade 0 (normal findings) 4 12.5 grade 1 (simple linear intersphicteric fistula) 4 12.5 grade 2 (intersphicteric fistula with intersphicteric abscess or secondary fistulous tract 4 12.5 grade 3 (transsphicteric fistula) 2 6.3 grade 4 (trans-sphicteric fistula with abscess or secondary tract within the ischioanal or ischiorectal fossa) 8 25 grade 5 (supralevator and translevator disease) 2 6.3 sinus tract + pilonidal sinus 8 25 total 32 100 data was evaluated regarding clinical complaints which showed 14(43.8%) perianal discharge followed by 11(34.4%) recurrent fistula past h/o operation and 1(3.1%) perianal bleed, past h/o fissure operation and h/o discharge and 2(6.3%) pilonidal sinus with discharge. discussion because of its excellent capability of demonstration of soft tissue contrast and multiplanner capabilities, mri is the best choice of the pre operative evaluation of perianal fistulas.12, 13 lunniss et al first utilize the mri for preoperative evaluation of fistula. they correlated mr and surgical findings and found 86-88% concordance rate.14 subsequent studies with high tesla mri suggested that mri is more sensitive. dynamic contrast enhanced magnetic resonance imaging (dcemri) was more accurate to identify complex fistula than surgical exploration and had a sensitivity of 97%.15 t2w spair images (fat-suppressed) shows high signal intensity fluid in the tract and low signal intensity fibrous wall of the fistula which provides the good contrast and delineate the layers of the anal sphincter.16, 17 in our experience, axial t2w spair and 3dt2w spair (fat suppressed images) was the most useful for locating the fistulous tract, its internal opening, secondary tracts and collection. gadolinium enhanced t1w images and substraction contrast mr fistulography are useful to detect abscess and active inflammation. stir (short inversion recovery) and dwi (diffusion weighted imaging) are additional sequences to whom contrast is contraindicated.12, 18 stir sequence sometimes gives fallacious high signal intensity in healed fibrous tract. t2w and dynamic contrast 28 29jssn jssnjournal of society of surgeons of nepal journal of society of surgeons of nepal jssn 2016; 19 (1) jssn 2016; 19 (1) enhanced mr sequence should be carefully evaluated which will help to avoid this fallacy.15 axial images provide the exact location of the primary tract, internal opening and differentiate intersphincteric from a transsphicteric fistula; the presence of involvement external anal sphincter. coronal images differentiate extension of supralevator from infralevator tract. in our study we found all positive cases of perianal fistula using combination of different mr sequences and imaging planes, which provided necessary details. in our study we found st. james university hospital classification grading of fistulas applicable in 24 of 32 cases. this mr based classification system provides simple anatomic details, which can be seen in axial and coronal images. classification or grading is important because it provides the treatment option, simple fistulotomy to complex surgical procedures.6 preoperative mri evaluation provides detail about primary, secondary tracts, abscess and high and low fistula and associated crohn’s disease which will benefit the patient. recurrent fistula is headache to surgeons and is a cause of anxiety to patients, and is associated with branching fistulous tract.13 incomplete diagnosis and missed extensions are the commonest cause of recurrence. in our study recurrence fistulae rate was 11(34.4%). all cases had not undergone preoperative mr examination. in last few years, mri has emerged as the best modality of choice in the detection and classification of perianal fistula. it has ability to detect complex fistula in simple way which helps the surgeon decide therapy with positive patient outcome. conclusion perianal fistulas are more common in males and according to the st. jame’s university hospital mr imaging classification; grade 4 fistulas are the commonest. mri is a well-tolerated, painless and noninvasive technique and has multiplanner capabilities with excellent tissue differentiation of pelvic muscle along with sphincter complex. mr imaging provides the excellent information about the fistulas, secondary tracts and abscess in relation to pelvis structures. acknowledgement i would like to express my sincere gratitude to dr. dan bahadur karki for the great suggestion and support during the study. further, i would like to thank dr. anup pradhan and ms. amrita chaulagain for their help in preparing manuscript. references 1. seow-choen f, nicholis rj. anal fistula. br j surg.1992; 79: 197-205. pmid:1555083 h t t p s : / / d o i . o r g / 1 0 . 1 0 0 2 / b j s . 1 8 0 0 7 9 0 1 0 7 h t t p s : / / d o i . o r g / 1 0 . 1 0 0 2 / b j s . 1 8 0 0 7 9 0 3 0 4 2. lima cmao, junqueira fp, rodrigues mcs, gutierrez cas, domingues rc, coutinho junior ac. magnetic resonance imaging evaluation of perianal fistulas: iconographic essay. radiol bras. 2010; 43(5): 330-335. https://doi.org/10.1590/s010039842010000500013 3. sainio p. fistula-in-ano in a defined population: incidence and epidemiological aspects. ann chir gynaecol. 1984; 73(4): 219–24. pmid:6508203 4. llauger j, palmer j, pe ́rez c, monill j, ribe ́ j, moreno a. the normal and pathologic ischiorectal fossa at ct and mr imaging. radiographics. 1998; 18(1): 61–82. pmid:9460109. https:// d o i . o r g / 1 0 . 11 4 8 / r a d i o g r a p h i c s . 1 8 . 1 . 9 4 6 0 1 0 9 5. morris j, spencer ja, ambrose ns. mr imaging classification of perianal fistulas and its implications for patient management. radiographics. 2000; 20(3): 623–635. pmid:10835116. https://doi. o rg / 1 0 . 11 4 8 / r a d i o g r a p h i c s . 2 0 . 3 . g 0 0 m c 1 5 6 2 3 6. goodsall dh, miles we. diseases of the anus and rectum. london: longmans, green and co; 1900. 7. park ag, gordon ph, hardcastle jd. a classification of fistula-in-ano. br j surg. 1976 jan; 63(1): 1-12. https://doi.org/10.1002/bjs.1800630102 8. seow-choen f., ho jm. histoanatomy of anal glands. dis colon rectum. 1994; 37: 1215-8. pmid:7995146 h t t p s : / / d o i . o r g / 1 0 . 1 0 0 7 / b f 0 2 2 5 7 7 8 4 9. halligan s, stoker j. imaging of fistula in ano. radiology. 2006; 239: 18–33. pmid:16567481 h t t p 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bartram c, buchanan g. imaging anal fistula. radiol clin north am. 2003; 41: 443– 457. https://doi.org/10.1016/s0033-8389(02)00122-7 14. lunnis pj, armstrong p, barker pg, reznek rh, philips rk. mr imaging of the anal fistulae. lancet. 1992; 340: 394-6. https://doi.org/10.1016/01406736(92)91472-k 15. spencer ja, ward j, beckingham ij, adams c, ambrose ns. dynamic contrast-enhanced mr imaging of perianal fistulas. ajr am j roentgenol. 1996; 167 (3): 735-41. pmid:8751692. h t t p s : / / d o i . o r g / 1 0 . 2 2 1 4 / a j r. 1 6 7 . 3 . 8 7 5 1 6 9 2 16. stoker j, rociu e, zwamborn aw, schouten wr, lameris js. endoluminal mr imaging of the rectum and anus: technique, applications and pitfalls. radiographics. 1999; 19: 383–98. pmid:10194786. h t t p s : / / d o i . o r g / 1 0 . 1 1 4 8 / r a d i o g r a p h i c s . 1 9 . 2 . g 9 9 m r 0 1 3 8 3 17. maier ag, funovics ma, kreuzer sh, herbst f, wunderlich m, teleky bk, et al. evaluation of perianal sepsis: comparison of anal sonography and mri. j magn reson imaging. 2001; 14: 254–60. pmid:11536402. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 2 / j m r i . 1 1 8 1 18. hori m, oto a, orrin s, suzuki k, baron rl. diffusion-weighted mri: a new tool for the diagnosis of fistula in ano. j magn reson imaging. 2009; 30 (5): 1021–1026. pmid:19856434. h t t p s : / / d o i . o r g / 1 0 . 1 0 0 2 / j m r i . 2 1 9 3 4 403 forbidden forbidden you don't have permission to access this resource. apache/2.4.54 (ubuntu) server at nepjol.info port 443 jssn_vol25i2-cut.pdf abstract journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np traumatic diaphragmatic hernia: an uncommon entity ellina dangol1, aditya prakash yadav1, umesh kumar yadav1, binod kumar rai1, vipul vivek pathak2 1department of surgery, national medical college and teaching hospital birgunj, nepal. 2department of anaesthesia, national medical college and teaching hospital birgunj, nepal. dr. ellina dangol, department of surgery, national medical college and teaching hospital, birgunj, nepal. email: dangol.lna@gmail.com traumatic diaphragmatic hernia is secondary to penetrating injuries and blunt abdominal and thoracic trauma. it is an uncommon entity. early diagnosis is necessary to decrease morbidity and mortality. here we report a case of 22-year-old male with the diagnosis of traumatic tenderness was present and bowel sounds were not appreciated and defect with intrathoracic herniation of abdominal viscera. laparotomy through the diaphragmatic tear. keywords: ct scan; laparotomy; traumatic diaphragmatic hernia. introduction traumatic diaphragmatic injury is an uncommon and rare injury. it occurs as a result of high velocity blunt trauma to abdomen, penetrating injury to chest or abdomen, with varies, as it may be asymptomatic or may have acute presentation with features of breathlessness or may present late with complications like obstruction, strangulation or perforation.3 be obtained in all cases of thoraco-abdominal injuries as it is useful in ruling out rupture diaphragm in asymptomatic cases as well as visualizing solid organs injuries and hollow viscus perforation in cases of multiple injuries.5 treatment of diaphragm rupture mainly consists of repair of diaphragm and can be performed through a thoracotomy can visualize all intra-abdominal injuries. the mortality is mainly related to associated injuries. case history a 22-years-old male came to the emergency of national medical college and teaching hospital with a history of stab injury by sharp knife with sustained injury of abdomen and grade findings i contusion ii iii laceration 2-10cm 2 laceration and tissue loss>25cm2 2,4: case report an uncommon entity. j sosc surg nep. journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np s 2 lumbar region above the iliac crest with retroperitoneal fat injury was over the right lateral subcostal region with ribs one was longitudinal over l3-l4 vertebra with muscle tear and active bleed. fourth was longitudinal over right lateral to t8-t10 vertebra with muscle tear and active bleed tenderness and guarding were present and bowel sound air entry over left side with normal breath sound over right. were normal. showed hyperlucent shadow in left lower zone and was figure 1 scan was done which showed left sided diaphragmatic defect figure 2 distal pancreas through diaphragmatic tear was found. the anterior wall of stomach, mainly the body of stomach, was collection of blood about 150ml in the left pleural cavity. primary closure of diaphragm was done with prolene 20cm distal to the duodenal-jejunal junction. abdominal drain of size 28fr kept over pelvic region. abdominal wall tube of 28fr was kept over left chest. postoperatively patient was kept in intensive care unit report on 2nd post operative day and was hemodynamically month. discussion diaphragmatic injury. it is mainly associated with multiple injuries8 and are diagnosed either with respiratory distress or as in intestinal obstruction.9 mechanism of injury mainly involves the shearing of stretched diaphragm at the point of diaphragmatic attachment due to sudden force transmission through viscera in abdomen. most common site of rupture of its origin from pleuro-peritoneal membrane which is structurally weak.10 left side rupture are more common as liver11 in the current reviews.12 the presented case also showed left sided traumatic diaphragm injury with herniation of abdominal content. figure 1. chest x-ray at the time of admission tomography scan of the patient. dangol e et al journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np tears can be initially missed or incorrect interpretation of radiograph is a frequent reason for incorrect diagnosis of diaphragmatic rupture.13,14 actually due to stomach herniated into the chest. such a mistake can lead to placement of unnecessary chest tubes in the presented case was confused with the left sided the suspicion of diaphragmatic eventration took the step of cect chest and abdomen and showed diaphragmatic herniation of bowel contents. when nasogastric tube is seen in chest but often masked right side.15 laparoscopy is another diagnostic method when in doubt or when other measures fail. references 1. in abdominal stab wounds: a prospective, randomized study. journal of trauma and acute care surgery. 2003 2. asensio ja, petrone p. diaphragmatic injury. in: cameron jl ed. current surgical therapy, 8th ed. 3. traumatic diaphragmatic hernia: pictorial review of ct 4. department of surgery/songkhla hospital. 5. hordiychuk a, elston t. traumatic diaphragmatic debarros m, martin mj. penetrating traumatic 8. presentation of a patient with a ruptured diaphragm complicated by gastric incarceration and perforation after apparently minor blunt trauma. canadian journal 9. traumatic rupture of diaphragm. the annals of for diaphragmatic repair there are many approaches, the choice depends on the circumstances of each case. laparotomy is considered by some authors as gold standard but others preferred thoracotomy. laparotomy laparoscopic repair is also becoming popular. in case of small defect simple suture is done whereas in case of large defect synthetic mesh is required. as this patient had peritoneal breach in other parts along with diaphragmatic injury laparotomy was considered as better option and since defect was wide enough for the primary repair there was no need for the mesh. the important thing in using rate of necrosis seen in emergency surgeries.18 conclusion traumatic diaphragmatic hernia is an uncommon entity that carries serious morbidity and mortality. a high degree of suscpicion is warranted in cases of abdominal and thoracic trauma. 10. j, d’agostino h. diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma 11. 12. carter bn. traumatic diaphragmatic hernia. am j 13. a review on delayed presentation of diaphragmatic 14. napolitano c. late posttraumatic diaphragmatic hernia. a clinical case report. minerva chirurgica. 1994 may 15. long-term sequelae. journal of trauma and acute care blaivas m, brannam l, hawkins m, lyon m, sriram k. bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. the american journal of emergency medicine. 2004 nov current status of traumatic diaphragmatic injury: lessons learned from 105 patients over 13 years. the annals of 18. jee y. laparoscopic diaphragmatic hernia repair using jssn_vol25i2-cut.pdf www.jssn.org.npjournal of society of surgeons of nepal j soc surg nep. 2022;25(2) 35 abstract ethical clearance: financial aid: authors retain copyright and grant the journal right journal. outcome analysis of cohen’s cross trigonal ureteric reimplantation in paediatric age group suman bikram adhikari, ramnandan p chaudhary, tul maya gurung, sanjay sah, shovita rana department of paediatric surgery ishan children and maternity hospital, kathmandu, nepal dr suman bikram adhikari, department of paediatric surgery ishan children and maternity hospital, kathmandu, nepal emailsumanchetri@hotmail.com none none taken introduction: cohen’s cross trigonal ureteric reimplantation is the in children with high success rate. the objective of this study was to evaluate and assess the outcome of open cohen’s procedure in children methods underwent cohen’s procedure between march 2010 and february 2020 results minutes for unilateral repair respectively. the mean length of hospital abdomen in all patients and micturating cystourethrogram in few patients conclusion: cohen’s uretric reimplantation is a standard procedure in operative technique should be pursued. keywords original article cross trigonal ureteric reimplantation in pediatric age group. j sosc surg nep. 2022; journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np introduction population.1 remarkable changes in recent years and favors nonin some instances still needs surgical correction like in renal scarring.2-3 in this era of modern technology, laparoscopic ureteric re-implantation or endoscopic procedures involving subureteric transurethral injection are commonly used for quick and minimally invasive and require short hospital stay.4 however, in developing countries like nepal where are managed with open ureteric reimplantation. cohen, in and minimal morbidity. the aim of the current study is to evaluate the outcomes of cohen’s ureteric reimplantation in our part of world. methods all patients who underwent cohen’s cross trigonal ureteric reimplantation at ishan children and maternity hospital were retrospectively reviewed. approval for this study was time, claviendindo postoperative complications and postoperative follow-up were documented and analyzed. study in children. data were assessed using the hospital statistics were performed with the same software. inclusion criteria: • patients who underwent cohens uretric reimplantation selected. • patients who need additional ureteric tapering procedures were also included. • patients who needed ureteric reimplantation as an • patient who were lost in follow up operative technique all ureteric reimplantations were performed using the cohen cross-trigonal technique. stents were routinely placed. in all patients, the bladder was accessed using a pfannenstiel incision and opened vertically. after were dissected and mobilized preserving vessels, nerves and vas in male child. a submucosal tunnel was prepared anchored to the trigonal muscle and mucosal re-adaption was performed using 5/0 polyglactin sutures. in case of megaureter, the ureter was tailored or tapered over 12fr feeding tube, ureteric stent was kept. bladder was closed in two layers. abdominal wall was closed in layers using absorbable suture. 8-10f retropubic drain tube and foley catheter was kept. follow up along with urine c/s was performed at one month during c/s showed no growth. there is chance of introduction of bacteria to urothelium. results this study consisted of 40 consecutive patients who underwent cohen’s procedure from march 2010 to february 2020. there were 25 girls and 15 boys. mean table 1 age at surgery (months) mean 32 (range: 6-96) sex male: female 15 (37.5%): 25(62.5%) site of vur (left:right:bilateral) 10:14:16 operation time one side (minutes) 249.4(200-290) operation time both sides (minutes) 158.3(130-180) hospital stay (days) mean 10.55 (7-15) follow-up (months) mean 28.13 (7-72) table 1. patient characteristics adhikari sb et al journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np figure 1 bladder diverticulum in close vicinity to ureteric opening] figure 2 figure 3 perioperative complications table 2 bladder was re-opened and intravesical clot was removed and haemostasis secured. another patient developed hospital acquired pneumonia in postoperative period for figure 1. indication for cohens ureteric reimplantation (n=40) figure 2. vur vs non-vur (n=40) complications n (%) clavien-dindo grade i 4 (10%) clavien-dindo grade ii 6 (15%) clavien-dindo grade iii 2 (5%) clavien-dindo grade iv 1 (2.5%) table 3 had ultrasound of kidney, ureter and bladder at 3 months of postoperative period. among the 24 unilateral procedures, 01 patient with obstructed megaureter had moderate to discussion damage after acute pyelonephritis has been understood since the mid-to late 20th century.8 subsequently, ureters swiftly gained popularity and were demonstrated 9 for high-risk patients with reimplantation remains the risk adapted, standard treatment.10 the most commonly used technique for ureteric reimplantation with less complications in children is cohen’s cross-trigonal reimplantation.9,11,12 table 2. complications/follow-up complications n (%) febrile uti 4 (10%) non-febrile uti 8 (20%) ureteric obstruction 0 (0%) recurrent vur 2 (5%) re-do surgery later 1 (2.5%) table 3. late complications during follow up journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 38 length which was created in the initial phase of practice. tunnel length toureteric diameter ratio of up to 1:4-5 was assumed. therefore, tunnel length was measured arbitrarily in our patients to maintain the aforementioned created by the cross trigonal transfer of the ureter or due to the current study was limited by the retrospective nature of the design. additionally, there were fewer numbers of reimplantated ureters as this is private children hospital. cases for open reimplantation. finally, the median followup time reported was suboptimal for clinical outcome. conclusion cohen’s ureteric reimplantation is a standard procedure in pursued. references 1. injection technique for endoscopic treatment 2. performed as an outpatient therapy. journal of 3. reimplantation: a minimally invasive technique for 4. chertin b, kocherov s, chertin l, natsheh a, farkas 5. there have been many reports on cohen’s repair with technique, the current institution has had two postoperative 13 and haid et al14. these two complications were encountered in the early phase of practice. stone formation12,15 make it less popular among some urologist. none of patients in our study had obstructive hydronephrosis and stone formation. grade ii complications are more likely to occur after a cohen’s the form of reactionary haemorrhage for which reoperation associated hospital acquired pneumonia. challenging, thus creating risk factors of lower success rates, were also present. the length of the submucosal tunnel and its relation to the diameter of the ureter is reported to be an important factor in successful ureteric reimplantation. chung jm, park cs, lee sd. postoperative ureteric obstruction after endoscopic treatment for jm, tamminen-möbius te. international system 8. 9. cohen sj. the cohen reimplantation technique. 10. urology. https://uroweb.org/guideline/paediatricurology/#3_13. 11. mure py, mouriquand pd. surgical atlas the cohen 12. adhikari sb et al journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 39 13. intravesical detrusorrhaphy. j pediatr surg. 2013;48:1813e8. 14. haid b, strasser c, becker t, koen m, berger 15. of surgical complications: a new proposal with of a survey. ann surg. 2004;240: 205e13. jssn_vol25i2-cut.pdf www.jssn.org.npjournal of society of surgeons of nepal j soc surg nep. 2022;25(2) abstract ethical clearance: financial aid: authors retain copyright and grant the journal right journal. comparative study of fine-needle aspiration cytology and histopathological diagnosis of salivary gland swelling introduction fnac is more accurate than other methods of fnac. it is simple and be repeated if needed. methods: this study is a prospective study of 80 patients subjected to with the preoperative fnac reports. in all 80 cases, informed consent was obtained prior to surgery. results: true-positive, true-negative, false-positive, and false-negative rates for carcinomatous lesions of salivary gland swelling were assessed. respectively for fnac when compared against histopathology. conclusion test used for the preoperative evaluation of patients with salivary gland swelling. fnac is very commonly used as an initial routine investigation. keywords: fnac; histopathology; salivary gland swelling; sensitivity; taken none none original article balaprasanth j1, vinod pb2 associate professor, alappuzha, kerala, india email: pbdrvinod@gmail.com srudy of fine needle aspiration cytology and histopathological diagnosis of salivary gland swelling. j sosc surg nep. 2022; 1 department of plastic surgery, christian india. 2 alappuzha, kerala,india journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np introduction the salivary glands consist of the parotid, submandibular, sublingual, and minor glands. the minor salivary glands are salivary gland tumors.1 and the remainder is distributed between the sublingual and countless minor salivary glands.2 major salivary gland tumors tend to be benign, whereas minor tumors tend to be malignant.3 in the 1920s and quickly gained wide acceptance among clinicians due to the ease of its performance and its rapid diagnosis.4 fnac is the main diagnostic tool used for the location and easy accessibility. due to the large variety of salivary gland neoplasms and the lack of tumor markers, diagnosing submandibular tumors is challenging for clinicians and pathologists. the inherent morphological heterogeneity of the lesions, of the cytopathologist in reviewing and diagnosing the lesions alter the ultimate diagnosis, treatment protocol, and outcome. able to distinguish benign from malignant lesions.11 fnac can better identify malignancy than any other investigations of cases. fnac for salivary gland lesions has been shown treating salivary gland pathologies12,13 and is simple, safe, many study-reports on the use of fnac are available in the literature, those addressing populations from coastal areas attending rural medical colleges with no access to frozen between fnac and histopathology in salivary gland swelling. methods committee and the institutional ethics committee, this prospective study was launched. patients attending surgery outpatient department with swelling in the neck and oral were conducted to identify salivary gland swelling. data were obtained using a pre-structured proforma after the study participants gave their written informed consent. 2019. the study enlisted the participation of 80 patients. male and female patients with salivary gland swelling patients subjected to fnac followed by surgery and swelling were included. patients below age 13 are referred to pediatric surgery, so they were not included. patients patient histories were collected and detailed clinical nerves, skin, or bone, a ct scan was also done. in cases were done prior to fnac. in straightforward cases, fnac our institution, so it was not utilized in our study. after consent was obtained, aspiration was done directly on the percutaneous or transoral root as an operative procedure. all the aspiration was done by the same team by the same team of cytopathologists. the aspirate was obtained under aseptic conditions with a 23-gauge needle needle was passed in multiple directions without taking it out of the tumor, and for large tumors, aspiration was done at various sites. smear-prepared on multiple slides papanicolaou’s stain. after the fnac report was obtained, patients were re-evaluated, and additional investigations like a ct scan were conducted for selected cases, after which patients were subjected to surgery with a proper anesthesia check-up. for all cases, informed written consent was obtained. since there is no facility for the frozen sections in our center, surgery for the swelling was scan report. specimens were assessed by post-operative histopathological evaluation. cytologically benign swelling arising from the deep lobe. for cytologically malignant cases, total parotidectomy with removal of the lymph nodes was done. for submandibular swelling, the gland with removal of the lymph nodes and adjacent structures was done in indicated cases. for minor salivary cytological diagnosis and histopathological diagnosis predictive value, and negative predictive value of fnac were calculated, and the diagnostic accuracy of fnac was assessed. comparative study of fine-needle aspiration cytology and histopathological diagnosis of salivary gland swelling journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 48 results eighty patients with salivary gland swelling subjected to fnac followed by surgery and histopathological duration of swelling ranged from 3 months to 15 years; the table 1 cystic carcinoma. after fnac, no patients had major site, and three showed bruising at the site. in the postoperative histopathological diagnosis, out the same diagnosis as fnac and three cases showed cases of mucoepidermoid carcinoma, four showed the adenoid cystic carcinoma, three showed the same diagnosis table 3 false-positive cases included one mucoepidermoid carcinoma of the parotid gland in a 45-year-old male who underwent total parotidectomy that proved to be a 55-year-old female proved to be a pleomorphic adenoma. false-negative cases were two cases of pleomorphic adenoma, one from the parotid gland and one from the adenoma and mucoepidermoid carcinoma, respectively. for the former, since it arose from the deep lobe, the patient underwent total parotidectomy. for the latter, arose from malignancy. age total female male 3 2 1 3 3 21 12 9 24 14 10 19 10 9 4 3 total 80 45 35 the male: female ratio was 1:1.28. site number percentage parotid submandibular 20 minor salivary gland 1 1.25 discussion salivary gland swelling in male and female patients the study. the highest number of patients was seen in the 1:1.28, consistent with a study that claimed that salivary gland lesions are more common in females.11 in our study, the frequency of swelling in the parotid, results of the majority of previous studies. most patients had a history of a gradually increasing mass of variable duration. facial nerve involvement was seen in one case, and lymphadenopathy was seen in two cases. most of the instances of malignant swelling were clinically similar to those of benign swelling, so the primary challenge of of malignancy.14 journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 49 et al, 15 in our study using fnac, pleomorphic adenoma was the and mucoepidermoid carcinoma was the most common corroborate with those of a study conducted in pakistan on 129 cases of parotid gland lesions.23 in our study using fnac, neoplastic, benign, and malignant lesions is comparable with other studies, in which the percentages 24 among the benign cases, pleomorphic adenoma was the common benign and malignant tumors were pleomorphic adenoma and mucoepidermoid carcinoma, respectively. these results agree with those of pratap and jain,25 panchal and shah, cases were reported in the study. false negatives have been reported in various studies, with rates ranging in this study, there was one case of mucoepidermoid carcinoma and one case of carcinoma as pleomorphic adenoma by fnac. fnac can quite easily diagnose pleomorphic adenoma, but occasionally, adenoma from mucoepidermoid carcinoma, adenoid cystic 28 there were two occurrences of false positives. the carcinoma of the parotid gland. the patient underwent total parotidectomy, and pleomorphic adenoma was diagnosed substance of pleomorphic adenoma could be misinterpreted may indicate low-grade mucoepidermoid carcinoma or mucoepidermoid carcinoma originating in the pleomorphic adenoma.29 because the morphological patterns of epithelial components show diversity in both pleomorphic adenoma and low-grade mucoepidermoid carcinoma, cases n(%) (fnac) same hpr discordant cases total cases hpr pleomorphic adenoma 44 3 chronic sialadenitis 8 2 pleomorphic adenoma: 2 8 0 cystic lesions 4 4 0 mucoepidermoid carcinoma 4 1 acinic cell carcinoma 2 0 adenoid cystic carcinoma 3 1 adenoma 0 0 0 total 73 7 test evaluated (fnac) histopathology positive histopathology negative total fnac positive 9 2 11 fnac negative 2 total 11 69 comparative study of fine-needle aspiration cytology and histopathological diagnosis of salivary gland swelling journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 50 aspirated material lacking the stromal component may result in a false-positive diagnosis. this misdiagnosis can be avoided by using multiple samples. for the second false positive, the cytological diagnosis indicated adenoid cystic carcinoma arising from the parotid gland. ct scan showed swelling arising from parotidectomy. the histopathological report showed between adenoid cystic carcinoma and pleomorphic acellular material and hyaline globules. the hyaline globules characteristic of adenoid cystic carcinoma may also be seen in pleomorphic adenoma. the stromal component of pleomorphic adenoma may thus be misinterpreted as basement membrane-like material seen in adenoid cystic carcinoma. there were two false-negative cases in the parotid gland, both of which were diagnosed as pleomorphic adenoma by in many studies. in a study by kotwal et al, three out of four mucoepidermoid carcinomas were diagnosed as pleomorphic adenoma cytologically. adenoma, for which the cytological diagnosis was pleomorphic adenoma. this misdiagnosis is of great clinical importance since this malignancy is very problem was emphasized in a study by klijanienko et salivary gland swelling.38 value, negative predictive value, and accuracy were those of most previous studies because we had a limited able oversaw the cytology division. additionally, more than site aspiration and repeated aspiration are usual practices. these could be the reasons for this study’s high accuracy inadequate aspirate or sampling errors remain important limitations of this technique and impose a great demand limitation in the number of malignant cases can contribute to the drawbacks of fnac. this can be overcome by conducting studies with larger samples. authors to reduce non-diagnostic aspiration due to false positioning of the needle outside the tumor or in the necrotic, hemorrhage, and cystic area. according to brennan et al,5 clinically suspicious cases should be reevaluated using appropriate imaging techniques and fnac should be repeated under ultrasound guidance cytopathologist. conclusion used for the preoperative evaluation of patients with salivary procedure with no major complications. it can be done as an outpatient procedure with good patient compliance and can be repeated if necessary. it is, therefore, of immense value in the diagnosis of benign and malignant lesions. fnac provides a more rapid and accurate diagnosis of salivary gland swelling than any other test. authors no. of cases accuracy 31 50 33 93.84 naz, hashmi, khurshid et al. 30 83.3 present study 80 95 authors year of study sensitivity (%) (%) sikdar, sriram, & ivan31 2018 100 85 naz, hashmi, khurshid et al.30 2015 poudel, shrestha, & 2020 90.32 present study 2019 81.82 journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 51 references 1. leegaard t, lindean h. salivary gland tumors: 2. nagarkar nm, bansal s, dass a, singhal sk, mohan 3. epker bn, henry fa. clinical histopathologic and surgical aspects of intraoral minor salivary gland 4. rapid microscopical diagnosis of tumors. br j surg. 5. brennan pa, davies b, poller d, et al. fine needle repeat aspiration provides further information in cases with an unclear initial cytological diagnosis. needle aspiration cytology in salivary glands lesions. show wide variation in reporting of study population 8. for diagnosing salivary gland tumors. j pathol transl 9. 509. 10. a comprehensive review. diagn cytopathol. 11. 12. 13. 14. epithelial parotid tumors. j coll physicians surg 15. the diagnosis of salivary gland swellings. kathmandu mh. diagnostic reliability of fnac for salivary gland swellings: a comparative study. diagn aspiration cytology in diagnosis of salivary gland lesions: a study with histologic comparison. 18. parotid gland masses: a clinicopathological study of 19. aspiration cytology in parotid lumps. j pak med 20. mihashi h, kawahara a, kage m. comparison diagnosis and histopathological diagnosis of salivary 21. chakrabarti s, bera m, bhattacharya pk. aspiration cytology and histopathology along with immunohistochemistry. j indian med assoc. 22. pilotti s. fine needle aspiration of parotid masses. 23. ali ns, akhtar s, junaid m, awan s, aftab k. 24. fine needle aspiration biopsy of the salivary glands. 25. salivary gland tumors a hospital-based study. inter comparative study of salivary gland lesions at gland lesions with histopathological correlation in a district hospital of jammu region. indian j pathol 28. 29. 30. naz s, hashmi aa, khurshid a. diagnostic role evaluation of salivary gland swelling: an institutional comparative study of fine-needle aspiration cytology and histopathological diagnosis of salivary gland swelling journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 52 31. histopathological correlation of salivary gland 32. 33. 34. 35. qizilbash ah, sianos j, young je, archibald sd. fine needle aspiration biopsy cytology of major khandekar mm, kavatkar an, patankar sa. fnac of salivary gland lesions with histopathological preoperative diagnosis or a cytopathologist’s riddle. 38. adenomas: diagnostic pitfalls and clinical jssn_vol25i2-cut.pdf www.jssn.org.npjournal of society of surgeons of nepal j soc surg nep. 2022;25(2) 40 abstract ethical clearance: financial aid: authors retain copyright and grant the journal right journal. indications and outcomes of abdominal drain in laparoscopic cholecystectomy in a tertiary care center in central nepal: a descriptive cross-sectional study introduction choice for symptomatic cholelithiasis. during this procedure, sometimes abdominal drain is placed in the right sub-hepatic space. the main objectives of this study were to assess the indications for the use of intralcs. methods: this is a prospective descriptive cross-sectional study department of surgery of a tertiary level teaching hospital in kathmandu, of intra-abdominal drain were selected for the study. the data were results the most common intraoperative indication for iad in lc. surgical site of the patients respectively. ssi was found to have a positive correlation conclusion: the prevalence of iad placement in lc in our study was almost double as compared to that of studies in other countries and predominantly more among males than females. cholelithiasis with cholecystitis and adhesions were the most common indications for iad placement. ssi in iad placement was found to be positively correlated with the operative time, post-operative hospital-stay and age of the patient. keywords: fever; hospital stay; intra-abdominal drain; laparoscopic cholecystectomy; operative time; post-operative; surgical site infection none none taken original article sandeep khanal email: drsandeep@gmail.com khanal s. indications and outcomes of abdominal drain in laparoscopic cholecystectomy in a tertiary care center in central nepal: a descriptive cross sectional dr. sandeep khanal, rapti academy of health sciences, department of surgery dang, nepal rapti academy of health sciences, department of surgery dang, nepal journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 41 introduction cholelithiasis is the most common biliary pathology seen in the out-patient department.1 its prevalence ranges from 2,3 among the younger age women than in men.4 is the treatment of choice for symptomatic cholelithiasis. prophylactic polyethylene drain placement in the gallbladder bed in the subhepatic space has been practiced widely, with the dictum of lawson tait, the 19th century either to detect early complications, such as postoperative hemorrhage or leakage, or to remove collections such as bile which could later be infected. some surgeons recommend the use of a short-term drain postoperatively based on during the operation and the accumulation of gas in the right sub-phrenic area often leads to shoulder pain.8,9 the value of surgical drainage in laparoscopic cholecystectomy 10 of randomized trials in open cholecystectomy.11 its use in developing countries where alternative modalities like routine imaging studies or interventional radiology are not easily accessible, has not declined. the use of iads in elective lcs and compare the outcomes of the iads with an aim to know how much of a value country. methods this was a descriptive cross-sectional study conducted department of surgery, nepal medical college teaching center located in kathmandu, at central nepal. ethical surgery residents and team. undergoing other surgeries of abdominal cavity along with apart from that all the patients with ultrasonographic lc followed by placement of the intra-abdominal drain during the duration of study were selected. convenience sample for the study. in all the cases with drain placement a after the surgery, patients with abdominal drain were with iad placement, we listed out parameters like surgical comparison of these variables was done to look for any analysis was done by statistical package for social sciences with t-test and p-value < 0.05 was considered statistically results predominantly more among males as compared to females. the mean age of the patients undergoing iad placement in lc was found to be 48±11.02 years. the majority of the patients were of the age group of 41 elective lc with placement of iad was 55 ± 9.8 minutes the most common preoperative indication for which iad placement had to be done was cholelithiasis with included symptomatic cholelithiasis with cholesterolosis table 1 table 1. preoperative indications for putting an abdominal drain in elective lc in patients with cholelithiasis. indications frequency % cholelithiasis with cholecystitis 21 35.0 cholelithiasis with empyema gallbladder 10 cholelithiasis with gallbladder polyp 13 symptomatic cholelithiasis with cholesterosis total 100.0 journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 42 the most common intraoperative indication for drain figure 1 encountered were suspicious of bile leak, unsecured cystic duct closure, subtotal cholecystectomy or uncontrolled spillage of pus in empyema for which drain had to be placed. iatrogenic bleed included cases of vascular injury, bed bleed which was controlled intra-operatively but with suspicion of bleeding again postoperatively then iad was placed. the patients developed fever. the average post-operative hospital stay of more than 10 days. ssi was found to have a positive co-relation with the pathogens and a greater chance of breach of the aseptic technique in the procedure due to longer operative time table 2 table 3 table 4 was obtained showing that as the patient ages, there were study. the drain was removed between 24 and 48 hours and mortality. discussion the prevalence of iad placement following lc in our to the hospital. also majority were referred cases from other centers suspecting the case to be complicated due to in ultrasonogram or thick walled gallbladder. in a study conducted by ahmet et al in 2013 in turkey, drain was 12 in another study the patients undergoing laparoscopic surgery, out of which 13 the prevalence of iad figure 1. pie chart diagram showing intraoperative indications for drain insertion. duration of surgery total p-value <30 mins mins mins surgical site infection no 2 2 51 0.01 yes 0 2 9 total 2 4 60 table 2. correlation between ssi and duration of surgery table 3. correlation between surgical site infection (ssi) and fever in post-operative day following iad for lc surgical site infection total p-value no yes fever no 49 8 yes 2 1 3 total 9 60 table 4. correlation between surgical site infection and postoperative hospital stay post-operative hospital-stay total p-value <5 days 5-10 days >10 days surgical site infection no 20 31 0 51 0.003 yes 2 5 2 9 total 22 36 2 60 of patients age group total p-value <20 yrs 20-40 yrs yrs yrs surgical site infection yes 1 0 2 9 0.021 no 0 14 33 4 51 total 1 14 39 6 60 khanal s journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 43 placement after lc in our study is thus comparable to other studies done in other developing countries. though in our study, more females underwent lc as were found more likely to have abdominal drain placed males having an iad placed.14 in another study by ahmet it did not specify the percentage or gender distribution of patients with iad placement after lc.12 the majority of the patients who underwent lc with 12 in another study by eun young kim et al in 2015, the average age of patients undergoing lc with iad placement in japanese population 15 a similar study by bajracharya et al conducted in nepal showed that the average age of patients was 41.30 years 14 the most common indication for placing an abdominal drain in our study was cholelithiasis with cholecystitis followed by symptomatic cholelithiasis with cholesterolosis, cholelithiasis with gallbladder polyp and cholelithiasis with gallbladder empyema. in a study by kumar et al done in 2012, the main indications for elective lc were acutely in a study by corwin et al done in 2011, out of 42 patients who went lc, the presence of gallbladder polyps with cholelithiasis was found to be the average operative time required for lc with iad placement in our study was found to be 55 ± 9.8 minutes ranging from 30 to 80 minutes. though the surgical approach and operating team were same for all the patients, variation in operative time could be due to the anesthesia time, minor variations in calot’s anatomy. in a similar study by sharma et al, the average time required for the operation 3 in the study by eun young kim et al in japanese population, the operative time recorded on 15 the most common intraoperative indication for drain a similar study by hussain et al, the indications for placing 18 in another study by shamim et al, adhesion in calot’s triangle was 19 el-labban et al in 2012, iad in lc was associated with 20 in a similar study done by with iad placement. 21 both the studies show comparative results with our study. the reason for our prevalence being slightly lower is probably due to a smaller number of cases in our study. none of the patients having high grade fever with chills or study of patients with iad after lc, conducted by chauhan 22 in another similar study done by shamim 19 the comparisons between these studies do not show much the average postoperative hospital stay in our study was al, the mean duration of post-operative hospitalization was 4±2.9 days.12 this study also showed that the placement of drain prolonged postoperative hospital stay when compared with patients without iad placement after lc. in another study by singh et al, the average duration of postoperative days.21 these comparisons show that the median duration of hospital day postoperatively with iad placement after lc is slightly higher in developing countries. association was found in a study done by chen et al which operative time and ssi, with close to twice the likelihood of ssi being observed across various time thresholds i.e., patients with ssis.23 24 this positive association was probably and a greater chance of breach of the aseptic technique in the procedure due to a longer operative time. ssi was also compared with fever which showed a negative are introduced at the time of the operative procedure from 25 however, fever was journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 44 infection.25 postoperative hospital stay as there was a positive surgical site infection and postoperative hospital stay. thus, study by mujagic et al conducted in switzerland. as the age of the patient increases, the patient has more chances of getting an ssi. in a similar study by talbot et al, the relationship between age and the risk of surgical site in another study by kaye et al, increasing age independently the sheer volume of patients and procedures studied patients were included for analysis.28 this large sample size allowed for the study team not only to derive the relationship between age and risk of ssi but also to validate consistent with our study which is the strength of our study. the limitations in our study was however it was done in and evaluated with outcomes comparison in studies of other developing countries. however we do not want to emphasize in putting a drain or not putting it. drains should not be placed routinely after lc as it increases pain and does not help in detecting or decreasing complications.29,30 conclusion the prevalence of iad placement in lc in our study is almost double as compared to similar studies done in other countries which could be due to limited resources. it was predominantly more among males. cholelithiasis with cholecystitis and adhesions were respectively the most common elective and intra-operative indications for iad placement in lc. ssi and fever were encountered respectively only in a small fraction of the patients. ssi operative time, post-operative hospital-stay and age of the patient. it may not be wise put the drain in very advanced hospital setup. however in developing countries like indications of iad in lc and association of the outcomes was quite similar on comparison with other studies in various countries. references 1. biological basis of modern surgical practice. 18th 2. national institute of health consensus and laparoscopic cholecystectomy. amer j surg. 3. after elective laparoscopic cholecystectomy. 4. m, dolapci m. a risk score for conversion from laparoscopic to open cholecystectomy. am j surg. 5. laparoscopic cholecystectomy to open surgery. surg 8. 9. low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy. br j surg. 10. decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis. 11. indications for elective cholecystectomy for 12. 13. 14. bajracharya a, adhikary s, agarwal cs. of university hospital in eastern nepal. health khanal s journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np 45 15. kim ey, lee sh, lee js, yoon yc, park sk, choi hj. is routine drain insertion after laparoscopic a multicenter, prospective randomized controlled kumar dl. laparoscopic cholecystectomy vs. 51. incidentally detected gallbladder polyps: is follow18. 19. shamim m, memon as, bhutto aa, dahri mm. cholecystectomy in a tertiary care institution. j pak 20. a, heissam k, el-kammash s. laparoscopic elective cholecystectomy with and without drain: a controlled randomised trial. j minim access surg. 2012; 8:90-2. 21. singh m, singh k, chawla is. laparoscopic cholecystectomy with and without drainage a 22. following elective laparoscopic cholecystectomy be a prospective randomised study. j minim access 23. 24. adm, ercole ff. incidence and risk factors for 25. of surgical drains with surgical site infections a prospective observational study. am j surg. 2019 and the risk of surgical site infection: a contemporary 2005 apr 1; 191:1032-5. 28. the risk for surgical site infection. j infect dis. 2005; 29. cholecystectomy in acute calculous cholecystitis: a randomised controlled study. postgrad med j. 2020 30. jssn_vol25i2-cut.pdf www.jssn.org.npjournal of society of surgeons of nepal j soc surg nep. 2022;25(2) abstract ethical clearance: financial aid: authors retain copyright and grant the journal right journal. every year, more than 200 million surgeries are performed around the world, and recent statistics show that adverse event rates for surgical pathologies remain unacceptably high, despite several national and global patient safety initiatives over the last decade. patient safety is diverse and highly complicated in nature, with several critical components. although concern for patient safety is fundamental in health care practice, its transition into knowledge is comparatively recent, and patient concerns and risk factors in surgical subspecialties. all surgical practitioners and health care organizations must therefore become better in endeavors to integrate patient safety measures in daily practice, and foster a patient safety culture. the purpose of this review article is to outline patient safety in surgical techniques that should be adopted and implemented. keywords: patient safety; quality; health professions; surgery. review article patient safety and organizational safety culture in surgery: a need of an hour in the developing countries sunil basukala1, sujan bohara2, anup thapa1, aashish shah3, soumya pahari4, yugant khand4, ojas thapa4, ayush tamang4, bivek bhagat4, bikash bahadur rayamajhi1 1department of surgery, shree birendra hospital, chhauni, kathmandu, nepal. 2 department of surgery, nepal mediciti hospital, lalitpur, nepal 3 department of anesthesia and critical care medicine, shree birendra hospital, chhauni, kathmandu, nepal. 4 department of surgery, nepalese army sanobharyang, kathmandu, nepal. dr. sunil basukala, assistant professor, department of surgery, nepal army institute of health science email: sunil.basukala@naihs.edu.np none none not applicable basukala s, bohara s, thapa a, shah a, pahari s, khand y et al. patient safety and organizational safety culture in surgery: a need of an hour in the developing countries. journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np introduction health care systems are under growing pressure to create events. the development of a patient-safety culture is critical in a systems-based approach to patient care and is the administrative focus of many surgical departments.1 the recent surgical malpractice crisis, which revealed might result from public broadcast of a sentinel occurrence, has stimulated the promotion of patient safety. errors in the operating room, in contrast to other medical settings, can be particularly devastating, with potentially highsuch as operating in the wrong location, performing the wrong procedure, forgetting sponges, unchecked blood transfusions, mismatched organ transplants, and unnoticed allergies, can be alleviated through better communication and safer hospital systems.2 as morbidity and death, the healthcare environment is seen as a high-risk setting, and health care services as a high-hazard sector. damage, however unforeseen, has 3, 4 patient safety is embedded in the practice of medicine and is a serious concern. however, it is only recently that it has been transformed into a specialized body of knowledge, care practitioners, health managers, and policymakers has begun to evolve. to err is human: establishing a safer institute of medicine released in 1999, highlighted the due to preventable medical errors. these medical errors are frequently the consequence of human error, and they organizational safety culture.5 terminologies patient safety or accidents associated with them. health risk management claims, and cause unnecessary economic losses to health care providers adverse event includes errors, accidents, delays in care, negligence, complications associated with treatment, etc. it an adverse event is not preventable does not imply that we should be unprepared to act promptly and appropriately if it occurs. error should be avoidable, the repetition of similar acts, in combination with organizational failures, makes this an event that almost causes harm to a patient, and that is avoided by luck or by an act at the last moment. and reminds the practitioner of the allergy. the prescription of drugs, about seven times more incidents than complete adverse events are estimated to occur. accident negligence omission of minimal precautions, or neglect. safety culture skills, and patterns of behavior, which lead to commitment, style, and ability in the management of the health and safety of an organization. those organizations with a positive safety culture are characterized by communication based on mutual prevention. table 1. common terminologies related to patient safety basukala s et al journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np the public outrage caused by the disclosure of these numbers impelled the problem of patient safety to the top of the priority lists of health professionals, managers, and hospital administration. as a result, patient safety has become a primary concern for everyone involved in health care. the goal of this review paper is to provide an overview of patient safety and organizational safety culture care. patient safety patient safety is perceived as the provision of safe health care or the protection of patients from harm by health care although both the patient and the practitioner are inherently and organizational aspects must also be acknowledged. patient safety, though relatively a new discipline, has as its main objectives to facilitate the avoidance of preventable associated with health care and to limit the impact of inevitable adverse events.1 of a common terminology. to overcome this problem, table 1 patient safety based on the international patient safety 8-15 patient safety also focuses on the analysis of the characteristics of health-care systems and on the promote an adverse event to occur while providing care. the potential latent risks in a system are vast, including slippery when it is wet, the necessity that personnel work information is transferred between professionals. typically, an undesirable outcome arises when many latent risks systems failure model. to varying degrees, every phase in a process has the potential for failure. the ideal system is analogous to a stack of swiss cheese slices. the holes in the represents a "defensive layer" in the process. an issue may locations, the problem is contained. each layer would act outcome. the greater the number of defenses and the fewer and smaller the holes, the more likely you are to detect and prevent errors.11 the swiss cheese model of accident causation illustrates that if hazards are aligned and levels figure 1 patient safety in surgery for more than a century, surgical treatment has been a vital component of global health care. the impact of surgical the incidences of traumatic injuries, malignancies, and cardiovascular disease continue to rise. every year, an estimated 234 million major procedures are conducted around the world, equating to one operation for every 25 people alive. however, surgical services are unevenly saved and disability avoided, access to high-quality surgical care remains a serious issue in much of the world. surgery is frequently the sole treatment that can alleviate impairments and lower the mortality risk from common undergo surgical treatment for severe injuries, another 10 million for pregnancy-related problems, and 31 million public health implications.21 according to research, surgical procedures in developed nations, with permanent surgery in underdeveloped countries.22 the issue of surgical safety is well known around the world. studies in wealthy countries demonstrate the scope and pervasiveness of the problem. poor infrastructure and equipment, unreliable supply and drug quality, inadequacies in organizational capacity and training, and chronic underfunding all contribute to the issues in developing countries. as a result, figure.1. swiss cheese model: a) hazards are not aligned with the “holes” in the levels of defense, therefore, accidents are less likely to occur. b) hazards are aligned and levels of defense do not lie between, therefore accidents can occur. patient safety and organizational safety culture in surgery: a need of an hour in the developing countries journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np surgical treatment has the potential to save the lives of millions of people around the world. for emergency and essential surgical care and the safety challenge, safe surgery saves lives, focuses on for patient safety began work on this challenge.28 the purpose of this challenge is to improve surgical care safety worldwide by creating a core set of safety criteria that can an agreement on four areas where major improvements in surgical safety may be realized. these are: surgical site infection control, safe anesthesia, safe surgical teams, and table 2 29-31 the nature of the challenge teamwork, safe anesthesia, and prevention of surgical site infection are fundamental to improving the safety of surgery and saving lives. basic issues of infrastructure and the ability to monitor and evaluate any changes instituted must be considered and addressed .30 the conventional framework for safe intraoperative care in hospitals consists of a routine series of events preoperative patient evaluation, surgical intervention, and preparation for proper postoperative care each with its own set of the procedure to be performed, checking the integrity of the anesthetic machine and the availability of emergency drugs, and ensuring proper preparedness for intraoperative occurrences are all interventions that can be made during the preoperative phase.32 appropriate and cautious antibiotic use, the availability of critical imaging, appropriate patient surgical judgments, meticulous surgical technique, and good communication among surgeons, anesthesia professionals, operation. following the procedure, a clear plan of care, an understanding of intraoperative events, and a commitment to high-quality monitoring may all help to strengthen the surgical system, increasing patient safety and improving results. there is also an acknowledged requirement for proper lighting and sterilization equipment. finally, safe surgery necessitates continuous quality assurance and monitoring.33-35 organizational safety culture the organizational safety culture is a critical part of regarded as an important aspect of service quality. it has even been proposed that patient safety begins with the implementation of a safety system at the organizational level, and that clinical error in acute-care hospitals can only be addressed by creating a safety culture. a safety group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and or assumptions that underline how people perceive and act upon safety issues within their organizations."15 a culture all activities of health professionals, the main objective of which is to avoid the occurrence of unnecessary damage to healthcare.38 "culture of blame." it does not look for individuals on whom finally, and fundamentally, it is a culture that compels us our colleagues so that everyone can learn from them. create a climate of patient safety as an organizational goal and a priority, the concepts of patient safety culture and safety climate and their implications for health care and organizations must be correctly understood by everyone involved in health care.40-42 surgical resources and environment trained personnel, clean water, a consistent light source, equipment, and sterile instruments prevention of surgical site infection safe anesthesia safe surgical teams hand washing presence of a trained anesthesiologist improved communication appropriate and judicious use of antibiotics professional anesthesia machine and medication correct patient, site, and procedure antiseptic skin preparation safety check informed consent atraumatic wound care availability of all team members instrument decontamination and sterility heart rate monitoring adequate team preparation and blood pressure monitoring planning for the procedure temperature monitoring patient allergies measurement of surgical services quality assurance peer review monitoring outcomes table 2. four areas of major improvements needed for surgical safety basukala s et al journal of society of surgeons of nepal j soc surg nep. 2022;25(2) www.jssn.org.np success in establishing a safety culture, with associated practices, may depend on prior success in achieving unidirectional, positive change in attitudes in order to evidence-based care delivery, communication, learning, and being just and patient-centered as important domains institutional culture for safety survey highlighted design improvements in health care, strategic planning, learning from errors, commitment to leadership, documenting and improving patient safety, encouraging and practicing teamwork, detecting possible risks, and employing procedures for reporting and analyzing adverse events and assessing improvements as relevant. to the establishment of a safety culture and quality improvement, open and transparent disclosure principles, health professional human resources crucial to ensuring institutions involved in patient safety, national patient safety accountability initiatives, and collaborative team as relevant to patient safety were: making patient safety everyone’s priority; teamwork; valuing individuals; open communication; learning, and empowering individuals. a "safety atmosphere" and predicting measurements of patient safety, as well as cultivating a non-punitive, open, and stimulating health care culture. a safety culture is also suggested in order to demand the proactive. because a supportive culture of patient safety is considered vital for enhancing patient safety, organizations measures related to patient safety, develop tools, and work and culture.41-45 conclusion current surgical safety, guidelines and checklists are issues and risk factors in various surgical subspecialties. as a result, it is critical for all surgical practitioners and health care organizations to become more aware of the overall apply patient safety measures in everyday practice, and to develop a patient safety culture. the purpose of this review paper is to outline patient safety in surgical techniques that should be implemented and followed for safe patient care. references 1. safety: from concept to measurement. annals of 2. new health system for the 21st century. 3. sammer ce, lykens k, singh kp, mains da, lackan the literature. journal of nursing scholarship. 2010 4. measuring patient safety climate: a review of surveys. 5. donaldson ms, corrigan jm, kohn lt, editors. to err is human: building a safer health system. 2009 jan 1:23-31. academic health science centres: towards the development of a collaborative position paper. nursing 8. 9. bernstein m, hebert pc, etchells e. patient safety in neurosurgery: detection of errors, 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