Chandra Shekhar Agrawal

Complex Posterior Urethral Disruptions: Management by Combined Abdominal Transpubic Perineal Urethroplasty

PURPOSE We present our short-term results of abdominal transpubic perineal urethroplasty for complex posterior urethral disruption. MATERIALS AND METHODS From January 2000 to March 2005, 21 patients with complex posterior urethral disruption underwent abdominal transpubic perineal urethroplasty. Complex disruption was defined as stricture gap exceeding 3 cm or associated perineal fistulas, rectourethral fistulas, periurethral cavities, false passages, an open bladder neck or previous failed repair. Preoperative voiding cystourethrogram with retrograde urethrogram and cystourethroscopy were done to evaluate the stricture and bladder neck. Followup consisted of symptomatic assessment and voiding cystourethrogram. RESULTS There were 11 adults and 10 prepubescent boys with an average age of 26 years (range 6 to 62). Mean followup +/- SD was 28 months (range 9 to 40). Mean stricture length was 5.2 +/- 1.4 cm. Of the 21 patients 12 had previously undergone failed urethroplasty. The mean period between original trauma/failed repair and definitive repair was 10.2 +/- 4.3 months. Urethroplasty was achieved through the subpubic route in 16 patients, while 5 required supracrural rerouting. In 20 of 21 patients (95%) postoperative cystourethrography showed a wide, patent anastomosis. Postoperative incontinence developed in 2 of 21 patients (9.5%). Seven of the 21 patients (33%) were impotent after the primary injury, while 3 of 14 (21.4%) had impotence postoperatively. There were no complications related to pubic resection, bowel herniation or periurethral cavity recurrence. CONCLUSIONS Combined abdominal transpubic perineal urethroplasty is a safe procedure in children and adults. It allows wide exposure to create a tension-free urethral anastomosis without significantly affecting continence or potency. Complications of pubic resection are now rarely seen.

Transorbital Orbitocranial Penetrating Injury due to Bicycle Brake Handle in a Child

Transorbital orbitocranial penetrating injuries (TOPI) are relatively rare and can be caused by a variety of unusual objects. Diagnosis of TOPI should be based on a detailed history and evaluation of available investigations as the penetrating injury may be overlooked. In the present case, a child sustained a penetrating injury with the brake handle of a bicycle due to the accidental fall of the bicycle on him and was managed conservatively.

Comparison of aspiration-sclerotherapy with hydrocelectomy in the management of hydrocele: A prospective randomized study

BACKGROUND Hydrocelectomy is practiced as the gold standard technique for the treatment of hydrocele worldwide. Aspiration and sclerotherapy is cheap, less invasive and safe compared to hydrocelectomy. However, the outcomes are inconsistent because of lack of uniformity in methods and sclerosing agents used. MATERIALS AND METHODS This was a randomized controlled study conducted in a university hospital for a period of one year. Sixty symptomatic adult males without fertility concern or coexisting scrotal pathology were enrolled. Aspiration and sclerotherapy and hydrocelectomy were performed in 30 each. PRIMARY OUTCOME MEASURES incidence of complications, loss of working days, cost involved, recurrence rate and patients satisfaction. Patients were followed up till 6 months after the procedures. RESULTS Eight patients (26.7%) after hydrocelectomy developed fever which was significantly more (p<0.05) than 2 patients (6.7%) following sclerotherapy. Four patients (14%) with hydrocelectomy had infection (p<0.05). The incidence of pain and haematocele between the two groups were comparable. Nine patients (34.6%) after sclerotherapy developed recurrence at 3 months. All patients developed recurrence after repeat aspiration and sclerotherapy. The level of satisfaction was more in hydrocelectomy 19 (95%) versus 13 (61.9%) patients in sclerotherapy (p<0.05). The cost involved was fivefold and the loss of working days sevenfold in hydrocelectomy (p<0.01) as compared to sclerotherapy. CONCLUSION Although aspiration and sclerotherapy had less complications, morbidity and was cheaper, it had lower success rate and less patients satisfaction than hydrocelectomy.

Benign cystic mesothelioma of the peritoneum in a child—case report and review of the literature

A 4-year old female child presented with clinical features of ascites that, on computed tomography, showed a huge thin-walled cystic lesion in the peritoneum. Laparotomy confirmed a unilocular cyst in the peritoneum adhered to the parietal wall and bowel but not originating from any internal organs. Histopathologic examination of the cyst wall was consistent with the diagnosis of benign mesothelioma. Benign cystic mesothelioma of the peritoneum has rarely been reported in children.

Isolated pancreatic tuberculosis mimicking as carcinoma: a case report and review of the literature

IntroductionPancreatic tuberculosis is a rare disease even in endemic countries for tuberculosis. Here, we report a case of pancreatic tuberculosis from tuberculosis endemic zone presenting as obstructive jaundice mimicking pancreatic cancer.Case presentationA 41-year-old male presented with features of malignant obstructive jaundice. Ultrasonography and computed tomography scan showed mass in the pancreatic head and uncinate process. He underwent a pancreatoduodencetomy. Histological examination showed typical features of tuberculosis. Antitubercular drugs were started and he remains well six months after surgery.ConclusionTuberculosis should be considered as a differential diagnosis to an obscure pancreatic mass in younger or middle aged patient residing in tuberculosis endemic zone.

Retroperitoneal inflammatory myofibroblastic tumor

Inflammatory myofibroblastic tumors are rare, and those located retroperitoneally are even rarer. The authors present the case of a 52-year-old male farmer with a lump in the lower abdomen of 2 months in duration that was retroperitoneal in location. It was excised, and histopathologic examination revealed an inflammatory myofibroblastic tumor. The present case is presented by virtue of its rare location.

Application of a plain abdominal radiograph transition zone (PARTZ) in Hirschsprung's disease

BackgroundA standard contrast enema for Hirschsprungs disease can sometimes be inconclusive in delineating a transition zone especially in neonates and infants. The aim of this study was to determine the utility and diagnostic accuracy of a plain abdominal radiograph transition zone (PARTZ) in predicting the level of aganglionosis.MethodsA prospective observational study of neonates and infants with biopsy proven Hirschsprungs disease was carried out from March 2004 through March 2006. All patients underwent a plain abdominal radiograph and a contrast enema followed by a rectal biopsy. The transition zone on a plain radiograph (PARTZ) and contrast enema (CETZ) were compared with operative and pathology reports. Results were analyzed by chi square test and expressed as their p values and 95% confidence intervals.ResultsPARTZ and CETZ suggestive of Hirschsprungs disease was seen in 24(89%) and 18(67%) patients respectively. The PARTZ and CETZ matched with the pathologic level of transition zone in 22(92%) and 13(72%) patients, p = 0.001, 95% CI (-1.87 to -0.79). In the 9 (33%) patients in whom contrast enema failed to reveal a transition zone, PARTZ was seen in 6/9(66%) patients and correlated with the pathological level of aganglionosis in 4/6(67%) patients, p = 0.001 95% CI (-1.87 to -0.79). The overall accuracy of PARTZ and CETZ was 96% and 84% respectively, p = 0.008, 95% CI (-6.09 to -3.6).ConclusionA plain abdominal radiographic transition zone is reliable in predicting the level of transition zone in cases of inconclusive contrast enema. It may be particularly helpful developing countries where laparoscopic techniques are not available to accurately identify the transition zone.

Prostate Cancer Screening in a Healthy Population Cohort in Eastern Nepal: an Explanatory Trial Study

BACKGROUND Prostate cancer features a substantial incidence and mortality burden, similarly to breast cancer, and it ranks among the top ten specific causes of death in males. OBJECTIVE To explore the situation of prostate cancer in a healthy population cohort in Eastern Nepal. MATERIALS AND METHODS This study was conducted in the Department of General Surgery at B. P. Koirala Institute of Health Sciences, Dharan, Nepal from July 2010 to June 2011. Males above 50 years visiting the Surgical Outpatient Department in BPKIHS were enrolled in the study and screening camps were organized in four Teaching District Hospitals of BPKIHS, all in Eastern Nepal. Digital rectal examination (DRE) was conducted by trained professionals after collecting blood for assessment of serum prostatic specific antigen (PSA). Trucut biopsies were performed for all individuals with abnormal PSA/DRE findings. RESULTS A total of 1,521 males more than 50 years of age were assessed and screened after meeting the inclusion criteria. The vast majority of individuals, 1,452 (96.2%), had PSA ≤4.0 ng/ml. Abnormal PSA (>4 ng/ml) was found in 58 (3.8%). Abnormal DRE was found in 26 (1.72%). DRE and PSA were both abnormal in 26 (1.72%) individuals. On the basis of raised PSA or abnormal DRE 58 (3.84%) individuals were subjected to digitally guided trucut biopsy. Biopsy report revealed benign prostatic hyperplasia in 47 (3.11%) and adenocarcinoma prostate in 11 (0.73%). The specificity of DRE was 66.0%with a sensitivity of 90.9% and a positive predictive value of 38.5%. The sensitivity of PSA more than 4ng/ml in detecting carcinoma prostate was 100% and the positive predictive value for serum PSA was 19.0% CONCLUSIONS The overall cancer detection rate in this study was 0.73% and those detected were locally advanced. Larger community-based studies are highly warranted specially among high-risk groups.

Epidemiology and management of paediatric head injury in eastern Nepal

BACKGROUND In children, majority of the head injuries are minor and management of critically ill children depend on a team approach using well-rehearsed, systematic management protocols that can be implemented within hours after injury. This study was carried out to ascertain the epidemiology and management of know the demographic profile and etiology of paediatric head injury in our setting, to know the clinical and radiological characteristics of head injury patients and to know the treatment options and outcome in paediatric head injuries. PATIENTS AND METHODS Details of all children (age <16 years) with head injury seen in 1 year from 01.04.2005 to 31.03.2006 were retrospectively reviewed. Demographic profile, clinical details, investigations, treatment offered, and outcome were noted in a proforma. All data were analyzed by appropriate SPSS 11.0 statistical software tools. RESULTS There were total 43 patients. Young male children were more commonly affected in present series with a mean age of 7.67 years (median - 5.010 years), range 6 months-16 year. Fall (65.11%) was the most common mode of injury followed by road traffic accidents (RTAs) (25.6%). Mild head injuries (65.11%) were most common. Most common complaint was loss of consciousness and all the patients with severe head injury presented loss of consciousness. All patients with mild head showed good recovery; with moderate head injury, nine patients showed good recovery and three patients recovered with moderate disability. Patients with severe head injury (three patients) had 100% mortality. CONCLUSIONS In urban areas of Nepal, RTAs like vehicular crashes, motor cycle accidents, and pedestrian hit by moving vehicle are more common and in rural areas fall from height are commoner. We need to develop child safety legislations and risk-specific intervention programs in Nepal.

Management of jejunoileal atresias: an experience at eastern Nepal

BackgroundIntestinal atresia is a common cause of neonatal intestinal obstruction, and management of this disease in limited setup of a developing country is very difficult.MethodsThis study is a retrospective study of patients with jejunoileal atresias and their postoperative outcome in a teaching hospital in eastern Nepal over a 5-year period.ResultsThere were 28 children (19 boys and 9 girls). 11 children (39.28%) had jejunal atresia and 17 (60.71%) had ileal atresia. Eight (28.5%) patients died, 6 were jejunal atresia (54.5%) and 2 were ileal atresia (11.7%). The most common cause of death was sepsis which occurred in 7 out of 8 cases (87.5%). The risk factors for mortality identified were leucopenia, neutropenia, delay in surgery, location of atresia and type of atresia. Jejunal atresia tended to have a higher mortality than ileal atresia, and severe types of atresia (type IIIb and IV) were more often associated with mortality than other types of atresia. The significant differences between jejunal and ileal atresia were the increased duration between presentation and surgery, longer postoperative and total hospital stay, presence of more severe atresias and an increased risk of mortality in case of jejunal atresias.ConclusionThe prognosis for this disease have definitely changed in the last few decades in developed countries but in our environment, problems like late presentation and diagnosis, lack of availability of good neonatal intensive care units and parenteral nutritional support still prevail.