Shailesh Adhikary

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.

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.

Giant cavernous hemangiolymphangioma of the bladder without cutaneous hemangiomatosis causing massive hematuria in a child

We report the first case of cavernous hemangiolymphangioma of the urinary bladder without cutaneous hemangiomatosis. A 5-year-old boy was admitted for investigation of a 2-month episode of gross hematuria accompanied by lower abdominal pain. Radiological investigations revealed a solid enhancing mass at the dome of the bladder with associated low-flow lesion in the posterolateral wall of the bladder. Physical examination did not show any cutaneous vascular malformations. A differential diagnosis of hemangioma or rhabdomyosarcoma bladder was made, but fine-needle aspiration cytology did not reveal any malignant cells. At surgery, a red, wide-based, nodular tumor was found on the dome of the bladder and extending to the base and lateral walls. Partial cystectomy and excision of the cystic lymphangioma was performed. Histological examination of the resected specimen showed it to be a cavernous hemangiolymphangioma. The postoperative course was uneventful and no recurrence was seen after 8 months.

Appendiceal tie syndrome: A very rare complication of a common disease

Acute appendicitis is the most common surgical emergency that we encounter. Adynamic Intestinal obstruction due to appendicitis or its complication may be seen time and often. Mechanical obstruction because of appendicitis is uncommon and even rarer for a closed loop obstruction to occur. Although it was described as early as 1901, very few cases have been reported. We report the case of a 20 years male who presented with generalized colicky pain abdomen, abdominal distension, vomiting and obstipation for three to four days. Vital signs were stable. His abdomen was distended and peritonitic, especially in the right iliac fossa. Rest of the physical examination was unremarkable. Blood tests were normal except for leucocytosis with neutrophilia. An abdominal X-ray finding was indicating a small bowel obstruction. A midline laparotomy was performed. On intraoperative examination, distended loops of small bowel from the jejunum to the distal ileum was observed, and a constricting ring around the terminal ileum created by a phlegmonous appendicitis with its tip adherent to the root of mesentery was found, obstructing an edematous loop of small bowel without signs of ischemia. As the bowel was viable simple appendectomy was done. Postoperatively, he had an uneventful recovery and was discharged after 3 d.

Intussusception due to non Hodgkin's lymphoma; different experiences in two children: two case reports

In children, non-Hodgkins lymphoma has been found to be the lead point in intussusception involving the terminal ileum. We present here two cases of ileal primary non-Hodgkins lymphoma which presented as intussusception, highlighting the differing presentations of these children and their outcome, with a brief review of the literature.

Doppler Study of Splanchnic Hemodynamics in Hirschsprung’s Disease

Background: Doppler studies of splanchnic vessels have demonstrated alteration in blood flow in bowel obstruction and strangulation. The aim of this study was to evaluate hemodynamic changes in celiac artery (CA), superior mesenteric artery (SMA) and inferior mesenteric artery (IMA) using pulsed Doppler sonography (PDS) in Hirschsprung’s disease. Material and Methods: Fasting splanchnic flowmetry of CA, SMA, and IMA arteries was performed using PDS preoperatively in 13 patients with Hirschsprung’s disease and 13 healthy age- and sex-matched controls. Diagnostic workup for Hirschsprung’s disease included a barium enema and a rectal biopsy. A primary transanal pull through was performed if the transition zone was at rectosigmoid or midsigmoid. Doppler studies were repeated on the 1st and 7th postoperative day under similar conditions. Mean flow velocity (Vmean) and the pulsatility index (PI) of the three major vessels was measured. Results: Patients with Hirschsprung’s disease showed increased blood flow velocities in CA, SMA, and IMA (p < 0.001), an increased resistance to blood flow in IMA (p < 0.001) and a decreased resistance to blood flow in CA and SMA (p < 0.005 and p < 0.001, respectively). The blood flow velocity for IMA normalized after resection of the aganglionic segment (r = 0.41, p < 0.005, 95% CI: 45.4–52.7). Conclusions: Hirschsprung’s diseaseis associated with alterations in splanchnic vessel hemodynamics which are reversible after corrective surgery. Doppler studies may play an important role in the assessment of bowel function after surgery.