Journal of Institute of Medicine Nepal (JIOM Nepal)

Lancet Commission on Global Surgery - A Public Health Initiative

Göran Kurlberg — Thu, 30 Apr 2020 00:00:00 +0000

With the advent of the epidemiological transition, the incidence of non-communicable diseases (NCDs) presenting as cardiovascular disease, diabetes, hypertension, malignancies and injuries make up the major part of the Global Burden of Disease.1-3

Japan: What to Do with Dead Bodies? A Burning Issue

Andy Crump — Thu, 30 Apr 2020 00:00:00 +0000

Death, the passing of a loved one, friend, colleague or just someone we may have known, is virtually always sad and often traumatic. However, it is a part of life and has to be coped with. Each year around 60 million people worldwide die from a wide and diverse number of causes. The problem of what to do with all those dead bodies is becoming a major conundrum for the families involved as well as for policy makers and governments. Natural and anthropogenic disasters, together with increasing incidence of major pandemics of infectious diseases is making finding a solution ever more difficult. A problem which is made worse by ever-increasing draconian rules about what can and cannot be done when disposing of a body.
Currently, there are two basic choices, either bury the body in the ground where such action is permitted or cremate it and dispose of the ashes in a culturally and legally acceptable fashion. Generally, both options are becoming prohibitively expensive. The cost of land and the burgeoning demand for land to be used for industry, agriculture, urbanised centres or leisure activities is making burial no longer an option for most people. Japan has long led the world in incineration technology and it has also led the world for many years in cremating its dead. Virtually all Japanese are now cremated, the funeral process involving a mixture of high technology and unique routines steeped in history. Despite widespread concerns that cremation can cause environmental pollution and may damage public health as a result, it is still deemed less polluting than burial. It is likely that countries around the globe will increasingly adopt a policy of cremating their deceased citizens and would do well to follow the lead in this respect being shown by Japan.

Comparison of Graft Uptake and Postoperative Hearing Results between Butterfly-Cartilage and Temporalis-Fascia Myringoplasty

Amiya K Sah — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Myringoplasty is one of the commonest surgeries done in Otology for chronic otitis media- mucosal type (COM-mucosal type). The objective of this study was to compare the graft uptake and post-operative hearing status between butterfly-cartilage and temporalis-fascia myringoplasty.
Methods
Patients of age ≥15 years with COM-mucosal type with dry, small to medium sized central perforation of pars tensa with clearly visible perforation margin were randomized into two groups of butterfly-cartilage myringoplasty and temporalis-fascia myringoplasty. Graft uptake and hearing results were assessed after six weeks and results were compared within and between the groups.
Results
Thirty-one patients in butterfly cartilage group and twenty-nine patients in temporalis fascia group were analysed. Graft uptake rate was 93.5% (29/31) in butterfly group and it was 86.2% (25/29) in temporalis fascia group with no statistically significant difference (p= 0.34) between the two groups. The mean pre and post-operative air bone gap in butterfly cartilage group were 20.65dB±8.35 dB; 12.86dB±7.39dB and that in the temporalis fascia group were 19.72±6.14dB, 13.16dB±6.26dB respectively. The difference of preoperative and postoperative hearing status, obtained within the two groups was statistically highly significant (p< 0.001). However, there was no statistically significant difference in hearing results between the two groups (p= 0.54).
Conclusion
The graft uptake rate and hearing results of butterfly-cartilage group and temporalis-fascia group were statistically significant within the group after myringoplasty but there was no statistically significant difference in between the two methods.

Effect of Preoperative Nebulized Ketamine on Incidence and Severity of Postoperative Sore Throat in Patient Undergoing General Anaesthesia with Endotracheal Intubation

Bigen M Shakya — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Postoperative sore throat (POST) has a reported incidence of up to 62% following general anaesthesia. POST was rated by patients as the eighth most undesirable outcome in the postoperative period. The objective of this study was to compare the incidence and severity of postoperative sore throat after saline and ketamine nebulization in patients undergoing general anaesthesia with endotracheal intubation.
Methods
The study was prospective double blinded randomized controlled trial . One hundred patients belonging to American Society of Anesthesiologists physical status I–II undergoing surgery under general anaesthesia with endotracheal intubation were randomized into two groups; group Saline (S) received nebulization with 5 ml of normal saline and group Ketamine (K) received nebulization with 1 ml of ketamine of concentration 50 mg/ml mixed with 4 ml saline. POST was assessed at zero hour, two hour, four hour, six hour, eight hour and 24 hour.
Results
The overall incidence of POST was 28%. Twenty two (44%) patients in group S and six (12%) patients in group K had postoperative sore throat at some point of the study. The POST was significantly reduced in group K at zero hour 3(6%), two hour 3(6%), four hour 4(8%), six hour 5(10%) and eight hour 3(6%) with p value <0.05 . The severity of POST was also significantly decreased in group K at zero hour, two hour, four hour, six hour, eight hour with p value <0.05.
Conclusion
Preoperative nebulization with ketamine reduces the incidence and severity of POST after general anaesthesia with endotracheal intubation.

Variation of Arteries Forming Circle of Willis in Adult Human Cadavers

Jyoti Gautam — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Circle of Willis is a large arterial anastomosis between internal carotid and vertebrobasilar arterial system. It is the principal collateral channel for constant blood flow to brain. Any changes in its morphology may cause vascular insufficiency of variable severity. Knowledge about its anomalies may elucidate occurrence of cerebrovascular disorders, its presentation, treatment, prognosis and prevention.
Methods
An observational study on 107 fresh cadavers was conducted at Maharajgunj Medical Campus from September 2016 to August 2017. After dissection of the scalp and removal of the vault and dura mater, the brain was obtained. Then the Circle of Willis was identified and observed for its completeness, symmetry, presence, origin and number of arteries forming it and the obtained data were documented, photographed and analyzed.
Results
Out of 107 cadavers, variations were noted among 15 (14%): out of which 10 were male and 5 female. Twelve cadavers had single variation while 3 had two variations. Accessory anterior cerebral artery was found in 7 (38.90%), fetal origin of right posterior communicating artery in 2 (11.10%), fetal origin of left posterior communicating artery in 4 (22.20%), early bifurcation of left posterior cerebral artery in 1 (5.60%), variant anterior communicating artery in 2 (11.10%), fused anterior cerebral artery in 1 (5.60%) and aneurysm in 1(5.60%) subjects were found.
Conclusion
Variations were noted among 15 cadavers (14%), 12 cadavers had single variation while 3 had two variations. The most common variation seen was accessory anterior cerebral artery found in 7 cadavers (38.90%). Most of the variations were found in midline anteriorly followed by right side.

Fracture Nasal Bone: Causes, Presentation and Management in a Tertiary Care Center in Nepal

Rajeev K Mahaseth — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Fracture of nasal bone, the commonest facial fracture is frequently encountered in ENT practice. This study was conducted to assess the causes, presentation and management of fracture nasal bone in a tertiary care center.
Methods
A retrospective chart review was done of patients admitted from August 2017 to July 2019 for management of isolated nasal bone fracture in the department of ENT and Head and Neck Surgery, Tribhuvan University Teaching Hospital.
Results
Thirty-five patients (31 males and 4 females) of 13 to 86 years (mean age 26 years) underwent closed reduction of fracture nasal bone. The injury was sustained following physical assault in 13/35 (37%), fall from height in 10/35 (29%), road traffic accident in 8/35 (23%) and sports injury in 4/35 (11%). Pain, epistaxis, swelling over nasal dorsum, nasal deformity and wound were the presenting symptoms which most often occurred in combination. Close reduction was done under local anesthesia in 28/35 (80 %) and under general anesthesia in 7/35 (20%). The time between trauma and closed reduction ranged from 1 to 16 days with a mean of 6.2 days.
Conclusion
Nasal bone fracture needing reduction was common following physical assault in males predominently of 21 to 30 years. A combination of pain, epistaxis and nasal deformity was the commonest presentation. Closed reduction of fracture under local anesthesia within 16 days of trauma was the usual practice.

Experience of Hydatid Cyst Management in a Tertiary Care Center in Kathmandu Nepal

Bijendra D Joshi — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Hydatid cyst is a common disease in Asian subcontinent produced by the larval stage of Echinococcus granulosus. The most common site of involvement is the liver. The mode of presentation can vary. The management of hydatid cyst includes medical treatment with albendazole, ultrasound guided aspiration and instillation of scolicidal agents as well as surgical treatment. Surgery can be perfomed by open or laparoscopic approach. The aim of this study is to analyze the cases of hydatid cyst of liver managed in our set up.
Methods
This is a retrospective study of 45 patients with hydatid cyst managed in Kathmandu Model Hospital over the last five years. Data were collected from the patients hospital records. Demographic parameters, chief complains, radiological findings, anti echinococcal immunglobulin findings, mode of management,complications of surgery were evaluated.
Results
Majority of our patients were female (66.7%). Mean age of the patients were 39±17.2 years (16 to 89 years).Most common symptom of presentation was pain in right upper quadrant of abdomen.Most common site of involvement was liver (93.33%)followed by spleen (4.4%). There was one case of ruptured pulmonary hydatid cyst which was referred.Operative management was done in patients (17.77%) out of which five patients (62.5%) underwent laparoscopic partial pericystectomy and omentoplasty.No major complications were encountered in any of the cases managed surgically.
Conclusion
Majority of cases occured in liver. Most cases were managed conservatively. Laparoscopic management of hydatid cyst is effective.

Comparison of Outcomes of Open versus Laparoscopic Living Donor Nephrectomy in Nepal

Prem R Sigdel — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Laparoscopic donor nephrectomy is the gold standard for kidney retrieval in live donors. Until recently, donor nephrectomies were performed only by open technique in Nepal. There is no information on the experience and outcomes of laparoscopic donor nephrectomy in Nepal. The study was done to compare the outcomes among donors undergoing open and laparoscopic nephrectomies, and to compare the graft related outcomes between the two groups receiving these kidneys.
Methods
In this retrospective study, 44 kidney donors from March 2019 to October 2019 were analyzed. Donors were divided into 2 groups: open donor nephrectomy (ODN) and laparoscopic donor nephrectomy (LDN). Parameters for analysis included demographic data, warm ischemia time, surgery time and length of hospital stay. Data on early graft function and complications in recipients till 30th post-operative day were compared.
Results
There were 22 donors each in the ODN and LDN groups. Baseline characteristics of the donors were comparable between two groups. Mean surgery duration (183.55±43.31 minutes vs 117.73±18.75 minutes) and first warm ischemia time (11.22±4.34 minutes vs 2.3±0.8 minutes) was significantly high in LDN. Hemoglobin drop, post-operative complications in donors, creatinine of donors at discharge, mean hospital stay, graft function at one month and complications in recipients were comparable among ODN and LDN. Pain score in 1st post-operative day was comparable between two groups, however, pain was significantly less in second post-operative day in LDN.
Conclusion
Laparoscopic donor nephrectomy is feasible in Nepal and associated with acceptable morbidity and graft function when compared to ODN.

Diagnostic Evaluation of Patients Presenting with Rectal Bleeding by Colonoscopy

Bala R Malla — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Rectal bleeding indicates the bleeding from lower gastro-intestinal tract occurring distal to ligaments of Treitz. Annual incidence of per rectal bleeding has been estimated to be 20% . Colonoscopy is the examination of choice for investigation. The objective of this study is to know the diagnostic yield of colonoscopy in cases with per rectal bleeding and to know the common causes of per rectal bleeding in adults
Methods
One hundred and twenty-nine adult patients, age more than 18years, who presented to Surgical OPD and ward of Dhulikhel Hospital during the year 2018 and 2019 were taken for the study irrespective of their sex. All the patients were subjected to fibre-optic colonoscopy after necessary preparation and the findings were recorded. Diagnosis was based on colonoscopic and histopathologic findings.
Results
A total of 129 (77 male and 52 female )patients with per rectal bleeding were evaluated with colonoscopy. The age ranged from 18 years to 79 years with the mean age 42.25 (SD+/- 15.29). Colonoscopy showed abnormalities in 102 patients (79.06%). The most common finding was hemorrhoids in 36 patients (27.90%) followed by colorectal malignant mass in 20 patients (15.50%). Polyps were diagnosed as the cause of rectal bleeding in 14 patients (10.84%).
Conclusion
Colonoscopy has good diagnostic yield at evaluating cases with per rectal bleeding. Hemorrhoids, colorectal malignant mass and polyps are the common causes producing PR bleeding in Nepalese adult population .
Keywords: Colonoscopy, hemorrhoids, per rectal bleeding,

Pediatric Ventriculoperitoneal Shunt: Outcome Analysis in a Tertiary Care Center in Nepal

Suman Phuyal — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Ventriculoperitoneal (VP) shunt is a commonly performed neurosurgical procedure in pediatric surgical practice. It results in a dramatic improvement in patient survival and neurological function but is associated with several complications requiring multiple shunt revisions throughout a patient’s lifetime. The main aim of the study was to evaluate the outcome especially complications of shunt surgery at our center.
Methods
A single-institutional, retrospective observational study was conducted in 60 operated cases of congenital hydrocephalus with a minimum follow-up for up to 6 months. Parameters for analysis included demographic data, etiology of hydrocephalus, surgery time, and type of complications.
Results
Out of 86 patients, 60 patients who fulfilled the inclusion criteria were enrolled in the study. The mean age of the patients at the time of VP shunt placement was 3 months, range from 8 days to 15 years with male preponderance. The majority of the patients belonged to the 0-1-year age group (76.8%). The commonest etiology of hydrocephalus was congenital aqueduct stenosis. Fifteen patients (25%) developed complications within six months follow-up period. Eight patients (13.3%) developed clinical shunt infection with four cases having culture positive. Four (6.67%) had mechanical complications in the form of shunt obstruction. Three patients had ascites, subdural collection, and shunt extrusion from the anus. The shunt related mortality was 1.67%.
Conclusion
The shunt infection and obstruction still remain the most important complications. Despite inherent problems, shunt surgery is the procedure of choice until a safer effective alternative is available.
Keywords: Complications congenital hydrocephalus, ventriculoperitoneal shunt

Outcomes of Children Presenting with Button Battery in Esophagus: A Retrospective Review

Bigyan R Gyawali — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Foreign body in esophagus is a common ENT emergency. Button batteries tend to have more grievous outcomes due to caustic mucosal injury to the esophagus. The objective of our study was to review the clinical profile and outcomes of the paediatric population in our center who presented with button battery in esophagus following accidental ingestion.
Methods
This was a retrospective study conducted in Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Hospital records of all the patients who presented with button battery esophagus and underwent rigid oesophagoscopic removal from January 2013 to January 2019 were reviewed and analyzed for patient demographics, time interval between ingestion and presentation, site of impaction, status of oesophageal mucosa at the time of rigid oesophagoscopic removal of the battery, early post-operative complications, outcomes at the time of discharge and on follow-up.
Results
Our final sample size was 11 and all cases were <15 years. The average duration from time of ingestion to presentation to our hospital ranged from 1 day to 2 months. Variable oesophageal mucosal findings such as superficial mucosal erosion, superficial ulcer with slough and granulations with deep discrete ulcer were seen at the site of impaction of the button battery. One case was diagnosed with bilateral abductor palsy on 10th post-operative day following rigid oesophagoscopic removal of the battery. All other cases didn’t develop any significant complications.
Conclusion
Button battery in esophagus results in oesophageal ulceration and thus warrants an early endoscopic removal. Delayed removal can also cause bilateral abductor palsy from the caustic damage to recurrent laryngeal nerve.

Keywords
Alkaline button battery, esophagus, rigid oesophagoscopy

Frequency of ABO Blood Group and its Association with Acute Coronary Syndrome in Patients Presenting in a Tertiary Care Center of Nepal

Surya R Pathak — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Coronary artery disease is the major cause of death all over the world. There are studies suggesting association between blood group and coronary artery disease. We attempted to study the frequency of ABO blood group and its association with acute coronary syndrome (ACS) in our hospital.
Methods
This is a retrospective, cross sectional study carried out in Manmohan Cardiothoracic Vascular and Transplant Centre from March 2018 to February 2019. Patients who were admitted with diagnosis of ACS were enrolled in the study. Data were recorded and analyzed using SPSS 20. Association between blood group and ACS was analyzed using chi square test and logistic regression.
Results
Total 430 patients were admitted with diagnosis of ACS during the study period, of which 307 (71.4 %) were male and Mean age was 61.22 years (±10.75). Blood group O was the most common type of blood group observed in 207 (48%) patients. ACS was significantly higher in blood group O compared to other groups after adjusting for normal ABO blood group prevalence in general population: blood group O vs. A (OR: 3.45, 95% CI: 2.48- 4.79, p- <0.001), blood group O vs. B (OR: 5.08, 95% CI: 3.53-7.33, p- <0.001), blood group AB vs. O (OR: 0.65, 95% CI: 0.41- 1.02, p- 0.064). Individuals with blood group O and B had increased risk of having STEMI and NSTEMI where as those with blood group A had increased risk of having unstable angina.
Conclusion
There was association between ABO blood group and coronary artery disease. Individuals with blood group O have increased incidence of ACS.

Keywords:
ABO blood group, acute coronary syndrome, coronary artery disease

Profile and Outcome of Adult Spine Pathologies Managed in a Neurosurgical Tertiary Care Center in Nepal

Hemant K Sah — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Spine pathology involves a wide spectrum of diseases and needs a multidisciplinary approach including surgery, rehabilitation and psychological support. It increases the burden to the family and society. This study describes diseases related to spine and spinal cord from a neurosurgical department of a tertiary hospital in Nepal.
Methods
This is a retrospective study of all spinal cases admitted between April 2019 to February 2019, in the Department of Neurosurgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal. All adult patients of ≥16 years, diagnosed with various spinal diseases were included. Based on the spectrum of causative pathologies, the study population was broadly categorized into trauma, degenerative, tumor, vascular and infection. Demographics, other variables, and outcome at 1 month were assessed.
Results
A total of 71 patients were included in this study. Male preponderance was observed in all categories. Twenty three patients (32.4%) had traumatic spine injury and fall from height was the most common mode of injury, accounting for two-third of the total spinal trauma patients. Cervical segment was involved in two-third patients. More than one-third of the spinal patients (36.6%) had a degenerative disorder involving lumbar (57.7%) and cervical regions (42.3%). Spinal infection was diagnosed in 11.2% of the patients with 62.5% diagnosed as Pott’s spine. Overall complications were seen in 20%. Pain improved in all patients while overall good outcome was noted in 63.2% of the patients.
Conclusion
Our study demonstrated a large patient burden and a clinical profile dominated by preventable causes such as RTA and fall injury. With early treatment and rehabilitation, significant improvement can be achieved. Further large scale multicenter studies are required to generalize the findings of this study to the whole population of Nepal.

Keywords:
Burden, Nepal, spine trauma, spine pathology

Anesthetic Management of a Case of Hemophagocytic Lymphohistiocytosis

Gentle S Shrestha — Thu, 30 Apr 2020 00:00:00 +0000

Hemophagocytic Lymphohistiocytosis (HLH) is characterized by an overwhelming activation of histiocytes and T lymphocytes leading to fulminant hemophagocytosis and organ damage. Anesthetic management of patients with HLH is associated with challenges such as pancytopenia, hemodynamic instability and infections. In addition to sepsis, metabolic acidosis, disseminated intravascular coagulation, multi-organ involvement with an exacerbation of symptoms with the use of anesthetic agents poses significant risk perioperatively. We present a case planned for excision of pilonidal sinus. The surgery was performed after thorough workup and with the patient in remission. Elective procedures should ideally be performed with patients in remission. Cases receiving concurrent therapy with immunomodulators and steroids require special attention due to possible interaction with anesthetic agents and the need for perioperative steroid supplementation.

Keywords:
Anesthetic management, hemophagocytic lymphohystiocytosis, pancytopenia, steroids

Granular Cell Tumor of Breast: Rare Tumor Masquerading as Malignancy

Suzita Hirachan — Thu, 30 Apr 2020 00:00:00 +0000

Granular cell tumor (GCT) is a rare soft tissue tumor that arises from the Schwann cells of peripheral nerves. It was first postulated by Abrikossoff in 1926 as Myoblastoma. About 5-15% of these tumors occur in the breast and less than 1% has the potential to be malignant. Here we present a case of 41 years old premenopausal woman with Benign GCT of the right breast, having clinically malignant features. The clinical and radiological features of GCT are similar to malignant lump. However, histology showing presence of sheets of polygonal cells with abundant granular eosinophilic cytoplasm with round nuclei and granules with Periodic acid–Schiff (PAS) positive, diastase resistant and S-100 antigen positive are confirmatory. Treatment of Granular cell tumor is wide local excision. There is apparently no role of chemotherapy and radiotherapy. The presence of GCT in the breast is quite rare and clinically as well as radiologically it may mimic malignancy, however with histopathology and appropriate immunohistochemistry, proper diagnosis can be made.

Keywords:
Breast cancer, excision, granular cell tumor

Low Grade Appendiceal Mucinous Neoplasm: A Report of Three Cases

Nisha Sharma — Thu, 30 Apr 2020 00:00:00 +0000

Low-grade appendiceal mucinous neoplasm (LAMN) is an uncommon malignancy with varied clinical features. The most alarming complication of this neoplasm is seeding of mucin into the adjacent peritoneum leading to pseudomyxoma peritonei (PMP). We report three cases of LAMN. Two cases were seen post appendicectomy in 23-year old and 36-year old females. The third case was seen in 53-year-old male post Whipple procedure and hemicolectomy. LAMNs are often diagnosed incidentally, as clinical presentation is barely specific and resembles acute appendicitis. Hence it is imperative to examine all appendicectomy specimens not to miss cases of appendiceal mucinous neoplasm which can have implications on the further management of the patient.

Keywords:
Appendectomy, mucinous appendiceal neoplasm, pseudomyxoma peritonei

Adnexal Torsion in Ovarian Hyperstimulation Syndrome in Early Pregnancy: A Diagnostic Challenge

Pradeep R Regmi — Thu, 30 Apr 2020 00:00:00 +0000

Adnexal torsion in ovarian hyperstimulation syndrome (OHSS) is rare but serious complication in pregnancy. It is more common in assisted reproductive techniques. Delay in diagnosis and treatment results in functional loss of ovary as well as termination of pregnancy. In this report, we are presenting a case of 27 years female with subfertility who conceived after ovulation induction presented at 7 weeks 6 days period of gestation with ovarian hyperstimulation associated with adnexal torsion. Later, she was treated with laparoscopic salpingo-oophorectomy.

Keywords:
Adnexal torsion, ovarian hyperstimulation syndrome, pregnancy

Palliative Toilet Mastectomy for Advanced Breast Cancer in a University Hospital of Nepal

Rupesh Verma — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
In Nepal, half of the breast cancer patients presented in advanced stage III (IIIA 18%, IIIB 22%), and stage IV (10%). Delayed presentations are due to lack of awareness, reluctancy and poor accessibility to health care services often leads to local complications like sloughing of fungating breast lesions, secondary infection and bleeding. The aim of this study was to analyze the advanced breast cancer (ABC) patients who underwent palliative toilet mastectomy.

Methods
Retrospective review of all patients presenting with ABC who underwent palliative toilet mastectomy in the breast unit of Tribhuvan University Teaching Hospital Kathmandu, Nepal from January 2016 to December 2018, was done. The data included were demographic profile, histopathological and immunohistochemistry report, indication of surgery, adjuvant therapy, timing of surgery, and quality of life after surgery.

Results
Total number of breast carcinoma patients was 155 within the duration of 3 years. There were 7 (4.5%) cases of breast cancer treated with palliative toilet mastectomy with mean age of 57.9±12.7 years. The mean tumor size was 4.3±1.3cm. The indications of palliative mastectomy were fungation-2 (28.5%), bleeding-2 (28.5%), ulceration-1 (14.3%), malodorous discharge with secondary infection-1 (14.3%) and hemiplegic patient with infection in 1 (14.3%). Luminal A molecular subtype was seen in 1 out of 7 patients (14.3%) with basal like subtype in 6 out of 7 patients (85.7%). Lympho-vascular invasion were seen in 4 out of 7 (57.14%). One patient underwent bilateral palliative mastectomy for progressive disease and margins were positive for tumor and remaining six patients had tumor free margins.

Conclusion
Advanced breast cancers are treated with neoadjuvant therapy prior surgery but the delayed presentation of these with fungating, ulcerative, infective and bleeding lesions make the initial palliative toilet mastectomy a useful option.

Keywords:
Advanced breast cancer, palliative toilet mastectomy, quality of life

Breast Cancer Surgery at a Cancer Center in Janakpurdham: An Initial Experience

Pamesh Jha — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Breast cancer is the second commonest cancer in Nepalese women. In most of the low income countries including Nepal, breast cancer is commonly diagnosed at late stage. The Binaytara Foundation Cancer Center (BTFCC), a 25 bed cancer hospital was established in Province 2, the most densely populated province, of Nepal in December 2018. We describe our experience of breast cancer surgery at the cancer hospital.

Methods
Surgical service was started from April 2019 after establishing an equipped operating room and post-operative and ICU wards. Total 51 surgeries were performed for both benign and malignant diseases by the end of 2019. The commonest surgery was breast surgery in 18 patients. Retrospective analysis of all six patients who were operated for breast cancer at the cancer center was done.

Results
Six female patients of this province were operated for breast cancer during this period. Age ranged from 40 to 56 years. Four patients were presented with locally advanced disease. Two patients received neo-adjuvant chemotherapy and two were subjected for upfront surgery. Modified radical mastectomy was done in four patients. For one patient with suspected hereditary localized breast cancer and one with Paget’s disease of the breast with non invasive ductal carcinoma, simple mastectomy was performed. Postoperative period was uneventful except one case with seroma formation. Other than one Paget’s disease of the breast, all were triple nipple breast cancer.

Conclusion
Breast cancer surgery is one of the important modality of treatment even for locally advanced disease in resource limited settings.

Keywords:
Breast cancer, outcome, mastectomy

Comparison of Nepalese and Swedish Patients with Colorectal Cancer Regarding Tumor Suppressor Methylation in Tumor and Mucosa Samples

Bikal Ghimire — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Colorectal cancer (CRC) is common with wide variation in incidence. However, the incidence in younger adults is showing an increasing trend with rectal preponderance. Such cases appear to present in advanced stage with poorly differentiated histopathology and the trend is stronger in developing countries. The aim of the study was to compare the MLH1 and in matched mucosa and tumor samples obtained from the large gut of Nepalese and Swedish patients with CRC.

Methods
Patients diagnosed and operated for CRC at Tribhuvan University Teaching Hospital, Nepal (n=39) matched for age with those operated at Sahlgrenska University Hospital, Sweden (n=39) were included in the study. Demographics and clinicopathological data were compared. The tissue methylation status was compared in the Nepalese and Swedish populations and correlated to clinicopathological data.

Results
There were 56% men and 44% women in the study. Their mean age was 53 years with a range of 20 to 78 years. Colon cancer amounted to 70% and 60% in the Nepalese and Swedish patients respectively and the majority of lesions were on the right colon. The colorectal cancer was commonly of stage III (52% and 38%) in the Nepalese and Swedish group respectively. Most of the tumors were well differentiated (41%) in the Nepalese population where as in Swedish patients it the differentiation was medium to low (52% and 11%). Methylation of MLH gene, in different CpG sites, when analyzed independently, showed that in about 18-20% of the cases, the degree of methylation is significantly higher in tumor tissue as compared to sites at least 10 cm away from the lesion.

Conclusion
Colon cancer is more common in men in Nepal with predominantly more on the right colon. Most of them present in advanced stage with higher MLH1 methylation.

Keywords:
Colorectal cancer, MLH1, p14ARF, methylation, MSI

Clinicopathological Review of Resectable Gastric Cancer at a Tertiary Level Teaching Hospital of Nepal

Prasan Kansakar — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
According to available data, gastric carcinoma is the most common malignancy arising from the gastrointestinal tract in Nepal. Our objective was to analyze the pathological features of gastric carcinoma in patients undergoing curative resection.

Methods
Retrospective analysis of histopathological reports of patients who underwent curative surgery for gastric cancer was performed at Department of Surgery, Tribhuvan University Teaching Hospital for a period of two years. Demographic characteristics, symptoms, site of tumor, type of surgery performed, macroscopic and microscopic characteristics including number of harvested lymph nodes, number of positive lymph nodes and tumor stage were analyzed.

Results
A total of 36 patients underwent curative resection. Mean age of the patients was 61.6 years with range of 21-82 years. Male:female ratio was 7:4. Pain abdomen was the predominant presenting symptom. Vomiting, hematemesis and malena were the other frequent symptoms. Endoscopy Borrmann type II tumor was seen in 27 (75%) of patients. Most patients underwent subtotal gastrectomy. In 25 patients, tumor was located in antrum. Lymphovascular and perineural invasion was seen in 21 and 20 patients respectively. Sixteen patients had poorly differentiated tumors. All but two patients had microscopic negative distal margin whereas proximal margin was negative in all patients. A mean of 15 lymph nodes were harvested. Twenty three patients had node positive disease. Pathological staging revealed Stage IA in 3 patients, Stage IB in in 5 patients , stage IIA in 4 patients stage IIB in 6 patients, stage IIIA in 6 patients, stage IIIB in 8 patients and IIIC in 4 patients.

Conclusion
Gastric carcinoma was common in seventh and eighth decade of life with male preponderance. Most of the patients presented with locally advanced gastric cancer. Tumors located in antrum requiring subtotal gastrectomy was the predominant finding.

Keywords:
Gastric cancer, pathological report, resectable tumor

Prevalence of Molecular Subtypes of Breast Cancer in a University Hospital of Nepal

Suzita Hirachan — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Breast cancer is the second most common malignancy in Nepalese women. It represents a group of heterogenous disease with diverse biologic, clinical and molecular characteristics requiring personalized treatment. Based on immunohistochemical markers, breast cancer is classified into distinct molecular subtypes. The aim of the study was to analyze the incidence of molecular subtypes of all breast cancer patients treated at University Hospital of Nepal in the period over 3 years.

Methods
A retrospective observational study was carried out in Breast Unit of Tribhuvan University Teaching Hospital, Kathmandu. Electronic medical records of all breast cancer patients treated between January 2017 to December 2019 were retrieved from the hospital database. Patient’s characteristic, histological features and molecular subtypes were collected and analyzed.

Results
A total of 156 surgically treated breast carcinoma patients were studied. The median age of study population was 55 years (range 28–82years). Among these, 69 (44%) were of ≤45 years and 87 (56%) were over 45 years. The mean tumor size was 29 mm (range 50-140 mm). The most common histology was invasive ductal carcinoma (93.5%). Luminal type A was positive in 68 (43%) patients while luminal type B was present in 12 (7.6%) patients. Triple negative subtype was observed in 50 (32%) patients while HER2 rich subtype was seen in 25(16%). Incidence of Triple negative subtype was highest in patients less than 45 years (42%). Luminal A subtype was correlated with low tumor grade and less positive lymph nodes metastasis.

Conclusion
The most common molecular subtype of breast cancer in Nepal is Luminal A having favorable features. The incidence of triple negative breast cancer is higher in Nepal, having an aggressive and clinically distinct subtype and is important for personalized treatment plan.

Keywords:
Breast cancer, immunohistochemistry, molecular subtypes, Nepal

Palliative Care Services at a Cancer Center in Janakpur Nepal

Sanjay Gupta — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Palliative care is one of the essential components of cancer care in Nepal. Most of our cancer patients present to the hospital quite late. In our everyday practice, we encounter many progressive incurable cancer patients who need palliative care. The goal of the palliative care is to relieve the pertinent symptoms or to improve quality of life (QoL) for patients with advanced cancer. We reviewed the palliative care services to the cancer patients at our center.

Methods
Retrospective analysis of the cancer patients who received palliative care alone or in adjunct to curative treatment in Binayatara Cancer Center since its establishment in December 2018 was done.

Results
A total of 108 patients received palliative care of which most were at advanced stage of disease (Stage IV). The male to female ratio was 1:1.45. The most common complaints for their visit was pain (62%) followed by nause and vomiting (32%), constipation (28%), anorexia (22%), shortness of breath, abdominal distension, seizure. Most of the patients with pain needed morphine (65%) for pain management followed by tramadol (25%) and NSAIDs (10%). Few of them were also supplemented with TCAs and anticonvulsants.Abdominal distension due to ascites was managed by ascitic tapping, Albumin supplementation while shortness of breath due to pleural effusion was managed by pleural fluid tapping. In one patient with pleural effusion, chest tube was inserted. Three patients with seizure due to brain metastasis were managed with anticonvulsant. A patient of prostate cancer with bony metastasis was managed with surgical orchidectomy.

Conclusion
While considering the appropriate and effective use of palliative care, a palliative care physician is often confronted with a full range of multidisciplinary treatment options, and technical considerations that could potentially relieve some symptoms of advanced cancer in our settings.

Keywords:
Advanced cancer, palliative care, quality of life

Efficacy of Integrated Intervention Program on Mental Health of Cancer Patients

Bibin Chand — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Copious researchers have made notable findings on the mental health of cancer patients and effect of various discrete therapies, but still there exist a significant paucity on integrated therapeutic interventions over their mental health. The objectives of this study were to find the prevalence of mental health morbidity and the efficacy of an integrated intervention program comprised of Aaron Beck’s Cognitive Behavior Therapy (CBT), Jacobson Progressive Muscle Relaxation Therapy (JPMRT) and self- imagery training on the mental health of cancer patients.

Methods
In this cross-sectional study, data was collected from 20 patients diagnosed with cancer aged between 40-55 years from an outpatient department of Cancer Institute, India. General Health Questionnaire by Goldberg & Hiller, 1979 (GHQ-28) was administrated to assess the mental health in four domains viz: somatic complaints, anxiety and insomnia, social dysfunction and severe depression. Integrated intervention program was conducted for four days per week for one month. Data was analyzed statistically by using normal probability curve (NPC) and paired t-test.

Results
An overall prevalence of negative mental health and significant positive effect by the integrated intervention on the mental health among cancer patients have been statistically corroborated in this pre-post research.

Conclusion
Integrated intervention program is efficacious in improving mental health in cancer patients.

Keywords:
Cancer, cognitive behaviour therapy, integrated intervention, JPMR, mental health

Clinical Overview of Cancer Patients in Province Two of Nepal: A Single Center Experience

Anshu K Thakur, Anish Shah, Barun K Ray — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
The incidence of cancer is rising in Nepal. It is estimated to reach 38.5 per 100,000 for males and 41.5 per 100,000 for females by 2020. The studies to determine the cancer burden in Nepal at provincial level have been insufficient and those that have been done are more inclined to Province 3. With establishment of a dedicated cancer facility in this area, we present an overview of clinical scenario of cancer patients in Province 2.

Methods
We performed a single centered, retrospective review of 118 patients who were registered in Oncology Clinics between May 2019 and February 2020. Demographics, diagnoses and the treatment strategies were obtained from the medical records.

Results
Median age of presentation for cancer was 55 years (range, 6 to 83 years) with maximum number of patients falling within range of 50-60 years (31.4%). 71 patients (60.2%) were female and 47 patients (39.8%) were male. The common presenting cancers were gastrointestinal (27.1%), breast (16.9%), head and neck (15.3), gynecological (13.6%), hematological (11.9%) and others (15.2%). Among the gastrointestinal cancers, carcinoma of gallbladder with 15 cases (46.9%) was the most frequently occurring, followed by colorectal cancer with 6 cases (18.8%) and esophageal cancer with 4 cases (12.5%). Among all, 78 patients (66.1%) received palliative care only, 25 patients (21.2%) received chemotherapy only, 8 patients (6.8%) underwent surgery only, 3 patients (2.5%) underwent surgery and received chemotherapy as well, 2 patients (1.7%) received both chemotherapy and palliative care and 2 patients (1.7%) were reassured and observed.

Conclusion
The most common age of presentation for cancer of any type was 50-60 years, with most common cancer being gastrointestinal in origin. Most of the patients received palliative care owing to their advanced stage at presentation.

Keywords:
Cancer, clinical overview, palliative care

Risk Factors Among Breast Cancer Patients Being Treated in Tertiary Level Hospital of Nepal: A Case Control Study

Asmita Rana — Thu, 30 Apr 2020 00:00:00 +0000

Introduction
Breast cancer is the leading cause of cancer death among females worldwide. Its incidence is on the rise in Nepal. However, the risk factors have not been studied in context of Nepal. The aim of this study is to identify and quantify the association of various risk factors with breast cancer in Nepal.

Methods
Hospital-based age-matched case-control study was conducted among 50 cases and 150 controls visiting BP Koirala Memorial Cancer Hospital, Bharatpur, Nepal. Semi-structured questionnaire was used to collect information on demographic characters, socio-economic parameters, reproductive history, dietary and personal habits, family history, history of contraception and history of benign breast disease. Height, weight, hip circumference and waist circumference were measured.

Results
Majority of the cases (52%) belonged to the age group of 46-55 years. The significant risk factors were ethnicity of Dalit/Madhesi (AOR 8.222, 95% CI 2.377-28.441, p-value 0.001), parity of 3 to 5 (AOR 5.614, 95% CI 1.140-27.639, p-value 0.03) and previous history of benign breast disease (OR 13.614, 95% CI 3.229-57.391, p-value 0.001). Hysterectomy was found to reduce the risk of breast cancer (OR 0.122, 95% CI 0.017-0.826, p-value 0.03). Knowledge of breast self-examination was significantly higher among cases than controls (AOR 36.29, 95% CI 5.788-227.555, p-value < 0.001). Knowledge of mammography was significantly lower among cases than control (AOR=0.133, 95% CI=0.028-0.647, p-value=0.01).

Conclusion
This study showed a number of factors to be associated with the increased risk of breast cancer. It was observed that the mean age at diagnosis is a decade earlier than in Western countries. Genetic component was not significant in context of Nepal. It is hoped that the findings of this study will facilitate further exploration and evidenced-based preventive measures for Nepalese women.

Keywords:
Benign breast disease, breast cancer, risk factors