Browsing by Author "Lakhey, Paleswan Joshi"
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Publication Adenosquamous Carcinoma of Gallbladder with Unusual Prognosis: A Case Report(Nepal Medical Association, 2023) Gyawali, Siddinath; Pokhrel, Biraj; Sharma, Deepak; Bhatta, Naveen Chandra; Kandel, Bishnu Prasad; Lakhey, Paleswan JoshiAbstract The adenosquamous carcinoma of the gallbladder is a rare variant accounting for only 1-4% of all primary gallbladder carcinoma. Regardless of the histological types, all gallbladder carcinomas have silent and rapid progression resulting in delayed diagnosis and poor prognosis. Even with medical and/or surgical interventions, the median survival of patients with adenosquamous carcinoma, one of the histological variants, is less than a year. However, we present a case of adenosquamous carcinoma with an unusually better prognosis. A 70-year-old female patient, after being diagnosed with gallbladder carcinoma was suggested for surgical resection but was lost to follow-up since then. Two years later, the patient presented and was managed with extended cholecystectomy. The slow progression and non-recurrence of the tumour during follow-up for two years after the surgery indicates a better prognosis in this case.Publication Day One Drain Amylase as a Predictor of Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy(Nepal Health Research Council, 2022) Pradhan, Sumita; Kandel, Bishnu; Bhandari, Ramesh Singh; Lakhey, Paleswan JoshiAbstract Background: Postoperative pancreatic fistula remains the most challenging complication following pancreaticoduodenectomy. As per the definition by the International Study Group on Pancreatic Fistula, post operative pancreatic fistula is diagnosed on or after postoperative day 3. However, several studies have demonstrated that drain fluid amylase on postoperative day 1 may be a better predictor. This study was conducted to determine the diagnostic value of day one drain amylase in predicting the development of post-operative pancreatic fistula. Methods: This was a prospective observational study of patients, who underwent pancreaticoduodenectomy between April 2016 and May 2017. Post operative pancreatic fistula was defined by the International Study Group on Pancreatic Fistula (2005) criteria. The diagnostic value of day one drain amylase was determined by doing a receiver operating curve analysis and compared with the postoperative day 3 value. Results: A total of 49 patients were included. Post operative pancreatic fistula developed in 28 patients (Grade A - 40.8%; B - 12.2%; C - 4.1%). Receiver operating curve analysis confirmed the predictive relationship of day one drain amylase with an area under the curve of 0.79 and kappa 0.5. For clinically relevant postoperative pancreatic fistula, day 3 drain amylase was the better predictor (AUC for DFA3 was 0.73 while AUC for DFA1 was 0.51). A day one drain amylase cut-off value of 350 U/L demonstrated a sensitivity of 75% and specificity of 77.8% with an accuracy of 76.2%. Conclusions: Day one drain amylase predicts postoperative pancreatic fistula in patients following pancreaticoduodenectomy but for clinically relevant postoperative pancreatic fistula, day three drain amylase is a better predictor. Keywords: Amylase; drain fluid amylase; pancreaticoduodenectomy; Pancreatic fistulaPublication Management and Early Outcomes of Bile Duct Injuries at University Teaching Hospital(Institute of Medicine, Tribhuvan University, 2024) Bhandari, Suyog; Thapa, Pradip; Sharma, Deepak; Maharjan, Narendra; Pradhan, Sumita; Kandel, Bishnu Prasad; Lakhey, Paleswan Joshi; Bhandari, Ramesh SinghAbstract: Introduction Bile duct injury (BDI) management depends upon the type, clinical presentation, available resources and expertise. Some BDI may be managed with endoscopic intervention with Endoscopic Retrograde Cholangio-pancreaticography (ERCP), sphincterotomy and/or stenting while others may require complex surgery and percutaneous interventions by interventional radiologists (IR). This study aimed to evaluate the management strategies and early outcomes of bile duct injuries at Tribhuvan University Teaching Hospital. Methods In this retrospective analysis, bile duct injuries in patients treated at Tribhuvan University Teaching Hospital, Kathmandu, Nepal over a period of two years were included (January 2020 to December 2022). In this study we have described the clinical presentation, Strasberg classification of BDI grade, different management techniques and their early outcomes. We calculated number and percentages for categorical variables, mean and standard deviation for continuous data. Results Out of 26 bile duct injuries, 12 (46.2%) patients underwent surgical management, 9 (34.6%) underwent percutaneous intervention and 5 (19.2%) underwent endoscopic intervention. Majority of the patient 15 (57.7%) had stricture as an indication for management. Patients who underwent surgical, endoscopic, and percutaneous management showed good early outcomes in 12, 5, and 8 patients respectively. The mean duration of hospital stay was 11.8±5.2 days and CCI was 15.2±9.7, for patients with index presentation who underwent surgery. Conclusion Management of bile duct injuries require multidisciplinary team approach and favorable outcomes can be achieved when managed with expertise at tertiary centers. Surgical management remains essential for complex cases, while percutaneous and endoscopic interventions offer viable alternatives for less severe injuries.Publication Postoperative C-Reactive Protein as a Predictor of Postoperative Pancreatic Fistula after Pancreaticoduodenectomy(Institute of Medicine, Tribhuvan University, 2025) Khadka, Namrata; Maharjan, Narendra; Bhandari, Ramesh Singh; Lakhey, Paleswan JoshiAbstract: Introduction Postoperative pancreatic fistula (POPF) has adverse effects on the outcomes of patients after Pancreaticoduodenectomy PD. Thus, an accurate predictor of POPF is essential. This study aimed to identify C-Reactive Protein (CRP) on the first postoperative day (POD1) as a predictor of clinically relevant postoperative pancreatic fistula (CR-POPF). Methods It was a prospective observational study performed at Tribhuvan University Teaching Hospital, Nepal, from March 2019 to November 2019. Forty-nine patients who underwent PD were enrolled in the study. Demography, clinicopathological characteristics, postoperative complications, and CRP on POD1 were recorded. Statistical analyses were performed to identify the association of POD1 CRP with CR-POPF. Results The mean age was 56.94 ± 10.10 years, with a nearly equal gender distribution. Clinically relevant postoperative pancreatic fistula (CR-POPF) occurred in 13 patients (26.5%). Patients with CR-POPF had higher mean postoperative day 1 serum C-reactive protein (CRP) levels (123.84 ± 42.90 mg/L) compared to those without CR-POPF (93.35 ± 67.02 mg/L); however, the difference was not statistically significant (p = 0.134). No significant associations were found between CR-POPF and preoperative or intraoperative variables, including pancreatic duct diameter, gland texture, and operative time. Conclusion Although serum CRP levels on postoperative day 1 were higher in patients who developed clinically relevant POPF, the difference was not statistically significant in this study. Therefore, CRP alone may not be a reliable early predictor of CR-POPF.Publication Short Term Outcomes after Elective Gastrointestinal Surgery in Octogenarians: A Retrospective Matched Cohort Study(Institute of Medicine, Tribhuvan University, 2025) Kandel, Bishnu Prasad; Koirala, Nishnata; Sharma, Deepak; Maharjan, Narendra; Maskey, Sumita Pradhan; Bhandari, Ramesh Singh; Lakhey, Paleswan JoshiAbstract: Introduction The incidence of gastrointestinal surgical conditions like malignancy increases with age. There is growing requirement of gastrointestinal surgery in elderly patients due to the aging of general population. Gastrointestinal surgery in octogenarian patients posses an unique challenges due to decreased functional status of organs and higher incidence of co-morbidities. Methods In this retrospective study we compared the co-morbidities and perioperative outcomes of octogenarian patients with case matched younger patients. There were 2115 patients who underwent gastrointestinal surgery from October 2021 to September 2024 out of which thirty four were octogenarian patients. Sixty eight younger patients who underwent similar surgical procedures were selected for comparison. Patients’ data were obtained from the medical records and the outcomes of surgery in two groups were compared. Results Octogenarian patients had more co-morbidities compared with younger patients. Occurrence of major postoperative complications (23.5% vs 8.8%; p value 0.04) and cardiac complications (20.6% vs 4.4%; p value 0.01) were higher in octogenarians. Postoperative hospital stay, intensive care unit stay, occurrence of overall complication and mean comprehensive complication index was similar in two groups. Conclusion Octogenarian had higher occurence of major complications after gastrointestinal surgery. Proper perioperative care is required for surgical management of octogenarian patients.