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 Histopathological Findings of Pancreaticoduodenectomy Specimens in a Tertiary Care Hospital in Nepal(Institute of Medicine, 2021) Karki, Shovana; Shrestha, Sonafi; Tiwari, Sansar B; Lakhey, Paleswan JoshiABSTRACT Introduction: Among the gastrointestinal malignancies, 5% of the tumors comprise peri-ampullary carcinomas. Adenocarcinoma is the commonest malignancy in the peri-ampullary region. The important histopathological prognostic factors are tumor size, location, extension, resected marginal status, lymphovascular (LVI) and perineural invasion (PNI) and lymph nodal status. This study was conducted to analyze the lesions and to describe the associated histopathological parameters. Methods: This study was carried out in the Department of Pathology, TUTH, Kathmandu, includes pancreatico-duodenectomy specimens submitted from April 2016 to September 2020. The related details were obtained from the archives of reports in the Department. Statistical analysis was performed using IBM SPSS v26. Results: Among 111 specimens, 100 (90%) malignant lesions, 10 (9.1%) benign lesions and 1(0.9%) pre-malignant lesions were seen. M:F ratio was 1.2:1 with mean age 55.5 years. Ampulla was the most common site of malignancy (61%) and adenocarcinoma was the commonest histological type. Chronic pancreatitis (4.5%) accounted for most of the benign lesions. Ampullary and pancreatic malignancies were detected in T2 stage, 55.7% and 77.8% respectively. LVI was seen in 61% and PNI in 72% of pancreatic malignancies. Positive resected margin was seen in 6% of malignancies. SMA was the most common positive margin. Conclusion: Pancreatico-duodenectomy was performed mostly for adenocarcinomas of ampulla. Pancreatic tumors were common in the older age group and they presented with LVI and PNI and at a higher T and N status as compared to ampullary or duodenal tumors. Keywords: Lymphovascular invasion, margins, perineural invasion, pancreatico-duodenectomy specimenPublication Management of Postpancreatectomy Hemorrhage Following Pancreaticoduodenectomy at a Tertiary Care Center in Nepal(Institute of Medicine, 2020) Subedi, Nirajan; Kandel, Bishnu; Ghimire, Bikal; Kansakar, Prasan BS; Bhandari, Ramesh S; Lakhey, Paleswan JoshiABSTRACT Introduction: Postpancreatectomy hemorrhage (PPH) is an important complication which significantly increases morbidity and mortality following pancreaticoduodenectomy (PD). This study aims to find the incidence, classification, management, and mortality associated with PPH following PD. This study also describes the changes in management and outcomes between the period of 2004-2014 and 2015-2019 in our institute as in the later time period there was use of CT angiography and interventional radiology (IR) to identify and control the bleeding site. Methods: This is a retrospective study in which medical records of patients having PPH following PD between 2004-2019 were analyzed. The grading and classification were done according to the International Study Group of Pancreatic Surgery (ISGPS). Management and outcomes were analyzed using standard descriptive statistics. Results: A total of 43 patients developed PPH out of 336 PDs. Out of 43 patients, 4 (9.3%) had Grade A, 16 (37.2%) had Grade B and 23 (53.5%) had Grade C PPH. Fifteen (35%) patients were managed conservatively, seven (16.2%) with IR procedure and 21 (48.8%) were reexplored. There were 16 (37.2%) mortalities, out of different factors- intraoperative blood loss >500 ml showed the predictability for mortality (p= 0.01). On comparing two time periods it was seen that the PPH rate was almost similar but the mortality decreased from 58.8% to 23.07%. Conclusion: PPH following PD is associated with high mortality. Increased use of IR procedure and CT angiography can decrease the relaparotomy rates and eventually decrease mortality. Keywords: Interventional radiology, pancreaticoduodenectomy, postpancreatectomy hemorrhagePublication 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 Multidisciplinary Management of Hepatolithiasis at a Tertiary Care Center in Nepal(Institute of Medicine, 2020) Maharjan, Narendra; Lakhey, Paleswan Joshi; Ghimire, Bikal; Kansakar, Prasan BS; Bhandari, Ramesh SABSTRACT Introduction; Hepatolithiasis is more prevalent in Far-East than in Middle-East countries. There are various treatment modalities available for hepatolithiasis like surgical and non-surgical procedures. Non-surgical procedures have higher recurrence rate. Methods: This is a descriptive retrospective study of the clinical data of hepatolithiasis patients treated at Tribhuvan University Teaching Hospital (TUTH), Maharajgunj from April 2016 to October 2019. Results: There were 14 patients and mean age was 45.8±14.8 years. It was more common in female (F: M = 4:3). Left sided hepatolithiasis was the most common type (50%). One (7.1%) patient had bilateral hepatolithiasis associated with unresectable cholangiocarcinoma. Eight (57.1%) patients were treated with surgical procedures; four (28.6%) patients underwent interventional radiological procedures and remaining two (14.3%) patients had combined surgical and intervetional radiological procedures. Complete stone clearance was achieved in 11 patients (78.57%). In surgical therapy group, seven out of eight (87.5%) patients achieved the complete stone clearance; two out of four (50%) patients in interventional radiology group and all patients in combined therapy group achieved the clearance. There was no recurrence among those patients who had complete stone clearance and there was no mortality. Conclusion: The management of hepatolithiasis should involve multi-modality (surgical and non-surgical) therapeutic techniques available, in order to achieve complete stone clearance and prevent the complications. Keywords: Hepatolithiasis, left lateral sectionectomy, percutaneous transhepatic biliary drainagePublication Outcome of Management of Walled-Off Necrosis: An Experience from University Hospital of Nepal(Institute of Medicine, 2024) Thapa, Pradip; Bhandari, Suyog; Sharma, Deepak; Maharjan, Narendra; Pradhan, Sumita; Kandel, Bishnu Prasad; Bhandari, Ramesh Singh; Lakhey, Paleswan JoshiABSTRACT Introduction:The patients with walled-off necrosis after acute necrotizing pancreatitis may require multiple interventions and may be associated adverse outcomes. Intensive care unit admission for organ failure and multistage step-up approaches are the cornerstones of optimal management. This study was conducted to evaluate the clinical characteristics and outcomes of the different strategies for the management of walled-off necrosis. Methods: This is a retrospective cross-sectional study of the patients with walled-off necrosis, managed from July 2022 to January 2024. The demographic data, clinical parameters and outcomes of different strategies including percutaneous and endoscopic drainage and laparoscopic and open necrosectomy were analyzed. Results: Twenty-five patients diagnosed with walled-off necrosis were evaluated. The mean age of those patients was 41.64±12.44 years, and 13 (52%) were females. The median time interval between the onset of acute pancreatitis and percutaneous drainage was 31 (28-42) days. Seventeen (68%) patients were managed with percutaneous transgastric drainage. Among four (16%) patients requiring step-up approach, one required endoscopic ultrasound guided drainage, two (8%) underwent open necrosectomy, one underwent laparoscopic necrosectomy. The median length of hospital stay was 16 (3-60) days. There were four (16%) mortalities, two (8%) after percutaneous drainage only, one after endoscopic ultrasound guided drainage and one after open necrosectomy, all due to sepsis and multiple organ failure. Conclusion: Initial percutaneous transgastric drainage is feasible, safe and effective in the management of majority of patients with walled-off necrosis, thereby reducing further invasive interventions and improving the overall outcomes of the patients. Keywords: Acute necrotizing pancreatitis; percutaneous drainage; step-up approach; walled-off necrosisPublication 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 Risk Score for Prediction of Severe Postoperative Complications After Pancreaticoduodenectomy(Institute of Medicine, 2021) Shah, Surendra; Bhandari, Ramesh S; Vaidya, Pradeep; Singh, Yogendra P; Lakhey, Paleswan JoshiABSTRACT Introduction: Morbidity after pancreaticoduodenectomy (PD) still remains high. Postoperative pancreatic fistula (POPF) is the most common cause of increased morbidity after PD. Assessment of predictability of risk score for severe postoperative complications was the objective of this study. Methods: This was a retrospective observational study. Patients undergoing pancreaticoduodenectomy at Tribhuvan University Teaching Hospital (TUTH) between January 2017 to December 2017 were included in the study. Variables were recorded from case sheets of the patients. The “Risk Score” was calculated using the pancreatic duct diameter and body mass index (BMI). Association of risk score and severe postoperative complications were analyzed. Results: A total number of patients were 43, including 23 (53.5%) males and 20 (46.5%) females. The mean age was 57.09 ± 11.85 years ranges from 29 years to 76 years. The POPF and delayed gastric emptying (DGE) was 23.3% (10/43); and post-pancreaticoduodenectomy hemorrhage (PPH) was 11.6% (5/43). Severe postoperative complications were present in 13.9% (6/43) patients. In univariate analysis, pancreatic duct diameter (p=0.045) and Risk Score (p=0.02) were significantly associated with severe postoperative complications after PD. However none of them were significant in multivariate analysis. Conclusion: Risk score failed to predict severe postoperative complication after pancreaticoduodenectomy. Keywords: Pancreaticoduodenectomy, postoperative pancreatic fistula, severe postoperative complicationsPublication 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.Publication Surgery for Solid Pseudopapillary Neoplasm: Observational Study at a Nepalese Tertiary Center(Institute of Medicine, 2023) Sah, Dhruba N; Bhandari, Ramesh S; Kansakar, Prasan BS; Ghimire, Bikal; Lakhey, Paleswan JoshiABSTRACT Introduction: Solid pseudopapillary neoplasms (SPN) are rare, relatively indolent tumors with potential malignant behavior. This study aimed to analyze the clinicopathological details, surgical management, and short- and long-term outcomes of operated cases of SPN. Methods: This was an observational descriptive study of diagnosed SPNs confirmed histopathologically after surgical resections at Tribhuvan University Teaching Hospital (TUTH), Kathmandu, Nepal from 2006 November to 2019 January. Patient’s clinical details, surgical procedures, perioperative outcomes, and follow-up were recorded. Long-term follow-up was evaluated for a minimum of three years post-surgery. Results: Over 13 years, a total of 15 cases with a median age of 22 years (11-52) were encountered and had female predominance (14, 93.3%). Five cases were diagnosed incidentally, while pain abdomen (5, 33.3%) was the most common presentation followed by lump (4, 26.7%). There were four tumors in the head of the pancreas, two in the uncinate process, two in the neck, four in the body, and three in the tail of the pancreas. Four cases underwent pancreaticoduodenctomy, three cases underwent enucleation, and four cases underwent central pancreatectomy. Similarly, one patient underwent spleen preserving distal pancreatectomy and three patients underwent distal pancretosplenectomy. Postoperatively, 20% developed major complications with Clavien-Dindo (grade III & above) out of which one patient had mortality. Over the median follow-up of 72 months, no recurrences were noted. Conclusion: Solid pseudopapillary neoplasms were relatively rare. Complete surgical resection was the most commonly used surgical management, post-operative complications were minimal and survival rate was excellent. Keywords: Pancreas; solid pseudopapillary neoplasm; surgery