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Background: Gallbladder cancer (GBC) is rare but aggressive. The extent of surgical intervention for different GBC stages is non-uniform, ranging from cholecystectomy alone to extended resections including major hepatectomy, resection of adjacent organs and routine extrahepatic bile duct resection (EBDR). Robust evidence here is lacking, however, and survival benefit poorly defined. This study assesses factors associated with recurrence-free survival (RFS), overall survival (OS) and morbidity and mortality following GBC surgery in high income countries (HIC) and low and middle income countries (LMIC). Methods: The multicentre, retrospective Operative Management of Gallbladder Cancer (OMEGA) cohort study included all patients who underwent GBC resection across 133 centres between 1st January 2010 and 31st December 2020. Regression analyses assessed factors associated with OS, RFS and morbidity. Findings: On multivariable analysis of all 3676 patients, wedge resection and segment IVb/V resection failed to improve RFS (HR 1.04 [0.84–1.29], p = 0.711 and HR 1.18 [0.95–1.46], p = 0.13 respectively) or OS (HR 0.96 [0.79–1.17], p = 0.67 and HR 1.48 [1.16–1.88], p = 0.49 respectively), while major hepatectomy was associated with worse RFS (HR 1.33 [1.02–1.74], p = 0.037) and OS (HR 1.26 [1.03–1.53], p = 0.022). Furthermore, EBDR (OR 2.86 [2.3–3.52], p < 0.0010), resection of additional organs (OR 2.22 [1.62–3.02], p < 0.0010) and major hepatectomy (OR 3.81 [2.55–5.73], p < 0.0010) were all associated with increased morbidity and mortality. Compared to LMIC, patients in HIC were associated with poorer RFS (HR 1.18 [1.02–1.37], p = 0.031) but not OS (HR 1.05 [0.91–1.22], p = 0.48). Adjuvant and neoadjuvant treatments were infrequently used. Interpretation: In this large, multicentre analysis of GBC surgical outcomes, liver resection was not conclusively associated with improved survival, and extended resections were associated with greater morbidity and mortality without oncological benefit. Aggressive upfront resections do not benefit higher stage GBC, and international collaborations are needed to develop evidence-based neoadjuvant and adjuvant treatment strategies to minimise surgical morbidity and prioritise prognostic benefit. Funding:Cambridge Hepatopancreatobiliary Department Research Fund.

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. MethodsThis 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. ResultsA 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. ConclusionRisk score failed to predict severe postoperative complication after pancreaticoduodenectomy.

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. MethodsThis 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. ResultsA 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%. ConclusionPPH following PD is associated with high mortality. Increased use of IR procedure and CT angiography can decrease the relaparotomy rates and eventually decrease mortality.

Background: Solid pseudopapillary neoplasms (SPN) are rare, relatively indolent tumors with potential malignant behavior. The incidence of these tumors is increasing due to the widespread use of cross-sectional imaging. Surgery remains the mainstay of treatment and the only curative option.The study aimed to analyze the clinicopathological details, surgical management and short- & long- term outcomes of operated cases of SPN.Methods:This is a retrospective review 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. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 23. Results: Over 13 years, a total of 15 cases with a median age of 22 years (11-52) had female predominance (14). Five cases were diagnosed incidentally while pain abdomen (5) was the most common presentation followed by lump (4). Locations of tumor were head (4), uncinate process (2), neck (2), body (4) and tail (3). Pancreaticoduodenectomies were performed in 4 cases, enucleation (3), central pancreatectomies (4), distal pancreatectomy (1) and distal pancreatico-splenectomies (3). Margins were negative in all cases with a median tumor size of 6 cm (2.5 -18). Postoperatively, 20% developed major complications with Clavien-Dindo (grade III & above) out of which 1 patient (6.7%) had mortality. The median hospital stay was 7 days (4-16). One patient was lost to follow-up while the remaining had a median follow-up of 72 months (38 months – 150 months) and revealed no issues. No recurrences were noted.Conclusion: SPNs are low-grade tumors with a good prognosis. Complete surgical resection is the treatment of choice, with excellent survival.

Biliary stents are frequently associated with various complications; however biliary stent migration causing duodenal perforation is rare and has only been reported in few cases.We present a case of 33 years old male with pain abdomen and fever for 2 days came to Emergency department. He had undergone open common bile duct exploration (CBD), clearance of stone and placement of CBD stent. In X-ray abdomen, biliary stent migration was suspected. CECT abdomen was done for the confirmation of diagnosis which showed migrated stent with duodenal perforation. Patient underwent exploratory laparotomy and Thal patch repair, pyloric exclusion, retrograde duodenostomy and feeding jejunostomy. Post-operative period was uneventful.Biliary stents are used to relieve biliary obstruction. There is increasing use of endoscopic retrograde drainage via plastic endoprosthesis and so the related morbidities. One of the rare but serious complications is intestinal perforation and duodenal perforation is seen in most of the cases, explanation being the relative fixed position of the duodenum.Although intestinal perforation is an uncommon complication following CBD stenting, we should suspect it in patients presenting with pain and fever.

Radical resection in a case of hilar cholangiocarcinoma is the only curative option. However resection in a hilar cholangiocarcinoma is a challenging procedure because of the low resectability rate. Only a few cases of hilar cholangiocarcinoma are operable because of the advanced nature of disease at presentation. Furthermore, the extent of surgery makes it a complicated process to attempt. We recently had a patient who underwent an open extended right hepatectomy and hepaticojejunostomy for a type IIIa hilar cholangiocarcinoma. The tumor was 20 mm in diameter and was located between the right hepatic duct and common hepatic duct. Radiological examination showed that the hepatic artery was not involved but the right portal vein was invaded by the tumor. CT volumetry was done and the future liver remnant was only 20% in the jaundiced patient. Preoperative drainage was done with percutaneous transhepatic biliary drainage from the left side. Portal vein embolization was done to augment future liver remnant to 30%. The patient underwent an extended right hepatectomy (right trisectionectomy combined with caudate lobectomy). The operation time was nearly 300 min, and the intraoperative blood loss was about 500 ml. However, in the postoperative period, the patient developed post hepatic liver failure which was managed successfully with conservative treatment. The postoperative hospital stay was 23 days. The final diagnosis was hilar cholangiocarcinoma with no nodal metastasis (pT2bN0M0) stage II (American Joint Committee on Cancer, AJCC).

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. MethodsThis 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. ResultsThere 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. ConclusionThe 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.

An informal workgroup of 9 hepatopancreaticobiliary (HPB) surgeons from 6 different countries on 4 continents shifted the focus of their quarterly tumor board discussions to their responses to the current COVID-19 pandemic. Just as they had discussing HPB cases, they share their experiences and ideas in dealing with the outbreak that faced their hospitals and communities. Their efforts to improve care proved that professionalism in surgery, like the global pandemic, has no boundaries.

Introduction The symptoms of primary duodenal adenocarcinoma, which is a rare but aggressive tumor, are vague and nonspecific and often result in a delayed diagnosis or misdiagnosis. This results in a tumor being diagnosed at an advanced stage when it becomes unresectable secondary to local and distant spread. Case presentation A 64-year-old Nepalese female presented to our hospital with epigastric pain, anorexia, and significant weight loss that developed over two-and-a-half months. Upper gastrointestinal endoscopy showed an ulceroproliferative growth in the first part of the duodenum with no features of duodenal stenosis. Contrast- enhanced computed tomography of the abdomen revealed heterogeneously enhancing, circumferential, asymmetrical thickening in the first part of the duodenum and multiple liver metastases. Biopsy of the mass revealed features suggestive of moderately differentiated adenocarcinoma of the duodenum. She was managed with palliative care during her hospital stay. The unique presentation in our case was that the tumor did not cause stenosis and the patient could consume food till the last day of her life. Conclusion In patients with primary duodenal adenocarcinoma, the non-stenotic lesion is also a possibility. Clinicians should always maintain a high degree of suspicion to avoid the delay in diagnosis or misdiagnosis.

Background Benign biliary stricture is an infrequent condition and the majority occur following cholecystectomy. This case report highlights the occurrence of such a stricture 11 years after cholecystectomy without development of biliary cirrhosis. Case presentation Our patient was a 55-year-old Nepalese woman who presented to our hospital with cholangitis of 1-month duration and a history of cholecystectomy 11 years ago. A diagnosis of benign biliary stricture without features of biliary cirrhosis was made, and the patient was successfully managed with a multidisciplinary approach. Conclusion Benign biliary stricture can present even decades after cholecystectomy. Roux-en-Y hepaticojejunostomy is the treatment of choice, and a long-term favorable outcome can be expected.

Introduction According to GLOBOCAN 2018, gastric carcinoma is the fifth most common cancer (5.7%) and third most common cause of cancer related death (8.2%) worldwide. Delayed presentation and advanced disease at diagnosis, owing to the overlapping symptoms, can be attributed to its high mortality. Gastrectomy is one of the most commonly performed surgery at our centre. This study aims to study the role of pre-operative serum carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA 19-9), neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) as predictors of adverse prognostic pathological features of gastric carcinoma patients who were considered for surgery at our centre. MethodsThis is a retrospective analysis of prospectively maintained database of all operated gastric carcinoma patients since June 2016 to January 2019. Various pre-operative variables including serum CEA level, serum CA 19-9 level, NLR and PLR were collected. Intra-operative surgical procedures performed and post-operative pathologic variables like tumor size, stage, grade, lymph node ratio (LNR), lymphovascular invasion (LVI) and perineural invasion (PNI) were collected. ResultsA total 60 patients were planned for surgical intervention over this duration. Mean age of the population was 56.8±12.5 years with slight male predominance (i.e. 55%). Mean CEA level was 6.17 ng/ml and CA 19-9 level was 72.1 U/ml. The mean NLR and PLR of the study population was 3.4 and 200 respectively. Fifty four patients had distal tumors and six had proximal tumors. Curative surgery was performed in 40 patients out of which 37 underwent subtotal gastrectomy and three underwent total gastrectomy. D2 gastrectomy was performed in 55% patients treated with curative intention. Advanced disease (T2 and above) was seen in 86.7% of patients. Preoperative CEA, CA 19-9, NLR, PLR were evaluated for association with pathologic features like tumor size, T stage, grade of tumor, LNR, LVI, and PNI but statistical analysis failed to show any significant association. ConclusionAdvanced disease at presentation is common in gastric carcinoma. Preoperative clinical parameters including tumor markers CEA, CA 19-9, NLR and PLR may not be useful to diagnose the advanced disease in gastric carcinoma patients.

Introduction: As cites, a common entity in practice of gastroenterology is path physiologically divided into high SAAG and low SAAG category, to rapidly classify, formulate a workup plan and expedite the diagnosis. The cause of low SAAG as cites is often due to local peritoneal cause e.g. peritoneal tuberculosis, peritoneal carcinomatosis etc, mandating the need of peritoneoscopy for definitive diagnosis. This study aims to present the peritoneoscopy and peritoneal biopsy result of patients with low SAAG as cites of uncertain etiology. Methods: Peritoneoscopy was prospectively performed in 12 patients with low SAAG as cites of unclear etiology. Patients with low SAAG as cites and willing to give consent for peritoneoscopy were enrolled in the study. Patients underwent laparoscopic peritoneoscopy under general anesthesia and appropriate biopsies were taken during the procedure for histopathological analysis. Results: Of the twelve patients with low SAAG enrolled in the study, 3 (25%) were male and 75% (9) were female. The success rate of the procedure was 100% and there was no procedure related complications. Specific findings were seen in all patients undergoing peritoneoscopy. Of the twelve patients, 9 (75%) patients has metastatic deposits in the peritoneum, 3 (25%) had benign etiology, 2/3rd (2) of whom had granulomatous deposits suggestive of tuberculosis and 1/3rd (1) had extensive dense adhesions and peritoneal fibrosis. Primary focus was revealed (ovary) in only 1 patient undergoing peritoneoscopy. Conclusion: Peritoneoscopy with simultaneous biopsy is safe, efficient and accurate diagnostic method due to its high diagnostic capacity and low complication rate in selected patients who have low SAAG as cites of uncertain etiology.

Background and aims: Organ transplant is often the only viable treatment option for various end stage organ failures. Inadequacy of organ procurement from living as well as cadaveric donors is common, more so in developing countries. The aim of this study was to find out the knowledge and attitude regarding organ transplantation. Methods: A questionnaire-based survey was carried out among 150 respondents, who were the visitors of patients admitted to ICU of three tertiary care centres in Kathmandu. Results: Majority of the respondents were male 105 (70%) and 132 (88%) were aware about organ transplant. Likewise, 111 respondents (84.1%) hold the belief that organ transplant save lives. Ninety-four of the responses (34.8%) believe that media was the source of knowledge and 121 (91.7 %) of the respondents stated that organ transplant should be promoted. Majority of them, 80 of the total respondents (60.6%) believed that organ can be donated by both living and deceased donors and 111 (84.1%) of them believed that organ transplant save lives. While 88 of the respondents (66.7%) have heard about brain death, 60 of them (45.4%) believe that there is an organ transplant act in Nepal. Out of all respondents who are aware about transplantation, 91 of them (68.9%) have opinion that they are willing to donate the organ of their beloved ones should there be a situation of brain death. Conclusions: The study concludes that respondents have adequate knowledge regarding organ transplantation. Respondents have overall positive attitude towards organ donation and transplantation.

Introduction and importance Chyle leak is the leakage of milk-like triglyceride-rich lymphatic fluid from the lymphatic system to the peritoneal cavity. The incidence of chyle leak after radical gastrectomy is very low. Case presentation A 77-year-old female presented with complaints of decreased appetite and weight loss for six months. Upper gastrointestinal endoscopy showed a polypoidal growth along the greater curvature and the histopathological report of the biopsy taken showed high-grade tubular adenoma with high-grade dysplasia. The patient underwent pylorus-preserving gastrectomy with D1 lymphadenectomy. Postoperatively, after initiation of the oral diet, the abdominal drain started draining milky white fluid, which was rich in triglyceride. The patient was managed conservatively with nil per oral, total parenteral nutrition, and somatostatin analogue. Clinical discussion The appearance of milky, nonpurulent fluid in abdominal drain concurrent with the initiation of oral feeding is characteristic of postoperative chyle leak. In our case, we managed the case successfully over a few days with total parenteral nutrition, nil per oral status, and somatostatin analogue. Conclusion The incidence of chyle leak after gastrectomy is low, if it occurs it prolongs the hospital stay. Higher age, female gender, and early enteral feeding have been seen as the risk factors for chyle leak. Conservative treatment is effective and is the treatment of choice., Highlights • Chyloperitoneum is the leakage of milk-like triglyceride-rich lymphatic fluid from lymphatic system to the peritoneal cavity. • Post-operative chyle leak increases with extensive intraoperative dissection • Higher age, female gender and early enteral feeding have been seen as risk factor for chylous ascites. • Total parenteral nutrition, somatostatin analogues, paracentesis along with low fat diet are curable in most of the cases.

Introduction Mucormycosis is a rare systemic fungal infection seen in immune-compromised patients. Gastrointestinal tract involvement is not usual. Case presentation A 36 years female presented with fever and progressive bilateral leg swelling for 25 days. She was diagnosed as nephrotic syndrome and started on methylprednisolone and cyclophosphamide. She developed hematochezia during hospital stay. On colonoscopy, ulcero-proliferative lesion was noted in caecum. Histopathology examination has confirmed it as mucormycosis of Caecum. Discussion Mucormycosis is an opportunistic angioinvasive disease caused by fungus zygomycosis it is a rare disease and often manifests as a life-threatening condition in immune-compromised patient. Invasion by fungal hyphae leads to arterial thrombosis, tissue infarction, hemorrhage and, necrosis. Diagnosis is confirmed by histopathological examination and culture. It is usually treated by the anti-fungal drug- liposomal amphotericin and surgical debridement. Conclusion Mucormycosis is a fatal systemic fungal infection, which can present as lower gastrointestinal bleeding in immunocompromised patients.

Introduction and importance Intra-ampullary papillary tubular neoplasms (IAPNs) are relatively rare kind of neoplasms occurring in the region of the papilla which exhibit significant malignant transformation. The patient was concerned about his pain and the possibility of malignancy. Case presentation We report a case of a 47-year-old male who presented with persistent upper abdomen pain. Following detail investigations, he was diagnosed as IAPN and managed by transduonal ampullectomy (TDA). Clinical discussion The insidious onset of IAPN along with its high risk of malignancy makes it mandatory for its proper treatment. Although, endoscopic approach is advantageous for initial therapy, it has some technical difficulties. Hence TDA forms the cornerstone in the management of IAPN with good prognosis. Conclusion Transduodenal ampullectomy is a safe and feasible option for IAPN. It can be the first choice of treatment in selected cases where endoscopic papillectomy is not available., Highlights • Intra-ampullary papillary tubular neoplasms (IAPNs) are unusual neoplasms capable of potential malignant progression. • We report a rare case of IAPN which was treated through transduonal ampullectomy (TDA). • TDA can be adopted as an alternative treatment approach to manage IAPNs with great efficacy and fair long-term results.

Anorectal autoeroticism is one kind of paraphilia where individual attains sexual pleasure through self inserting objects into ones rectum. We present here a case of 40 years old man presented in Surgery department with retention of steel glass into his rectum which he had inserted himself to achieve sexual satisfaction.

Introduction and importance Choledochal cyst is an important risk factor for cholangiocarcinoma. Concomitant hilar cholangiocarcinoma with choledochal cyst with cholelithiasis is a rare finding. Case presentation A 52-year-old male presented with non-specific complaints of generalized weakness for 3 months. Transabdominal ultrasound showed dilated common bile duct with hyperechoic mass at hilar region; further evaluation with magnetic resonance cholangiopancreatography and contrast-enhanced computer tomography of abdomen and pelvis revealed concomitant intraductal hilar cholangiocarcinoma (Bismuth Corlette type 1) with Choledochal cyst (type IVa) with cholelithiasis. After optimization patient underwent left hepatectomy with common bile duct excision with cholecystectomy with Roux-en-Y hepaticojejunostomy. Histopathological examination confirmed it to be well-differentiated adenocarcinoma, intestinal type at the hilar confluence. Clinical discussion An asymptomatic male patient with the concomitant finding of perihilar cholangiocarcinoma (Bismuth Corlette type I) with choledochal cyst type IVa with cholelithiasis is a rare finding. The patient was managed with surgical excision of the common bile duct with Roux-en-Y hepaticojejunostomy and cholecystectomy. Diagnostic evaluation should be proper not to miss or overlook such a synchronous lesion. Conclusion Incidental finding of concomitant perihilar cholangiocarcinoma with the choledochal cyst is rare. Proper evaluation of the patient with CECT abdomen and pelvis and MRCP is necessary for the diagnosis. Proper surgical resection with adequate lymph node removal is important for surgical clearance., Highlights • Choledochal cyst and cholelithiasis are the risk factors for cholangiocarcinoma. • Concomitant perihilar cholangiocarcinoma with choledochal cyst and cholelithiasis without symptoms is rare. • Proper clinical evaluation along with multimodal imaging is essential for diagnosis and management. • Surgical R0 resection including adequate perihilar and pericholedochal lymph node removal is important for surgical clearance.

Introduction and importance Choledochal cysts (CC) are rare cystic dilatation of the biliary trees. Malignancy is one of the important significant findings in CC and its incidence increases with age. Associated squamous cell carcinoma of the choledochal cyst is an uncommon pathological finding. Case presentation We present a 21-year-old male diagnosed with type 1 CC and planned for excision of the cystic dilated extrahepatic biliary tract with hepaticojejunal anastomosis in Roux-en-Y but underwent pancreaticoduodenectomy due to intraoperative palpable mass of CC which was adhered to the duodenum and pancreatic head. Histopathology of the excised specimen revealed squamous cell carcinoma (SCC) of the choledochal cyst. Discussion CC represents a rare biliary cystic disease. Though infrequent, malignant transformation in CC includes cholangiocarcinoma, adenocarcinoma, and rarely SCC. The post-operative management for SCC in CC is ill-defined and carries a grave prognosis. Conclusion The choledochal cyst should be completely excised wherever possible to avoid the possible malignant transformation in CC including SCC.

Background. Acute pancreatitis (AP) is associated with extensive fluid sequestration. The aim of this study was to determine association of fluid sequestration at 48 hours after hospital admission (FS48) in AP patients with demographics, clinical parameters, and outcomes of AP. Methods. A prospective observational study was carried out on all adult patients with AP admitted to Tribhuvan University Teaching Hospital, Nepal, from January to September 2017. FS48 was calculated as the difference between fluid input and output in the first 48 hours of admission. The Kruskal-Wallis test with post hoc Dunn’s test examined the difference in FS48 between mild AP, moderately severe AP, and severe AP. Linear regression analysis was used to evaluate association between FS48 with patients’ characteristics and outcomes of AP. Outcomes of AP assessed included pancreatic necrosis, persistent organ failure, length of stay, and in-hospital mortality. Results. Eighty patients (median age 44 years; 57% male) with a median FS48 of 1610 mL were evaluated. The median FS48 for mild AP, moderately severe AP, and severe AP were 1,180 mL, 2,380 mL, and 3,500 mL, respectively. There was a significant difference in pairwise comparisons between mild AP and moderately severe AP, along with mild AP and severe AP. Younger age, other etiology, and higher creatinine were independently associated with increased FS48. Increased FS48 was significantly associated with pancreatic necrosis, persistent organ failure, and in-hospital mortality. Conclusions. In our study population, younger age and higher creatinine were predictors of increased FS48. Increased FS48 was associated with poorer outcomes of AP.

Background Pancreatic ascites refers to the massive accumulation of pancreatic fluid in the peritoneal cavity and is a rare entity. Chronic alcoholic pancreatitis is the most common cause. Ascites is commonly seen in patients with alcoholic liver disease and is usually a consequence of portal hypertension. Biliary pancreatitis, pancreatic trauma and cystic duplications of biliopancreatic ducts, ampullary stenosis, or ductal lithiasis are the remaining causes. Case presentation A 53-year-old Chhetri man, a chronic alcoholic, presented with epigastric pain and abdominal distension. He had made several previous visits to a local hospital within the past 6 months for a similar presentation. Serum alkaline phosphatase 248 IU/L, serum amylase 1301 IU/L, and lipase 1311 IU/L were elevated while serum calcium was decreased (1.5 mmol/l). Ascitic fluid amylase was elevated (2801 IU/L). A computed tomography scan of his abdomen revealed features suggestive of acute-on-chronic pancreatitis. The case was managed with a conservative approach withholding oral feedings, starting total parenteral nutrition, paracentesis, octreotide, and pigtail drainage. Conclusion Pancreatic ascites is a rare entity. Diagnosis is suspected with raised ascitic fluid amylase in the presence of pancreatic disease. Such cases can be managed by conservative approach or interventional approach. We managed this case through a conservative approach.

Introduction Paraduodenal hernia is a rare cause of internal hernia. It is the herniation of small bowel through a peritoneal sac in the duodenum. It occurs due to incomplete rotation and fixation abnormalities of the primitive midgut during fetal development. We report a case of right sided paraduodenal hernia in an adult male. Case presentation This is a case of 36-year-old gentleman who presented with complaints of abdominal fullness and upper abdominal pain for 1.5 months and 7 to 8 episodes of vomiting. CT scan of abdomen gave an impression of right-sided paraduodenal hernia. Exploratory laparotomy with hernia repair was performed and patient was discharged without complications. Discussion Right sided paraduodenal hernia is the protrusion of viscera through the fossa of Waldeyer. It is frequently associated with malrotation and strangulation. Its diagnosis is frequently delayed. Symptoms are non-specific and may need laparotomy for diagnosis. Technique of choice for surgical management remains inconclusive. Conclusion Paraduodenal hernias are frequently diagnosed late or incidentally because of vague symptoms. They are rarer and carry higher lifetime risk of strangulation and bowel obstruction. Surgical management is necessary after diagnosis., Highlights • Paraduodenal hernia is a rare case of internal hernia due to abnormalities in fetal development. • Right sided paraduodenal hernia is three times rarer than its left sided counterpart. • Symptoms are vague and nonspecific which can delay the diagnosis with the risk for strangulation and bowel necrosis. • Treatment is by hernia reduction with defect repair or widening.

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Introduction and importance Lupus enteritis is uncommon in patients with SLE and usually presents with anorexia, vomiting, and abdominal pain. Intestinal perforation as an initial manifestation of SLE is rare and can have a grave prognosis if not timely diagnosed. Case history We report an unusual case of a 22-year-old regularly menstruating female who presented with features of perforation peritonitis as an initial manifestation of lupus enteritis. Intraoperatively, a gangrenous ileal segment with multiple perforations was present. Thus, with an intraoperative diagnosis of perforation peritonitis, a gangrenous segment of the small bowel was resected and a double-barrel jejuno-ileostomy was created. Discussion Lupus enteritis manifesting initially as bowel perforation can be an uncommon cause of acute abdomen. A plain chest X-ray can show gas under the diaphragm suggesting bowel perforation. A contrast-enhanced CT scan of the abdomen is the gold standard in diagnosing lupus enteritis with a good prognosis on steroids. Conclusion Primary closure, resection, and anastomosis of small gut or diverting stoma are required for management of perforation. A high degree of clinical suspicion is required for early diagnosis thus preventing the grave prognosis of such an entity., Highlights • Bowel perforation in patients with SLE is rare. • Diagnosis of this lupus enteritis is challenging owing to its rarity and non-specific presenting features. • High degree of suspicion and timely diagnosis can prevent fatal complications.

Introduction Improved perioperative care combined with proper training has helped in achieving excellent outcomes following liver surgery even in low volume centers. Extended resections require additional surgical skills as well as perioperative care and when done in proper has equally good results. Here, we present the outcome of extended liver resections performed in developing HPB unit of low volume center. Methods Retrospective review of the medical records of all the patients undergoing extended hepatectomies were analyzed. Results Total 86 liver resections were performed, out of which 61 were major liver resections (three or more segments) performed over 6 years period. Out of them, total 11(18% of major liver resections) extended hepatectomies have been performed. All were right extended hepatectomies only. For liver augmentation, 2 underwent successful right side and segment 4b portal vein embolization, 2 patients had open right side portal vein ligation and one had ALPPS procedure. Rest of the patients didn't require any augmentation procedures. Postoperatively, 1 patient had grade 3 PHLF, 2 grade 2 PHLF and resolved, 2 bile leaks and resolved. Patient with ALPPS procedure had grade 3 PHLF has died on 3rd postoperativ week. Rest 10 patients were discharged on average of 12 hospital days. Conclusions Better patient selection combined with proper training and improved perioperative care, extended hepatectomies can also be safely performed with acceptable outcomes even in low volume centers of developing nations.

Introduction and importance Extrahepatic portal vein obstruction (EHPVO) with portal hypertension is rare in children. Intestinal varices as new collaterals accompanying portal hypertension are very rare. Presentation of case We report an unusual case of a 12-year-old boy with EHPVO with gastrointestinal bleeding from ectopic jejunal varices, without any gastroesophageal varices. Discussion Portal hypertension is the most common cause of EHPVO. Among various ectopic varices, intestinal varices are found distal to the duodenum and present with complaints of hematochezia, melena, or intraperitoneal bleeding. The diagnosis of the EHPVO is aided by imaging investigations like Doppler ultrasound, computed tomography, or magnetic resonance imaging. A multidisciplinary team including gastroenterologists, interventional radiologists, surgeons, and intensivists is crucial in the management of ectopic varices. Conclusion Jejunal varices must be considered in the differential diagnosis of gastrointestinal (GI) hemorrhage in patients with a negative source of bleed on upper and lower GI endoscopy., Highlights • Intestinal varices are rarely developed as new collaterals accompanying portal hypertension with EHPVO (Extrahepatic portal vein obstruction). • Jejunal varices must be considered in patients with a negative source of bleed on upper and lower GI endoscopy.

Background Acute mesenteric ischemia poses a diagnostic challenge due to nonspecific clinical clues and lack of awareness owing to its rarity. Ischemia due to mesenteric venous thrombosis has a good prognosis compared to arterial cause and can be managed conservatively with early diagnosis. The portomesenteric venous system is an unusual site of thrombosis in patients with protein S deficiency, and its thrombosis is an uncommon cause of acute mesenteric ischemia. Case presentation We present a case of a 27-year-old Mongolian man who presented with acute abdominal pain increasing in severity, and refractory to repeated attempts at treatment with a misdiagnosis of acute peptic ulcer disease. Contrast-enhanced computed tomography of his abdomen detected complete occlusion of the superior mesenteric vein, an extension of acute thrombus into the portal vein, and ischemic mid-jejunal loops. Early diagnosis and immediate anticoagulation with continuous intravenous infusion of unfractionated heparin prevented subsequent consequences. On further workup, our patient was diagnosed with isolated protein S deficiency. We started lifelong thromboprophylaxis with warfarin to prevent recurrence and our patient was asymptomatic on the latest follow-up 5 months after discharge. Conclusion Despite accurate detection of acute mesenteric ischemia by contrast-enhanced computed tomography, high index of suspicion is indispensable for its early diagnosis. Early diagnosis and immediate anticoagulation will prevent subsequent complications and need for surgical intervention. Young patients without known risk factors presenting with venous thrombosis in atypical sites should be investigated for prothrombotic diseases.

Introduction: Incidence of acute pancreatitis (AP) varies in different parts of the world. The published data are mainly based on retrospective analysis of hospital admissions, which show that there are considerable geographical differences in the incidence rate. There are also regional divergences with regard to the etiology, and its impact on morbidity and mortality. Therefore, we compare the clinical course of acute biliary and non-biliary pancreatitis at the Tribhuvan University Teaching Hospital (TUTH) as well as we compare the morbidity and mortality and duration of hospital stay in these groups. Methods: This prospective study included the patients with a diagnosis of AP over a period of one year. Eighty-five patients with the diagnosis of AP were included in the study. Revised Atlanta classification system (2012) was used to diagnose and define the severity of disease. The occurrence of local and systemic complications, median duration of hospital stay and mortality in AP was studied. Results: Among 85 patients, 34 patients were females and 51 were males. Among them, 46 patients belonged to the biliary group and 39 belonged to the non-biliary group. Alcohol intake was the major etiology in the non-biliary group (n = 26) and all of them were male. The majority of the gallstone induced AP patients were female (n = 29). Twenty-nine patients developed severe acute pancreatitis (SAP: 16 in biliary and 13 patients in non-biliary group). Complications were mostly seen in SAP. The acute fluid collection was the most common local complication (15 patients in biliary and 15 patients in non-biliary group, p > 0.05) and respiratory failure was the most common systemic complication (18 patients in biliary and 16 patients in non-biliary group, p > 0.05) in both groups. Three patients in biliary group and four patients in non-biliary group died due to multi-organ failure (p > 0.05). There was no statistical significant difference in the median duration of hospital stay in these groups. Conclusion: Though pathogenesis vary for different etiologies, once the disease process has started, local complications, systemic complications, duration of hospital stay and mortality in AP depends on the severity of the disease irrespective of the etiology.

Background: Bile duct injury is a serious complication following both open and laparoscopic cholecystectomy. The extent of injury may be severe enough to consider biliary reconstruction procedures like Roux-en-Y hepaticojejunostomy or even hepatectomy in rare instances for the definitive management.Case: A 56 year old female, who underwent open cholecystectomy and detected bile duct injury intraoperatively. Small feeding tube was placed in the bile duct, exteriorized and patient was referred to our center for further management. Liver function tests at presentation revealed cholestatic patterns of liver derangement but the patient did not show any signs suggestive of sepsis. Endoscopic Retrograde Cholangiopancreatography revealed complete stricture of common hepatic duct. Magnetic Resonance Cholangiopancreatography revealed Bismuth type 4 bile duct stricture. The plan was to perform a bilateral hepaticojejunostomy, however, because of the very difficult anatomy and failure to identify the right duct, right hepatectomy with left duct hepaticojejunostomy was performed as a definitive management for her type IV bile duct injury. The patient had an uneventful post-operative course.Conclusion: Infrequently, liver resection remains an important therapeutic option in cases of complicated and major forms of bile duct injuries where the bilateral biliary reconstruction is not feasible.