Rationale for routine preoperative liver function tests before elective cholecystectomy

Preoperative work-up before elective cholecystectomy often undergoes a range of routine investigations that includes liver function tests (LFTs). There is fear of concomitant common bile duct stones (CBDs) in patients with negative ultrasonography (USG) findings, i.e. with no dilatation of bile ducts or presence of stones in it or clinical features of hepatitis or jaundice. Studies show that clinical practice of preoperative workup of routine liver function tests for every elective cholecystectomy patient is questionable, possibly because of peer pressure or defensive medicine practices or simply a ‘copy-paste’ from the practices of seniors.1,2 Preoperative blanket tests on the pretext of ‘finding any abnormalities’ has poor scientific merits. The preoperative LFTs for uncomplicated, elective cholecystectomy patients rarely add value and do not alter the already planned decision based on symptomatology, history, physical examination, and ultrasound diagnosis of cholelithiasis. The clinical pathway for the management in most cases remains unchanged. The practice of menu-style routine tests adds to the cost and rarely adds further useful information sufficient enough to alter the planned clinical pathway.

Nepal\u27s response to contain COVID-19 Infection

Nepal is a landlocked country bordering two most populous countries, India and China. Nepal shares open border with India from three sides, east, south and west. And, in north with China, where the novel coronavirus infection (CVOVID-19) began in late December 2019. The first confirmed imported case in Nepal was reported in 2nd week of January 2020. The initial response of Nepal to COVID-19 were comparably slow but country geared efforts after it was declared a \u27global pandemic\u27 by WHO on 11 March, 2020. Government of Nepal\u27s steps from 18 March, 2020 led to partial lock down and countrywide lockdown imposed on 24 March, 2020. Government devised comprehensive plan on 27 March, 2020 for quarantine for peoples who arrived in Nepal from COVID-19 affected countries. This article covers summary of global status, South Asian Association of Regional Cooperation (SAARC) status, and Nepal\u27s response to contain COVID-19 infection discussed under three headings: Steps taken before and after WHO declared COVID-19 a global pandemic and lab services regarding detection of COVID-19. Nepal has documented five confirmed cases of COVID-19 till the end of March 2020, first in second week of 15 January, 2020 and 2nd case 8-weeks thereafter and 3rd case two days later, 4th on 27 March and 5th on 28 March. Four more cases detected during first week of April. Non-Pharmacological interventions like social distancing and excellent personal habits are widely practiced. Country has to enhance testing and strengthen tracing, isolation and quarantine mechanism and care of COVID-19 patients as Nepal is in risk zone because of comparably weak health system and porous borders with India. The time will tell regarding further outbreak and how it will be tackled. Keywords: COVID-19; lockdown; Nepal; pandemic; response

Use of mask in COVID-19 era: absence of evidence is not evidence of absence

World Health Organization (WHO) in its interim guidance of 6 April 2020 advises policy makers on the use of masks for healthy people in community settings. The rationale for mask use by healthy person is prevention from COVID-19, when there is risk of exposure, like working in close contact with public, people with comorbidities, where physical distancing cannot be maintained such as travelling in buses, staying in slum areas. Furthermore, WHO says the purpose and reason for mask use should be clear– whether it is to be used for source control (used by infected persons) or prevention of COVID-19 (used by healthy persons).1 Centers for Disease Control (CDC) United States of America (USA) updated its advisory on 4 Apr 2020, and recommended everyone (except some) should wear at least a cloth face covering when they have to go out in public. It will protect other people in case you are infected.2,3 This advisory of no strict demand on use of face masks could be possibly due to unavailability of disposable masks. Previous studies reveal that cloth masks were least effective in preventing flu like illness in healthcare staff.3-5 Studies are not in favor of wearing cloth mask arguing limited evidence of its effectiveness, improper and inconsistent use, and false sense of safety among public that may disregard other essential public health interventions, like hand washing and social distancing.4 &nbsp

Routine use of antibiotic prophylaxis in low-risk laparoscopic cholecystectomy is unnecessary: A randomized clinical trial

SummaryBackgroundLaparoscopic cholecystectomy uses smaller incision and trocars that lessen the contamination and exposure of wound, resulting in less infection. However, the antibiotic prophylaxis is still widely practiced, like in our institute, a continuation of the era of open surgery. Recent studies reveal no advantage of routine use of antibiotic, and there is growing consensus against it. Besides cost, antibiotic increases emergence of multidrug resistance. Because of the controversies, we conducted this clinical trial.MethodsThis randomized clinical trial, conducted from October 1, 2009 to September 31, 2010 at Patan Hospital, included 154 patients in prophylactic antibiotic group (GrAP) with cefazolin 1 g IV as per existing practice and 156 in no antibiotic group (GrAPn). Symptomatic laparoscopic cholecystectomy patients of American Society of Anesthesiologist (ASA) 1 and 2 (without diabetes) were included. Patients with complicated gall stones (cholangitis, choledocholithiasis, and pancreatitis) and who required conversion were excluded. Wound was observed during follow-up within 1 week. Data on patient characteristics, use of antibiotic, bile spillage, and postoperative wound infection were entered in predesigned proforma. Microsoft Excel was used to analyze the data.ResultsIn total, 310 patients were eligible for analysis, 154 in GrAP and 156 in GrAPn. Both groups were comparable in patient demographic and clinical characteristics such as average age (40.3 vs. 41.6 years) and sex (female 77.6% vs. 78.6%). Overall wound infection occurred in 4.8% (15/310). There was no significant difference in wound infections among the two groups (p = 0.442): GrAP 3.9% and GrAPn 5.8%. There was no mortality in this series.ConclusionRoutine preoperative antibiotic prophylaxis is not necessary in low-risk symptomatic gallstone patients undergoing laparoscopic cholecystectomy

Revisit the hospital policy in the era of COVID-19

Key-points Patient with recent history of dry cough, fever and breathlessness (influenza-like or severe acute respiratory illness) without alternative explanation/diagnosis needs to be managed as COVID-19 unless proved otherwise. Suspected COVID-19 patient having fever and recent loss of taste and smell be tested for COVID-19. Patient with severe acute respiratory illness of unknown aetiology be tested for COVID-19. Patient with bilateral consolidation on chest X-ray or ground glass appearance on chest CT or interstitial oedema on chest ultrasound (not fully explained by volume overload) be tested for COVID-19 in moderate to high risk communities/countries. Suspected COVID-19 patients with lymphopenia, high ESR or rise in C-reactive protein and suspected of viral fevers be tested for COVID-19. Screening of pregnant women for COVID-19 with rapid testing preferably with Elisa in moderate to high risk communities/countries. Screening with rapid testing preferably with Elisa prior to invasive interventions, including operations, in moderate to high risk communities/countries. Limit the exposure of hospital staff who are susceptible to develop severe complications of COVID-19. Hospitals provide PPE to staff depending upon exposure as per international/national/local guidelines. Hospitals implement infection prevention control measures meticulously in context of COVID-19

Clinical profile and surgical outcome of abdominal hydatid cyst at a university hospital in Nepal

Introductions: Hydatid cyst is caused by the tapeworm. It is common in sheep and cattle rearing communities. Liver is the most common affected organ. There are various methods of surgical approaches for hydatid cyst. Methods: This was a retrospective descriptive study of patients operated for intra-abdominal hydatid cysts from July 2012 to June 2018 at Patan Hospital, Patan Academy of Health Sciences, Nepal. Ethical approval from institutional review committee was obtained. Patient files with incomplete data were excluded. Variables analyzed were, age, gender, site and numbers of cyst, methods of surgery, complications and mortality. Data were descriptively analyzed. Results: There were 19 patients of abdominal hydatid cysts who underwent surgery during the study period. Five records files could not be accessed and were excluded. In remaining 14, male were 6 (42.85%), female 8 (57.15%), mean age 39.57±17.35 years (14-70), cyst size 11±4.22 cm (5-21), complain of abdominal pain in 10 (71%). Open surgery for liver cyst was done in 11 and laparoscopic in one, and open splenectomy for two splenic cysts. One patient developed superficial wound infection. Four had cystobiliary communication of which one underwent ERCP. Post ERCP patient developed acute severe pancreatitis and expired. Mean hospital was 8.57±2.24 days (6-14). Conclusions: Liver was the main organ involved, abdominal pain and lump were main presenting complaints. Surgery had successful outcome. Open surgery was the mainstay of treatment. Keywords: echinococcus granulosus, hydatid cyst, hydatidosi

Self-prescribed nutrition supplements for hair loss following laparoscopic sleeve gastrectomy bariatric surgery: extent of the problem in a cohort of Chinese patients

Introductions: Hair loss is common after bariatric surgery. This study analyzes the extent and risk factors of hair loss following laparoscopic sleeve gastrectomy (LSG), and satisfaction of self-prescribed supplements. Methods: All patients of LSG bariatric surgery during June 2013 to August 2016 at Shanghai East Hospital affiliated to Tongji University, Shanghai, China were included in the study. Study variables were- age, gender, preoperative body mass index, hemoglobin, albumin, total cholesterol, iron, zinc, copper, folic acid, vitamin B12, vitamin D, and postoperative excess weight loss (% EWL), time and degree of hair loss, satisfaction of using supplements. Logistic regression was used to analyze risk factors for hair loss. Results: Total of 86 patients underwent LSG. After exclusion data on 54 patients (M=11, F=43) were analyzed. Hair loss was reported by 42/54 (77.8%, M=6, F=36), starting at 3.43±1.36 months and ending at 8.59±3.38. All of 11 severe hair losses were in female. The female gender, preoperative serum folic acid, and %EWL were significant risk factors for hair loss. Hair regrowth was reported by 39/42 (92.86%). The 15 patients who used various self-prescribed iron and zinc supplements reported no satisfactory benefit.  Conclusions: Hair loss was seen in 3/4th of patents after LSG bariatric surgery. Self-prescribed nutrition supplements were used by 1/3 of patients without satisfaction. Female gender, preoperative serum folic acid, and %EWL were significant risk factors for hair loss. Keywords: bariatric surgery, hair loss, laparoscopic sleeve gastrectomy LSG, obesity, nutrition supplement

Necrotizing enterocolitis: clinical characteristics and outcome of a cohort of 106 cases at a children’s hospital in North China

Introduction: Necrotizing enterocolitis (NEC) in neonates, especially in the preterm, is a life-threatening condition. This study aims to analyze the clinical profile of NEC to get an insight for better understanding and management.  Method: This was a retrospective analysis of neonatal NEC during the six-year period from 2014 to 2019. The prevalence and time for the development of NEC, clinical profile (term and preterm, low birth weight, gender, breast and formula feeding, abdominal distension, vomiting, hematochezia, apnea, fever, altered mental status, blood transfusion, breast or formula-fed, intestinal perforation, Bell’s stage and time for the development of NEC) and maternal factors (gestational hypertension, diabetes, premature rupture of membranes PROM, intrauterine fetal distress, placenta previa) were analyzed. Features in preterm and term neonates were compared. Ethical approval was obtained.  Result: There were 106 NEC (0.87% of 12,184 neonatal admissions), 62 (58.49%) male, 90 (84.91%) preterm, and 85 (80.19%) LBW. Overall, 88 (83.02%) were Bell’s stage II, and severe stage III was seen in eight (19.04%) out of 42 babies with formula feeding as compared to one (1.56%) out of 64 in breastfeeding. The median time for the development of NEC was 6 days of life. The yearly prevalence of NEC per thousand neonates admitted during 6-years increased from 2.90 in 2014 to 12.06 in 2019. Overall mortality was 14 (13.20%).  Conclusion: The yearly incidence of NEC increased with a higher incidence in preterm, in low birth weight and formula-fed neonates

Outcome of gastrointestinal surgery during COVID-19 lockdown in a tertiary care hospital, Nepal

Introduction: Perioperative strategies have been changing due to the COVID-19 pandemic to prevent the risk of postoperative complications and transmission of infection. This study was aimed to assess the outcome of gastrointestinal surgery and the risk of transmission by implementing COVID-19 testing criteria and surgical strategy. Method: This was a retrospective descriptive study conducted at the department of surgery at Patan Hospital, Nepal, during COVID-19 lock-down from 24 march to 15 June 2020. All patients who underwent gastrointestinal (GI) surgery were included. High-risk patients (as defined by the Hospital Incident Command System, HICS) were tested for COVID-19 preoperatively. Surgery was performed in COVID operating room with full protective gear. Low-risk patients were not tested for COVID-19 preoperatively and performed surgery in non-COVID OR. Data from patient’s case-sheets were analyzed descriptively for age, gender, comorbidities, hospital stay, RT-PCR results, surgeries, and postoperative complications. Result: There were total 44 GI surgeries performed; 31(70.5%) were emergency, 5(11.3%) semi-emergency and 8(18.2%) oncology. There were 11(25%) patients tested for COVID-19 preoperatively and were negative. Nine HCWs tested for COVID-19 randomly were negative. Severe postoperative complications developed in 3 patients, with one mortality. Conclusion: Among GI surgeries, there was no increase in postoperative complications and transmission of COVID-19 to the patients or HCWs following the implementation of standard testing criteria and surgical strategy