Background: Peripheral artery disease is an important vascular disease. There is an increased incidence of acute limb ischemia in cases of peripheral artery disease. Objective of this study was to assess the prevalence of peripheral artery disease among high-risk patients attending out patient department in Shahid Gangalal National Heart Center, Janakpurdham. Methods: A total of 386 high risk patients for Peripheral Artery Disease were included in the study. Informed consent was taken from patients undergoing the study. Patients underwent ankle brachial index calculation to make a diagnosis of peripheral artery disease. Patients having ankle brachial index of <= 0.9 was considered to have peripheral artery disease. Patients diagnosed with peripheral artery disease further underwent doppler study. Results: The study showed the prevalence of peripheral artery disease to be 17.4% among high-risk patients attending Shahid Gangalal National Heart Centre, Janakpurdham. The prevalence of peripheral artery disease was more in females as compared to male which was statistically significant. Most of the high-risk patients were patients with hypertension at Shahid Gangalal National Heart Centre. Conclusions: Peripheral artery disease prevalence is significant among high-risk patients attending Shahid Gangalal National Heart Centre, Janakpurdham. High risk patients should undergo evaluation of peripheral artery disease for early detection and treatment. Keywords: Ankle brachial index; chronic kidney disease; coronary artery disease; hypertension; peripheral artery disease.

Background Lung cancer is one of the leading cause of cancer related death. Most common histopathology of lung cancer is non-small cell carcinoma of which adenocarcinoma is the most common. There are limited number of studies done in Nepal to know different aspects of lung cancer. Objective To know demographic parameters of patients diagnosed as lung cancer in a university hospital. The study also aims to know the different histopathological diagnosis of lung cancer. Method All the patients presenting to outpatient department (Cardio Thoracic and Vascular unit) of Dhulikhel Hospital, if are diagnosed as cancer of lung/bronchus will be included in the study. The duration of the study was January 2017 to December 2021. The details on age, gender, presenting symptoms, histopathology of lung cancer, operability will be included in database and will be analyzed. Result There were total of 127 patients diagnosed as lung cancer. Male:female ratio was 1.7:1. Overall mean age was 63.23 years (SD 13.5 years, Range 19-89 years). Non small cell carcinoma was the most common type of lung cancer with 83.7%. In non small cell carcinoma, most common type was Squamous cell carcinoma followed by undifferentiated and Adenocarcinoma. Only five (3.93%) cases were in operable stage. Conclusion Despite the fact that lung cancer is one of the most common cancer, patients usually present late and moslty are not in operable stage. This study shows that squamous cell carcinoma is the most common histopathology in lung cancer cases.

INTRODUCTION:Peripheral vascular trauma can result in limb or life-threatening injuries. Early surgical intervention leads to a better outcome. Diagnosis is made clinically, by non-invasive and invasive imaging modalities. Our aim in this study is to find out the prevalence of peripheral vascular trauma among vascular surgery cases operated in a tertiary care centre of Nepal.METHODS:This is a descriptive cross-sectional study of peripheral vascular injuries that underwent operative management in a tertiary care hospital of Nepal from January 2018 to May 2020. Ethical approval was taken from the Institutional Review Committee of Kathmandu University School of Medical Sciences (Registration Number 79/20). Convenience sampling technique was used. Data for the study was retrieved from operation records of the patients along with their treatment summaries and entered and analyzed in the Statistical Package for Social Sciences version 20.0. All cases with complete records were included. Conservatively managed cases and cases that underwent primary amputation were not included in the study. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.RESULTS:Among 624 vascular surgery patients, 40 (6.41%) (4.48-8.33 at 95% Confidence Interval) patients had presented with peripheral vascular trauma during the study period. There were 26 (65%) cases where the upper limb was involved.CONCLUSIONS:The prevalence of vascular surgery for peripheral vascular trauma among vascular surgeries operated in our study was similar to other studies done in similar settings. Vascular injury needs urgent intervention and appropriate management will result in a high chance of limb salvage and survival.

Introduction: A systematic approach to analysis of the fluid in conjunction with the clinical presentation allows clinicians to diagnose the cause of an effusion, narrow the differential diagnoses, and design a management plan. However, the number of cases where pleural fluid examination gives no proper diagnosis is depressingly high. This study aims to find out the prevalence of negative pleural fluid cultures among patients with pleural effusion in a tertiary care hospital. Methods: This was a descriptive cross-sectional conducted among 273 patients with pleural effusion admitted to a tertiary care hospital between January, 2019 and February, 2020. Ethical clearance was taken from the Institutional Review Committee (Reference number: 134/20). Convenience sampling was done. All patients whose pleural fluid was sent for analysis during the study period were included in the study. Pleural fluid analysis was done, and data were analysed using Statistical Package for the Social Sciences 25.0. Point estimate was done at a 95% Confidence Interval along with frequency and percentages for binary data. Results: Among 273 pleural fluid cultures from patients with pleural effusion, negative pleural fluid cultures were seen in 269 (98.53%) (97.12-99.96 at a 95% Confidence Interval). Conclusions: Our study reported that the prevalence of negative pleural fluid cultures was higher when compared to similar studies conducted in similar settings. The routine pleural fluid analysis could add a very little to the diagnosis and management of pleural effusion.

Radiofrequency ablation (RFA) is one of the recent yet adequately studied minimal invasive surgery for varicose veins. The aim of this manuscript is to share our technique of RFA for varicose veins. The technique has been revised over time and has been standardized over all the surgeons doing this procedure in our institute. We have been using few of the terms to define specific scenario in relation to the procedure.

Introduction: Peripheral arterial disease is a condition due to partial or complete occlusion of arteries excluding that of heart and brain. Lower extremity arterial disease is specific to lower limbs. Some of the patients are asymptomatic while a majority present with claudication, rest pain, ulceration or even gangrene. Methods: We took all admitted cases of lower extremity arterial disease from January, 2015 to December 2018. ABI was used as the first clinical tool for the diagnosis of PAD in patients with history or physical examination findings suggestive of PAD as per AHA guidelines. Outpatient arterial Doppler ultrasonography complemented by lower limb CT angiogram was used as a confirmatory tool for the diagnosis and also to assess anatomical location and severity of stenosis. Results: Total of 54 cases of lower extremity arterial diseases were identified with a mean age of 59.2 years (S.D. 11.4). Right lower limb was involved in 35(50%). Mean age was 58 years(SD 13.1). Mean duration of symptom was 3.4 years (SD 3.3). Claudication was present in all the patients. 32(45.7%) had ulcers. Toe(44.3%) was most commonly involved. Decreased local temperature(91.4%) and color change(87.1%) were major symptoms. 35(50%) of the patients had gangrene. Mean peak systolic velocity was lowest in the peroneal artery. 16.6% patients got additional peripheral bypass surgery. Conclusion: Claudication, decreased local temperature and color change were very common findings of lower extremity arterial disease. Gangrene was present in half of the patients.

End Stage Renal Disease is a last stage of Chronic Kidney Disease which is characterized by Glomerular Filtration rate of less than 15 ml/min/1.73 m2 . Hemodialysis is the most commonly used modality for treatment of Chronic Kidney disease. Among the access for hemodialysis arteriovenous fistula is the most common modality. However most common problems of fistula are significant stenosis of more than 50% which is characterized by limb swelling, pigmentation, tortuous veins, and difficulty maintaining flow during dialysis from AV fistula. These can be managed either by minimal intervention or with surgical intervention. Very few hospitals in Nepal and other countries have an angiographic suite to perform minimal intervention include angiogram with angioplasty. So in this case we try to address the use of C-Arm to perform angiogram or fistulogram and even angioplasty for the management of significant stenosis or complications of arteriovenous fistula.

Background: Varicose vein is prominent dilated veins of lower limbs. Incomplete treatment and local recurrence are still the clinical challenge among the vascular surgeons. We aim to evaluate the range of imaging on color duplex describing the anatomy of veins, their variants, valve competencies, territories of defective venous system, demographic data, and the factors contributing among the patients referred to Vascular Outpatient Department of Kathmandu University Hospital. Objective: The aim was to know the ultrasound (US) color duplex parameters of superficial venous system in varicose vein. Materials and Methods: We included 299 patients during the study of 6 months with varicose veins for detailed US Doppler analysis. Gray-scale US was done to study the anatomy of veins followed by color duplex and color duplex spectrometry to determine the reflux of the superficial venous system. Quantification of reflux was determined by the use of Valsalva maneuver. Association of great saphenous vein (GSV) cross-sectional diameter and saphenofemoral junction incompetence was also studied. Results: Of 299 varicose vein cases, 52.50% were female. Among involved cases, the mean of GSV diameter was 5.43 mm in the right and 5.68 mm in the left. Saphenofemoral junction diameter was 7.89 mm in the right and 8.17 mm in the left. Receiver operative characteristics curve showed GSV diameter at femoral condyl of 4.5 mm as best cutoff value for the diagnosis saphenofemoral junction reflux. Conclusions: US color duplex is investigation of choice for varicose vein as a preoperative analysis tool, quantifying the superficial valve incompetency, studying and mapping the venous anatomy, and planning the surgery.

True aneurysm is dilatation of an artery which consists of all layers of the arterial wall. True radial artery aneurysms are very rare. The most common cause of radial artery aneurysm is iatrogenic trauma. Here, we report a case of iatrogenic true radial artery aneurysm. A 38-year-old male with a history of right radial artery cannulation for anticoagulant therapy to treat right leg deep venous thrombosis presented to our outpatient department with a complaint of swelling on the radial side of the volar aspect of the right arm. He was treated conservatively with steroids, but symptoms did not subside. Doppler ultrasound and computed tomography scan suggested true radial artery aneurysm. In view of pseudoaneurysm, surgical plan was made. During surgery, the aneurysm seemed to be involved in all the vessel layers. The aneurysm was excised, and ligation of both the ends was done. Anastomosis was not done owing to good flow in the distal part from the ulnar artery and damage to a long segment of the radial artery. Patients on anticoagulants are at a risk of aneurysm formation than patients who are not. It can be diagnosed clinically and radiologically.

INTRODUCTION:Diaphragmatic eventration can be congenital or acquired. Diagnosis is delayed due to no symptoms or very mild ones and is generally done by imaging modalities. This condition is managed by plication of the affected part of diaphragm by various surgical approaches.PRESENTATION OF CASE:A forty seven years lady presented with one year long history of abdominal pain, bloating and fullness after meals who was being treated in line of peptic acid disorder. She had developed bilateral foot drop after typhoid fever at seventeen years of age. Clinical examination and imaging with chest x-ray, chest ultrasound and computed tomography scan suggested eventration of left hemidiaphragm. Plication of eventration of left hemidiaphragm was done via mini thoracotomy of the left thorax. There were no postoperative complications and she was discharged on the sixth postoperative day.DISCUSSION:Acquired eventration of diaphragm is commonly due to traumatic phrenic nerve palsy but rarely can be associated with a history of infection causing nerve palsies. Thoracic ultrasound is an emerging modality for diagnosis supporting X-rays and CT Scans. Plication of eventration with minimally invasive techniques has less number of hospital stay and less pain compared to open approaches.CONCLUSION:Non-traumatic diaphragmatic eventration due to acquired phrenic nerve palsy following an unknown febrile illness is a rare case to be reported in Nepal. The aim of treatment is expansion of intra-thoracic space which is done by plication of the diaphragm.

Background: Venous pigmentation and ulceration in varicose veins pose significant financial and psychological burdens and affect quality of life. Not all varicose veins progress to this stage (C4-C6 in CEAP classification), and knowing the predictors for progressing to pigmentation/ulceration in varicose veins helps address high-risk patients early on. Materials and methods: This is a retrospective observational study done in patients diagnosed with varicose veins in the great saphenous system and subjected to radiofrequency ablation with or without any adjunct procedure during the time frame of January 1, 2018 to December 31, 2019. Using standardized questionnaires, physicians interviewing participants at the time of examination noted risk factors for pigmentation/ulceration in the form of age, gender, duration of illness, and symptoms. Results: Among 247 limbs with varicose veins that involved the great saphenous vein and were subjected for radiofrequency ablation, C3 stage was observed in the highest percentage of cases (44.5%) followed by C2 stage (27.9%). Pigmentation or ulceration were observed in 27.5% of cases. Duration of illness (longer duration), male gender, and age (higher age) were identified as predictors of pigmentation or ulceration. Conclusion: Large-scale studies to identify cutoff values for duration of illness and age would help clinicians in making treatment decisions.

Introduction: In late December 2019, COVID-19 was first seen in Wuhan, China which has been spreading to the whole world in subsequent months. Till the time this manuscript is written, COVID-19 has infected more than 2million people and killed more than 129843 people all around the world. First step in fighting against COVID-19 is to have appropriate knowledge and correct attitude and practices. Methods: This study was done to know the knowledge, attitude and practices on COVID-19 amongst medical students of Kathmandu University School of Medical Sciences (KUSMS) using internet based structured questionnaires. The survey was conducted from April 2, 2020 to April 09, 2020 (one-week after lock down following COVID-19 spread in Nepal). Structured questionnaire was used by the Medical students of Kathmandu University Hospital. There were 19 questionnaires regarding Knowledge, three regarding Attitude and five regarding Practices. Results: Out of 631 responders, the mean correct Knowledge score was 83.4%. Of the 19 Knowledge questionnaires, the mean score was 15.8 (Range 0-19). Regarding the Attitude questionnaire, 81.7% responders had a positive attitude toward COVID-19 being controlled globally in near future. Majority of the responders wore masks when going out in recent days (96%) and 97.6% of responders didn’t go to crowded places during this period. Conclusion: Medical Students have good knowledge, optimistic attitude and appropriate preventive practices towards COVID-19. Better knowledge is associated with online or onsite training obtained about COVID-19 outbreaks. Optimistic Attitude and appropriate preventive practices was associated with better knowledge of the responders.

INTRODUCTION:Arteriovenous fistulas are a preferred choice for hemodialysis access in chronic kidney disease patients. There is increased adoption of arteriovenous fistula creation in Nepal. Our objective is to study various arteriovenous fistulas that have been created in our center.METHODS:This is a descriptive cross-sectional study conducted in a tertiary care hospital including all cases of arteriovenous fistula creation from January 2018 to December 2019. We obtained the ethical clearance from the institutional review committee of Kathmandu University School of Medical sciences. Convenient sampling method was used. Detailed vascular mapping and color doppler ultrasonography was done in the bilateral upper limb as preoperative preparation and to choose a site for arteriovenous fistula creation. Data were entered into the Statistical Package for the Social Sciences version 20 for analysis.RESULTS:Among 50 patients, the most common location was brachiobasilic 20 (40%) patients followed by brachiocephalic 18 (36%), radiocephalic 11 (22%), and arteriovenous graft between the brachial artery and axillary vein 1 (2%). The mean duration of hospital stay was 1.44 days. Three (6%) patients required re-intervention, all within 24 hours. Two (4%) patients had a failure of arteriovenous fistula requiring the creation of a new arteriovenous fistula.CONCLUSIONS:Brachiobasilic was the most common location for arteriovenous fistula creation. Reintervention was not common.

Introduction: The association of bacteriology in the pathogenesis of urolithiasis is a known and fact. The urinary tract stones being the most common problem that brings the patient to the surgical outpatient department; it is important to know the relation between the types of stone and the organism isolated from the urine for better management of the patient. The aim of this study was to find out the urine bacteriological profile of patients with kidney stones. Methods: This is a descriptive cross-sectional study done over 18 months in a tertiary care hospital in Nepal. Ethical clearance was taken from the Institutional Review Committee (No: 03/16). Preoperative urine cultures were done routinely in all the patients who agreed to take participate in the study. The biochemical stone analysis was done. Urinary microbial floras and stone composition were noted. Data entry and analysis was done using Statistical Package for the Social Sciences version 25.0. Results: Among 107 patients, kidney stones were more common in males and most of the patients were in their 2nd to 4th decade. Female patients 45 (42.05%) had more predilections towards the urinary tract infection. Among 15 (14.01%) positive cultures, Escherichia coli 10 (67%) was the most common organism isolated followed by Klebsiella; 4 (27%), and Pseudomonas; 1 (6%). Conclusions: Thus, we would like to state that Escherichia coli, though being a non-urease producing organism, is a major organism isolated in the preoperative culture of urine in a patient with kidney stones.

Trauma is an uncommon cause of common femoral artery aneurysm (CFAA). We present a 31-year-old male with a history of intravenous drug abuse with an incidental finding of the right leg CFA aneurysm during ultrasonography Doppler for deep vein thrombosis. The aneurysm was surgically excised and repaired with polytetrafluoroethylene graft as good peripheral veins were not available due to the history of repeated puncture. Peroperative finding was a right-sided CFA aneurysm measuring about 3 cm × 1 cm with the distal end 1 cm below profunda femoris. In cases of growing CFAA, surgical excision and anastomosis between proximal and distal segments using a conduit are the treatment modality.

BACKGROUND The study compared the peak reflux velocity and reflux time in cases of varicose veins and non-varicose veins with a focus on quantifying the reflux parameters. METHODS This is a hospital based observational comparative study. The limbs with CEAP Clinical classification of C2 or more were taken as diseased limbs and contra-lateral limbs with no symptoms or disease were taken as control limbs. RESULTS Altogether 792 limbs (452 diseased limbs and 340 control limbs) were evaluated with color duplex. Mean Great Saphenous Vein diameter was 5.68 ± 2.07 mm and 4.00 ± 1.34mmin diseased limbs and control limbs respectively (p=0.0001). Mean sapheno-femoral junction diameter was 8.23 ± 2.64 mm and 6.16 ± 1.93 mm in diseased limbs and control limbs respectively (p=0.0001). Mean peak reflux velocity in diseased limbs was significantly higher than control limbs (77.38 cm/sec vs 7.95 cm/sec; p=0.0001).  Similarly mean reflux time was significantly longer in diseased limbs than non-diseased limb (406.58ms and 67.28 ms respectively; p=0.0001). An optimal cut-off point of 27.4 cm/s for peak reflux velocity and 250 ms for the reflux time at Sapheno-Femoral junction had a discriminatory power between the two groups. CONCLUSION The quantification of peak reflux velocity seems to be more consistent than reflux time in determining the superficial venous reflux. An optimal peak reflux velocity cut off point of 27.4 cm/sec has the discriminatory power between diseased and non-diseased limb.

Introduction: Varicose vein is a common venous condition affecting quality of life presenting as an asymptomatic condition to a feeling of heaviness, pain, pigmentation, palpable superficial veins, itchiness and ulceration. Proper management of varicose vein is of huge importance due to its high prevalence and the impact it has on patients' quality of life, productivity as well as on health-care resource burden. Various conservative and invasive interventions are available for the management of varicose veins. Here we present our experience with the invasive intervention of varicose veins during a period of six years at a tertiary care center (Dhulikhel Hospital) in Nepal. Although Radio Frequency Ablation (RFA) is recently introduced in Nepal, it has shown promising outcome. Method: This is a retrospective descriptive cross-sectional study between the years 2013 and 2018 at the Dhulikhel Hospital among patients that underwent surgical management of varicose veins. For ease in interpretation, patients who underwent surgery for both lower limbs in the same setting are considered as separate cases. Results: In a total of 533 limbs, the most common vein involved was isolated great saphenous vein in 70.4%. In terms of side affected, 157 patients (33.8%) were affected on the right side, 238 (51.3%) were affected on the left side and 69 (14.9%) patients had bilateral involvement. The most common clinical feature was prominent vein present in 94.5% limbs. This was followed by pain in 55.7%, pigmentation in 25.3%, itchiness in 14.6% and ulceration in 13.1%. Mean hospital stay was 1.1 days (S.D. 0.64, Range 0-3). In terms of complication, one case with deep vein thrombosis (0.18%) developed in the seventh postoperative period. There was skin burn in two cases (0.53% of RFA cases) and in 11 cases (2.06%) there was painful superficial thrombosed veins of which three required excision under local anesthesia (0.56%). Conclusion: There are multiple invasive interventions for varicose veins. With the availability of the facilities, RFA is the procedure of choice in feasible cases. The most common complication after surgical treatment was painful thrombosed superficial veins. DVT was a rare complication.

Background. Varicose veins are dilated, tortuous, superficial veins usually seen on lower limbs. Various surgical modalities are available for varicose veins including open surgery (Trendelenburg operation), Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA) and Sclerotherapy. The aim of this study is to look for the outcome of adjunct sclerotherapy for varicose veins done as an adjunct with Radio Frequency Ablation. Objective. To know the possible outcome regarding benefits and complications of adjunct sclerotherapy with Radio Frequency Ablation. Methodology. We combined Radio Frequency Ablation of varicose veins with necessary phlebectomy and perforator ligation and performed adjunct sclerotherapy for residual significant varicosities with polidocanol (2%) mixed with 2 ml NS and 2 cc of air (Tessari method) to patients undergoing varicose vein surgery in between 2016 and 2017. Records on complications were enquired immediately following surgery and on 1 st follow up done within 3–5 days of the procedure. Results. Among 256 limbs subjected to varicose veins surgery 51 limbs were given adjunct sclerotherapy. Among them, five limbs had perivenous spillage with some localized swelling while there was allergic reaction in one patient as immediate postprocedural complication. Nine limbs had painful thrombosed veins during early follow-up. Conclusions. Adjunct sclerotherapy showed complication rate of roughly one tenth and one fifth of the treated cases in immediate and early postoperative follow-up.

The direct inguinal hernia has a wider neck and thus usually doesn’t present as strangulation or incarceration in comparison to the indirect component. When direct inguinal hernias are untreated for a longer duration, they may get strangulated and incarcerated. Hence such long-standing direct hernias with features of intestinal obstruction and /or peritonism should be promptly seen and diagnosed to prevent massive and unwanted intestinal resection. We are reporting a case of 83-year-old male presented to Surgical Emergency Department of Dhulikhel Hospital, Kathmandu University hospital with complaints of swelling in the right inguinoscrotal region for 12 years and progressed to become irreducible and painful for 12 hours. Clinically he had an acute intestinal obstruction. Intra-operatively we found a direct hernia containing congested small bowel loops and toxic fluids. The toxic fluid was suctioned and after confirming viability, modified Bassini’s repair was done with reinforcement of the posterior wall. Even direct inguinal hernia of longer duration can cause acute or sub-acute intestinal obstruction with or without features of peritonism. This complication is more common in elderly patients.