Introduction: and importance: Kidney transplantation is one of the best treatment options for patients with end -stage renal disease. More than 90% of patients awaiting renal transplantation die without getting the kidney for transplantation. Brain dead donor kidney transplantation can bridge this gap proficiently. We aim to report details of the first six patients who had undergone brain-dead donor kidney transplantation in the history of transplantation in Nepal.Case presentation: We conducted a descriptive analysis of clinical data of six adult recipients with kidney transplantation from three brain-dead donors. We described postoperative complications, length of stay, graft function which was documented with serum creatinine, acute rejection episode, delayed graft function, and patient/graft survival of recipient. Recipients were between 15 and 56 years old. Three patients experienced delayed graft function. Urinary tract infection was observed in two patients, both of whom were treated with antibiotics. One patient had acute graft rejection. None of our patients required reoperation. Length of hospital stay ranged from 9 to 32 days. The postoperative graft function was 100% in all patients. There was no graft loss, and no death was observed during follow-up.Clinical discussion: Following the initiation of the brain-dead donor transplantation program, a lot of work needs to be done to make it a regular practice. Thus, this program needs support from all sections of society and government. This can be the only solution to decrease the huge gap between the supply and demand of organs in Nepal.Conclusion: This case reports indeed revealed impressive success in initiating a brain-dead donor kidney trans-plantation program in a developing country that in terms of quality, meets comprehensive standard with acceptable graft function and patient/graft survival in under limited resources healthcare setting.

OBJECTIVES: We sought to evaluate the impact of different national clinical guidelines (with consistent and conflicting recommendations) on clinician's practice in the UK. METHODS: In this cohort study, we analysed data from National Lung Cancer Audit comprising all patients diagnosed with lung cancer between 2008 and 2013 within England and Wales for consistent (British Thoracic Society and National Institute of Clinical Excellence) recommendations for lower/more permissive lung function but opposing stage (N2) selection parameters for surgery. RESULTS: From 2008 to 2013, data from 167 192 patients with primary lung cancers were included. The proportion of patients undergoing surgery for lung cancer increased from 9.5% to 20.5% in 2013 (P < 0.001) as the number of general thoracic surgeons in the UK increased from 40 to 81 in the corresponding timeframe. Mean forced expiratory volume in 1 s of surgical patients increased from 76% (22) to 81% (22) in 2013 (P < 0.001). Of the patients undergoing surgery, the proportion of patients with N2 disease across the 6-year interval was broadly consistent between 8% and 11% without any evidence of trend (P = 0.125). CONCLUSIONS: Within 3 years of new clinical guideline recommendations, we did not observe any overall change suggesting greater selection for surgery on lower levels of lung function. When presented with conflicting recommendation, no observable change in selection was noted on surgery for N2 disease. The observed increase in surgical resection rates is more likely due to greater access to surgery (by increasing number of surgeons) rather than any impact of guideline recommendations.

Background:The incidence of chronic liver disease is increasing in the Nepalese population. Liver transplantation (LT) is the best option for patients with end-stage liver disease (ESLD). Nepal's first liver transplant was performed in 2016 in an international collaborative effort at Shahid Dharmabhakta National Transplant Centre (SDNTC), Bhaktapur, Nepal. We aim to report details of the first five patients who had undergone liver transplantation in SDNTC before the beginning of the COVID-19 outbreak in the history of transplantation in Nepal. Method:A descriptive analysis of the clinical data of five adult recipients of liver transplantation at SDNTC was done. We described the patient's demographics, length of stay, and survival of all the first five patients who had undergone four living donor liver transplantations and one brain-dead donor liver transplantation in SDNTC before the beginning of the COVID-19 outbreak. Results:Recipients were between 36 and 63 years old. The recipients of the four live donor liver transplants (LDLT) and one brain-dead donor liver transplant (DDLT) had alcoholic liver disease and cryptogenic liver disease, leading to end-stage liver disease. The model for end-stage liver disease (MELD) scores ranged from 23 to 34. Out of five, four recipients and four donors are doing well and relishing the prospect of a normal life, while the recipient of a brain-dead donor liver transplant passed away due to postoperative primary graft failure. Conclusion:Despite the small number of liver transplants that have been done, the success of these has created confidence in a sustainable liver transplantation program in Nepal.

Surgery for pulmonary aspergillosis is infrequent and often challenging. Risk assessment is imprecise and new antifungals may ameliorate some surgical risks. We evaluated the medical and surgical management of these patients, including perioperative and postoperative antifungal therapy.

OBJECTIVE The purpose of this study was to establish the safety and feasibility of a recently adopted policy to type and screen (TS) (group and save) only for selected patients who had low likelihood of transfusion requirement. METHODS The TS only policy was applied to patients undergoing first-time elective lobectomy with Hb of >11 g/dl, aged <70 years, with no clotting abnormality and no history of neoadjuvant therapy. A retrospective analysis of prospectively collected data was made of 208 consecutive patients undergoing elective lobectomy from November 2009 to October 2010. The patients who were only type and screened (Group TS, n = 87) were compared with those who had preoperative cross matching (XM) (Group XM, n = 121). The perioperative characteristics, transfusion requirements and outcomes were compared between the two groups. RESULTS Preoperative characteristics of the two groups were similar, except that the XM group were significantly older, with lower mean preoperative haemoglobin levels. Postoperative complications (9 vs 13%, P = 0.24) and hospital mortality (0 vs 0.8%, P = 0.5) were similar between TS and XM, respectively. On the day of operation, 16 patients (13%) required transfusion in the XM group. Six patients in the TS group were cross matched, of whom only 3 (3.4%) actually required transfusion. The mean postoperative Hb levels in XM were also significantly lower (12.96 vs 10.88 gm/dl). In the XM group, 260 units of blood were unnecessarily cross matched and had to be returned to the blood bank compared with zero units in the TS group. There was no delay caused by unavailability of blood at the time of clinical need. CONCLUSION Our data suggest that it is safe and feasible to adopt a policy of type and screen only in selected patients undergoing elective lobectomy, who have low likelihood of transfusion requirement.

Ann Thorac Surg 2005;79:1776-1777 Mohan P. Devbhandari, Lucia Raco, Mark T. Hendrickse and Andrew J. Duncan Cautionary Tale Congenital Bronchoesophageal Fistula in a Patient With Crohn's Disease: Ahttp://ats.ctsnetjournals.org/cgi/content/full/79/5/1776 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Resuscitated donor hearts have been used to expand the donor pool in recent years. Concerns remain over the short and long term outcome of these organs due to the potential ischemic damage.

In an effort to improve the current lung cancer treatment outcomes in Britain, National guidelines were published followed by the introduction of National Lung Cancer Audit (LUCADA) project. LUCADA has defined active treatment as any therapeutic intervention with the aim of improving the quality or length of patients' survival irrespective of whether it is curative or palliative. From August 2003 to December 2006, all patients diagnosed to be new primary lung cancer referrals were enrolled into a prospective study. Out of the total of 433 patients the majority of patients were male (62%) and the mean age was 69 years. The histologies were small cell lung cancer (SCLC), non-small cell lung cancer (NSCLC) and other cancers in 67 (15.5%), 306 (70.7%) and 11 (2.5%) patients, respectively, while 49 (11.3%) patients had no histological confirmation. Overall, the active treatment rate was 72% with 74 (18%), 158 (36%), 66 (15%) and 11 (3%) undergoing surgery, chemotherapy, radiotherapy and other methods, respectively. The active treatment rates for histologically proven SCLC, NSCLC and all lung cancers excluding SCLC were 83%, 77% and 71%, respectively, compared to the LUCADA national average of 73.5%, 66% and 56.5%, respectively. Among the NSCLC patients overall five-year survival was 27.4%. The stage specific survivals were 64.0%, 58.3%, 24.1% and 11.5%, respectively, for stages I, II, III and IV. These reassuring results show that south Manchester has good active treatment rates for lung cancer with survival outcomes comparable to other major series.

a Abstract In an effort to improve the current lung cancer treatment outcomes in Britain, National guidelines were published followed by the introduction of National Lung Cancer Audit (LUCADA) project. LUCADA has defined active treatment as any therapeutic intervention with the aim of improving the quality or length of patients' survival irrespective of whether it is curative or palliative. From August 2003 to December 2006, all patients diagnosed to be new primary lung cancer referrals were enrolled into a prospective study. Out of the total of 433 patients the majority of patients were male (62%) and the mean age was 69 years. The histologies were small cell lung cancer (SCLC), non-small cell lung cancer (NSCLC) and other cancers in 67 (15.5%), 306 (70.7%) and 11 (2.5%) patients, respectively, while 49 (11.3%) patients had no histological confirmation. Overall, the active treatment rate was 72% with 74 (18%), 158 (36%) ,6 6(15%) and 11 (3%) undergoing surgery, chemotherapy, radiotherapy and other methods, respectively. The active treatment rates for histologically proven SCLC, NSCLC and all lung cancers excluding SCLC were 83%, 77% and 71%, respectively, compared to the LUCADA national average of 73.5%, 66% and 56.5%, respectively. Among the NSCLC patients overall five-year survival was 27.4%. The stage specific survivals were 64.0%, 58.3%, 24.1% and 11.5%, respectively, for stages I, II, III and IV. These reassuring results show that south Manchester has good active treatment rates for lung cancer with survival outcomes comparable to other major series. 2010 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

We report the case of a patient who underwent a redo surgery for a leaflet escape from a Bjork-Shiley tilting disc mitral prosthesis inserted 18 years previously. The escaped disc remained lodged in the thoracic aorta without any complication. She ultimately died of terminal heart failure 13 years after the second operation. We believe this to be the longest survival with a dislodged leaflet from a mechanical valve. Removal of dislodged disc is recommended in literature but there may be a place for watchful observation in exceptional cases with no haemodynamic compromise.

Objective: To ascertain the causes of delays in treatment to all patients presenting to our centre with a working diagnosis of lung cancer. All were entered prospectively into a 'tracking study'. Methods: Of 342 consecutive confirmed cases of newly diagnosed lung cancer presenting between September 2003 and December 2005, 193 were general practitioner referrals and 149 presented through casualty and internal referrals. The former group formed the basis of the study. Of GP referral patients, 92 had a positive diagnostic bronchoscopy (group Bronch+). Their waiting times were compared with 94 others with negative result (group Bronch-). For uniformity of comparison the non-GP referral patients were excluded from this study. Results: There were no significant differences in the age, clinical presentation or clinical staging of the two groups. Bronch+ had higher proportion of mate patients (p = 0.05). Bronch+ group had higher proportion of small cell and squamous cell carcinoma whereas Bronch- group had higher prevalence of adenocarcinoma (p = 0.02). More patients in Bronch- underwent curative (36 vs 18, p = 0.01) intent treatment. Though the median intervals (days) between the referral to first chest outpatient appointments were similar between the two groups (1 vs 1, p = 0.89), the intervals from out-patient to decision-to-treat (33 vs 57, p = 0.001) and decision-to-treat to treatment (8 vs 12, p = 0.05) were significantly longer for Bronch- group. Overall the median referral to treatment interval for Bronch- was significantly longer compared to Bronch+ (45 vs 75, p = 0.001). Most of these delays occurred in the intervals from outpatient appointments to decision-to-treat. Conclusions: A negative initial bronchoscopy in a suspected lung cancer patient implies a greater potential for excessive delays in diagnosis and treatment in spite of a greater chance of curative treatment. Most of the delay occurs in the interval from the outpatient appointment to decision-to-treat. Patients with negative bronchoscopy require a more concerted effort to achieve a timely diagnosis and treatment. (C) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

A 19-year-old primigravida, with a history of mechanical mitral prosthesis at the age of six years following previous repair of an atrioventricular septal defect, presented at 26 weeks' gestation with cardiogenic shock secondary to obstruction of the mitral prosthesis. She underwent successful emergency redo mitral valve replacement and caesarean section. At operation the prosthesis was found to be virtually completely obstructed with pannus. Both mother and baby had an excellent outcome following surgery. The case report is presented with a brief review of the literature.

Background: Recent United Kingdom National Cancer Plan guidelines have specified a number of waiting time targets to prevent delays in the treatment of lung cancer. This study was performed to compare our waiting times with national recommendations.Methods: All newly diagnosed cases of lung cancer presenting to our institution were entered into a prospective tracking study by a dedicated audit officer. From September 2003 to December 2005, a total of 342 patients were entered into the study. Of these, 193 (56%) were referred by general practitioners; the remaining 114 (46%) were internal referrals. The Cancer Plan waiting time targets are mainly applicable to general practitioners referrals, which formed the study group.Results: All the patients were seen in chest outpatient clinics within the recommended 2-week period. However, there was a delay in starting all forms of treatment. The median waiting time to any form of treatment was 60 days (recommendation, 62 days for all patients). From specialist referrals, the median waiting times for radiotherapy, surgery, and chemotherapy were 43, 25, and 16.5 days compared with recommended maximums of 28, 28, and 7 days, respectively.Conclusion: These data demonstrate that although patients receive outpatient consultation in the recommended time period, the National Cancer Plan treatment target of 62 days for patients referred by general practitioners is not being achieved. A concerted effort by all clinicians is required to meet the prescribed target times.

A teenager with palpitations and hypertension was found to have an intrapericardial pheochromocytoma of the left atrium with multiple feeding collaterals. Radiologic embolization was carried out on the major feeding arteries to the tumor preoperatively with good angiographic result. Surgery was carried out the following day through a median sternotomy approach and cardiopulmonary bypass. Minimal bleeding was observed due to prior embolization. The patient made a rapid postoperative recovery and was discharged 7 days later.

The UK has been reported to have the lowest resection and survival rates for lung cancer patients. These reports were based largely on retrospective data from the cancer registry and are now outdated. To monitor the present day surgical resection rate at our institution all newly diagnosed cases of lung cancer presenting to us were enrolled into a prospective tracking study. From September 2003 to March 2005 all suspected primary lung cancer referrals to the North West Lung Centre were tracked to identify patients with newly diagnosed lung cancer. The histology of 247 patients confirmed to be new lung cancer cases were small cell (SCLC), non-small cell (NSCLC) and mixed cancers in 33 (16%), 170 (83.5%) and 1 (0.5%) patients, respectively, while 43 patients had no histological confirmation. Overall, 43 patients (17%) underwent surgery while chemotherapy and radiotherapy were used in 91 (38%) and 43 (17%), respectively. Out of 170 confirmed NSCLC patients, 43 (25%), 65 (38%) and 27 (16%) patients underwent surgery, chemotherapy and radiotherapy, respectively. The remaining 35 (20%) did not receive any treatment because of patient wishes or poor condition. The surgical resection rates were 17% for all lung cancers and 25% for NSCLC. Current surgical resection rates at the South Manchester University Hospital are comparable to international standards. Similar data from the rest of the UK are required to determine the national resection rate, which may not be as low as once thought to be.

BACKGROUND:Recent guidelines have specified a number of waiting time targets to prevent delay in the treatment of lung cancer. This study was carried out to assess the quality of lung cancer services and compare with national recommendations.METHODS:All newly diagnosed cases of lung cancer presenting to our institution via general practitioner referral were entered into a prospective tracking study by a dedicated audit officer. From September 2003 to March 2005 a total of 247 patients were entered into the study. Of these 133 (54%) were referred by general practitioners and the remainder 114 (46%) were internal referrals. The Cancer Plan waiting time targets are mainly applicable to GP referrals, which formed the study group.RESULTS:All the patients were seen in chest out-patients clinic within the recommended two weeks period. However there was a delay in starting all forms of treatment. The median waiting time to any form of treatment was 60 days (recommendation 62 days for all patients).CONCLUSION:This data demonstrates that although patients receive out patient consultation in the recommended time period, the National Cancer Plan 62 days GP referral to treatment target is not being achieved. A concerted effort by all clinicians is required to meet the prescribed target times.

A 76-year-old man who had undergone a routine coronary artery bypass grafting operation developed severe haemodynamic instability in the early postoperative period in spite of multiple inotropic supports. Due to persistent instability of haemodynamics and worsening acidosis his chest was re-explored with detection of no obvious abnormality. An intra-aortic balloon pump (IABP) was inserted for additional support. The chest had to be left open overnight and closed formally next morning. A chest X-ray at that stage showed a large hiatus hernia with huge gastric dilatation compressing the heart. Decompressions of the stomach lead to dramatic improvement in his circulatory status with rapid weaning of inotropes and IABP and he could be extubated. This case illustrates the importance of recognising the presence of hiatus hernia in preoperative chest X-ray and prophylactic NG tube insertion at the time of cardiac surgery in these cases.