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Introduction: Acute Calculous Cholecystitis is a condition in which the gallbladder becomes inflamed due to cholelithiasis. Early diagnosis, severity grading and appropriate intervention reduce both morbidity and mortality. The aim of this prospective study is to correlate the severity with the outcome of acute calculous cholecystitis according to Tokyo Guidelines. Methods: This was a hospital based prospective study conducted in the Department of Surgery, Nepalgunj Medical College Teaching Hospital for a period of two years from April 2017 to March 2019. The patients were classified into three groups according to the severity grading in the Tokyo guidelines (TG18/ TG13). Clinical characteristics among these patients were analyzed for comparison. Results: Among all diagnostic criteria, right upper quarter (RUQ)h abdominal pain (94%) Murphy's sign (94%) and thickened gallbladder wall (80%) had the highest sensitivity rates (p<0.032), whereas elevated white cell count (32%) and RUQ abdominal mass (32%) had the lowest sensitivity rates (p<0.035). Higher sensitivity rates of diagnostic criteria were related to severe cholecystitis, except for Fever (46%) and elevated white blood cell (WBC) count (32%). All the 28 patients in grade I and selected patients 3 out of 6in grade II underwent early laparoscopic cholecystectomy (LC) without any conversion and increased morbidity and mortality. Out of16 patients in grade III there was 2 mortalities due to ARDS, 1 needed Ultrasonography (USG) guided cholecystostomy, 1 underwent emergency cholecystectomy. 16 patients, 3 in grade II and 13 in grade III underwent interval laparoscopic cholecystectomy safely. There were no major postoperative morbidities except for superficial surgical site infection (SSI) in 1 patient in grade III who underwent emergency cholecystectomy Higher grade of severity was associated with increased morbidity and mortality (p<0.03). Conclusion: A combination of diagnostic criteria with different path physiologic findings, as noted in the Tokyo guidelines, can help clinicians make the correct diagnosis for patients with acute cholecystitis and there was strong correlation between the severity and outcomes of acute cholecystitis.

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.

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).