Background: The incidence of incisional hernia is high especially in high risk patients, it is more common after midline incisions than other incisions, wound closure techniques is an important factor in reduction of incisional hernia, small bite sutures, onlay mesh augmentation and sublay mesh augmentation of midline sutures helps reduction of midline incisional hernia. In this study we are trying to choose the optimum site of mesh placement for augmentation of midline sutures. Patients and methods: In this study we have two groups of high-risk patients undergoing abdominal surgery through midline incisions, Group I; 24 patients, the midline incision closure was reinforced by only polypropylene mesh. Group II; 23 patients, the midline incision closure was augmented by preperitoneal polypropylene mesh. Results: We recorded non-significant differences regarding the demographic data of patients, risk factors, ASA, and type of carried out surgery. The follow up time was 30.6±5 months in group I and 31.5±3.8 months in group II. In group I; we recorded 4 cases of seroma, 1 case deep wound infection this patient developed incisional hernia 2 months later, chronic pain in 4 patients resolved after 8 to 12 months, no hematoma or wound dehiscence In group II; we recorded no hematoma or chronic pain denoting a significant difference between groups, no incisional hernia, 2 cases of superficial wound infection, one case of hematoma and one case of wound dehiscence. Conclusion: The preperitoneal mesh position is superior to the onlay position with lower complications rate and lower incidence of incisional hernia.

Background: Hemorrhoids are the most common disease of the anus and large intestine. A number of procedures are available for their treatment ranging from medical, conservative, and surgical. Due to the wide prevalence and worrisome symptoms of this disease, efforts are continuously made to introduce new techniques for its treatment. Objective: This study compares two surgical techniques, namely, open hemorrhoidectomy (OH) and laser hemorrhoidoplasty (LH). Material and Methods: This interventional study recruited randomly 100 patients with hemorrhoids and divided them into two groups of 50 patients each for undergoing the OH and LH procedures. Postoperative pain was measured using the VAS scale. Operating time, duration of hospital stays, and complications were noted for each group, and they were followed up on postoperative days (15, 30, and 60 days). The data was analyzed using IBM SPSS software version 21. Results: The mean age of presentation was 41.64±12.29 years in the LH group and 41.36±12.94 years in the OH group and male to female patients’ ratio was 1:0.28. In both groups, majority of the patients presented with bleeding complaint. Postoperative pain (3.54 vs 5.15) and operative time (20.64±4.47 vs 37.6±3.49 mins) were less in the LH group compared to OH group. The duration of hospital stay was also significantly less in the LH group (1.24±3.36 days) compared to OH group ((1.24±3.36 days; P0.01). The postoperative complications and the recurrence rate were also markedly less in the LH group. However, the cost of LH was higher than that of OH. Conclusion: Despite its higher cost, LH is a preferred procedure due to its reduced recovery time and postoperative pain, chances of recurrence, and fewer postoperative complications.

Background- Aim: Laparoscopic cholecystectomy has been considered as the procedure of choice for symptomatic cholelithiasis. Previous abdominal surgery is clarified to have a high rate of conversion and attributed to dense adhesion. So, the present investigation was directed to estimate the probability and safety of the laparoscopic cholecystectomy among the patients who had previous upper abdominal surgery. Methods: A prospective clinical trial was carried on 48 patients presented with symptomatic gallstone disease with history of previous upper abdominal surgery underwent laparoscopic cholecystectomy. The current study was carried out in the department of General Surgery, Zagazig University Hospitals, Egypt through the interval from February 2019 to February 2020. Results: The mean age of the studied patients was 47.78±11.68 years. Most of them presented with biliary colic (81.25%) and the mean operative time was 144.22±9.5 minutes. Three cases were converted to open with (6.25%) conversion rate. The mean hospital stay was 2.8±1.1 days. The morbidity rate was (4.16%) in the form of wound infection in three cases, bile leakage from cystic duct in one case, paralytic ileus in two cases, and umbilical hernia in two cases. No cases were clarified with a bile duct injury or postoperative bleeding and there was no blood transfusion required. No mortality was reported. Conclusions: Laparoscopic cholecystectomy is a feasible and safe treatment for the symptomatic gallstone disease in the selected patients with previous upper abdominal surgery. However, appropriate preoperative preparations, patients’ assessment, careful intraoperative techniques, and well-experienced surgeon are mandatory for good outcomes.

Background: We evaluated our protocol of extrafascial transfissural approach for liver resection with intrafascial approach that we use in case of donor hepatectomy. Material and Method: We use extrafascial transfissural approach with finger fracture technique for liver resections and inftrafascial approach with clamp crush technique in case of donor hepatectomy. Major hepatectomy defined as resection of 2 or more adjacent segments. We compared these two techniques with regard to blood loss, operative time, morbidity and mortality. We also evaluated over all factors responsible for 90 days mortality. statistical analysis was done using SPSS version 23.(IBM).Categorical factors were evaluated using chi square test and numerical factors were analyzed using Mann Whitney U test. Multivariate analysis was done using logisitic regression method. Ethical approval for our clinical study was obtained by human research COA number SBI 3246. Results: We evaluated 31 liver resections done in last two years. 24 liver resections were done using extrafascial transfissural approach for various liver tumors and 7 living donor hepatectomies were done using intrafascial technique with clamp crush methods. Median age of patients was 54 years, 20 patients were males and 11 were females. median operative duration was 200 minutes. 25 were major resections ,4 were minor liver resections. All minor liver resections were in transfissural approach however there was no statistical significant difference between them. Being live liver donors patients in intrafacial group they were younger than extrafascial transfissural group. (p=0.01). On univariate analysis there was more blood product requirement in extrafascial transfissural approach but there was no difference in multivariate analysis. Conclusion: Extrafascial transfissural approach is comparable to intrafascial approach without affecting morbidity and mortality in liver resection.

Introduction: Breast cancer surgery is becoming less extensive and been performed as day-care surgery. Unfortunately, there are still patients presented at later stage, needing mastectomy and axillary clearance. Single night stay is a concept of overnight hospitalization after surgery with the intended aim of discharging patients the following day with or without the drain. The aim of this study is to describe the initial experience of a single night stay protocol for patients post modified radical mastectomy. Methodology: This study was a prospective cohort looking at all patients coming for unilateral modified radical mastectomy for breast cancer in a single institution. Only those who were willing to be discharged with drains, have support at home and able to come back for follow up were included. All enrolled patients were given drain care pamphlets and educated on drain care both by doctors and breast care nurse. Patients with stable vital signs, ambulate with optimal pain control and able to care for the drains were discharged (Group A) and the rest will be grouped into Group B. They will be reviewed back in the clinic on day 3 and day 5 post operatively and drains will be removed when less than 30 mls over 24 hours. Result: A total of 75 patients were recruited in the 17-month period study. 63(84.0%) patients were successfully discharged after a single night stay. In the Group A, seroma incidence was 60.3%, drain related complication 22.2%, wound complication 11.1% and readmission 3.2% and not significantly different from Group B. None of the factors such as age, T stage of tumor, hand dominance, site of surgery, education level, and operating time affect the success of discharge. Conclusion: Single night stay following modified radical mastectomy for breast cancer is feasible in selected and motivated patients. The complication is not significantly different but proper cost analysis study should be done to look at its effectiveness.

Introduction: The aim of this study is to evaluate the cost benefit and short-term outcomes of laparoscopic and open Anterior Resection (AR) of rectosigmoid cancer in Hospital Universiti Sains Malaysia. Methods: Between January 2000 and December 2014, a retrospective data of 115 patients underwent AR either laparoscopic or open technique were evaluated. Outcome parameters were postoperative complications, length of hospital stay and surgical oncological margin. The cost parameters were intraoperative, postoperative and total operative cost. Results: The mean age was 58 years old and majority was Malay. The laparoscopic approach were performed in stage I, II and III cancer. The open approach distributed in all stages of disease. The laparoscopic or open approach gave no difference in the oncological resection margin outcome (p 0.345). The surgical site infection occurred in 2 patients (1.7%) for laparoscopic AR and 3 patients (2.6%) for open AR. Two patients in AR developed major early complication of anastomotic leak. However it was not statistically significant (p 0.333). The mean length of stay (LOS) was 11.41 days (SD, 3.65; range 6 to12 days) in the laparoscopic AR group and 8.26 days (SD, 1.22, range 7 to 25) in the open AR group. Laparoscopic AR group recorded shorter hospital stay with mean of 8.3 days while open AR recorded mean of 11.4 days (p 0.001). Conclusion: Cost analysis showed significant in the LOS cost (p 0.001), intraoperative cost with reusable trocar (p 0.001) as well as total operative cost with reusable trocar (p 0.001).

Background: Radical nephrectomy is done traditionally using an open approach through a flank retroperitoneal incision or an anterior transperitoneal incision. The anterior approach includes midline, subcostal and chevron incisions. Patients and methods: We retrospectively evaluated the patients with kidney cancer who were admitted to the surgical oncology unit in our center from January 2017 till January 2020. The data were analyzed for the included patients comparing the outcomes for those who were managed through a subcostal incision versus other surgical approaches. Results: Forty patients were recruited. The median mass size in imaging was 7.5 cm (2.5-17). The Operative time was shorter in laparotomy (149.8+/-65) minutes while longer in laparoscopic cases (165 +/-32.1) minutes (P-vale=.53). Perioperative complications number in laparotomy was (7/32) and in laparoscopic surgery (0/8) (P-value=.32). Incisional hernia in open surgery 4/29 patients but in laparoscope 1/8 (p-value=1). The postoperative stay was longer in open surgery 3 (2-17) days then laparoscopic surgery 2.5 (1-7) days (p-value=.16). The Operative time was significantly shorter in subcostal incision arm than the midline incision arm (122.1 vs 174.5 minutes (P=0.033). There were no significant difference between the 2 open arms as regard the hospital stay (3 vs 4 days), blood loss and incidence of incisional hernia. Conclusion: The subcostal incision is a good alternative to the traditional midline incision in cases of RCC and allows adequate exposure with shorter operative time without a significant increase in the incidence of incisional hernia, blood loss or postoperative complications.

Background and Aim: To compare the outcomes of abdominal incision closure by staples and suture based on surgical site infection (SSI), postoperative pain, postoperative scarring, wound dehiscence, cost effectiveness and speed of incision closure. Methods: Of the 120 patients, 60 underwent skin closure with staples and the remaining 60 with sutures. Wounds were evaluated on postoperativedays(POD) 3, 7 and 14 for signs of infection, wound gaping,postoperative pain and at 1 month for cosmesis. Intraoperative assessment was done for duration of skin closure and cost-effectiveness. The data was coded and entered in Microsoft excel and then analysed using statistical software, SSPS. Results: SSI in staple group (20%) was higher than suture group. Postoperative pain showed similar results with p value 0.193. Sutures were cost-effective when compared to staples. Wound dehiscence was found in 1 (1.7%) and 4 patients (6.7%) in staple and suture group respectively with a p value of 0.171. Median time for closure of the wound is found to be 2.64 min in staple group and 9.04 min in suture group with p value of 0.00. Staple group had better cosmetic outcome when compared to suture group. Conclusions: Skin staples significantly reduce the operative time and provide better cosmetic outcome and although expensive, has no significant difference in SSI, postoperative pain postoperative complication and wound dehiscence as compared to skin suture material.

Background: Chronic non-healing leg and foot ulcers had considerable morbidity. Platelet-rich plasma (PRP) release various growth factors that can modulate healing process. PRP is a simple, safe, effective procedure for different types of chronic ulcer. The aim: to evaluate and compare between PRP dressing and traditional dressing in the treatment of chronic non-healing leg and foot ulcers of different etiologies as regards the cost of overall treatment (number of dressings) and effectiveness (reduction of the size of the ulcer in cm). Methods: Patients were divided into group A: received PRP dressing (N=22) and group B: received traditional ordinary dressing (N=22). Patients treated with PRP at the once-weekly interval for a maximum of 12 dressings while patients with ordinary dressings may need one dressing every other day for a maximum of 12 weeks. The reduction in the size of the ulcers in both groups was assessed using a centimeter-scale and Digital photographs before each session. The number of dressings in every patient was calculated. Results: In Group A (22 patients): 18 patients (82%) were completely healed at a variable time till the end of the study (12th week). Non-healing ulcers in 4 patients (15%). one case healed with more 2 dressings at the end of the14th week and the three cases healed after skin grafting. Group B: 14 patients (64%) were completely healed at the end of the study (12th week).non-healing ulcers in 8 patients (36%).two cases healed with more dressings at the end of the 17th week, two cases with skin graft and the last 4 cases healed after PRP dressing once weekly for 4 dressings. Conclusion: PRP gel dressing once weekly showed significant benefit regarding the healing rate of the ulcer and reduction of the overall treatment cost.

Seroma formation following mastectomy is a common morbidity without any effective preventive measure despite numerous studies. It is believed that this is contributed as a result of an inflammatory process. Methodology: This is a randomized control trial conducted in two centers. The aim was to find out whether intravenous dexamethasone which has an anti-inflammatory effect would reduce the formation of seroma, shorten duration of hospitalization and duration of drain used in study subjects compared to control. Patients undergoing mastectomy and axillary clearance were randomized to receive single dose intravenous dexamethasone 8 mg before surgery or intravenous normal saline as placebo. All patients had drain insertion, drain volume were recorded and drain was removed latest by day 5. Result: A total of 40 patients were eligible and recruited with 21 patients in study group and 19 in control group. Age, weight, height, BMI of both groups were comparable. The median for total drain volume per patient was significantly higher in the control group [585 ml and 358ml respectively (p=0.004)]. The median duration of drain used, and hospitalization were also significantly longer in the control group [both 5 and 4 days respectively (p~0 and p-0.003 respectively)]. The incidence of seroma was higher in control group 9/21 (42.8%) and 3/19 (15.8%) in study group (p=0.089). Hence, the number of aspiration of seroma was higher in the control group compared to the study group and this was statistically significant [20/26 (76.9%) vs. 6/26(23.1%) p=0.000]. Conclusion: Single dose dexamethasone significantly reduced the drain volumes, duration of drain, hospitalization and number of aspirations in subjects who had seroma, but the incidence was not significantly reduced. Use of peri-operative dexamethasone for prevention of nausea, vomiting and pain is safe and confer the added advantages in patients undergoing mastectomy

Background: We sought to determine the incidence of perioperative blood transfusion, common transfusion triggers, and the impact of perioperative blood transfusion on postoperative mortality in a sample of South Africans (SA) undergoing elective open abdominal surgery. Patients and Methods: We conducted a retrospective study of 289 adults who underwent elective laparotomy at a quaternary SA hospital over a 5-year period. Patients were identified from a pre-existing laparotomy registry. Registry data related to patient demographics, surgery-related parameters, comorbidities, perioperative blood transfusion, transfusion triggers, and postoperative mortality were obtained from each patient’s medical record and analysed using descriptive statistical methods. The association between perioperative blood transfusion and postoperative mortality was tested using bivariate statistics. Results: The incidence of perioperative blood transfusion was 24.6%. A drop in hemoglobin concentration was cited as the transfusion trigger for 53.5% of patients who were transfused, followed by observed clinical blood loss (46.5%). Postoperative mortality was 19.7% in patients who were transfused versus 6.4% in patients who were not transfused (p=0.001). Conclusion: Perioperative blood transfusion is common in SA patients undergoing elective open abdominal surgery. Haemoglobin level is the predominant transfusion trigger in our setting. Perioperative blood transfusion is associated with increased postoperative mortality

Purpose: To investigate the effectiveness of a short-term intradialytic exercise program, accompanied by music of their preference, on the levels of anxiety in hemodialysis (HD) patients measured both subjectively and objectively. Methods: Thirty HD patients have been randomly divided into two groups: The Investigation Group (Group A: n=15), who completed a 12-week intradialytic exercise program, while listening to music of their preference and the Control Group (Group B: n = 15), who received usual care. At the beginning and the end of the 12-week study physical functional capacity, acute (STAI) and permanent (TRAIT) anxiety and skin conductance response (SCR) were assessed as main parameters, while patients’ age, years on HD and hemoglobin were considered as secondary parameters. Results: At the end of the study there was a statistically significant improvement of physical performance by 11.8% (p0.05) only in Group A. There was no statistically significant difference on acute anxiety, or permanent stress and skin conductance response in either group, although the intervention group showed an improving trend. Conclusions: A short-term intradialytic exercise training program, accompanied by music of the patients’ preference, improves their functional capacity, without clearly affecting the level of anxiety in HD patients. A more comprehensive approach, longer intervention or outpatient settings may be required for the management of anxiety.

Εισαγωγή: Η Ιπποθεραπεία είναι μια θεραπευτική παρέμβαση που χρησιμοποιείται από φυσιοθεραπευτές, εργοθεραπευτές και λογοθεραπευτές. Φιλοσοφία της προσέγγισης Hi.K.E.R. είναι ότι η διαδικασία των αλλαγών στον εγκέφαλο, στον χώρο της θεραπευτικής ιππασίας, προϋποθέτει την δημιουργία ενός δομημένου πλαισίου εκπαίδευσης. Σκοπός: Ο σκοπός της παρούσας μελέτης είναι να μετρηθεί η επίδραση της ιπποθεραπείας στην ανάπτυξη αδρών κινητικών λειτουργικών προτύπων σε παιδιά με Εγκεφαλική Παράλυση. Μέθοδος: Οι συμμετέχοντες θα ενταχθούν σε ένα καθιερωμένο πρόγραμμα ιπποθεραπείας μέσω προσέγγισης HI.K.E.R. Τα παιδιά θα συμμετέχουν σε 30 λεπτών πρόγραμμα 1 φορά την εβδομάδα για 8 εβδομάδες. Η κλίμακα GMFM θα χρησιμοποιηθεί για τη μέτρηση της αδρής λειτουργικότητας, καθώς και η κλίμακα αξιολόγησης της Hi.K.E.R. η οποία αφορά κινητικές δραστηριότητες οι οποίες εκτελούνται πάνω στο άλογο Αποτελέσματα: Στην αρχική βάση αξιολόγησης μετά την παρέμβαση του προγράμματος πποθεραπείας των 8 εβδομάδων, τόσο στη GMFM-88 όσο και στη Hi.K.E.R. υπήρχε στατιστικά σημαντική διαφορά. Οι τελικές βαθμολογίες στα 5 επίπεδα της GMFM- 88 παρουσίασαν σημαντική στατιστικά διαφορά σε συνάρτηση με το χρόνο, ενώ στην κλίμακα Hi.K.E.R. στην κατηγορία Γ δεν παρατηρήθηκε σημαντική στατιστικά διαφορά σε συνάρτηση με το χρόνο Συμπέρασμα; Στη μελέτη μας σημειώθηκε σημαντική αύξηση σε όλες τις κατηγορίες του GMFM-88, το οποί υποδηλώνει τα ευεργετικά αποτελέσματα της ιπποθεραπείας στην ανάπτυξη της αδρής κινητικής λειτουργίας. Ωστόσο παρόλο που η GMFM είχε θετική έκβαση σε όλα τα επίπεδα, στη κλίμακα αξιολόγησης Hi.K.E.R. στο επίπεδο D και E δεν παρατηρήθηκαν σημαντικές διαφορές. Αυτή η μελέτη έχει επιδείξει μέτρια αλλά σημαντικά οφέλη στην αδρή κινητική λειτουργία ακολουθώντας ένα εξατομικευμένο πρόγραμμα σύμφωνα με τη προσέγγιση Hi.K.E.R.

Background: Cholecystitis is one of the most common surgical diseases, and effective empirical antibiotic therapy is essential in the treatment of acute cholecystitis. Objective: To determine the bacteriological analysis, antibiotic sensitivity and resistance pattern of bile culture from laparoscopic cholecystectomy patient. Method: This cross-sectional study was conducted from July 2017 to March 2018 in Hospital Sultanah Nurzahirah, Kuala Terengganu, Malaysia. Bile sample was taken intra-operatively from a number of 62 patients who underwent elective uncomplicated laparoscopic cholecystectomy for cholelithiaisis. The samples were sent for bacteriological assessment and antibiotic sensitivity testing. The factors affecting the positivity of bile culture was age, diabetic, obesity, previous treatment of antibiotics and prophylaxis antibiotics. Results: The prevalence for positive bile culture in the study was 19%. There was no anaerobic bacteria detected, Klebsiella Pneumonia was the commonest organism isolated which were 9 out of 12 samples (75%), compared to Escherechia coli which were 8 out of 12 samples (66.67%). From the antibiogram, it showed cefuroxime has the highest number of antibiotic sensitivity tested (11 out of 12), followed by gentamicin (9 out of 12) and ciprofloxacin (7 out of 12). There were 6 samples with ampicillin resistance, and 1 sample with cefuroxime resistance. From Multiple Logistic Regression analysis, with every 1 year increment of age, there is 1.10 higher odds of having positive bile culture when other variables are adjusted (p = 0.017). Those who have previous antibiotic treatment will have 7.98 higher odds of having positive bile culture when other variables are adjusted (p=0.035) Conclusion: The prevalence of positive bile culture sample in uncomplicated laparoscopic cholecystectomy is high (19%). The antibiotic treatment practice need to be improvised as the data shows patient with previous antibiotic treatment has 7.98 higher odds of having positive bile culture.

Εισαγωγή/Σκοπός της μελέτης: Ο 19ος αιώνας, εποχή έντονης επιστημονικής ανάπτυξης, αποτέλεσε την απαρχή της σύγχρονης Ιατρικής. Τα εγχειρίδια Ιατρικής υπήρξαν το βασικό μέσο διάδοσης της νέας γνώσης. Σκοπός της παρούσας μελέτης είναι η παρακολούθηση της εξέλιξης της Χειρουργικής μέσα από την συστηματική μελέτη των ιατρικών παλαιτύπων Χειρουργικής της εποχής. Υλικό και Μέθοδος: Αντικείμενο της μελέτης μας αποτέλεσαν τα παλαίτυπα Χειρουργικής του 19ου αιώνα. Βάση αναζήτησής υπήρξαν βιβλιογραφικές πηγές που καλύπτουν τη συγκεκριμένη χρονική περίοδο. Οι πρόλογοι, τα εισαγωγικά σημειώματα και οι πίνακες περιεχομένων αποτέλεσαν το αντικείμενο μελέτης και ανάλυσης, που μας παρείχε πολύτιμες πληροφορίες για την εξελικτική πορεία της Χειρουργικής στην Ελλάδα το 19ο αιώνα. Συζήτηση/Αποτελέσματα: Η ίδρυση και λειτουργία της Οθωνείου Ιατρικής Σχολής δημιούργησε αυξημένες ανάγκες σε διδακτικά συγγράμματα. Οι ανάγκες αυτές καλύφθηκαν με μεταφράσεις ξενόγλωσσων εγχειριδίων, αλλά και με τη δημιουργία συμπιλημάτων και πρωτότυπων έργων εφάμιλλων των αντίστοιχων ξένων. Η συγγραφική δραστηριότητα, πέρα από τις κοινωνικοοικονομικές δυσχέρειες στις οποίες προσέκρουσε, ανέδειξε και το γλωσσικό πρόβλημα και οδήγησε στη σταδιακή δημιουργία ελληνικής ιατρικής ορολογίας. Η συστηματική χρήση των ιατρικών εγχειριδίων Χειρουργικής συνέβαλε στη σταδιακή ανάπτυξη της ιατρικής εξειδίκευσης με την εκτέλεση συνθετότερων και πιο εξειδικευμένων επεμβάσεων. Τέλος, η ανακάλυψη της αναισθησίας και η πρόοδος της χειρουργικής αντισηψίας, που υιοθετήθηκαν πλήρως από τους Έλληνες χειρουργούς, δημιούργησαν νέες προοπτικές στην εξέλιξη της χειρουργικής πρακτικής. Συμπεράσματα: Τα παλαίτυπα Χειρουργικής του 19ου αιώνα αποτελούν βασικό εργαλείο μελέτης της εξέλιξης της Χειρουργικής στην Ελλάδα, μιας πορείας που αποδεικνύεται αντίστοιχη των χωρών της Ευρώπης.

Intracystic papillary carcinoma of the breast is a rare malignancy affecting postmenopausal women, accounting 0.5-2% of all breast cancers. Patients usually present with a slow growing breast lump with bloody nipple discharge. Breast ultrasound usually shows an encapsulated solid- cystic mass. Establishing a tissue diagnosis is challenging where fine needle aspiration or tissue biopsy is usually unrepresentative, and excision biopsy is recommended. There is no treatment consensus but it carries a good prognosis, having a high survival rate, low recurrence rate and rarely having nodal or distant metastases. We report a case of intracystic papillary carcinoma which recurred 6 years from the initial mastectomy and axillary clearance, in a reconstructed breast of a young premenopausal lady, with favorable histopathological findings

Acute gastric dilatation is rare yet can result in fatal complication. Few aetiologies have been described in the literature but the exact pathogenesis remain unclear. A 13-year-old girl was admitted to our care following a motor vehicle accident (MVA). She complained of pain and distension of the upper abdomen and computed tomography (CT) scan showed grade II liver and splenic injury, which was treated conservatively. The stomach was grossly dilated on CT scan, occupying the upper abdomen thus decision for decompression with Ryle’s tube (RT) and nil per oral was made. She had a good recovery and there was no complication with regards to the acute gastric dilatation (AGD). In conclusion, we acknowledged that early recognition of AGD is mandatory to prevent grave complications.

Long term complications presenting decades after bariatric surgery are being reported as this branch of medicine is aging. We encountered 41 year old female with 26 weeks pregnancy, she had laparoscopic gastric bypass done in 2007. She presented in 2019 with non-remitting abdominal pain, even after 2 days with full investigations including MRI abdomen. She then had blood in nasogatric aspiration and on endoscopy found to have ischemic changes generalized to enteric lumen distal to gastrojejunal anastomosis. On exploration, found to have generalized ischemia of small intestines, on careful exploration, internal herniation behind mesojejunal window of bilio-pancreatic limb to alimentary limb anastomosis was found and except 1 feet of bilio-pancreatic limb rest of the small intestine salvaged. She recovered well and even gave birth to healthy baby at full term. We share our experience of this case, challenges involved and learning message out of it along with review of literature.

It is reported that pancreatic ascites represents an extremely rare entity with unfavorable outcomes. It results from persistent leakage of pancreatic secretions in the peritoneum from pancreatic duct injury. Herein, we deal with a very rare case of a high-risk patient who underwent subtotal gastrectomy in emergency setting due to a ‘huge’ gastric perforation. The seventh post-operative day the patient presented severe pancreatic ascites due to iatrogenic disruption of the pancreatic duct during the subtotal gastrectomy and underwent emergency laparotomy. It has to be highlighted that pancreatic ascites is an extremely rare entity and treatment options depend on the etiology and on the degree of pancreatic duct injury. It has to be highlighted that the operating surgeon should always take into account the patient’s overall condition in order to decide which therapeutic option is the most appropriate.

Background: Bile duct injuries is the primary concern of general surgeons during and after cholecystectomy, with an incidence ranging from 0.08% to 0.4%. Through the description of two cases we intend to discuss the management of most frequent types of bile duct injuries after cholecystectomy and examine some possible sources of error. Case reports: We have treated 2 cases previously operated by other surgical teams. Case report 1: patient undergoing laparoscopic cholecystectomy with lesion of the main bile duct, treated with its reconstruction with positioning of a T-drainage tube. Case report 2: patient with jaundice previously treated for incarcerated incisional hernia and gallbladder stones. We verified the presence of a stenosis of the main bile duct which was resolved with the positioning of a T-tube drainage Discussion: Many descriptions and classifications regarding iatrogenic lesions of the bile duct after cholecystectomy have been described, although some of them represent a good guide on the surgical approach to be adopted, but the surgical skills possessed by the operator remain the most important variables Conclusions: All possible precautions must be considered in order to avoid the possibility of damaging the biliary tree. In our opinion an anterograde approach during cholecystectomy offers greater safety.

Background: This is a case of a rare encapsulated papillary carcinoma with foci of invasive apocrine carcinoma, in a male breast. We had to report this case due to the extreme rarity of the coexistence of these phenomena, especially in males, with a comment about the appropriate management and prognosis of this type of neoplasms. Case presentation: We present a case of a 54 years old man who attended our hospital’s surgical department in order to be examined for a lumb he had noticed beneath his left areolar region. Clinical and radiologic evaluation revealed a circumscribed lesion and it was decided that it should be surgically removed and examined by a pathologist. The diagnosis was that of an encapsulated papillary carcinoma with adjacent foci of in situ and invasive carcinoma and extensive apocrine differentiation of the neoplastic cellular population. Conclusion: This is the first reported to this day case of encapsulated papillary carcinoma in a male patient with associated invasion of the surrounding breast by carcinoma of apocrine type. It seems that not all encapsulated papillary carcinomas behave in an indolent fashion. The pathological evaluation and histological diagnosis prerequisites thorough sampling and scrutinous examination not just of the cystic component but of the surrounding breast parenchyma as well.

Total abdominal aortic occlusion is an infrequent vascular case encountered in the field of surgery. It may result from aortic embolus, in situ thrombosis of a previously atherosclerotic abdominal aorta, sudden thrombosis of small abdominal aortic aneurysms, traumatic elevation of a distal aortic intimal flap (resulting in dissection and thrombosis), and other, rarer etiologies. The case has a published mortality rate of 75% with conservative treatment or surgical intervention. We report 2 cases of total abdominal aortic occlusion presented to non-vascular center with typical symptoms of sudden onset bilateral lower limb pain and weakness for 1 day. Diagnosis was established by CTA Aorta and patient were treated conservatively in a non-vascular center. Both patient did not survive of the disease and its associated complications. We discussed the symptoms, diagnosis and treatment of choice in this article.