Μολονότι η επίπτωση του αδενοκαρκινώματος της οισοφαγογαστρικής συμβολής (esophagogastric junction-EGJ adenocarcinoma) αυξάνεται σημαντικά σε παγκόσμια κλίμακα και παρά το γεγονός ότι η πρόγνωσή του εξακολουθεί να παραμένει φτωχή, δεν έχει επιτευχθεί έως και σήμερα συναίνεση αναφορικά με τον ορισμό και την ταξινόμησή του και δεν έχει καθιερωθεί κοινά αποδεκτή, προτυποποιημένη μέθοδος για την αντιμετώπισή του. Η χειρουργική εκτομή, παρά την πρόσφατη καθιέρωση της πολύτροπης διαχείρισης (multimodal management) ως αρχικής επιλογής αντιμετώπισης του τοπικά προχωρημένου και/ή με διηθημένους λεμφαδένες αδενοκαρκινώμτος της EGJ, εξακολουθεί να συνιστά τη μόνη δυνητικά θεραπευτική μέθοδο αντιμετώπισης της νόσου. Όμως, ακόμα και το θέμα του χειρουργικού σχεδιασμού αντιμετώπισης του αδενοκαρκινώμτος της EGJ εγείρει αντιπαραθέσεις κυρίως ως προς τον τύπο της ενδεικνυόμενης χειρουργικής επέμβασης και την κατάλληλη έκταση λεμφαδενεκτομής. Σε αυτό το πλαίσιο της εμμένουσας ασάφειας και των αντιγνωμιών, σκοπός αυτής της ανασκόπησης είναι η παρουσίαση επικαιροποιημένων δεδομένων αναφορικά με τον ορισμό, την ταξινόμηση και τη θεραπευτική στρατηγική αντιμετώπισης του αδενοκακρινώματος της EGJ.

Background: Bariatric surgery is the most effective and durable treatment of obesity and associated diseases. But in the postoperative period after restrictive operation exist the problem of the worsening or development of de novo symptoms of gastroesophageal reflux disease (GERD). Is it possible to avoid the development of postoperative GERD after a restrictive bariatric procedure, by carrying out the simultaneous metabolic procedure and antireflux procedure with the preventive purpose? Methods: Realization of comparative clinical study of the efficiency and quality of life of obese patients (without symptoms of GERD in the preoperative period) after different bariatric procedures: laparoscopic sleeve gastrectomy (LSG), laparoscopic gastric great curvature plication (LGCP) and simultaneous laparoscopic Nissen fundoplication with laparoscopic gastric great curvature plication (LNGCP). Based on the results obtained from the curation of 53 patients with obesity and metabolic syndrome. Follow-up period was 1 year. Results: Despite the best weight loss result was in the LSG group, weight loss was comparable in all three groups, but the highest quality of life score (SF36) was observed in the LNGCP group. In our opinion, this phenomenon is associated with the development of de novo clinical manifestations of GERD in 2 patients from the LSG group and in 6 patients from the LGCP group, which affected the final quality of life of patients with LSG and LGCP groups. Conclusion: The implementation of simultaneous surgery shows corresponding results of weight loss, preventing of GERD symptoms and a more pronounced positive effect on improving the quality of life of patients in short-term period.

Background-aim: Health care associated infections (HAI) are infections that affect millions of people annually worldwide. It is reported that surgical site infections (SSI) are the leading cause of HAIs, they account for up to 20% of all HAIs and are associated with high mortality and prolonged duration of hospitalization. The aim of this article is to review the recent scientific evidence dealing with SSI and SSI prevention using topical antibiotics before primary closure. Search methods: A literature search of MEDLINE/Pubmed Database has been conducted using the following search words: SSI, topical antibiotics, primary closure. Results: Numerous systematic reviews and several meta-analyses have been published up to date, analyzing SSI prevention by using topical antibiotics. Conclusions: The question of whether topical antibiotic agents before primary closure are beneficial to prevent SSIs has not been answered clearly yet, but it seems reasonable to assume that the use of topical antibiotic agents before incision closure to reduce SSI cannot be clearly recommended. However, it can’t be excluded definitely from the prophylactic measures. The recent evidence suggests that future well-conducted prospective studies are needed in order safe and robust conclusions to be reached

Aim: Pain control is an important issue in patients with inoperable cancers of upper abdominal organs. Although various pharmacological drugs are adequate for this, more invasive and interventional methods such as celiac plexus block (CPB) come forward for the cases which are unresponsive to conventional medical treatments. In this study our aim was to evaluate the contribution of CPB to patient comfort in patients with inoperable cancer. Material and Methods: Thirty-four patients who were diagnosed with inoperable malignant and underwent CPB during five years period were included. All procedures were performed with the guidance of endoscopic ultrasonography (EUS) and ethanol was used as the neurolytic agent. Results: Majority of the cases were female (%55.9, n:19) and the median age was 66 years (range: 56-78 years). Most of the patients had pancreatic cancer (38.3%, n:13), and the remaining patients had gastric cancer, Klatskin tumor, gallbladder cancer and hepatocellular carcinoma. Pain resolved completely in 16 patients (47.2%) and was controlled with non-narcotic analgesics in six patients (17.6%) after the procedure. None of the patients developed any major complication or paraplegia. Conclusion: It was observed that pain control was not sufficiently achieved in the advanced grade of invasion. For this reason, patient selection should be done meticulously and CPB should be performed in the early period of pain in order to obtain an effective response.

Introduction: Colorectal surgical procedures (CRS) are associated with the highest SSI rate. Factors, such as hospitalization and previous antibiotic therapy, influence the microbiology of SSIs. Thus, the microbiology of the infection, combined with increasing pathogen resistance, may limit empiric therapy effectiveness. Methods: This prospective cohort study of 495 patients was conducted in emergency unit at a tertiary care hospital in Egypt. Postoperatively surgical site infected cases after emergency colorectal surgery were identified using CDC, USA definition for SSI. After discharge from hospital, patients were followed up for 30 days to check any signs of SSI. After identifying a patient with SSI, pus culture swabs were sent to the microbiology laboratory. Results: Out of 495 patients 126 (25.45%) patients developed SSI. Out of 126 SSI patients only 105 patients (83.33%) had positive swab/puss culture reports Methicillin-sensitive Staphylococcus aureus (MSSA) was the most common isolated organism in the positive cultures (51 / 105 patients) (48.57%), followed by E-coli (30 / 105 patients) (28.57%). the percentage of gram-positive bacteria in cultures was (87 / 105) (82.86%) while gram negative bacteria was (51 /105) (48.57 %), the anaerobic bacteria percentage was (12 /105) (11. 43 %), multiple growth was detected in (33 / 105) (31.43%). Conclusion: Methicillin-sensitive Staphylococcus aureus and E-coli is most common organisms isolated on positive cultures in SSI after emergency colorectal surgery.

Introduction: Postoperative pancreatic fistula (POPF) remains the Achilles heel of Whipples pancreaticoduodenectomy. Although multiple approaches to decrease POPF rates have been reported, an effective preventive strategy has not been found. Methods: The morphological nature of pancreas in eighty-two consecutive cases of Whipples pancreaticoduodenectomy done in high volume pancreatic at Kasturba medical college, Manipal between January 2014 to July 2019 and its contribution in formation of POPF has been studied. Results: Of the cases taken in the study, 48.8% patients has a non dilated pancreatic duct and 50% patients had a soft pancreatic consistency. Both Non dilated pancreatic duct and soft pancreas were statistically significant in contributing to a biochemical leak but was not proven to be a significant risk factor in formation of POPF. Conclusion: This result is contrary to the validated notion that Pancreatic morphology tends to be the most consistent factor that affects formation of Pancreatic fistula.

Introduction: Locally advanced gallbladder cancer (GBC) is known to be associated with poor outcome. Curative resection is considered the treatment of choice. Hepatopancreatoduodenectomy (HPD) has been a surgical option in selected cases, but there is lack of conclusive evidence regarding the same with majority of data from Japan and China. Indian literature regarding HPD is sparse. We herein report our instituitional experience as a series of 9 cases of locally advanced GBC who underwent HPD. Materials and Methods: Records of 9 patients who underwent HPD for locally advanced GBC from January 2011 to December 2017, were reviewed retrospectively. Patient records were reviewed for demographic characteristics, clinical presentation, radiological findings and outcome of surgery in terms of morbidity and mortality and overall survival. Data was reported as median with range and percentage. Results: There were 6 females and 3 males with a median age of presentation of 39 years with a performance status of ECOG 1 in our study. The most frequent symptom was abdominal pain (100%) . Preoperative diagnosis was made by triphasic CECT abdomen. Portal vein embolisation was done in three patients with right portal pedicle involvement. Diagnostic laparoscopy was done in all patients to rule out dissemination. All patients underwent HPD with R0 resection being achieved in 7(77.7%). Right trisectionectomy was performed in 3 patients and segment IVB and V resection was done in rest of the 6 patients. Morbidity rate was 33.3% and no hospital deaths were reported. All patients received gemcetabine based adjuvant chemotherapy . 6 patients died of recurrence with a median survival of 15 months. 3 patients are recurrence free after a median follow up of 30 months. Conclusion: HPD could be performed in selected patients of locally advanced GBC with acceptable morbidity, which can achieve a longer recurrence free overall survival as compared to palliative therapy.

Background: Simple anal fistula is a common surgical condition that could be treated efficiently with fistulotomy or fistulectomy, fistulotomy wounds take around 6 to 7 weeks to achieve complete healing, some studies offered different methods to enhance fistulotomy wound healing, among these methods was marsupialization of the fistulotomy wound edges. This study was carried out to evaluate the effect of marsupialization of fistulotomy wound in simple anal fistula. Patients and methods: 70 patients with simple anal fistula participated in this trial, they were randomly allocated into two groups, group A; underwent fistulotomy alone and group B; underwent fistulotomy with marsupialization of the wound edges, follow up data including postoperative complications and state of wound healing together with preoperative data were recorded and analyzed properly. Results: The demographic data, presenting manifestations and pathological findings showed non-significant differences between both groups, the operative time was significantly shorter in group A( fistulotomy), late postoperative pain after 1 week was significantly better in group B (fistulotomy and marsupialization), no significant differences between both groups in terms of complications (bleeding, incontinence and urine retention), complete wound healing time was significantly shorter in group B (4.8) weeks than group A (6.8) weeks. Conclusion: Marsupialization of the fistulotomy wound edges in simple anal fistula slightly prolongs the operation time but significantly improves postoperative pain and efficiently enhances wound healing time.

Introduction: Upper Gastrointestinal Bleeding (UGIB) requiring endoscopic intervention is a common scenario in hospitals. However, not all patients require emergency or urgent endoscopy to be done. This study will validate and associate Glasgow-Blatchford Score (GBS) with Forrest classification. This is to predict the severity of Non-Variceal Upper Gastrointestinal Bleed according to Glasgow Blatchford Score and validate this scoring system in Hospital Universiti Sains Malaysia. This study will also associate between two scoring system of Glasgow Blatchford Score and Forrest Classification between Non-variceal high-risk bleeding with major bleed and non-variceal low risk bleeding with minor bleed. Methodology: Data collected from June 2016 till February 2017, 113 patients with Non-variceal bleed underwent emergency OGDS were retrospectively reviewed and were stratified according to Glasgow Blatchford Score to high and low risk. This stratified risk is associated with Forrest classification to determine its endoscopic findings. Results: Majority are in the high-risk group 107 (94.7%) patients and low risk group 6 (5.3%) patients. Patients in the low risk group was followed up for 30 days and showed no complications or mortality. This study showed patients has a median score of 10.27±3.54. From the data analysis of Glasgow Blatchford Score showed 95.45% sensitivity and 5.49% specificity. Endoscopic findings showed 22 (19.5%) patients had major bleed and 91 (80.5%) patients had minor bleed. Using Fischer Exact Test, there is no significant association between risk and outcome (p-value > 0.950). Conclusion: Based on this study alone, we cannot suggest Glasgow Blatchford Score as a predictor for severity of Upper Gastrointestinal Bleeding. This is because as shown in the results, there were no significant association between GBS and Forrest classification. However, this nonsignificant result maybe compounded by several factors as discussed, namely due to underlying Chronic Kidney Disease with anemia, the timing of endoscopy and initiation of medication. With this bias identified, it can be used as a guide in designing and conducting a better study in the future in order to come to a better conclusion about GBS in our population

Εισαγωγή: Τα προγράμματα ERAS εισήχθησαν στα τέλη της δεκαετίας του 1990, προήλθε από τη χειρουργική επέμβαση του παχέος εντέρου, αλλά εξαπλώθηκε σε άλλες χειρουργικές επεμβάσεις, συμπεριλαμβανομένων, μεταξύ άλλων, γαστρεντερικών, ηπατοκυτταρικών, ορθοπεδικών, καρδιακών, θωρακικών, κεφαλιού και τραχήλου, μαστού και γυναικολογικής χειρουργικής. Τα προγράμματα ERAS υποστηρίζονται από προεγχειρητικές, περιεγχειρητικές και μετεγχειρητικές διαδικασίες Ο τελικός σκοπός είναι να ελαχιστοποιηθεί η μετεγχειρητική δυσλειτουργία οργάνων και να ενισχυθεί η αποκατάσταση [Kehlet 2008 ]. Σκοπός: Σκοπός της παρούσας μελέτης είναι να αποδειχθεί ότι η πρώιμη κινητοποίηση μπορεί να επιταχύνει την επίτευξη της γρηγορότερης λειτουργικής αποκατάστασης, ότι μειώνει το ρυθμό των μετεγχειρητικών πνευμονικών επιπλοκών, του φλεβικού θρομβοεμβολισμού και των λοίμωξεων Μέθοδος: Η συλλογή των πληροφοριών έγινε από μελέτες οι οποίες αποδεικνύουν την αποτελεσματικότητα της φυσικοθεραπείας προεγχειρητικα και μετεγχειρητικά σύμφωνα με τις αρχές των πρωτοκόλλων ERAS Αποτελέσματα: Τα πρωτόκολλα ERAS αναμφισβήτητα προάγουν την ταχεία ανάρρωση με σκοπό τη μείωση του μετεγχειρητικού στρες και των επιπτώσεων του. Συνεπώς, ακολουθούν μια προγραμματισμένη, τεκμηριωμένη περιεγχειρητική φροντίδα. Προκειμένου να εφαρμοστούν τα πρωτόκολλα ERAS χρειάζεται η ομαλή συνεργασία επαγγελματιών υγείας διαφορετικών ειδικοτήτων. Συμπέρασμα: .Η ασθενής που ακολουθεί ένα πρωτόκολλο ERAS κινητοποιείται ταχύτερα, ανεξαρτητοποιείται γρηγορότερα, σιτίζεται μόνη της, λαμβάνει την αγωγή της από το στόμα και εξέρχεται συνετότερα.

Σκοπός της μελέτης ήταν η αξιολόγηση της αξιοπιστίας της ελληνικής έκδοσης της κλίμακας Addenbrooke’s Cognitive Examination (ACE) III για την εκτίμηση των νευρογνωσιακών λειτουργιών σε περιεγχειρητικούς ασθενείς σε σύγκριση με την ήδη καθιερωμένη και σταθμισμένη στην ελληνική γλώσσα κλίμακα Montreal Cognitive Assessment (MoCA). Υλικό και μέθοδος: Προοπτική μελέτη παρατήρησης στην οποία συμπεριλήφθηκαν 97 ασθενείς που υποβλήθηκαν σε προγραμματισμένη χειρουργική επέμβαση. Η κλίμακα ACE III (English Version 2012) αρχικά μεταφράστηκε στην ελληνική γλώσσα και στη συνέχεια αντίστροφα από την ελληνική στην αγγλική για εξασφάλιση μεγαλύτερης αξιοπιστίας του ερωτηματολογίου. Οι δοκιμασίες MoCA και ACE III εφαρμόστηκαν σε κάθε συμμετέχοντα πριν και 48 ώρες μετά τη διενέργεια της χειρουργικής επέμβασης. Αποτελέσματα: Οι δύο κλίμακες παρουσίασαν πολύ καλή συσχέτιση μεταξύ τους [R=0.877; pί στην καθημερινή κλινική πράξη για την εκτίμηση της νευρογνωσιακής κατάστασης περιεγχειρητικών ασθενών.

Background: Local anesthetic infusion using a pre-peritoneal catheter is a relatively new method of analgesia. There was no report published in Malaysia. In this prospective cohort study, we report the efficacy and safety of this mode of analgesia in 64 consecutive patients that underwent colorectal resections. Methods: Patients were recruited between May 2018 to Mac 2019. The analgesia was performed via a multi-hole catheter placed in the pre-peritoneal space. Additional analgesics were used as needed. Postoperative pain was quantified with the visual analog scale score. Outcome measure of total dosage of intravenous opiates analgesics, time to first feces, length of stay, and catheter related complications were recorded. Results: There were 26 open and 36 laparoscopic resections. The highest pain score was observed on day one post-surgery which was below 5. The highest mean usage of opioid analgesics per day was at 9mg. There were 30 patients avoided the use of intravenous morphine infusion. Mean time to first defecation is 40 hours. Average length of stay was 6 days. There were 3 cases of complications related to preperitoneal catheter analgesia. Conclusion: Preperitoneal catheter analgesia is a safe and effective analgesic method without the systemic side effects of intravenous opioids.

Melanoma is an aggressive malignant neoplasm of melanocytes characterized by high metastastic potential with local recurrence and low survival rate. Most of melanoma are cutaneous lesions but involvement of rare location such as eye, salivary gland, oral cavity and mucous membrane of the nasopharynx has also been documented. Amelanotic melanoma is a rare type of cutaneous melanoma which is characterised by the absence of melanocytes. The clinical diagnosis of amelanotic melanoma represents a challenge for the clinician to differentiate it from other benign or malignant skin tumours. We report a case of amelanotic cutaneous malignant melanoma resembling high-grade sarcoma which metastasized to adjacent parotid gland and intraparotid lymph nodes. This case illustrate the challenge in the diagnosis of amelanotic melanoma and we highlights the significance of immunohistochemical studies for reaching an accurate diagnosis.

The angioembolization of GDA is proven one of the effective and safe procedures for bleeding upper gastrointestinal bleeding after the failed endoscopic intervention. Even though it has low complications rate, but hazardous consequences still can happen. The distal migration of the embolization coils can lead to dreaded complication of distal arterial occlusion. We reported a case of acute lower limb ischemia following angioembolization of GDA that successfully managed by simple embolectomy.

Spontaneous splenic rupture is a rare complication of chronic pancreatitis which is easily misdiagnosed. The aim of the present study was to present a case report and to conduct a mini review of the literature on the atraumatic splenic rupture. This is the case of a 47-year-old man with chronic pancreatitis and had eight documented flare-ups in the previous eighteen months. He presented with one day history of stabbing upper abdominal pain radiating to the back and both flanks. There were no pain relieving or precipitating factors. Patient denied any history of trauma. His Hb was 12.8, WBC 12.4, neutrophils 10.3 and CRP 9. The provisional diagnosis on admission was an acute on chronic episode of pancreatitis. Overnight he developed severe pain and tachycardia. An urgent CT requested, which demonstrated a large heterogenous collection surrounding the spleen. He underwent a splenectomy and his recovery was uneventful. An early overlap between the two clinical pictures made the diagnosis extremely difficult; awareness of atraumatic splenic rupture may help make early diagnosis.

Jejunal diverticulum are rare and usually asymptomatic. However, it may present with a wide spectrum of chronic non-specific symptoms and rarely lead to an acute presentation. We report a case of 83 year old Malay women, presented with 1 week history of generalized cramping abdominal pain with distension and watery stool. Clinical examination revealed abdomen was peritonitis. Erect chest x-ray shows pneumoperitoneum. Patient underwent an emergency laparotomy with findings of multiple jejunal diverticula with single perforation. Affected small bowel was resected with end to end anastomosis done. Histopathological examination showed evidence of acute diverticulitis with background of diverticular disease. Unfortunately, patient succumbed to death post-operative because of cardiac complications. Jejunal diverticulosis in elderly can lead to significant morbidity and mortality. Thus it should be suspected in elderly patients presenting with chronic cramping abdominal pain and altered bowel habits.

Basal cell carcinoma (BCC)is the most common cutaneous malignancy that arises from the deepest layer of the epidermis and is a relatively non-aggressive, slow-growing tumor. It usually occurs in outdoor workers, laboring for long hours exposed to direct sunlight. The prognosis for these patients is excellent, but if the disease is allowed to progress it may cause significant morbidity mainly due to local tissue destruction and rarely, metastasis. We report two cases of BCC located at unusual sites: the right lateral upper thigh and over the sternum in patients who were indoor workers with no skin exposure to sunlight. Both the patients were managed surgically with excellent outcomes with no requirement of adjuvant treatment.