ntroduction: Enhanced recovery after surgery is widely especially in the colorectal surgery units. However, there is paucity of data in Malaysia context. We report the application and outcome trends over a 1-year period in a colorectal surgery unit of a public hospital. Method: This is a prospective study involving patients who underwent surgery for colorectal cancer in the colorectal unit, Hospital Sultanah Aminah, from August 2020 to August 2021. Results: The cohort comprises 70 patients operated in a 1-year period from August 2020 to August 2021. There were 33 males and 37 females. The mean age was 63.26 years (SD 11.398), (range 25 to 81). Most of them were of American Society of Anesthesiologists (ASA) 2 category (n=43, 61.4%), followed by ASA 1(n=24, 34.3%) and 3(43%) of ASA 3 status. The mean duration of surgery was 171 min (81min to 310min). Anastomotic leak (n=8) and ileus (n=8) were seen in 11% of the study population respectively. There were 6(8.6%) readmissions, with surgical site infection being the commonest reason. The average length of stay was 5.13 days (2 to 18). Of the 26 components of ERAS that were audited for compliance, only 5 showed poor adherence of less than 75% while the rest scored between 75 and 100%. Conclusion: The increase in adherence to ERAS protocol reduced the length of stay and readmission rate. This series demonstrated a low mortality rate, with comparable morbidities to existing standards.

Background: laparoscopic anterior resection (LAR) is a feasible, safe approach and became a widely used for rectal cancer after neoadjuvant chemo-radiotherapy, but short term and oncological outcome for converted cases to open surgery, may be questioned in an obese patient. Objective: validating the short-term and oncological outcomes after laparoscopic resection and after conversion to open surgery for upper rectal cancer in obese patients. Patients and methods: A prospective study included 156 patients, operated in two tertiary hospitals, randomly allocated into two groups. Group I is open anterior resection (OAR), this is the control and Group II, laparoscopic anterior resection (LAR). As a main part of the study we searched the MEDLINE (PubMed), CENTRAL (Cochrane Central Register of Controlled Trials), Scopus, and ClinicalTrials databases for all articles related to laparoscopic anterior resection up to February 2020.The primary endpoint was the validation of difficulty of laparoscopic AR in morbidly obese patients with the achievement of negative resection margin, easy stapling and completeness of TME. The secondary outcomes were short term of oncological outcome mainly locoregional recurrence Results: Laparoscopic group (LAR) included 88 patients and open group (OAR) included 56 patients. LAR patients exhibited early recovery and better functional outcome, less peri-operative and early postoperative sequale, bleeding was less but not statistically significant, less wound infection with significant least significance difference (LSD) 0.001 and proper total mesorectal excision with significant P Value:0.02 and significant LSD: 0.01. Laparoscopic resection showed better oncological outcome specially for longitudinal and circumferential margin, but no statistical difference in retrieved lymph nodes nor early locoregional recurrence and prolonged operative time. Conclusion: The short-term outcome as well as the oncological outcome after LAR are significantly different from those after converted cases in obese patients. but each technique has the same early locoregional recurrence. Conversion to open is burdensome to patient and physician and jeopardize the outcome.

Aim of the study: This systematic review and meta-analysis aimed to analyse post-operative morbidity after liver resection, and also study various factors associated with mortality via metaregression analysis. Material and Methods: PubMed, Cochrane Library, Embase, google scholar, web of science with keywords like liver resection, mortality, hepatectomy. Weighted percentage post-operative morbidities were analysed. Meta-analysis and meta-regression were done by the DerSimonian-Liard random effect model. Heterogeneity was assessed using the Higgins I2 test. Publication bias was assessed using a funnel plot. Funnel plot asymmetry was evaluated by Eggers test. Morbidity was defined as any postoperative morbidity mentioned. Results: A total of 46 studies was included in the final analysis. Total 45771 patients underwent liver resections. 16111 patients experienced complications during the postoperative period. Weighted post-operative morbidity was 30.2% ( 95 % C.I. 24.8-35.7%). Heterogeneity was high with I2 99.46% and p-value 0.01. On univariate analysis, major liver resections were significantly associated with heterogeneity. (p=0.024). However, residual heterogeneity was still high with I2 98.62%, p0.001. So, multifactor metaregression analysis major hepatectomy (p0.001), Open hepatectomy (p=0.001), cirrhotic liver (p=0.002), age (p0.001), blood loss (p0.001), and colorectal metastasis (p0.001) independently associated with postoperative morbidity. Residual heterogeneity was moderate I2= 39.9% and nonsignificant p=0.189. Conclusion: Liver resection is associated with high postoperative morbidity and various factors like major hepatectomy, Open hepatectomy, cirrhotic liver, blood loss, and colorectal metastasis were associated with morbidity and responsible for heterogeneity across the studies.

Aim:Sleeve gastrectomy has been increasingly successful in recent years and the laparoscopic procedure has become the most common for the treatment of morbid obesity, thanks to its feasibility, safety and excellent results. RSG is still expanding, as an alternative surgical option. The aim of the study is to analyze if there are differences between laparoscopic and robotic techniques. Materials and methods: From May 2017 to February 2022, we selected 209 patients suffering from morbid obesity. We analyzed patients who underwent laparoscopic sleeve gastrectomy (LSG) and patients who underwent robotic sleeve gastrectomy (RSG), which were treated at the Department of Medical and Surgical Sciences of the University of Foggia. Results:We studied 209 patients, 153 female and 56 male, who underwent sleeve gastrectomy. The mean age was 41.3 years. The mean weight was 129.7 kg and the mean BMI was 46.4 kg/m2. 67 patients underwent the robotic technique and 142 the laparoscopic one. The mean length of hospitalization was 5.47 days and was the same for both patient groups (p = 0.89). The mean operative time was 63,1 min for the laparoscopic approach and 97,4 min for the robotic technique (including the docking time (p = 0.041). The conversion rate and mortality are zero. There was only 1 case of re-do surgery in a patient undergoing the robotic approach after gastric band failure. We found 3 cases of post-operative complications: 2 leaks treated surgically and one bleeding underwent to medical treatment. Conclusions: There aren’t significant differences between the robotic and laparoscopic groups in terms of length of stay, EWL and complications, except for the mean operative time that is slightly higher in the robotic group and this difference is statistically significant. RSG proved to be a safe and efficient procedure, with satisfactory results comparable to LSG. Longer and larger studies are needed for a better comparative evaluation.

Background: LSG has recently gained popularity as a stand-alone bariatric procedure for teenagers. To our knowledge, there is very little evidence to compare early postoperative weight loss to long-term postoperative weight loss in teenagers. The purpose of this study was to evaluate the early results and short-term outcomes of LSG in morbidly obese adolescents in terms of improved co-mor- bidities, excess weight loss percent and perioperative and postoperative complications. Methods: A retrospective study was conducted on 50 obese adolescents aged 12 to 18 years old with a BMI of at least 40 kg/m2, 35 kg/m2 with accompanying co morbidity, or a BMI for age and gender of the 99th percentile in patients aged 18 years old. Between October 2016 and December 2019, all patients underwent LSG at Tanta University Hospital and its affiliated facilities in Egypt. Up to 12 months after surgery, all patients in our study were evaluated on their weight reduction, eating habits, comorbidity status, and any postoperative complications. Results: Fifty patients had a mean preoperative weight of 132.68 kg and a mean preoperative BMI of 49.6 kg/m2. There were no significant postoperative problems or deaths. Only one patient was readmitted after an average hospital stay of 2.3 days. At 12 months, the average postoperative weight was 78.54 kg, with a statistically significant difference in weight loss. Furthermore, at 6 and 12 months, the average EWL percent was 36.5 and 51.2, respectively, with a statistically significant difference, and the average BMI excess was 22.23 kg/m2. At 1, 3, 6, and 12 months after surgery, the average BMI was significantly lower. All obesity-related co morbidities significantly improved one year postoperatively. Conclusion: This research claims that, LSG is a safe and effective treatment for teenage obesity, with considerable short-term weight loss and comorbidity remission after 12 months.

Introduction: Three ports conventional method of laparoscopic appendectomy is the most preferred technique worldwide. A newer technique, single incision laparoscopic surgery has been developed to gain advantage of one port over three ports like less pain, bet- ter cosmetic result, less chances of wound infection, early return to normal activities etc. This study was carried out to compare these two techniques. Methods: In this prospective study total 120 patients were included; 60 in each group. The parameters analyzed were total duration of surgery, post-operative pain, surgical site infection, mean hospital stay, time taken for return to daily activities and cosmesis after 3 months. Results: Duration of surgery was significantly high in single incision group (median 70 vs 120, p 0.0005). The mean hospital stay, return to normal activity and cosmesis after 3 months were significantly better in single incision group (p 0.0005).However, there were no difference in post-operative pain and SSI. Conclusion: Single incision technique is a safe and alternative procedure for laparoscopic appendectomy. Although operative time was higher, but the duration of hospital stays, return to normal activities and cosmesis were better in single incision approach. Fur- ther randomized control study with large sample size is required for recommendation.

Introduction: Pregnancy with acute Appendicitis is one of the most common surgical emergency in obstetrics. It is associated with maternal and fetal complications so early diagnosis and treatment are life saving. Aim & objective: To study the clinical, laboratory features and maternal and fetal outcome in pregnant patients with acute appendicitis. Methodology: Present study was a prospective study carried out on pregnant patients diagnosed with acute appendicitis. Data included sociodemographic data, clinical history and clinical examination. All patients underwent investigations like Complete blood count, C reactive protein, urine routine and microscopy and USG abdomen. Obstetric outcome and maternal complications were noted. Results & discussion: Majority of the pregnant patients with appendicitis 15(50%) were from the age group of 26-30 years. Majority of the patients 20(66.67%) were in second trimester followed by patients in first trimester 06(20%). Patients in third trimester were 4(13.33%). All the patients were presented with pain. Nausea and vomiting was present in 40% patients each. Out of total 30 patients, 27 patients were operated. 3 patients were on conservative management. In our study, 08(26.67%) patients had bad obstetric outcome. Out of 30 patients 5(16.67%) patients had spontaneous abortion and Premature delivery was seen in 3 patients.

Background: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a procedure that requires a unique set of skills and experi- ence by trained specialists. Post ERCP Pancreatitis is the most common complication occurring in 1.3 to 15.1% of individuals. This study will evaluate the possible patient and procedure related factors causing Post ERCP Pancreatitis (PEP). Methodology: This is a retrospective study involving ERCP done in Hospital Universiti Sains Malaysia (HUSM) over the last 8 years (January 2010 to December 2017).Pancreatitis is diagnosed as presence of epigastric pain and raised serum amylase ( 3 times upper limit of normal value). Result: A total of 394 patients were included for the audit. There was a gradual increase in number of patients throughout the years from a total number of cases of 38 in 2010 up to 91 and 129 in the last 2 years respectively. The most common indications for ERCP procedure were stone disease (n=256) and Obstructive jaundice (n=124). The successful rate of the procedure was about 77.2%. The most common complications were hyperamylasemia (n=41) and pancreatitis (n=39). 21 of the 39 patients with pancreatitis were in- cluded in the PEP study. Most of them had mild pancreatitis with 1 patient with severe pancreatitis based on Ranson’s scoring. Factor stone extraction was found out to be significantly associated with PEP. There were more proportion of patients with incomplete stone extraction found in PEP patients compared to those without PEP [n (%) no PEP vs PEP: 58 (45.0) vs 12 (75.0); p = 0.033]. Pancreatic cannulation was statistically not significant initially in univariate analysis; however, it was found out to be significant after controlling for factor stone extraction. Patients with pancreatic cannulation were at 5.74 times higher odds of having PEP compared to patient without pancreatic cannulation [adj OR (95% CI): 5.743 (1.363, 24.199); p = 0.017]. Conclusion: Our audit showed that our centre has a similar result compared to other international centres in terms of indications and complications of ERCP. Regarding PEP, no patient related factors were significant but in terms of procedure related factors, incomplete stone extraction and pancreatic cannulation were significant.

Introduction: C reactive protein has been shown to correlate with the severity of inflammation. Since the operative difficulty during laparoscopic cholecystectomy is proportionate to the degree of inflammation, this study was carried out to assess the predictive accuracy of high sensitivity C reactive protein (hs-CRP) level with the operative difficulty and outcome. Methods: This was a prospective study, which included patients who underwent elective laparoscopic cholecystectomy. Difficulty during surgery was graded into mild, moderate, severe, and extreme based upon intra-operative parameters. The association of intraoperative difficulty grading with hs-CRP, total leucocyte count, liver function test, and ultrasonographic findings were studied Results: A total of 103 patients were included in the study. 87 patients were found to have mild to moderate difficulty intra- operatively and 16 were found to have severe to extreme difficulty. Association of hs-CRP with operative difficulty was found to have an adjusted odds ratio of 1.25(1.04, 1.51) with a p-value of 0.009. For a cut-off of 9.63, the sensitivity and specificity of hs- CRP were 62.5% and 62.1%. The positive predictive value and the negative predictive value were 23.25% and 90% respectively. For the calculated cut-off, the accuracy of hs-CRP was 62.13% while overall accuracy for hs-CRP was seen to be 70.5% with a confidence interval of 0.553-0.858. Conclusion: The study shows that the preoperatively measured hs-CRP has moderate sensitivity and specificity for predicting the operative difficulty in elective laparoscopic cholecystectomy. The previous history of acute cholecystitis was also found to be an independent predictor of operative difficulty.

Background : Laparoscopic Cholecystectomy (LC) is a gold standard management for symptomatic cholelithiasis. However, LC might be difficult by the various risk factors. Preoperative risk factors are very important for the surgeon and patient in anticipating of difficulty during surgery. This study is to identify clinical, radiological, and perioperative risk factor with difficult elective laparoscopic cholecystectomy in Malaysia. Methods: This is a retrospective record review of patients who underwent elective laparoscopic cholecystectomy from 2013-2018 in single tertiary hospital in Malaysia. The patient’s characteristics, clinical history, laboratory data, ultrasonography results and intraoperative details were retrospectively analyzed to evaluate predictors of difficult LC. Results: A total of 154 patients who underwent elective laparoscopic cholecystectomy and fullfill the criteria were included in our study. The conversion to open surgey rate was 4.5%, the mean operative length was 91.71 minutes and the mean hospital stay post operative was one day. The prevalence of difficult elective laparoscopic cholecystectomy in HUSM was 55.2% (95% CI = 47.3, 63.0). The multivariate analysis showed the patient history of cholangitis (p value=0.006), history of ERCP (p value=0.028), thick gallbladder wall on ultrasound (p value=0.011), dense adhesion (p value=0.001) and fibrosed Calot’s triangle (p value=0.008) intraoperatively had significant association with difficult laparoscopic cholecystectomy. Conclusion: From our study, we can conclude that patient history of cholangitis, history of ERCP, thick gallbladder wall on ultrasound, dense adhesion and fibrosed Calot’s triangle intraoperatively were found to be the predictive factors of difficult LC.

Aim: The aim of our study is to evaluate the role of diagnostic laparoscopy in patients with chronic right iliac fossa pain and document the correlation between laparoscopic and radiological findings. Methods: The study is a 2 year prospective observational study including cases presenting with chronic right iliac fossa pain in which a conclusive diagnosis can’t be made on the basis of other investigations. All patients underwent diagnostic laparoscopy and the findings were documented. Laparoscopy is considered positive if there is a pathological finding present correlating to patient’s symptoms and whether the patient got relieved after subsequent intervention or not. Result: There were total 40 patients, out of which 67.5% were females and 32.5 % were males. Most of the patients (55%) were in the age group of 15-25 years. Majority of the patients (67.5%) presented within 3 months to 6 months duration from the onset of their symptoms. Most of the patients (62.5%) had normal clinical examination. Ultrasonography abdomen had no evident findings in 30 % patients and in remaining 70 % patients the ultrasonography findings were not correlating with patient’s symptoms. In this study we were able to make diagnosis in 92.5 % cases. We were able to diagnose 16 case of recurrent appendicitis (40%). There were 2 case of acute on chronic appendicitis (5%) and one case of Amyand’s hernia (2.5%) with appendix as content of hernia sac. We were able to diagnose 5 cases (12.5%) of abdominal Koch’s. In 10% cases, adhesions were cause of pain. We were able to diagnose 9 patients (22.5%) with gynaecological pathology as the cause of CRIF pain. In our study we were able to diagnose and avoid unnecessary laparotomies in 95 % of patients. Laparotomies were performed in only 2 cases (5%) for open adhesiolysis in which dense adhesions were present. The complications were reported in only 3 patients (7.5%). Overall 90% patients reported improvement of symptoms following intervention. Conclusion: Diagnostic laparoscopy should be performed in selected group of patients with CRIF pain with equivocal radiological diagnosis as an early investigative procedure. In a poor socio-economic country like us diagnostic laparoscopy should be promoted in place of costly radiological investigations as it can provide diagnosis and treatment at the same setting. Recurrent appendicitis is the most common cause of CRIF pain in young adults especially in females.

Aim: to assess the effectiveness of Combining Botox injection with excisional haemorrhoidectomy in 3rd degree haemorrhoids as a post operative pain control strategy. Method: 40 patients were included, randomized into 2 groups, group A underwent Botox injection in combination with surgery, group B underwent surgery only, the 2 groups received oral paracetamol, local anaesthetic for postoperative pain management, they were followed up for pain score after 24 hours and after 1 week and during first bowel motion, return to work, post opera- tive complications and mortality. Wexner score was assessed at 1 week and after 6 months Results: 40 patients were included group A (15 male /5 females) group B (12 male/8 female) mean post operative pain score in the first 24 hours (4) and (7) respectively, mean pain score during the first bowel motion (6) and (8) respectively, mean pain score after one week (3) and (4) respectively. One patient from group A developed and abscess at the site of injection and no other complications or mortality is recorded. Mean time to return to work in group A patients is 8 days and group B (9 days). Mean Wexner score in group a was 2 and group was 1 and after 6 months the mean Wexner score was 0 for both groups Conclusion: Botox injection in combination with excisional haemorrhoidectomy is effective strategy in pain management within the first 24 h post operative

Background: Hemorrhoids are one of the most common diseases in the world, with a high prevalence that includes all age groups and both sexes. Rubber band ligation (RBL) is a non-invasive, non- operative treatment that can be done in an outpatient. Objectives: The study was conducted to determine the effectiveness of (RBL) treatment of hemorrhoids grade I-III and follow-up of these patients to evaluate this type of treatment in terms of symptomatic relief and recurrence of hemorrhoids and its complications. Study design: A prospective, and interventional study was undertaken over the period of 2 years in two private clinics with a sample size of 479 patients with internal hemorrhoids. Result: Out of 479 patients with internal hemorrhoids, 94.8% was male. The success rate was 80.4% and it is a relatively high rate. There were no major complications were noticed in this study, despite of simple minor complication that are encountered in any surgical procedures, include very mild pain (16.2%), retention of urine (14.4%), vasovagal attack (5.2%), mild infection at the site of the procedure (5.6%), thrombosis (5.4%), few drops bleeding (9.6%). All these complications need simple treatments. Conclusions: RBL was easy, non-complicated safe surgical procedure for the treatment of internal hemorrhoids can be done in the outpatient clinic with high rate of successful and minor complications.

Background: The haemorrhoidal disease is one of commonest benign anorectal disorders. Symptomatic hemorrhoids who failed conservative measures will require an intervention. The newer treatment modalities such as stapled haemorrhoidopexy are currently widely practiced to overcome the unfavorable outcomes of excisional hemorrhoidectomy. The objective of this study was to compare two hemorrhoidopexy staplers (MERIL’S 2 - rows with 3 - rows stapler). Materials and Methods: Patients (n=51) from two tertiary hospitals in Malaysia ages between 20 and 69 years presented with symptomatic grade 3 internal hemorrhoids from July 2018 till July 2019 were enrolled in this study The primary endpoint was to see the difference of early postoperative complications which includes postoperative bleeding, recurrence, postoperative pain, and early anal stenosis between 2 staplers. Participants were enrolled after signing informed consent, meeting the eligibility criteria, and receiving randomization assignments. The patients were subsequently assessed at 2, 4, and 12week intervals postoperatively in the surgical clinic. Results: The incidence of postoperative pain was similar at 2 weeks, 4 weeks, and 12 weeks. The incidence of postoperative bleeding was also similar, not showing a positive correlation. There was no difference in early recurrence of haemorrhoidal disease with the use of either stapler. The incidence of early anal stenosis, on the other hand, was also similar in both groups at the end of 3 months and no significant differences were reported.

Background/aim of study: Study the clinical and pathological features of Borderline Ovarian Tumors and evaluating the different surgical procedures and outcome Borderline Ovarian Tumors Patients and Methods: This study is a retrospective study of sixty-six cases diagnosed as borderline ovarian tumors (BOTs) who presented to the Damanhour Oncology Center, Ministry of health, Egypt, during the period from January 2005 to December 2017. Results: the most frequent pathological type was serous (63.6%) and mucinous (31.8%), with all other types accounting for less than 4.5% and the most frequent stage was IA (62.7%) followed by stage IB (17.6%) and IC (7.8%) Median follow-up period for whole group was 20.5 months ranged from 7.to 91.3 months. At the end of the study only one case was died with cumulative overall survival (OS) 98.0%. Conclusion: surgical stage is important prognostic factor for long disease-free survival

Background: Meckel diverticulum (MD) is one of the most common congenital anomalies of the small intestine. Traditionally op- erative management of MD involves laparotomy with diverticulectomy. Today laparoscopic surgery is becoming increasingly pop- ular. However, questions about what type of surgery should be chosen in children with MD still under debate. The aim of this study was summarized own experience in the management of MD in children. Material and Methods: We retrospectively evaluated results of management of 87 patients with MD that treated at L’viv regional children’s clinical hospital «OXMATDYT» for 2010-2019 years. Among all patients, 75 (86.2%) of them required the emergency surgery and 12 (13.8%) underwent the elective surgery. The open laparotomy approached in 66 (75.9%) patients, while 21 (24.1%) patients approached laparoscopically. Results: Segmental ileal resection with anastomosis (19 patients), wedge-shaped resection of MD (37 patients), and simple diver- ticulectomy (10 patients) was applied at the open surgery. Laparoscopic diverticulectomy was performed at 14 patients and tran- sumbilical laparoscopic-assisted diverticulectomy – at 7 patients. Operative time and length of hospital stay was shorter in patients that were operated laparoscopically (p0.05). Conclusion: The diagnosis of MD still remains a challenge because of overlapping clinical features of other acute surgical and inflammatory conditions of the abdomen. Laparoscopy is safe and effective in the management of simple and complicated MD in children. It is useful as both a diagnostic and therapeutic modality. Laparoscopic-assisted approach appears to be safe, feasible, and produces similar results to traditional laparotomy.

Background: The COVID-19 virus sweeps the whole world, with millions of people infected and a hundred thousand dead. This pandemic does not affect normal people only; it affects surgeons also. The number of surgeons worldwide is limited, especially experienced ones at risk of infection and death. Patients pay the cost of surgical shutdown by postponing their scheduled surgical procedure, which may affect their health and make them more morbid. During the pandemic, surgery is limited during the pandemic to emergent cases. There is a need to establish a way to provide surgical service from experienced surgeons without the possibility of virus transmission to these experienced surgical staff. Robotic and robotic telesurgery is emerging, a recent diagnostic and therapeutic tool that offers excellent surgical service without affecting the surgical team. Robotic surgery can be used in different fields of surgery in emergent and non-emergent cases during the pandemic and after the pandemic settles down. The aim: was to evaluate the role of robotic surgery, and Tele-surgery in offering global surgical services for emergent and non- emergent cases during and after the pandemic fades away. It is a way to face future pandemics without affecting higher senior surgical staff, especially during the lockdown period. Evaluate the role of Tele-surgery as a way of continuous training for younger surgeons during the pandemic. Conclusion: robotic and robotic Tele-surgery is an excellent method for providing surgical services by experienced surgeons to patients.

Background: Thyroid cancer is a globally increasing disease. Differentiated cancers are the commonest and fortunately, carry a good prognosis. Patients and methods: This is a retrospective study aiming at analyzing the data of recurrent thyroid cancer patients in a tertiary cancer center in 13 years period. The main objectives were studying the pattern of recurrence, the impact of redo-surgery and the prognosis of these patients. Results: The mean age of the patients was 48 years, and they were predominantly females with papillary thyroid cancer. The recur- rence was mainly nodal (66.3% of patients) and the commonest site of distant spread was the lungs (13.4% of patients). Redo-surgery carried a high complication rate (40.4%). Many factors contribute to persistent disease, of highest significance is the presence of op- erative residue, the elder age and the prolonged postoperative hospital stay. Conclusion: Meticulous surgery and avoiding operative residue are the key for decreasing recurrence and avoiding complications.

The purpose of this case series is to see how successful HFNOT is at preventing postoperative hypoxemia and improving oxygenation in patients undergoing emergency abdominal operations. All the patients were put on High flow nasal oxygen therapy (HFNOT) with a flow rate of 40-60 Litre/min and a FiO2 of 40% after a successful spontaneous breathing trial (SBT). At 12 and 24 hours after extubation, there was a considerable improvement in oxygenation (p 0.0001), as evidenced by an increase in PaO2 values (128± 5.86, 147± 6.70) and improvement in PaO2/FiO2 (320±14.69, 367.9±16.52). We found that HFNOT improves oxygenation in emergency abdominal surgery patients 12 and 24 hours after extubation.

Background: Women with large breasts or women with obesity traditional transverse incision for mastectomy sometimes results in persisted fold of skin at the lateral end of the scar, giving a dog ear deformity, and causes poor cosmoses, interferes with wearing of external breast prosthesis, can be an annoying problem to the patients, and may be a source of a long-term complaint, requiring surgical correction. Aim: Evaluate the access to axilla and prevention of lateral dog-ear deformity after mastectomy with a Y-shaped incision and wound closure specially designed for women with obesity in Zagazig university hospitals. Method: This Clinical study was held in the surgery department at Zagazig University Hospital From Oct 2019 to March 2020. Included 60 obese females (BMI of equal to and more than 35) with cancer breast. Undergoes Y-shaped incision modified mastec- tomy. Results: There were two cases of hematoma and one case for each of flap margin necrosis, surgical site infection, axillary triangle marginal necrosis, and apex necrosis. Conclusion: According to our study the end of operation scare was cosmetically satisfied to operator and all patients with better outcome and less complication and hospital stay. In obese women Y shaped incision can overcome cosmetic operation obstacles and provide excellent accessibility to axilla and satisfied scare and less complication.

Background: The self-reported prevalence of constipation is higher in black South Africans when compared with other races. De- layed stool transit increases the time that the colonic lumen is exposed to carcinogens linked with colorectal cancer (CRC). Thus, constipation is a potential marker for identifying black African patients at risk for adenomatous polyps or CRC who could be fast- tracked for colonoscopy in resource-limited settings. Objective: TodescribetheproportionofabnormalcolonoscopieswithfindingsofadenomatouspolypsorCRCamongblackSouth Africans undergoing investigation for constipation. Methods: A retrospective chart review was performed involving 141 black African patients who underwent colonoscopy for con- stipation at a regional hospital in Durban, South Africa from October 2014-October 2017. Data extracted from each patient’s chart included demographics and the colonoscopy findings. The data were analysed descriptively and with the z-test. Results: A total of 53/141 patients (37.6%) had abnormal colonoscopies. Of the 53 patients with abnormal colonoscopies, adeno- matous polyps were identified in 4 patients (7.5%), while CRC was identified in 6 patients (11.3%). For patients with abnormal colonoscopies, the proportion of adenomatous polyps and CRC was similar in younger and older age groups (p=0.136 and p=0.342). The proportion of adenomatous polyps and CRC was similar in females and males with abnormal colonoscopies (p=0.246 and p=0.308). Conclusion: Approximately1inevery3blackSouthAfricanswithconstipationhadabnormalcolonoscopies.Anotableproportion of patients with abnormal colonoscopies had adenomatous polyps or CRC. Black South Africans presenting with constipation should be fast-tracked for colonoscopy.

Η Διοίκηση Ολικής Ποιότητας περιλαμβάνει όλες τις λειτουργίες μέσω των οποίων οι ανάγκες και οι προσδοκίες του πελάτη και της κοινότητας, καθώς και οι στόχοι του οργανισμού εκπληρώνονται με τον πιο αποτελεσματικό και οικονομικά αποδοτικό τρόπο, μεγιστοποιώντας τις δυνατότητες όλων των εργαζομένων σε μια συνεχή προσπάθεια βελτίωσης. Σε αυτό το πλαίσιο, η ικανοποίηση των ασθενών είναι ένας σημαντικός και συχνά χρησιμοποιούμενος δείκτης για τη μέτρηση της ποιότητας στην υγειονομική περίθαλψη. Στο παρελθόν έχουν διεξαχθεί αρκετές έρευνες που εξετάζουν την ικανοποίηση των ασθενών από την ποιότητα των παρεχόμενων υπηρεσιών των νοσοκομείων χωρίς να έχει δοθεί ιδιαίτερη έμφαση στην ικανοποίηση των εσωτερικών πελατών, δηλαδή των επαγγελματιών υγείας. Ωστόσο, η απόδοση τους είναι ζωτικής σημασίας για τη συνολική απόδοση του Νοσοκομείου και το αποτελεσματικό σύστημα υγειονομικής περίθαλψης. Σκοπός της παρούσας βιβλιογραφικής ανασκόπησης είναι η αποτύπωση της συμβολής της Διοίκησης Ολικής Ποιότητας στις υπηρεσίες Υγείας και στην ικανοποίηση των εργαζομένων σε αυτές

Introduction: Negative pressure wound therapy (NPWT), or vacuum-assisted closure, is a supportive treatment used in the healing of open wounds that apply sub atmospheric pressure to the surface of diabetic wounds Material and methods: A Randomized controlled study including 60 patients randomized into two groups 30 patients for (NPWT) &30 patients for conventional dressing, suffering from diabetic foot wounds with infection, necrotic tissue, ulcer. Results: (43.3%) in the NPWT group were females, (56.7%) were males. (36.7%) in the Conventional treatment were females whereas (63.3%) in the Conventional treatment were males. Both groups were classified according to the type of the wound, clean or infected, the need of surgical debridement, intervention. At 3 months follow up, group NPWT 24 (85.7%) cured with complete healing, 4 (14.3%) patients grafting was done, also 2 of 30 patients stopped, one withdrawn his consent and the other had below- knee amputation (BKA). In the conventional dressing group, 14 (51.9%) only had complete healing and 4(14.3%) grafted, 9(33.3%) of 30 patients still on dress- ing, 3 patients lost from analysis of the study with major complications in the form of major amputation. Conclusion: granulation tissue rate, wound surface area, graft take was better in the NPWT group as compared to the conventional dressing group, also the overall hospital stay, amputation rate were less in the NPWT. Thus, NPWT can be considered as a superior option in the healing of the diabetic wounds, decreasing amputations rate in diabetic foot.

Background: Buerger’s disease is a non-atherosclerotic inflammatory angiopathy, characterized as inflammatory endarteritis. It affects small and medium size arteries and veins of the upper and lower extremities, and is often associated with high amputation rates. Treatment of Buerger’s disease remains rather challenging as most pharmacological therapies are unable to prevent disease progression. Case presentation: We present a case of a 65-year-old female patient with Buerger’s disease who was successfully treated with prostaglandins in a public hospital of the capital city of Greece, Athens. Treatment was administered intravenously in-hospital for a total duration of 28 days. By the end of treatment, pain was better tolerated and lower limb ulcers had significantly improved. Follow-up evaluation revealed the patient’s condition remained stable. Conclusion: Prostaglandins may play an important role in the treatment of the Buerger’s disease. Intravenous administration of prostaglandins relieves pain, improves wound healing and reduces the rate of amputation in patients with Buerger's disease.

Pseudoaneuryms of visceral arteries are relatively rare. They carry high risk of rupture and may have misleading presentation leading to delay in diagnosis and treatment. We observed a case of a 53-year-old lady with the presentation of obscure-overt gastrointestinal bleeding associated with ob- structive jaundice. This patient had underwent computed tomography scan after repeated endoscopy failed to reveal the cause of bleeding, which has showed an arterially enhancing lesion at liver segment V with its supply from accessory right hepatic artery origin from superior mesenteric artery. A subsequent digital substraction angiography demonstrated a large multilobulated pseu- doaneurysm of this artery and successful embolization performed using gelfoam. A followup CT scan in 1 month later showed thrombosed pseudoaneurysm. We have learned that high suspicion of biliary disorder should be made when gastrointestinal bleeding is associated with jaundice. An early imaging should be considered when repeated endoscopy is unable to determine the cause of bleeding. Non operative management using transcatheter embolisation can be the treatment of choice in pseudoaneu- rysms to avoid potentially risky and difficult surgery.

Primary lymphomas of the small bowel are rare. Despite their rarity, primary lymphomas of the small bowel are poses significant challenge to clinicians since their evaluation, diagnosis, management, and prognosis are distinct from the lymphoma at othersites and other types of gastro intestinal tract tumours. He we report an unusual presentation of ileal Burkitts lymphoma presenting as ileocolic intussusception in an adult. We present an interesting case of 65-year-old gentleman with hypertension and type 2 diabetes mellitus presented to us with right lumbar abdominal pain associated with constitutional symptoms with physical examination showing right lumbar mass. All relevant investigations were carried out. CT Abdomen showed terminal ileal mass with no distant metastasis while colonoscopy revealed mass at terminal ileum with histopathological assessment suggestive of Burkitts lymphoma. Following a multidisciplinary team discussion patient underwent right hemicolectomy followed by systemic chemotherapy and currently relapse free.

Transverse colon volvulus is rare among the colonic volvulus, usually presented as a surgical emergency at the second and third dec- ades of life. We present a rare case of transverse colon volvulus in a 27-year-old man who complains of sudden onset of generalised abdominal pain and distension associated with bilious vomiting for three days. On examination, the abdomen is distended and tender on palpation. Chest radiography showed Chilaiditi’s sign and non-specific “coffee bean” sign on the abdominal radiography. Computed Tomography (CT) scan of the abdomen suggestive of transverse colon volvulus. Emergency laparotomy with transverse colectomy was performed and we found the transverse colon volvulus twisted along the narrowed transverse mesocolon. Segmental colectomy was our treatment of choice for colonic volvulus because of acute presentation of intestinal obstruction and lower recurrence rate. Colonic endoscopic decompression would have been an alternative initial approach in those who did not present with clinical suspicion of peritonitis, however, this was associated with a higher risk of perforation due to the proximal site of the volvulus and recurrence compared to colopexy or segmental colectomy.

Aortic graft infection with anaerobic organism is uncommon. The clinical implications, natural history, and optimal therapy of anaerobic infections are still unknown. Extensive review of the literature disclosed only one case of Clostridium perfringes aortic graft infection[1]. There are infrequent reports of aortic graft infection by anaerobic organism. These infections have been ob- served to be closely related to large bowel pathologies. This report represents our only encounter with clostridial infection of an aortic graft following emergency aneurysmectomy with inlay graft repair. Its clinical significance and management are discussed

Anatomy of the biliary tree is made up of a complex system with multiple variants of the intrahepatic and extrahepatic ducts. Thorough and in-dept knowledge of the extrahepatic biliary anatomy and its variants coupled with imaging modalities and a high index of suspicion while operating will help prevent major catastrophe when performing hepatobiliary surgery. We report a case of a lady presenting with obstructive jaundice secondary to distal common bile duct stone. An incidental finding of an aberrant right posterior sectoral duct draining into the cystic duct was identified during endoscopic retrograde cholangiography. She sub- sequently was planned for laparoscopic cholecystectomy. Her surgery was uneventful, and no biliary injury was encountered. A thorough knowledge of the extrahepatic biliary anatomy and its variants coupled with imaging modalities and a high index of suspicion while operating will help prevent major catastrophe

Anorectal abscesses are one of the most common problems in Diabetic patients. One of the sequelae is a recurrent abscess or complex fistula-in-ano, which could lead to patient rapiddeterioration, pelvic sepsis and reduce the quality of life. However, com- plex anorectal abscess with impaired defecation function is extremely rare. This condition and plan of treatment should be appro- priately addressed. We reported a case of complex recurrent anorectal abscess complicated with anal stricture, that patient pre- sented with faecal incontinence.

Quite often hemangiomas of the liver are found accidentally in prophylactic studies or are an accidental finding in operations on another occasion. In most cases, hemangiomas are cavernous, less commonly capillary or mixed. A higher percentage are single than multiple. Despite the proven benignity of the process, the presence of hemangiomas is associated with a risk of rupture and acute bleeding. We present three cases of spontaneous rupture of hepatic hemangiomas and a detailed literature review on the topic, in support of the thesis that hepatic hemangiomas rupture. The clinical - pathological and operative factors of three cases of spontaneous rupture of hepatic hemangioma were prospectively studied. Between 2007 and 2015, 3 women with spontaneous rupture of hepatic hemangioma were operated on in our institution. Two of them are of the subcapsular rupture type, and the third has a spontaneous rupture to the free abdominal cavity and hemoperitoneum.The treatment of patients with symptomatic giant hemangiomas should be modified individually by systematic follow-up or even prophylactic resection in selected cases.