The spleen has several important functions in the human body, the leading of which is protective Therefore, its removal is often not safe, but is accompanied by various complications, primarily infectious and vascular, which can occur even 20 years after surgery. The most serious consequence of asplenia is the development of instant sepsis, which is accompanied by mortality of up to 70%. Therefore, it is important, first of all, to prevent infection in these patients. Using the literature from the MedLine database, modern ideas about the immunological function of the spleen, the pathogenesis of complications and the main ways of prevention, including the use of vaccines, antibiotics, are described. Particular attention is paid to the awareness of people with asplenia or hyposplenism.

Microsurgical methods, such as free vascularized lymph node transfer (VLNT) and lymphatico-venous anastomosis (LVA), have been increasingly used in the last two decades to treat lymphedema patients. The aim of our study was to evaluate the effective- ness of VLNT in the management of upper and lower limb secondary lymphedema in a long-term follow-up period. During a period of 8 years, 782 patients were examined in our lymphedema clinic with primary or secondary upper or lower limb lymphedema. From a total of 137 surgically managed patients, 92 underwent a VLNT. Their mean age was 48.3 years and mean BMI 28.4. The values concerning the volume of the affected limbs, the infection rates, the feeling of pain and heaviness and the overall function, were measured at the induction of patients in the study and at the last follow-up appointment. Follow-up ranged from 28 to 120 months. Postoperative lymphoscintigraphy of the operated patients showed positive findings in 78,9% of our cases. The mean volume of the affected limb was decreased by 55.2% at the last follow-up examination, the infection episodes were significantly reduced, and all patients reported significant reduction of pain and feeling of heaviness of the affected extremity with an overall functional improvement. The vascularized lymph node transfer represents an effective microsurgical procedure in volume reduction, decrease of infections, and functional improvement of secondary upper and lower limb lymphedema patients.

Background/aim of the study. Biopsy of sentinel lymph nodes in case of malignant skin melanoma was first performed by Don- ald Morton et al. in 1992, aiming to avoid frequent postoperative complications of elective lymph dissection. The purpose of this article is to present our innovations in performing sentinel lymph node biopsy with Patent Blue V in patients with malignant skin melanoma which improves its efficiency and thus helps other teams using the same technique. Material and Methods: The double-detection method for sentinel lymph node biopsy was performed on 58 patients. The aver- age duration of the procedure was 30 minutes. The highest percentage (39.7%) of our patients with sentinel biopsy were those with tumor thickness between 1.1 and 2.0 mm according to Breslow’s depth classification. Our modifications included: - a more significant number of sites for injection of Patent blue V (8-10 sections); - additional injection of 1 ml Patent blue V at the primary site; - warming of the area of injection of Patent blue V to accelerate the resorption of the colorant in the lymphatics and better col- oring of the nodes. Results. The success rate in finding the sentinel lymph nodes employing the double-detection method (scintigraphy and a color- ant) was 96.5%. Conclusions. The rationalizations which we present increased the percentage of successful sentinel biopsies using double detec- tion method including Patent Blue V. They could be an alternative to the manual gamma-probe for sentinel biopsy for any surgi- cal team that does not have one.

Aim: The analysis aimed to study the effect of preoperative pulmonary rehabilitation on post-operative pulmonary complications, overall morbidity, and mortality after esophagectomy. Methods: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (2020) and MOOSE guidelines. The meta-analysis was done using Review Manager 5.4. We compared post- operative pneumonia, postoperative pulmonary complications, morbidity, and mortality between the preoperative respiratory Prehabilitation group vs. no prehabilitation group. Heterogeneity was evaluated using the I2 test. The random-effect model was used with I2 was more than 25% otherwise fixed-effect model was used. I2 less than 25%, 25-50%, and more than 50% were taken as low, moderate, or high heterogeneity. Results: Seven studies consisting of 606 patients were included in the analysis. 322 patients in the respiratory prehabilitation group and 284 in the control group. There was no statistically significant difference in postoperative pneumonia (p=0.11), post- operative pulmonary complications (p= 0.09), All cause morbidity and mortality. (p=0.98, and 0.30 respectively). However, heter- ogeneity was moderate to high in most analyses. Conclusion: There is no conclusive evidence as of now regarding the benefits of preoperative pulmonary rehabilitation in esoph- agectomy. However, further studies are needed to confirm it.

Aim: This systematic review and meta-analysis aimed to study the incidence of acute kidney injury after liver resection and to analyze various factors affecting it by metaregression analysis. Methods: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (2020) and MOOSE guidelines. The meta-analysis was done using Review Manager 5.4 and the JASP Team (2020). JASP (Version 0.14.1) (University of Amsterdam). Weighted percentage incidence with 95% confidence intervals were used. Univariate metaregression was done by DerSimonian-Laird methods. Factors with a p-value less than 0.05 in the univariate meta regression model were entered in the multivariate metaregression model. Heterogeneity was assessed using the Higgins I2 test. The random-effects model was used in meta-analysis. Results: Total 14 studies including 15510 patients were included in the final analysis. 1247 patients developed Acute Kidney Injury. Weighted Acute kidney injury percentage after liver resection was 15% with a 95% confidence interval of 11%-19%. On univariate metaregression analysis major hepatectomy (p=0.001), Underlying cirrhosis of liver (p=0.031), AKIN definition used (0.017), male sex (p<0.001), open surgery (p=0.032), underlying diabetes (0.026). On multivariate metaregression analysis major hepatectomy (p=0.003), underlying cirrhosis (p<0.001), male sex (p<0.001), AKIN classification used for defining acute kidney injury (p < 0.001, independently predicted heterogeneity and hence acute kidney injury. Conclusion: Liver resection is associated with a high incidence of acute kidney injury. Major hepatectomy, male sex, underlying cirrhosis were independently predicting acute kidney injury.

Background: Laparoscopic Sleeve Gastrectomy (LSG) is a form of bariatric surgery which helps to achieve sustainable weight loss in obese patients. Objectives: To evaluate the efficacy and benefits of LSG in diabetic control amongst obese patients in Hospital Tuanku Ja’afar Seremban (HTJS). Methods: Cross sectional study of all obese patients with type 2 diabetes mellitus (T2DM) who had undergone Laparoscopic Sleeve Gastrectomy (LSG) in HTJS from 2012 to 2016. Various parameters including body mass index (BMI), fasting blood glucose (FBG) and HbA1C levels before and after LSG were compared and analysed. Results: 8 patients with T2DM underwent LSG between 2012 and 2016. Mean age of 44.25 (range of 22-55). Their weight ranged between 83-171 kg (BMI 35.3-61). All patients had poor glycaemic control preoperatively as evidenced by an average FBS of 8.48 and HBA1C of 7.77. Almost all patients had drastic drop in glycaemic control as early as one month. On average, all patients had their HBA1c reduced by 27.7% (range of 12.3-45.7) from their initial value. Duration of diabetes has no significant association with diabetic remission (p=0.46). Conclusion: LSG not only helps to achieve ideal body weight but also to accomplish sustainable glycaemic control in obesity.

Background: Despite the recent advances in imaging modalities for the investigation of abdominal trauma the precise diagnosis of urgent exploration is not always possible. There is a great danger that an injury to the diaphragm or intestines may be overlooked. That widens the Indications for exploratory laparotomy to the extent that up to 27% of exploratory laparotomies turn out to be non- therapeutic negative explorations. Aim and objectives: Evaluate the efficacy and safety of laparoscopy and its role in patients with blunt abdominal trauma (BAT) and assess the added role of laparoscopy over the traditional imaging modalities such as Computed tomography (CT). Patients and methods: This study was a retrospective comparative study carried out from April 2018 to April 2021 and included 35 patients of adult male and female trauma patients at Assiut University Hospital, Trauma unit who presented blunt abdominal trauma after resuscitation and doing the routine examination and investigations. Result: The study included Patients aged between 20 and 58 years with a mean BMI 25.33 kg/m2. 65.7% of the patients were males, CT was significant in detecting intra-abdominal injury sensitivity was 93.94%, specificity was 100%, NPV was 50% and PPV was 100% with an accuracy of 94.3%. In the studied patients, 93.9% of the patients with intra-abdominal injury detected with laparoscopy were positive in CT. Therefore, there is a significant agreement between CT and laparoscopy. Conclusion: Dealing with trauma patients needs a cooperative trauma team with a fast and systematic approach. Both clinical and radiological diagnoses are complementary. But also some patients may need additional modality as laparoscopy to avoid unneeded abdominal exploration.

Objectives: Evaluation of outcomes of the non-operative management (NOM) of patients who had a blunt splenic injury (BSI) and the predictors for such outcome. Patients & Methods: The study included 95, 68, and 61 patients of grades I, II, and III, respectively, according to the AAST grading of splenic trauma. Patients were evaluated at the intermediate care unit for trauma extent and severity using the New Injury Severity Scale (NISS), consciousness using Glasgow Coma scale, hemodynamic status, and gave blood samples for estimation of hemoglobin concentration (Hb. conc.). Patients who showed deterioration were shifted either to urgent splenectomy or admitted to ICU. The success rate of NOM was defined as control of hemodynamic instability if present, stable splenic injury, the quantity of hemoperitoneum if present with no need for ICU admission for any indication, and survival rate of patients who had succeeded or failed NOM. Results: During NOM, 29 patients were admitted to ICU, 21 patients underwent urgent splenectomy and two patients deceased. Fifteen of patients admitted to ICU completed their NOM uneventfully and 5 patients underwent elective splenectomy, while 9 patients were deceased. Five of the 26 patients who underwent splenectomy died. The total survival rate was 92.9%; 187 patients completed NOM (94.4%) and 21 had surgery (80.8%) with a significant difference in favor of NOM. Statistical analyses defined high at admission Hb. conc., young age, normal SBP, low NISS score, and low AAST grade were the predictors for NOM success with decreasing order of importance. Kaplan-Meier regression analysis defined SBP at 106 and 104 mmHg as the cutoff points for the probability of NOM success and survival. Conclusion: Proper selection of BSI patients allowed a high success rate (83.5%) and survival rate (94.4%) of NOM. Young aged patients with low NISS scores and high SBP and hemoglobin concentration are the ideal candidate for NOM with suspected high success and survival rates, irrespective of injury grade. High SBP and low NISS scores are the best predictors with high positive predictive value and sensitivity for the success of NOM.

Background: Post-operative adhesions are the most common cause of small bowel obstruction and are a significant source of morbidity. Gastrografin is of diagnostic and therapeutic benefit. This study aims to review the local management and outcomes of adhesive small bowel obstruction (ASBO) and specifically the role of gastrografin. Methods: This retrospective cohort study was conducted between January 2020 to July 2021 at two regional hospitals in Kwazulu- Natal (KZN). All patients admitted with ASBO during the study period were included. Details regarding existing co-morbidities, number and type of previous surgeries and the clinical, radiological and biochemical findings on admission were collected. Out- come measures such as length of hospital stay, post procedural morbidities and mortalities were analysed. Results: Of the 77 patients admitted; 49 were male (64%) and 28 females (46%). The commonest previous surgery performed was laparotomy for appendicitis. Gastrografin was administered in 58 patients (77%) of which successful resolution of symptoms was seen in 24 patients (41%). Operative management (OM) was undertaken in 53 patients (67.5%). Significant predictive risk factors for OM included peritonitis (p =0.004); metabolic acidosis (p = 0.003) and the presence of feculent material in the nasogastric tube (NGT) (p = 0.0013). Conclusion: Peritonitis, metabolic acidosis and feculent effluent in the NGT was associated with an increased risk of surgery but did not predict the presence of ischemic bowel. Further study is warranted as this may save health care costs and reduce patient expenditure.

Introduction: Fournier’s gangrene(FG) is an acute, rapidly progressive, necrotizing fasciitis of the scrotum, perineal and perianal region causing gangrene of the skin and subcutaneous tissue. FG is associated with a high mortality rate of 14 %. Methods: Out of 101 patients were admitted from 1st may 2014 to 31st may 2019, with a diagnosis of Fournier’s gangrene or ex- tended Fournier’s gangrene (eFG), 93 patients were included in the present study. Results: FG is associated with a high mortality rate of 14 %. Fournier’s Gangrene Severity Index(FGSI) score at admission of more than 9 is associated with 92.8% mortality and a score lesser than 9 is associated with 100% survival. Conclusion: The study found that certain factors like delayed admissionintohospital,feverandalteredsensoriumatthetimeofadmis- sion;cirrhosisofliver and presence of more than 1 premorbid illness, hypotension, thrombocytopenia, hypoalbuminemia,acidosisand acutekidneyinjuryatthetimeofadmissionhad impact on the outcome of FG or eFG .

Background: Infantile hypertrophic pyloric stenosis (IHPS) remains the most often cause of projectile vomiting in infants during first month of life that required surgical correction. During many years open pyloromyotomy remains a gold standard of treatment in newborns with IHPS. Today, laparoscopic pyloromyotomy gradually accepted by pediatric surgeons. However, there are still contradictory results in the literature regarding the benefits and disadvantages of laparoscopic compared to the open procedure to treat infants with IHPS. The purpose of the study was to analyze cases of IHPS treated at L’viv regional children’s clinical hospital «OXMATDYT» using the open and laparoscopic technique. Material and Methods: A retrospective study was conducted 98 cases of IHPS treated from January 2009 to December 2020. The patients were divided into two study groups, depending on surgical approach. The patients from the first group were operated by open pyloromyotomy (OP) and patients from the second group underwent laparoscopic pyloromyotomy (LP). Results: OP was performed in 76 patients and 22 patients were operated laparoscopically. The operation time was slightly shorter in open group, but this difference was insignificant (p=0.124). Despite a slightly shorter operative time in OP group, these patients more often had postoperative vomiting (15.8%) and significantly longer time to start oral intake (7.9±1.7 hours, p0.001) compared with patients of LP group. The perforation of mucosa was noted in one child of LP group. The frequency of wound infection was almost the same in both groups of patients (p=0.906). Incisional hernia (2.63%) and adhesive bowel obstruction (2.63%) were noted in case of OP. Conclusion: Both technics are the safe and effective for the treatment of patients with IHPS. Laparoscopy has several advantages over open pyloromyotomy, without additional complications.

Background: Inguinal lymphadenectomy is performed in both therapeutic and prophylactic scenarios for lower limb and genitourinary malignancies. Video endoscopic inguinal lymphadenectomy (VEIL) is a relatively new solution that may decrease the morbidity of the procedure. This is a prospective pilot study, where patients with cutaneous and genitourinary cancers admitted to the hospital from March 2017 to October 2018 were included. The enrolled patients underwent VEIL via superolateral inguinal approach. This study aims to evaluate the feasibility, safety, and short-term outcomes of the superolateral VEIL approach. Results: 23 patients underwent VEIL and were followed-up for a period ranging from 5 months to 2 years. 18 patients underwent unilateral and 5 underwent bilateral VEIL (total 28 limbs), VEIL has succeeded in 27 limbs. The number of excised lymph nodes per limb was 9.9 + 4. The wound complication rate was low, occurring in only 2 limbs (7.4%). Recurrence occurred in 7 cases, 1 isolated local, 3 nodal and 3 distant (2 with concomitant local). During the follow-up period 3 succumbed of visceral metastasis and 1 of pulmonary embolism. The patients showed high cosmetic satisfaction. Conclusions: VEIL is a safe and feasible technique for patients with vulvar, anal, and cutaneous carcinomas. It allows a decrease in post-operative morbidity without compromising the oncologic control.

Background: Inguinal hernia repair is the most frequently performed operation in general surgery. The Lichtenstein repair involves the implantation of a mesh prosthesis ventral to the transversalis fascia.Postoperative pain and disability are frequent after the introduction of tension-free surgical repair with the use of prosthetic mesh, patient's comfort was reported to be substantially improved over that obtained by the traditional, tension-producing techniques. The use of cyanoacrylate (CA) as a way of securing the mesh could lead to better results and avoid tension on the pubis, muscles, or nerves. Method: Prospective observational study for 6 months at General Surgery Department at Zagazig University Hospitals.24 patients were divided into two groups: group A undergoes hernioplasty using glue for mesh fixation and group B using sutures fixation. Patients were followed for 6 months for post-operative pain, recurrent, and complication. Results: In our analysis mean age of the glue group was 50±7 years while in the sutures group was 49.3±6.7 years. mean operation time in the glue group was 41.2±5.1 min while in the sutures group was 47.6±4.9 min with statistically significantly higher mean operation time in the sutures group. In long-term follow-up showed no significant difference between both groups. Conclusion: According to the results obtained in our study, it seems that the Histoacryl glue can be a good alternative for the fixation of mesh in Lichtenstein inguinal hernia repair, mimicking the tissue incorporation and mechanical behavior of sutures with a shorter operating time. It is accompanied by a reduction in chronic inguinal pain

Background: Spontaneous pneumothorax and/or subcutaneous emphysema are a rare complication of COVID-19 pneumonia. These are may be caused by structural lung damage or may be increased with using continuous positive airway pressure (CPAP) respiration. Here in this study, we will describe the association of pneumothorax and subcutaneous emphysema with COVID-19 infection. Methods: The study include 18 patients in Najaf, Iraq. Ten patients with pneumothorax, 2 patients with hydro-pneumothorax and 6 patients with emphysema over a period of four months. Results: The pneumothorax was diagnosed in 55.55%, subcutaneous emphysema was diagnosed in 33.33%, while hydropneumothorax was diagnosed in 11.11%. There were 4 out of 18 patients on CPAP (22.22%), one patient developed subcutaneous emphysema and three patients end with pneumothorax, p-value 0.003. The right side is most commonly affected by pneumothorax 44.44%. Tube thoracostomy was done in 66.66% for all patients with pneumothorax and hydropneumothorax, while the observation was done for 33.33%of patients. The mortality was occurred in 1/18 patients (5.55%), p-value 0.001. Conclusion: COVID-19 pneumonia may be complicated with spontaneous pneumothorax and subcutaneous emphysema so, the pa- tient of COVID-19 infection should be monitored carefully to detect such a rare complication.

Background: Early diagnosis and isolation of coronavirus cases contributed to reducing the spread of the pandemic. This can be achieved through systematic population screening with real-time polymerase chain reaction (PCR) test or rapid Sars-Cov-2 anti- gen test for COVID-19. Objective: The purpose of this study was to highlight the factors that led citizens to carry out a coronavirus test. Methodology: A retrospective study was implemented. The study population consisted of citizens who visited a Primary Healthcare Centre in Northern Greece to undergo a coronavirus test. The data were collected for the period October 2020 to May 2021. Results: The study population included a total of 6,601 people, of which 3,891 people performed PCR tests and 2,710 people performed rapid tests for the coronavirus. Among the people who came for PCR tests, 58.5% were females, while the corre- sponding percentage in the case of rapid tests was 63.4%. The most common reasons for carrying out PCR tests were case con- tact (37.3%), fever (35.4%), pharyngitis (11.3%), and anosmia (5.1%). In the case of rapid tests, the most common reasons were screening (38.1%), fever (18.7%), case contact (12.9%), and pharyngeal pain (11.8%). During the autumn and winter months, more people came for PCR tests due to contact with a positive case (40.5%) compared to the spring months (31.1%) (p 0.001). During the autumn and winter months, more people came for rapid tests for precautionary reasons (53.7%) compared to the spring months (29.8%), (p 0.001). People who came for rapid tests due to shortness of breath were older (mean age = 68.2) than the others (p 0.001). Similarly, subjects who underwent PCR tests due to dyspnea were older (mean age = 55.5) than the others (p 0.001). Conclusions: Carrying out a coronavirus screening test is one of the most important measures to control and contain the pan- demic, as nowadays, the basic test for the detection of coronavirus is the rapid test, which has significant advantages over the molecular test.

Background: Centers performing high-volumes of thyroid surgery commonly report lower complication rates than low-volume centers. Typical thyroid surgery complications include recurrent laryngeal nerve injury, hypoparathyroidism, external branch of the superior laryngeal nerve injury and haemorrhage. The aim was to assess the prevalence of complications of all thyroid operations over a 5-year period. Methods: An audit was performed at Kalafong Provincial Tertiary Hospital, Pretoria, South Africa, of all thyroid surgeries, in patients 18 years and older, from 1 January 2015 to 31 December 2019. Results: Ninety-six thyroid operations were performed of which the majority were female (93.8%). The majority of patients, 68 (71.6%), did not have any complications. There were 25 (26.9%) patients that had thyroid surgery complications, but 27 complications in total (2 patients had 2 complications). There were 18 transient complications and 8 permanent complications. The majority of the transient complications were due to hypoparathyroidism, 14 (14.7%), followed by 4 (4.2%) recurrent laryngeal nerve injuries and 1 (1.1%) post-operative haemorrhage. The permanent complications were due to hypoparathyroidism in 7 (7.4%) patients and 1 (1.1%) patient with recurrent laryngeal nerve injury. Age (P= 0.466), thyroid diameter (P= 0.711) and thyroid weight (P=0.540) were assessed as risk factors for surgical complications of which none were statistically significant. There was a correlation between thyroid surgery complications and the use of ligasure (P= 0.019). Conclusion: A center performing low volumes of thyroid surgery can provide thyroid surgery with acceptable complication rates. Transient hypoparathyroidism was the most frequent complication of thyroid surgery.

Background: New techniques and devices are recommended to accelerate recovery and reduce post-surgical pain, complications, and recurrence in hemorrhoidectomy. We aimed to compare the use of conventional suture and LigaSure in the Milligan Morgan hemorrhoidectomy in terms of effectiveness and its effects on the quality of life in the 1-year postoperative period. Materials and Methods: The patients who underwent an operation for grade 3 or 4 hemorrhoidal disease between January 2018 and January 2019 were included. LigaSure was administered to the patients in group-1, and suture ligation was administered to the patients in group-2. The groups were compared by questioning the social, functional, and clinical aspects of quality of life with multiple choice questions prepared by the researcher. Results: A total of 57 patients, 32 patients in the LigaSure group and 25 patients in the suture group were operated. The mean age of the patients was 46 (22-82). Pain control was achieved in an average of 4 days in the Ligasure group and 7 days in the suture group, and the difference was statistically significant (p0.05). The main difference between the groups in terms of quality of life was clinical, and clinical complete recovery was observed in 29 (90%) patients in Group 1, while this rate was 64% with 16 patients in Group 2 (p0.05). Conclusion: When LigaSure is used in the Milligan Morgan technique, the need for postoperative analgesic and bleeding are reduced, life quality of the patients’ increases, but its applicability worldwide is limited in economic terms.

Background: Superior mesenteric artery (SMA) syndrome is a manifestation of duodenal obstruction due to external compression caused by the superior mesenteric artery. This happens when there is narrowing of the aortomesenteric angle which results in the duodenum being impinged by the superior mesenteric artery and the aorta resulting in obstruction. It is an uncommon entity and there are less than 400 cases reported in the literature. We present a review of five patients that were managed at our institution using endoscopically inserted double lumen nasojejunal tube feeding discussing their presentation, management and outcomes. Case presentation: There were five patients that presented to our institution between May 2019 and May 2020 for SMA syndrome with symptoms of abdominal distention and vomiting. The patients were between 19 to 49 years of age and there was equal male to female distribution. Three patients were managed conservatively non-operatively and two patients eventually required a duodenojejunal bypass procedure. All patients had complete resolution of symptoms and remain well with good nutritional outcomes on follow up. Conclusions: SMA syndrome can be managed non-operatively using a nasojejunal tube without the morbidity of parenteral nutrition and central line related complications. However, surgical intervention may be required in cases with no improvement with such measures and can be done with good outcomes.

Introduction: Globally, Injuries and fatalities occur in all forms of transportation but road traffic accidents accounts rank first among all causes. Head injuries are leading causes of death from motorized two wheeler accidents with significant mortality de- spite optimal use of the standard medical facilities. Material and methods: This prospective observational study was conducted in the Department of General Surgery, MGMMC, Indore to see the magnitude of head injury due to motorized two wheeler road traffic crash. Result: A total of 251 cases of head injuries due to motorized two wheeler crash were reported for the study. Riders constituted (79.3%) and pillion riders (20.7%). Most victims were male (88.88%). Majority of victims were not wearing helmet. Linear fracture of vault (37.8%) was the commonest pattern of fracture observed in two wheeler accidents. Conclusion: This study highlights that wearing helmets by the two-wheeler riders are very essential in preventing injury and re- ducing the casualty during a RTA. There is need for increased helmet use among two-wheeler rider in both rural and urban areas.

Aim: The purpose of this study was to assess free style Perforator Island flaps in reconstruction of post oncologic facial moderate size defects regards: flap viability, esthetic outcomes, and donor site morbidity as primary outcome; and compare the esthetic outcomes of freestyle perforator flap with traditional local flaps as secondary outcome. Patients and methods: 24 cases were operated with free style local perforator flap pattern. A preoperative handheld Doppler device was used to locate the available perforators in the area adjacent to the defect tissues and the flaps were designed taking into account the laxity of the surrounding skin in order to allow primary closure of the donor site. All procedures were performed under general anesthesia. Results: The results of the aesthetic outcome evaluation of the flap done by the surgeons’ panel. The panel was very unsatisfied in only one case regarding all flap parameters (the case with lost flap). Conclusion: Freestyle perforator flaps can be based on one or more perforators obtaining a reliable blood supply together with great flexibility in design, free choice of orientation, arc of rotation up to 180°, wider range of motion compared with local flaps, and primary closure of the donor site along the relaxed skin tension lines to minimize any adverse scarring

Background: Prostate-specific antigen (PSA), shows increased expression breast cancer (BC), wherein its level declines after surgery, suggesting that PSA is produced by the tumor itself, making it suitable for evaluation as a BC marker. However, there is paucity of evidence establishing sufficient sensitivity and specificity of PSA in BC detection. Objective: To compare and correlate total PSA levels in women with and without breast cancer. Material and Methods: The study enrolled 60 female patients aged 30-85 years, histopathologically diagnosed with breast malignancy in Group A (cases) and 60 healthy, age-matched women, free of breast malignancy or lumps in Group B (controls). Blood investigation for serum levels of total PSA was done for all participants. Detailed tumor examination was performed for Group A. Diagnostic accuracy of serum PSA was measured by comparing with histopathological diagnosis. The results were compiled and analyzed using SPSS version 20 statistical software. Results: The mean serum total PSA level in Group A (0.0105 ± 0.007 ng/mL) was found to be significantly greater than in Group B (0.0048 ± 0.0036 ng/mL) (P0.00001). The proportion of females positive for PSA marker in Group A (61.66%) was also significantly greater than in Group B (16.66%) (P0.0001). With a sensitivity of 61.66%, specificity of 83.33%, the total diagnostic accuracy of serum levels of total PSA was found to be 72.5%. Conclusion: As the sensitivity of PSA marker was found to be mediocre in this study, it seems unsuitable as a screening tool for BC diagnosis.

Background: Double J (DJ) stents are basic and commonly used tools in urology. They are self-retaining at both renal pelvis and bladder used in upper urinary tract obstruction, infection caused by hydronephrosis, safety concerns (post endourological procedures) and renal failure secondary to ureteral obstruction. Despite advances in technology, ideal stent has not been invented yet leading to LUTS lower urinary tract infections after stent placement with incidence of 50%–70% postoperatively. Our study was undertaken to analyse early complications of DJ stenting postoperatively at our centre. Methods: Prospective study on postoperative patients with DJ stent in situ for various indications. Follow up of patients attending surgery department was taken. Detailed history and clinical examination with symptoms of complications were recorded at 2nd and 4th postoperative week from time of placement of double-J ureteral stent till its removal. Results: Total 87 patients, with mean age 42.89 ± 14.69 years and M:F 2.49:1 underwent DJ stenting for various indications. Majority of patients had complications like flank/suprapubic pain (47.12%) followed by urgency (42.52%) and haematuria (37.93%) in 2nd postoperative week which were managed conservatively, which reduced to significant rate till 4th post-op week. Major complications like stent migration/encrustations were not seen in any patient. Conclusion: DJ stents have become routine and essential part of urological procedures. Patients must be well informed and counselled about the potential early complications such as frequency, urgency, incontinence and pain along with late complications post stenting.

Introduction: non-thermal treatment of varicose vein which do not require using tumescent anaesthesia decrease the risk of nerve damage and still highly effective method . Patients and Methods: This is a prospective study conducted on 35 cases presented by chronic venous insufficiency. Duplex as- sessment was done. Cyanoacrylate glue was used in all cases for occlusion .Follow up was done immediately and at three and six months. Results: this study applied on 35 patients and 38 limbs, 28 females and 7 patients were male, with a mean age 26.3±8.3years,clin- ical presentation from C2-C6, The occlusion rate was 100% immediately and 96% at 3 months and at 6 months was 92.5%. Conclusion: Treatment of varicose vein with cyanoacrylate is the least invasive technique with a successful and promising method with minimal side effects.

Aim of study; Evaluation of the technical feasibility, durability, complications and patency of rates of stent graft for management of cephalic arch vein stenosis in cases of failing AVF. Patients and Methods: Retrospective analysis for patients referred to vascular clinic with malfunction of AVF due to CAS managed with covered stent therapy from March 2020 till June 2021. Results: 9 patients with endovascular stent-grafting of cephalic vein arch stenosis with age range 27-54 year (mean age: 41.8). All patients received Viabahn® covered stent. Technical success rate was 100%. No major complications. . All patients have shown patent stent graft during outpatient visit with only two patients who developed stent graft edge stenosis at one month and 4 month respectively that was corrected by balloon angioplasty with a high-pressure balloon in one patient and in the other patient a bare metal stent was used. Primary patency rate was 85.7% Conclusion: The use of stent-grafts to address the entire diseased segment in the cephalic vein may reduce recurrence rate and limit the rate of re-interventions.

Background: Agenesis of vermiform appendix is a very rare occurrence. It posed intraoperative dilemma towards the surgeon. Several criteria should be fulfilled before the conclusion of agenesis of vermiform appendix can be made. Case presentation: We report a case of missing appendix during surgical exploration in patients with clinically diagnosed appen- dicitis. The post-operative diagnosis was adhesion colic. Conclusion: The diagnosis of agenesis of vermiform appendix should not be made unless the ileocecal and retrocecal area are thoroughly explored and caecal wall examined for intussusception of vermiform appendix.

Iatrogenic inferior vena cava injury (IVC) in a planned surgery is a rare complication. Here we are reporting a case of iatrogenic IVC injury complicated with extensive thrombosis after open right simple nephrectomy retroperitoneal approach for non- functioning kidney. He was complaining of bilateral lower limb swelling and back pain immediate post-surgery. He underwent computed tomography for his complain which revealed stenosis of infra-hepatic IVC with extensive thrombosis extending from bilateral common iliac till left common femoral vein. He underwent laparotomy, thrombectomy and vena cava reconstruction using interposition ePTFE grafting technique. One year follow up his graft still patent.

Duodenal injury following abdominal trauma is rare and associated with high rates of morbidity and mortality. High index of suspicion is required for diagnosis. We report a case of large duodenal perforation due to blunt abdominal trauma. A 39-year-old was brought to the hospital by ambulance following a road traffic accident. She was brought to the emergency depart- ment in unstable condition however responded well to resuscitation. There was generalized tenderness with peritonitis on abdominal examination. Contrast enhanced computed tomography (CT) of the abdomen showed duodenal perforation, grade III liver injury, rib fractures, lung contusion, and stable pelvic fracture. Urgent exploratory laparotomy was performed revealing a grade III duodenal injury with liver injury confirming the CT findings. A peritoneal lavage was performed followed by primary repair of duodenal injury with pyloric exclusion, and a gastrojejunostomy bypass. Patient developed short bout of paralytic ileus post-operatively but recovered well thereafter. Traumatic duodenal injury is rare but associated with significant morbidity and mortality, especially in delayed diagnosis and treat- ment. Treatment strategy should be individualized and carefully formulated based on severity and nature of injury, patient’s condition, existing comorbidities, and available expertise.

End-stage renal disease (ESRD) incidence is increasing worldwide and contributes to a significant healthcare burden. The majority of ESRD patients opted for haemodialysis as a preferred choice of renal replacement therapy leading to more placement of central venous lines. Central venous obstruction (CVO) is common in patients with prior history of central venous catheterization. Management of CVO is important with aims to alleviate patient’s symptoms as well as preservation of the arteriovenous fistula for haemodialysis. Surgical bypass is often considered when the endovascular technique is not feasible. Herein we report an unusual case of surgical bypass of the axillary vein to superior vena cava for treatment of central venous obstruction.

The trichobezoar is an infrequent cause of intestinal obstruction in different portions of the gastrointestinal tract. Most of the cases reported are located in the stomach and are associated with psychiatric disorders such as trichotillomania and trichophagia. We reported a 12-year-old female who came to the emergency room presenting with abdominal pain, nausea, vomiting, and weight loss in the previous weeks. Physical examination showed a mobile mass in the epigastrium. After diagnostic studies were completed, an exploratory laparotomy was performed. Surgical findings revealed multiple trichobezoars with a large one located in the stomach and the others three ones locates in different segments of the jejunal. All trichobezoars were removed through a gastrostomy and jejunal enterostomy, respectively. After the surgical procedure the patient had an adequate postoperative course and was discharged seven days later without complications. Further management required psychiatric, nutritional, and social as- sistance services follow-up for a multidisciplinary management.

Peritoneal dialysis (PD) is one of the dialysis modalities for end stage renal disease patient. It offers advantage of home ambulatory and patient-center treatment.Encapsulating Peritoneal Sclerosis (EPS) is a rare but devastating complication of long-term peritoneal dialysis patient. We have reported a young female patient who has transferred from peritoneal dialysis to hemodialysis six months prior, presented with late stage of EPS with abdominal mass. She was diagnosed with EPS based on her spectrum of symptoms and radiological features of peritoneal fibrosis of small bowel segment. Conservative approach with corticosteroids, tamoxifen and bowel rest with total paren- teral nutrition was adequate to offload her obstructive symptoms. Multidisciplinary discussion has been done with the consideration of potential surgical approach with prior nutritional optimization if medical therapy fails. Multidisciplinary approach and individualization based on the disease severity, response to medical therapy and presence of alarming signs provide a platform for EPS management.