Aim of the Study: The aim of this study is to compare the potential effects of standardized heparin sodium and tinzaparin sodium,which is a member of low molecular weight heparin (LMWH), on microvascular thrombosis in the late phase of intraabdominal polimicrobial sepsis on an experimental model of caecal ligation and puncture. Material and Methods: Thirty Wistar albino rats with an average weight of 250-300 gr were divided into 5 groups in a randomized fashion: Control (C) group (6 rats), caecal ligation and puncture (CLP) group (6 rats), conventional heparin (H) group (6 rats), tinzaparin sodium (T) group (6 rats), combined heparin and tinzaparin sodium (H+T) group (6 rats). Only laparotomy was done to rats in the control group. CLP of Wichterman’s was done to all other groups. After 2 hours 200 IU/kg of heparin sodium to all rats in the H group, 200 IU/kg of tinzaparin sodium to all rats in the T group, 100IU/kg heparin sodium and 100 IU/kg tinzaparin sodium to all rats in the H+T group were injected subcutaneously. All rats were sacrified 24 hours after CLP. Blood samples for leucocyte counts, thrombocyte counts, hemoglobin levels, antithrombin-III levels were obtained. Lung and intestinal tissue samples were obtained for histopathological investigation. All the tissue samples were assessed by the same pathologist who is unaware of the groups. All the data obtained were analyzed by SPSS version 13.0 Windows program, intergoup differences were analyzed by Kruskal Wallis and Mann Whitney U nonparametric tests. Results: Leucocyte levels at 24. hour in all groups were found to be statistically higher than the leucocyte levels in the C group. Thrombocyte levels at 24. hour in all groups were found to be statistically lower than the C group. Thrombocyte levels in the H group, T group and H+T group were statistically higher than the thrombocyte levels in CLP group. Antithrombin-III levels at 24. hour in all groups were found to be statistically lower than the antithrombin-III levels in the C group. Antithrombin-III levels in the T group were statistically higher than the antithrombin-III levels in the H group. In all treatment groups microvascular thrombosis in lung and intestinal tissue samples were lower than the C group whereas the effects of heparin sodium and tinzaparin on inhibiton of microvascular thrombosis were found to be similar. There was no difference between treatment groups and control group when inhibition of late phase inflammation is regarded. Conclusion: While inhibiting microvascular thrombosis, anticoagulant therapy does not prevent sepsis induced inflammation.Anticoagulant treatments may be adjunctive rather than a definitive treatment in sepsis. Tinzaparin sodium may be a more appropriate choice in microvascular thrombosis treatment in sepsis since it offers a lower hemorrhage risk than unfractioned heparin with a similar antithrombotic potential.

Aim: Pilonidal sinus disease is a surgical disease that usually occurs in young men with sinus tracts in natal cleft. There are also risk factors such as obesity, family history, hairy body structure and body hygiene. The stage of the disease is also an effective factor in treatment planning. In our study, we performed a retrospective analysis according to the staging system of the patients we operated for pilonidal sinus. Materials and Methods: A total of 159 patients who were operated with the diagnosis of pilonidal sinus between July 2016 and August 2017 were included in the study. The patients were evaluated according to the staging system in terms of age, gender, length of stay, body mass index (BMI), history of abscess drainage, duration of complaints, family history and morbidity. Results: The patients were between 18-43 years old. The mean age was 23,0. 130 (81.8%) of the cases were male and 29 (18.2%) were female. Number of patients with stage I was 35, number of patients with stage IIA was 49, number of patients with stage IIB was 18, number of patients with stage III was 44, number of patients with stage IV was 3 and number of patients with stage R was 10. Statistically significant correlation was found between disease stage and BMI, duration of complaints, family history and duration of hospitalization (p<0,05). Statistically significant correlation wasn't found between disease stage and age and morbidity (p>0,05). Conclusions: BMI, duration of complaints and family history effect the stage of pilonidal sinus disease. Also, the increasing stage of the disease is prolonged hospital stay.

Background: The prevalence of various non-communicable diseases has steadily increased in South Africa with diabetes mellitus and peripheral vascular disease now amongst the foremost causes of morbidity and mortality. Despite major advances in the treatment of peripheral arterial disease, a significant proportion of patients require major lower limb amputation (LLA). Clinical and functional outcomes of patients undergoing major LLAs in South Africa have been poorly researched. This study aims to audit major LLA and mobility of patients post amputation at a regional hospital in Durban, South Africa. Methods: A retrospective clinical audit was conducted. Eligible patients were identified from electronic patient records over a two-year study period. Data on demographic characteristics, comorbidities, procedural characteristics and mobility post LLA were collected. Results: Median age of patients was 60 years old (interquartile range [IQR]: 50-69). Predominant ethnicities were Black African (n=96; 46.6%) and Indian (n=82; 39.8%). Diabetes mellitus and hypertension were the most prevalent comorbidities in the study population (74.3% [153/206] and 49.5% [102/206] respectively). Overall inpatient mortality of patients was 12.1% (25/206). 37.9% (22/55) of patients had a functional prosthesis, and of these 22.7% (5/22) had an above knee prosthesis with more below knee amputees 77.3% (17/22) receiving prostheses. Conclusion: The prevalence of postoperative inpatient mortality following LLA was high with few patients ambulating with a functional prosthesis. There is a need to strengthen existing patient education and primary healthcare initiatives on diabetic foot care, chronic disease management and optimization of medical treatment in order to prevent these morbid complications.

Background: Traumatic diaphragmatic injury has a high mortality that usually afflicts adjacent organs. In an effort to investigate the diagnostic and therapeutic measures for more proper options, we studied the cases of more than 100 patients for a wide range of data and compared them with the recent related studies. Material and Methods: A total of 123 cases were observed for a variety of demographic, clinical and paraclinical data. Using the routine methods of statistical analysis, the data was utilized to determine associations and other results. Results: The average age in the cases was 35.6 years with more than 90% being male patients. Penetrating trauma was slightly more frequent than blunt trauma. Violence was the most prevalent mechanism, with thorax observed as the most common region of trauma. Hemothorax was discovered in approximately one-fifth of the patients. Associated organ damage was observed in more than 80%, with splenic damage having the highest prevalence. More than 95% of the patients were diagnosed utilizing chest X-ray. The most common type of surgery was laparotomy, performed on nearly 85% of the cases. The mortality rate was around 20%, being significantly higher in blunt trauma. Conclusion: All male traumatic patients aged 20 to 40 need to be examined for traumatic diaphragmatic injuries. Chest X-ray is a highly effective and inexpensive procedure if utilized intraoperatively. Laparotomy continues to be the recommended therapeutic measure. The patients require careful daily examination following surgery, especially in blunt trauma.

Background: Peripheral artery disease (PAD) is 3 to 4fold higher in diabetic patients, with concomitant coronary and chronic kidney disease and increased risk of complications particularly contrast-induced nephropathy (CIN) after traditional fluoroscopically guided endovascular interventions. The aim of this study was to compare the safety, accuracy of diagnosis and feasibility of automated CO2-DSA with standard Contrast-DSA in the evaluation of PAD. Methods: Prospective, single-center study to report our early experience in 50 Limbs of diabetic CLI patients with chronic kidney disease using automated carbon dioxide angiography (ACDA) during the endovascular treatment and to evaluate its diagnostic accuracy vs Contrast DSA. Results: Mean age was 62.76 ± 11.34 y, lesion distribution 36 (72%) patients with superficial femoral artery block, 10 (20%) patients with Infra popliteal disease, 4 (8%) patients aortoiliac disease. The primary efficacy endpoint was achieved in all patients. No statistically significant Increase in Serum creatinine pre and post CO2 injection in exclusive cases 35(70%) and added contrast cases15 (30%) with statistically significant Increase in ABPI pre and post CO2 Angioplasty and highest amount of CO2 volume was given in SFA block cases. 10(71.4%) cases of Below knee and 4(28.6%) cases of SFA angioplasty had added 5 ml of iodinated contrast, follow up over 6 months Conclusions: ACDA can be utilized to guide PAD interventions, significantly decreasing to small volumes of contrast when needed (if not eliminating) the need to use iodinated contrast in patients with contrast allergies or compromised renal function at baseline.

The Gastric carcinoma with lymphoid stroma (GCLS) is a rare type of gastric carcinoma and mostly associated with EBV (Epstein-Barr virus). A 64-year-old man presented with a non-specific chronic abdominal pain for 4 months. Endoscopy examination showed polypoid tumor at the posterior wall of antrum and biopsy came back as showed diffuse-type gastric cancer tumor. CT staging showed localized tumor and surrounding lymphadenopathy with no distal metastasis. Total gastrectomy with D2 lymphadenectomy and intraoperatively the tumor is large with multiple large regional lymphadenopathies. The histopathological examination revealed undifferentiated gastric cancer with dense lymphocytic infiltration and positive for EBER 1, (pT2N1M0 EBV- positive GCLS). His final pathologic staging is favorable defying all preoperative and intraoperative findings. The overall patient recovered well and tolerating adjuvant chemotherapy. Literatures showed that EBV positive GCLS showed a better prognosis than EBV negative GCLS and conventional adenocarcinoma. The exact mechanism that contributes to the better prognosis of this type of cancer remains uncertain. EBV status may be more important than the proportion of undifferentiated tumor cells even in the presence of abundant lymphocytic infiltration as favorable prognostic factor of GCLS.

Introduction: Foreign body aspiration causing airway following motor vehicle accident is rare in adults. Airway management after a traumatic event is the mainstay of ATLS protocol. Adequate exposure in this clinical scenario is important and is life-saving. Case Scenario: A-37-year-old motorbiker involved in a crash and brought to Emergency with a low GCS. Initial assessment showed the airway and breathing was abnormal with suspicion of a tension pneumothorax. Other vital parameters such as the circulation and blood pressure was unremarkable. There were no obvious external injury and repeated FASTscan ruled out intra-peritoneal bleeding. However despite chest tube insertion, the oxygenation was difficult to maintain hence a CT scan was performed to investigate traumatic head injury and the thorax which inadvertently showed a foreign body obstructing the right secondary bronchus causing distal collapse of the lung. Attempts through minimally invasive procedure failed hence a bronchoscopy assisted thoracotomy exploration and retrieval of foreign body performed. Patient recovered well following intervention and was discharged well. Conclusion: Options of foreign body retrieval depends on the expertise and facilities available. There is no one modalities that fit all purposes. Diagnostic dilemma with low index of suspicion with individual never exposed in such emergency situations can be misleading and can bring to a dead end which may cause patients life. Ultimately, salvage surgery when all the minimally invasive options failed.

Peritoneal Tuberculosis is a rare form of extrapulmonary tuberculosis. It commonly presents as acute abdomen. We are presenting two cases of peritoneal tuberculosis which presented to us as acute abdomen – peritonitis. The initial diagnosis was acute appendicitis whereby they had undergone open appendicectomy and another laparoscopic appendicectomy. We would like to highlight the intraoperative findings of peritoneal tuberculosis both in open surgery and laparoscopic surgery. Both of our patients are in their twenties, fit with no co-morbidity and denies previous contact to pulmonary tuberculosis, hence, making the provisional diagnosis of peritoneal tuberculosis unlikely. The common intra-operative findings of peritoneal tuberculosis are whitish peritoneal nodules overlying the peritoneal wall or bowel wall and inflamed thickened omentum with ascites fluid due to chronic exudative inflammation. The duration of anti-tuberculous treatment for peritoneal tuberculosis should be tailored individually, however, most physician will adopt the extrapulmonary tuberculosis treatment regimes which is 9 to 12 months. In conclusion, the diagnosis of peritoneal tuberculosis is a challenging endeavor in clinical setting, however, it is important for surgical residents to be able to recognize the intraoperatively to initiate prompt treatment.

Background: Mesenteric cystic lymphangioma is a rare benign lesion of the mesentery of small bowel with an uncertain aetiology. It occurs predominantly in children. The clinical presentation is diverse, it can be asymptomatic, incidentally discovered abdominal cyst or presents with symptoms of acute abdomen. Case presentation: We report a case of a mesenteric cystic lymphangioma that presented with signs and symptoms leading towards appendicular mass. It was a case of a 13-year-old boy, with no pass medical illness, presented to us with 1-week history of right lower abdominal pain and mass. Abdominal imaging showed multiloculated cystic mass with peripherally displaced small bowel, suggestive of mesenteric lymphangioma. He then underwent laparotomy, resection of mesenteric cyst and the affected small bowel. Histopathological report showed mesenteric lymphangioma of the ileum. Conclusion: Mesenteric cystic lymphangioma can presents with a misleading presentation. With complete surgical resection, the prognosis is excellent.

A 58-year-old woman with a diagnosis of medullary thyroid carcinoma who, after performing a total thyroidectomy with bilateral functional cervical lymphadenectomy, presented a chylous fistula as a complication. In the first place, medical treatment is attempted, as it is not effective, embolization of the thoracic duct is performed by interventional radiology, but on the 12th day surgery was decided with ligature of the thoracic duct with Teflon pledgets, being the definitive treatment. Although the incidence of cervical lymph node fistula is rare, it must be taken into account given the high morbidity that it causes in some patients. The management of lymphatic fistula is not yet fully standardized, most authors recommend medical treatment, but when this fails, surgical treatment is the alternative.

Esophageal duplication cyst is a rare congenital malformation. Incidence is around 1 in 8200 patients. Esophageal duplication is second most common site of gastroenteric duplication after small intestine. We describe here a case of Esophageal duplication cyst in 62-year-old male, who presented with chest pain and dysphasia to solid food for 6 months. Thoracoscopic enucleation was done and the patient was discharged a few days later. Thoracoscopic excision should be the treatment as it offers faster and better recovery.

In recent times, the emergence of skin substitutes has changed the approach of reconstructive surgeons in managing deep wounds of various aetiologies. Skin substitutes have important roles in treatment of deep dermal and full thickness wounds mainly requiring extensive coverage due to burns, trauma, or oncological defects. Skin substitute can be divided into 2 main types which are biological and synthetic substitutes. Skin substitute that replace the dermis are called dermal regeneration templates(DRT) and require skin grafting to reconstruct the epidermis. In this report a paediatric patient presented with a swelling over the left dorsum of foot that was found to be a dermatofibrosarcoma protuberance (DFSP). He underwent a wide local excision with the resulting deep wound exposing the tendons and was covered with dermal regeneration template Integra® and negative pressure wound therapy and later on, epidermal autograft.