Abstract Objective: Pseudocyst is the most frequently observed cystic lesion of the pancreas and generally develops on the basis of pancreatitis. The aim of this study was to present cases of pancreas pseudocyst treated with endoscopic or surgical cystogastrostomy. Material and Method: A retrospective evaluation was made of patients who underwent an invasive procedure because of pancreas pseudocyst between January 2021 and June 2023. Results: The patients comprised 5 (55.5%) females and 4 (44.5%) males with a mean age of 50 years. The etiology of pseudocyst was observed to be biliary pancreatitis in 6 (66.6%) patients, postpartum pancreatitis in 2 (22.2%) patients, and pancreas head cancer in 1 (11.1%) patient. Cystogastrostomy was performed with placement of an endoscopic stent in 4 (44.5%) patients, laparotomy was performed in 3 (33.3%) patients when the endoscopic intervention failed, and direct surgical cystogastrostomy was performed in 2 (22.2%) patients. The mean time between pancreatitis and the invasive intervention was 115 days. The procedure was repeated in 4 (44.5%) patients applied with a stent and in 1 (11.1%) patient who underwent laparotomy. Change of stent was made in 2 patients applied with a stent. According to the Pan pancreas pseudocyst classification, all the patients were type 4. During a mean 7-month follow-up period, wound site infection was observed in 2 patients, and intra-abdominal abscess in 1. Conclusion: Cystogastrostomy with minimally invasive endoscopic drainage+stent can be used as the first option in the treatment of pancreas pseudocysts. When endoscopic interventions are not appropriate or not successful, conventional surgery can be safely selected.

Background: Biliary sepsis is one of the most common problem encountered in a daily basis practice in general surgery. Early intervention is required in order to reduce the mortality and morbidity in this group of patient. Hence multiple aetiological factors should be rectified in choosing either one of these procedures to reduce the morbidity and good outcome in patients. Therefore, this study is performed to identify these factors, to ensure appropriate early intervention in order to achieve less morbidity and mortality in biliary sepsis or obstructed patient. Methods: This is a retrospective study of case record of patients diagnosed with biliary sepsis or obstruction in Hospital Universiti Sains Malaysia from 1st January 2019 to 31st December 2020. Subjects who met the inclusion criteria were recruited in this study. The outcome of PTBD and ERCP, aetiological factors leading to its failure were studied. The data were analysed using Statistical Package for the Social Sciences (SPSS) version 27. Results: During the period of study, 83 patients were included in this study. Median age of patient involved in biliary drainage was 58.8 years in PTBD and 60.6 years in ERCP. While 71.4% of patients were male in PTBD arm compared with 53.7% patients in ERCP group who underwent biliary drainage. About more than 95% (97.6% - PTBD and 95.1 % - ERCP) of patients were Malay in origin, followed by Chinese 2.4 % in PTBD and 4.6% in ERCP arm. No significance differences observed in premorbid conditions of both arms. While on clinical presentation to hospital, most patients have right hypochondriac pain, jaundice and fever in both arms with no significant p-value in comparison. However noted significant symptoms for malignancy was noted in 23 (54.8%) patients in PTBD arm with p-value 0.001. The mean length of hospital stay was 4.9 days and 6.9 days for ERCP and PTBD respectively with p = 0.102. The success rate in ERCP arm was higher compared PTBD (87.8 vs 78.6%) although no significant p-value difference was observed. Multiple logistic regression demonstrated that only malignancy factor has significant association with success of PTBD with p = 0.039. Meanwhile in ERCP arm, none of these variables were significant (p value 0.001) after the multiple logistic regression. However when compared factors contributing to success ERCP over PTBD using Multiple Logistics regression, the variable that were significant (p value 0.05) were malignancy (p value =0.009), ALT (p value =0.003) and Ultrasound findings for stone (p value =0.011). Conclusion: In this study overall result shows similar success and complication rate between ERCP and PTBD although ERCP arm slightly higher. When look into superiority between these two procedures, ERCP shows better outcome in biliary drainage with the background of malignancy, raised ALT and imaging findings for stone

Background: Increasing adoption of the laparoscopic approach for gastric carcinoma (GC) has been observed. While recent evidence suggests that this surgical approach improves short-term outcomes, there is a lack of comprehensive research on midand long-term outcomes. This study aimed to evaluate the mid- and long-term outcomes of laparoscopic gastrectomy (LG) with D1-D2 lymph node dissection for all stages of GC. Methods: A retrospective study was conducted on patients with GC who underwent the laparoscopic approach between January 2004 and December 2019. Demographic information, perioperative data, operation details, length of hospital stay, morbidity, mortality, and pathological and oncological outcomes were analyzed. Results: A total of 70 patients met the inclusion criteria, with a median age of 73 years. Subtotal gastrectomy was performed in 52 cases (74.3%), while total gastrectomy was performed in 18 cases (25.7%). The median operative time was 270 minutes, and the median postoperative stay was 10 days. Morbidity was 35.7%, with a mortality rate of 7.1%. Disease-free survival (DFS) rates were 61.2% at three years and 52.3% at five years. Conclusions: LG is a feasible and safe surgical procedure for GC. Advanced age should not be considered a contraindication for LG.

Background: The perioperative outcome in geriatric patients is a scarcely studied topic.The objective of this study was to identify the 30 day morbidity and mortality in geriatric patients undergoing major elective Gastrointestinal surgery and the risk factors predicting the same Methods:.We prospectively followed up 93 patients ,65 years and above whose preoperative functional status was documented using the Katz Activities of Daily Living ,Lawtons Instrumental Activities of Daily Living ,Clinical frailty scale , gait speed , timed up - go test and Charlsons comorbidity index. The 30 day morbidity comprised of Grade 2 and above Clavien Dindo complications. Results: The 30 day mortality and the 30 day morbidity was 3.2% and 26.9% respectively. The morbidity predicting risk factors were prior history of falls, timed up - go test >14 seconds, significant weight loss ,malignancy and open surgeries. Conclusion: Age is not an independent predictor of morbidity. Poor preoperative functional and nutritional status, malignancy and open surgeries carried increased risk.

Introduction: There is no agreement about the extent and the quality benchmarks of colon cancer resection. Segmental resection is being increasingly used in the era of minimally invasive surgery. Materials and Methods: The authors here assess retrospectively a cohort of 342 patients aiming at defining the impact of segmental resection on recurrence and survival and further delineating the complex relation of specimen length and nodal ratio in this dilemma. Results: Although the specimen length differs significantly between anatomical and segmental colectomies (median 25 vs. 17.5cm), the final outcomes [recurrence rate, overall survival (OAS) and disease-free survival (DFS)] were comparable. In addition, the specimen length correlates with the retrieved nodal count, without affecting the outcomes. Finally, nodal ratio provides a strong predictor of worse outcome, especially if beyond 11% (recurrence rate 47.4% vs. 23.3% and mean DFS 42.7 vs. 106.3 months). Conclusions: Segmental resection of colon cancer is a safe option. The specimen length correlates with nodal yield but does not affect the survival. LNR beyond 11% is a marker of worse prognosis

Brief Background Information: Prophylactic negative pressure wound suction therapy (NPWT) for infected wounds may benefit in the management of surgical site infection (SSI). We studied the efficacy and safety of NPWT with delayed primary closure (DPC) to prevent SSI. Methods: During an emergency abdominal inquiry, contamination from neighbouring skin bacteria and intestines is common, leading to wound infection. In our work, we use polyurethane foam that has been subjected to negative pressure (80 mmHg). Once there was enough granulation, DPC was conducted. The drawbacks of NPWT, the onset of SSI, and the length of hospitalisation were all studied retrospectively. Results: There were 44 cases of dirty/infected wounds (n = 14) and contaminated wounds (n = 30). The NPWT lasted an average of seven days (with a range of 5 to 11 days). The NPWT was stopped in two (4.5%) patients due to pain from wound traction. SSI was identified in 14 (31.8%) cases, with incisional SSI occurring in 2 (4.5%) cases and organ/space SSI happening in 12 (27.3%). The average hospitality time was 17 days, with a range of 7-91 days. The kind of SSI or the degree of the wound had no effect on postoperative hospitalisation (). Conclusion: It was capable of performing preventive NPWT with DPC, which may be particularly effective for wounds that are severely polluted but have a low risk of incisional SSI.

Introduction: Laparoscopic cholecystectomy (LC) is now gold standard procedure for surgical treatment of symptomatic gall stones. Rouvière's sulcus (RS), which marks the level of the right posterior portal pedicle, is such a landmark and is identifiable in at least 80% of patients. This article aims at studying the incidence of rouviere’s sulcus in terms of frequency, morphology, its relation with CBD and its relevance in LC in patients with symptomatic gallstones. Materials & methods: This is a prospective descriptive study of 114 patients who presented with symptomatic gallstone disease, consented to participate in study and underwent laparoscopic cholecystectomy. The study conducted from February 2021 till Oct 2022 at L. N. Medical college & J. K. Hospital, Bhopal, Madhya Pradesh. Results: Out of 114 patients who underwent laparoscopic cholecystectomy, 74 (64.9%) patients were female and 40 (35%) patients were male. Open type was found in 61 patients (53.5%). Fused type was found in 27 (23.68%) of patients. The sulcus was not present in 26 (22.8%) of patients. Most of the age of presentation of symptomatic cholelithiasis was noted in fourth decade (34.23%). Conclusion: Identification of Rouviere's sulcus can be helpful as an additional reference point to avoid major bile duct injury. It can be better visualized after retracting the fundus of the gallbladder. Its anatomy and its relation to CBD, can be better appreciated.

Background: Laparoscopic cholecystectomy (LC) is the standard modality of treatment for cholelithiasis and is associated with lesser complications than its open counterpart. Surgical site infections (SSIs) can lead to significant morbidity and mortality and are limited in clean and clean-contaminated wounds by the use of antibiotic prophylaxis. Studies have shown beneficial effects of prophylaxis in cases of open cholecystectomy but their effect in laparoscopic surgery is not well implanted. Materials and methods: All the patients fulfilling the inclusion criteria were divided into 2 groups. One of the groups received postoperative prophylactic antibiotics and one did not. Both the groups were assessed for early and late surgical site infections and the outcomes were later compared. Results: The mean ages of the patients were 39.9±14.8/38.9±12.9 in non antibiotic and antibiotic groups respectively . The age distribution was almost similar in both the groups. No cases with early or late surgical site infections or their complications were found in any of the two groups. There was no significant difference in the length of stay in the hospital in both the groups (p=0.75). Duration of drain placement after the surgery was also similar (p=0.50). Conclusion: In our study no post operative SSIs or infectious complications were present in any of the groups. Even though these findings do not seem to be statistically significant, the similarities between the two groups and the absence of infectious cases in both of them shows that the infection rates are already very low in these patients and using prophylactic antibiotics does not seem to be rational.

Background: Over 20 million people undergo hernia repair globally every year. The corona mortis, a common anatomical variation of the retropubic vessels, is a source of bleeding during laparoscopic hernia repair. Knowledge of its anatomy is therefore critical for the surgeon. Despite its clinical importance the available data is insufficient or obscure. Methods: We conducted a literature review using Pubmed, Embase and Google Scholar about the surgically relevant anatomical characteristics of corona mortis. Results: Corona mortis is more common than previously thought. Studies showed that the incidence ranges from 27% to 83% of the population. The vessels are more often present unilaterally and arterial in origin. A study showed that a reduction in gas pressure during laparoscopic surgery led to a significantly decreased rate of complications. Conclusions: Corona mortis anatomy knowledge is crucial for the surgeon performing laparoscopic hernia repair. The vessels should be identified accurately intraoperatively in order to avoid iatrogenic damage. Available descriptions of this vasculature vary significantly between authors. Further studies are needed. Novel Aspects: our aim is to describe the anatomical characteristics of corona mortis as it pertains to laparoscopic hernia repair

Aim: To compare the effectiveness of routine ilioinguinal nerve division versus preservation with respect to post-operative groin pain and paraesthesia Methods: 120 patients undergoing hernioplasty for inguinal hernia were divided into two groups. In group A, there were 60 patients subjected to prophylactic ilioinguinal nerve division. In group B, there were 60 patients in whom preservation of ilioinguinal nerve was done during the hernia repair. Patients were followed up at 1 month and 6 months following surgery to assess the incidence of chronic groin pain and pain during daily activities. Results: At 1 month follow up there was no significant difference between the two groups with respect to chronic groin pain or pain during daily activities. However, the incidence of chronic groin pain was significantly less in Group A compared to Group B at 6 months follow-up.The incidence of post-operative hypoesthesia and numbness is insignificant in both the groups at 1 month and 6 months follow up. Conclusions: Prophylactic ilioinguinal nerve division during open hernia surgery significantly reduces the incidence of chronic groin pain without any sensory loss

Background: Oncoplastic surgery for breast cancer in patients with large breasts has attained high popularity. It achieves both safe oncological and good cosmetic outcomes. This study aims to compare the outcomes of therapeutic reduction mammoplasty in medium-sized to large-breasted females with breast cancer using inverted T scar versus the vertical scar technique. Patients and methods: Fifty women with medium-sized to large-sized breasts who were candidates for breast conservation underwent reduction mammoplasty with either inverted T scar (group A) or vertical scar (group B). Patients with central breast cancer and those with inability to obtain free margins were excluded from the study. Surgical outcomes, oncologic safety, and cosmetic results were compared between both techniques. Results: There was no significant difference between the two groups regarding age and weight (P>0.05). Most of the cases had a mass in the upper outer quadrant (60%). On follow-up, wound dehiscence occurred more in the inverted t group (16%). It was 8% in the vertical scar group. The cosmetic outcomes were assessed in the inverted t versus vertical scar mammoplasty groups, showing excellent results in 15 (60%) cases versus 16 (64%) patients, respectively. In a median follow-up of 24 months, no cases showed local recurrence. Conclusion: Application of therapeutic reduction mammoplasty in the treatment of breast cancer in medium-sized and largebreasted females is oncologically safe with good aesthetic outcome. Inverted T and vertical scar techniques have comparable outcomes. They have nearly equal satisfactory cosmetic results with less postoperative morbidity in the vertical scar technique

Abstract The treatment of non-lactational breast abscesses has traditionally been incision and drainage (I+D) with biopsy of the abscess wall to rule out serious pathology. We postulated a low incidence of serious pathology in this setting and set out to investigate the yield of biopsy in these patients in our institution. Method: Patients were identified from theatre records at Edendale Hospital, South Africa. Patient files were reviewed for demographics and histology reports were retrieved for analysis. Descriptive statistics were used to summarise the data. Results: During the six-year study period (2014 to 2019), 599 I+D of breast abscesses were performed on 546 patients. Inclusion criteria were met by 194 patients. The mean age was 33 years (range 18-83). The majority of patients (78%) were younger than 40 years. Histology was benign in 99%: abscess without other pathology - 85.6%, fat necrosis - 4.1%, tuberculosis - 3.6%, cyst - 2.1%, dermatitis - 1.5%, secretory adenoma – 1.5% and granulomatous mastitis - 0.5%. Malignancy was identified in only 2 patients (1%), who were both over 40 years of age. Tuberculosis of the breast was only found in patients below the age of 40 years (mean 26.4 years). Three patients had recurrences. Conclusion: The yield of significant pathology in biopsies of non-lactational breast abscesses is low. Most of these abscesses are due to benign pathology; thus, a routine biopsy can be omitted and performed selectively. Drainage by aspiration is an acceptable alternative to I+D in selected cases.

Background: Roles of breast conserving surgeries in patients with central breast cancer are still controversial. Recently, improved survival rates were recorded for central breast cancer who received breast conservative surgeries. But most comparative studies regarding safety of breast conservative and non-breast conserving surgeries in central breast cancer are not conclusive. So, comparative studies assessing survival advantages and outcomes of performing conservative and non-breast conserving surgeries in central breast cancer are needed. The study purpose is to assess the safety of performing breast-conserving surgery in central breast cancer patients and to evaluate survival rates of patients suffered from central breast cancer that underwent breast-conserving surgery. Patients and methods: After application of inclusion criteria 250 patients were included in the study and divided into 2 groups. The first group included 100 patients and underwent breast conservative surgery and the other group included 150 patient underwent radical surgery. We followed our patients for about 5 years, collected recurrence and survival data. Results: Patients who were managed by breast conservative surgery were older, with low grade tumor, low TNM stage tumor, more likely to be ER positive and PR positive, have more favorable, recurrence free survival rate, and overall survival rate than patients with radical surgery (P 0.001). Conclusions: breast conserving surgery is a safe and effective surgical procedure for adequate management of patients with central breast cancer.

Background: Breast pain is a very common complaint in women and it can negatively affect daily life. Breast pain treatment ranges from massage and simple pain relievers to psychotherapy sessions and use of drugs with serious side effects. One of the methods to prevent breast pain is to provide external breast support with the use of appropriate bra. This need is especially evident in female athletes. In our study, we aimed to investigate breast pain frequency and the effects of bra usage habits. Material and Methods: Aged 18 years and older premenopausal female athletes and volunteer women in the community were included in the study. Participation was ensured by an on-line survey consisting of 20 questions. Results: A total of 54 athletes and 191 women in control group were included in our study. Among the participants, breast pain complaints were found to be high in both athletes (61.11%) and the control group (69.63%). In total, breast pain was associated with the menstrual cycle mostly (95.03%). Having breast ultrasound previously and diagnosis of fibrocystic disease were significantly higher in patients with breast pain (p0.05). Breast pain was less in the lean-normal weight group (p=0.035). Breast pain increased with exercise in 38.88% of athletes. Breast pain had a negative effect on exercise performance in 27.77% of athletes. The use of bra was more common all day long in the control group, on the other hand, the use of sports bra in daily life was more common in female athletes (p0.05). Conclusion: Breast pain is an important public health problem in women. External breast support is important for breast pain control. It is important to choose a suitable bra for individual needs

Background: Surgery is offered to patients with Graves’ disease (GD) refractory to medical or radio-iodine therapy. Total thyroidectomy (TT) has been shown to lower recurrence rates of hyperthyroidism because the whole thyroid tissue is removed but subtotal thyroidectomy (ST) is thought to be associated with lower risk of postoperative complications. Aim and objectives: To compare between the two techniques regarding postoperative recurrence of hyperthyroidism, hypocalcaemia and hypoparathyroidism. Subjects and methods: This was prospective controlled clinical trial, was carried out at Department of General Surgery , Assiut University Hospital , Assiut , Egypt on 80 patients were allocated randomly to one of the treatment groups Group TT And Group ST With a 1: 1 ratio, during two years duration (2020-2021), Result: There were significant difference between both groups as regard recurrent hyperthyroidism . Conclusion: With our findings demonstrating lesser relapse of hyperthyroidism and similar safety profiles of TT in tandem with a high proportion of patients eventually needing thyroxin replacement after ST, we believe that TT should be the surgical procedure of choice for patients with GD. We find little reason to continue to offer ST as an alternative.

Introduction: Acute appendicitis is one of the most common surgical emergencies. The ALVARADO score was developed to aid in the diagnosis of acute appendicitis. However, this score has poor sensitivity and specificity when applied to Asian populations. RIPASA score was then developed to help to diagnose acute appendicitis in Asian populations. The aim of this study was to compare between ALVARADO score and RIPASA score in the diagnosis of acute appendicitis in the local population. Methodology: Clinical data were obtained retrospectively from 188 files of patients who were diagnosed with acute appendicitis and undergone appendicectomy at Hospital Universiti Sains Malaysia from 2016 to 2017. All clinical data pertaining to the ALVARADO score and RIPASA score parameters were obtained from the files and written in performa. All patients diagnosed with acute appendicitis and who had undergone appendicectomy were included in the study except patients with pregnancy, age less than 5 years old and operation for other indications. Both data were analysed using SPSS version 24 and the sensitivity and specificity of each scoring system were compared. Results: A total of 188 patients were included in the study with mean age of 27.62 + 12.722 years old and mostly female. Negative appendicectomy for the patient in this study was 13.8%. RIPASA score with a cut of point 7.5 is more sensitive at 84.6% compared to the ALVARADO score with a score >7 78.4% and the specificity of the RIPASA score 57.7% is more than the ALVARADO score of 42.3%. Conclusion: RIPASA score is a better scoring system compared to the ALVARADO score in the diagnosis of acute appendicitis.

Background: Pilonidal disease has numerous management techniques available to surgeons worldwide. Because of the variety of clinical manifestations, several methods of intervention are needed; as a result, we hope for careful selection of the best technique for the patient's severity and recurrence. Aim: To prevent possible recurrence after bilateral subcutaneous fatty flap(BSF), a novel method for treating pilonidal sinus illness and Z-Plasty(ZP) with fasciocutaneous flap. Patients and methods: All prospective patients having recurrent pilonidal sinus and operated on at our institute, Surgical Department from Jan. 2022 to Dec. 2023. In total, 50 cases have sacrococcygeal disease ( SCD), and 25 patients in Group A had bilateral subcutaneous fatty flap surgery. In contrast, the 25 patients in Group B were treated by Z-Plasty(ZP) with fasciocutaneous flap surgery. We assessed the length of the procedure, the level of postoperative pain, the length of the hospital stay, the postoperative complications, and the likelihood of recurrence. Results: The wound size was in the bilateral Subcutaneous fatty flap (BSF) 28.11 ± 8.48 mm relative to the (ZP) 23.84 ± 8.44 mm). Also, the complete healing was comparatively prolonged in the BSF (13days) relative to the ZP group (30 days). The surgery duration differs significantly (P 0.001) between the groups; it was lower in the BSF group (29.15 ± 7.69 mins) than in the ZP (23.03 ± 6.06 mins). In the BSF group, the hospitalization was four days. Still, ZP group (11days), The time for work recovery or activity was shorter in the BSF (11 days) relative to the ZP group (36 days). BSF had more reasonable satisfaction than the ZP group, duration of wound healing in BSF being 11 days but in ZP 30 days. Additionally, the duration of pain in the group was ZP (38 days but in the BSF group (11 days). Return to work in BSF 11 days and in ZP 36 days; The median satisfaction scores attained 8 (28.1%) in BSF and 9 (37%) in the ZP (P = 0.046). The median VAS scores attained 37.8% BSF and 44% for ZP (P = 0.934). The highest VAS score was equal to group B, which was 6. Conclusion: when treating pilonidal sinus disease, the bilateral subcutaneous fatty flap is superior to the ZP flap

Objective: Evaluate if the elevated systemic immune inflammation index (SIII) is a predictor of five-year survival in patients with lung cancer (LC) treated at the Alta Complejidad “Virgen de la Puerta” Hospital and Víctor Lazarte Echegaray Hospital during a period 2013 to 2018. Methods: A retrospective cohort analytical study was carried out in which 134 patients with lung cancer were included, divided into 2 groups according to whether or not they were exposed to elevated SIII (greater than 660), in which the five-year survival was determined by analysis of Kaplan-Meier and multivariate analysis by Cox regression to obtain the estimate of the Hazard Ratio. Results: Survival at 12, 36 and 60 months was analyzed, where patients with elevated SIII had a survival of 62.6%, 48.7% and 10.3%, showing a trend of lower survival at 5 years (HR: 7.762, CI95 %: 3,226-18,678). No patient with a history of smoking had survived 5 years after the PC was diagnosed; the multivariate analysis determined that smoking is a factor of worse survival (HR: 2,836, 95% CI: 1,213-6,630). Cancer stages III and IV were associated with a worse survival prognosis compared to stage I, meaning an increase in mortality of 9.91 and 14.5 times, respectively. Conclusion: the elevated systemic immune inflammation index (SIII) is a predictor of five-year survival in patients with LC

Intoduc.on: Lower extremity wounds have been always a challenge for reconstruc:ve surgeons. Free perforator flaps are considered to be the best op:on for this problem but require the complexity of microsurgery. So, pedicled perforator flaps have emerged as alterna:ve op:ons for lower limb reconstruc:on. Pa.ents and methods: Prospec:ve study was conducted upon 40 pa:ents with trauma:c soD :ssue defects in the leg and foot in the period from (9/2017) to (8/2019). The free flaps used were, Anterolateral Thigh flap (ALT) and Medial Sural artery perforator flap (MSAP). In pedicled perforator flaps group, 10 cases were designed as propeller flaps while the other 10 flaps were designed as perforator plus flaps. Results: Free flaps were mainly used for large sized defects; we had one case of par:al flap loss and one case of complete flap necrosis. There was no difference in the survival of free flaps regarding the number of venous anastomoses or number of perforators which the flaps were based on. MSAP flap was the first op:on for coverage of large sized defects on foot and ankle as it s a thin and pliable flap, while ALT flap was used for coverage of larger defects on the leg. Pedicled perforator flaps were used mainly for small to medium-sized defects especially in the lower third of the leg; we had 3 cases of flap loss in propeller flap design while we had no cases of flap loss in perforator plus flap. Conclusion: Perforator flaps have become a reasonable solu:on for soD :ssue defects of the lower extremity. Careful as-sessment of the dimensions, loca:on, pa:ent comorbidi:es, availability of surrounding soD :ssue and presence of adequate perforators are mandatory for proper perforator flap selec:on.

Over the years, rapidly increased scientific evolution managed to depict severe clinical entities among surgical implementations. In particular, abdominal surgical dissections and especially, cases of pancreatic cancer demand assiduous therapeutic mapping with ultimate scope increased patient’s quality of life. In terms of pancreatic carcinomas, can achieved gastric venous congestion postoperatively. According to current bibliography, such cases are very difficult to be depicted. Proper diagnosis and therapeutic mapping with total pancreatectomy and splenectomy can resolve such issues

Background: Pancreatic ductal adenocarcinoma (PDAC) is aggressive, with more than 80% present with metastatic disease, and an overall survival of less than a year with systemic chemotherapy treatment. Cytoreductive surgery (CRS) and intraperitoneal chemotherapy are two treatment modalities being explored to improve the survival rates of these patients. Case presentation: A 45-year-old man presented with epigastric pain, mass, and weight loss. Investigations revealed a pancreatic tumour with liver and extensive peritoneal metastases. After 18 cycles of chemotherapy, there was significant disease regression which allowed CRS and HIPEC to be performed. HIPEC, PIPAC, and repeated intraperitoneal liquid chemotherapy have been shown to be safe. Longer survival and reduced disease related complications are among the advantages seen in published data. Conclusion: Complete cytoreduction and HIPEC, repeated cycles of either intraperitoneal chemotherapy or PIPAC, are associated with longer survival and reasonable adverse effects. Patients diagnosed with PDAC and peritoneal metastases should be considered for these treatment strategies

Median Arcuate Ligament Syndrome (MALS) also known as Celiac Axis Compression Syndrome (CACS) or Dunbar syndrome which is a very rare condition with an incidence of about 2 cases per 100,000 patients caused by compression of the celiac trunk by the median arcuate ligament . The etiology of Dunbar’s syndrome is not well known as it is rare and is difficult to diagnose and treat. An abdominal CECT in a 22-year-old woman with a 4 months history of postprandial abdominal pain and vomiting showed thickening of median arcuate ligament measuring 6mm causing narrowing of the proximal celiac trunk forming a hooked or a J-shaped appearance suggestive of median arcuate ligament syndrome or celiac artery compression syndrome. After thoroughly ruling out the other causes of the above mentioned symptoms, Laparotomy and release of the median arcuate ligament was done, which resulted in relief of the patient's symptoms.The diagnosis of median arcuate ligament syndrome should be considered in patients with postprandial abdominal pain that does not have a clearly established etiology and surgical decompression/release of median arcuate ligament is the mainstay of management