Apart from being one of the most technically demanding and complicated procedures in gastrointestinal tract surgery, pancre-aticoduodenectomy is commonly followed by the development of serious postoperative complications that are typically related to the failure of pancreatic ductal anastomosis. Pancreatic enzymes leaking into retroperitonum insult neighboring organ and tissues, leading to severe inflammatory reaction and fistula formation that represents the most feared, life-threatening compli-cation following pancreatic head resection. Various operative anastomotic techniques for the management of pancreatic rem-nant have been proposed throughout the years however, none of these proved to be superior over the others in terms of de-creasing the rate of post-pancreatectomy pancreatic fistula. The aim of this study is to review the various established anasto-motic and adjunctive techniques that can potentially decrease the rate of postoperative pancreatic fistula following pancreati-coduodenectomy. Additionally, the study describes the preventive mesures and the current management of pancreatic ductal anastomosis failure.

Abstract. Lap Cholecystectomy is the gold standard surgery in treatment of gallstones. One of the technological advancements in LAP Cholecystectomy is the usage of Ultrasound Scissors in ligature. The Ultrasound Scissors in contact with the tissue, sets the protein molecules in high frequency oscillation. The result of this process is that the chemical bonds of the proteins are hydro-lyzed, while is being achieved gradually vascular occlusion, hemostasis and the tissue is being truncated. There is negligible in-crease in the temperature of the tissues while the spread of the heat is less than one millimeter.Objective: The purpose of our research is the safe ligature of the cystic duct only with the usage of Ultrasound Scissor and with-out the installation of tissue staples.Methods: Our research was conducted based on 30 patients (6 males and 24 females) with a median age of 56.1 years who un-derwent scheduled Laparoscopic cholecystectomy using ultrasound scissors. Intraoperatively, after the identification and surgi-cal preparation of the cystic duct, two surgical ligation clips were placed in its central part. At the peripheral of the ligation clips, was performed parallel cross section of the cystic duct using only ultrasound scissors. After the removal of the gallbladder from the peritoneal cavity, a small orifice was formed on the gallbladder preparation and air with pressure was injected into it. Then with the use of a manometer it was observed at what values the cystic stump was ruptured.Results: The range of values at which the opening was achieved, it was between 60mmHg (81.6cmH2O) to 270mmHg (367cmH2O), with an average space of 177.1 mmHg (240.7cmH2O) for all surgical preparations.Conclusion: The normal pressure into the bile duct varies between 8 - 16 cmH2O. In our research the pressure values, where the rupture of the cystic truncation was achieved, were much higher (ppm 240.7 cmH2O).With this fact we can conclude that the cystic duct ligation can be performed safely only with the use of ultrasound scissors without postoperative leakage from the cyst-ic stump. Moreover for the establishment of this specific Laparoscopic technique further experimental studies will be required.

Background: Patients with multiple severe systemic diseases present a high rate of complications after abdominal surgery under general anesthesia especially in emergency setting. Herein, we deal with two cases of high-risk patients who underwent colec-tomy in emergency setting at our Department under continuous spinal anesthesia as a primary method of anesthesia and we provide a brief review of the literature on this issue.Methods: Two cases performed using spinal anesthesia alone (T5-T6 sensory level) in patients with multiple severe chronic sys-temic diseases. Surgical operations included right hemicolectomy and subtotal colectomy.Results: Intraoperative conditions were adequate with spinal anesthesia alone for successful completion of the procedure in both cases. Our patients recovered without postoperative complications.Conclusions: Abdominal surgery can be safely performed using spinal anesthesia alone in selected high risk patients in emergen-cy setting, making this option an alternative to general anesthesia.

Background: This study was conducted to evaluate whether preoperative biopsy or the time from biopsy to sentinel lymph node biopsy independently effect sentinel node positivity in early stage breast cancer.Material and Methods: This was a retrospective study done by reviewing the medical records of 970 patients who were operated at department of general surgery at a university hospital between June 2002 and December 2012. Patients with a history of previous breast surgery and/or neoadjuvant chemotherapy were excluded. 721 women with clinically and/or radiologically node-negative early stage invasive breast cancer were included in the study. Results: Sentinel node metastases were identified in 37% of cases (n=262). In multivariate analysis the most relevant variables that contribute to sentinel node positivity, in descending order, were as follows: Lenfovascular invasion, multifocali-ty/multicentricity, tumor size, hormone receptor status, histologic subtype, tumor palpability. Neither the biopsy method nor the time from breast biopsy to sentinel lymph node biopsy was associated with the sentinel node positivity. Neither of them was associated with the sentinel node metastasis size.Conclusion: We can offer preference to the patient a choice between breast-conservation surgery and mastectomy prior to op-eration according to the result of preoperative biopsy.

Introduction. Motor vehicle accidents are one of the leading causes of death in the world. The autopsy serves as a quality indica-tor for missed injuries in clinical management.Objectives. To identify and describe missed injuries in motor vehicle fatalities by comparing clinical records and autopsy findings in Central Durban during the year 2012. Methods. The study was a retrospective descriptive analysis of missed injuries determined at autopsy at an Durban-based mor-tuary. 181 cases were accepted into the study. Copies of the hospital notes and summaries were studied which were obtained from the case files in the archives of the Forensic Medicine and Pathology Department in Inkosi Albert Luthuli Central Hospital. The data collected was captured and analysed using the Statistical Package for Social Sciences (SPSS version 21). Results. Missed injuries were detected at autopsy in 41% of cases. The regions with missed injuries in decreasing order were the thorax (56.6%), head and neck (47%), the abdomen (31.6%), pelvis (15.8%), face (3.9%) and limbs (2.6%). Cases with the most missed injuries were generally pedestrians and had a low Glascow Coma Scale score. In-hospital investigations were done ade-quately in most cases but injuries were still missed. The period of survival of case subjects with missed injuries were reduced compared to the subjects without missed injuries. Conclusion. The study confirmed that injuries contributory to the cause of death are missed clinically. The regions with the most commonly missed injuries were the head and chest.

AIMS/ Objectives: Pancreas is affected by a variety of disease processes which include acute inflammation with its complications, chronic inflammation and mass lesion. This study aims at assessing the usefulness of plain X- ray , Upper GI barium study, Ultra-sonography, CT and MRI scan in the evaluation of pancreatic disorders and also to correlate these studies with ERCP / histo-pathological finding / operative finding.Materials and Methods: this was a single centre prospective study conducted from July 2014 to June to 2016 by the department of Surgery and Radiodiagnosis. The patients were selected from those attending the surgical out patients and emergency de-partment at the hospital. The study group comprised of 75 patients from all age groups, presenting with symptoms and clinical signs and suggestive of pancreatic pathology. Patients with finding suggestive of pancreatic disorders were take up for imaging modalities like plain X- ray abdomen, X- ray chest PA view, Barium meal upper gastrointestinal study, ultrasonography, CT scan, MRI with MRCP (whenever needed). Statistical analysis was performed by the SPSS programme for windows version 17.0. All the data were tabulated and analysed. All the variables are presented as absolute numbers and percentages.Results: The study included 75 subjects, 54 of whom were male and 21 female. The age of the patients varied from 12 to 70 years. The etiology in 38.5% of patients was chronic alcohol intake and all these patients were male. The most common finding on plain X ray was pleural effusion with basal atelectasis. The most common finding on barium meal upper GI studies was muco-sal irregularity. On CT scan and MRI of pancreatic neoplasm, peripancreatic fat plane involvement was the most common finding.Conclusion: ultrasonography is superior to CT scan for determining the nature of fluid. CT sensitively detects mass lesion in pan-creatic parenchyma and delineation of its extent while MRI has high soft tissue contrast

The rectosigmoid junction (RSJ) is the segment of the gut where the colon merges with the rectum. However, the precise loca-tion of the RSJ as well as the existence of a true anatomical sphincter in the area remains controversial.The junction has characteristic morphologic features and specific functional significance. Physiological studies have demonstrat-ed a high-pressure zone within the RSJ, while others found evidence of an anatomical sphincter. Authors have attributed a pacemaker role as well as regulating defecation through mechanoreceptors and reflex arcs. The purpose of this study was to determine the location as well as the morphology of the RSJ and determining whether specific features contribute to its function as a sphincter.The RSJ was studied in 30 adult human cadavers in situ and in vitro following low anterior resection of the rectum. The study in vitro was conducted macroscopically and histologically after fixation of the rectosigmoid specimens with formalin 10%.The RSJ was found to be a distinct zone with mean length of 2.75 cm. A remarkable thickening of the muscular layer as well as a subsequent narrowing of the lumen, following fixation with formalin was recorded.The study suggests the presence of a functional sphincter at the RSJ lacking the features that constitute an anatomical true sphincter, regulating the passage of the stools from the sigmoid colon to the rectum

Renal cell carcinoma has been shown to cause venous migration and causing tumour thrombus in the Inferior Vena Cava. It is very important for a pre-operative imaging to be done which will decide in surgical approach for the patient. We have a case report of Renal Cell Carcinoma with a supradiaphragmatic tumour thrombus reported. However, after a multi-disciplinary discussion conclud-ed the findings differed and postoperative histopathology confirmed even further downstage of this tumour. We would like to dis-cuss the imaging modalities available and surgical approach based on imaging findings.

Background: Abdominal impalement are rare but dramatic injuries involving viscera and vascular structures that are associated with very high morbidity and mortality. Rapid assessment, critical decision making and necessary actions are required at the pre-hospital, resuscitative and operative level for effective management of such injuries.Case presentation: We report a case of 22-year-old gentleman with transabdominal impalement by a long cylindrical metal lamp post of 12cm diameter during a road traffic accident. He was promptly resuscitated and rushed into the operating theatre for an emergency laparotomy. He sustained jejunal and mesenteric transection, as well as small non-expanding right zone II retro-peritoneal haematoma. Damage control surgery with small bowel resection was performed, followed by relaparotomy and small bowel anastomosis 48 hours later. The patient recovered and was discharged well on day 8 of admission.Conclusion: We discuss the intricacies and challenges of managing a transabdominal impalement injury. The outcome after mas-sive abdominal impalement can be optimised by (a) rapid transportation with adequate resuscitation with the impaled object in-situ (b) targeted and regular reassessment of the patient’s haemodynamic status (c) early empirical antibiotic administration (d) damage control surgery, and (e) post operative intensive care and rehabilitation

Introduction. Anorectal melanomas are rare, and they usually presented as an aggressive tumour. Most of the patient presented with perianal complains such as anal pain, bleeding, tenesmus, mass before the emergence of metastatic complaints. It contrib-utes to less than one percent of all colorectal cancers. It is commonly affected females in their sixties. Case Presentation.We are reporting a case of a 53 years old lady, presented with progressive enlargement of left inguinal mass with a small pigmented berry-like anal mass. She was initially presented to a private hospital with a left inguinal abscess which she had incision and drainage done. She presented to us after 2 weeks later with poor healing wound and progressive enlargement of left inguinal mass with pigmentation. Incisional biopsy of the left inguinal lump shows metastatic melanoma. Colonoscopic exami-nation shows a small pigmented lesion confined to the anal canal. The biopsy of the lesion shows malignant melanoma. Staging computed tomography scan showed extensive regional lymph nodes metastasis with lungs and liver metastasis. Conclusion. The prognosis of Anorectal Melanomas is poor as they are usually presented as advanced metastatic disease. It is not unusual for anorectal melanoma to present as metastasis disease, however, it is rather unusual that the patient does not have any predominant anorectal complains upon initial presentation

Meckels diverticulum is the congenital anomaly of gastrointestinal tract. The frequency of its occurrence is about 1 - 3%. There are various complications associated with diverticulum, including hemorrhage, intestinal obstruction, inflammation and perforation. Intestinal obstruction is the most common complication in adult. The Aim of the work is demonstration of the case of strangulated bowel obstruction combined with the torsion of Meckels diverticulum. The female 27 years old was admitted to the surgical department urgently with nausea, vomiting, cramping abdominal pain. The obtained results of the examination were evaluated as acute small bowel obstruction. An emergency surgery was performed - exploratory laparotomy. It was detected: axial torsion of Meckels diverticulum followed by gangrene, its topside was attached to the dorsal peritoneum by retained fibrous vitelline band. This diverticulum also formed a loop which caused strangulation of the small intestine. The correct diagnosis of Meckels diverticulum before surgery is generally impossible, because complicated diverticulum imitates many other abdominal pathologies. The torsion of the Meckels diverticulum is one of the rare complications. In our case, one patient encountered two complications of the Meckels diverticulum: its torsion with gangrene and acute intestinal obstruction. Exploratory laparotomy is a mandatory procedure for the detection of complicated Meckels diverticulum and correct treatment

Bezoars in gastrointestinal system are very rare and usually cause nonspecific symptoms. We report on a case of an 86 year old male, which presented with acute obstructive small bowel ileus caused by an impacted phytobezoar. The patient underwent exploratory laparotomy and removal of the bezoar through laparotomy. The postoperative course of the patient was uneventful.

Gastrointestinal tract is the most common extra nodal site involved by lymphoma with the majority being non-Hodgkin’s type. Though lymphoma can involve any part of the gastrointestinal tract, the most frequent sites in order of its occurrence are the stomach followed by small intestine and ileocecal region. Gastrointestinal tract lymphoma is usually secondary to the wide-spread nodal diseases and primary gastrointestinal tract lymphoma is comparatively rare. Gastrointestinal tract lymphomas are often not clinically distinct and indistinguishable from other benign and malignant conditions. Intestinal T-cell lymphoma is a rare hematological malignancy that can present as primary intestinal lymphoma or as a manifestation of systemic disease. Inflamma-tory bowel disease, celiac disease, immunosuppressant and infectious etiologies such as Epstein–Barr and human T-lymphotropic viruses have been reported as risk factors but no direct causal link has been located

Background: Buried Bumper Syndrome (BBS) is a condition resulting in the submucosal embedding of the per-cutaneous endo-scopic gastrostomy tube bumper and a known long term complication of Percutaneous Endoscopic Gastrostomy (PEG) tube ren-dering the tube non-functional. This manuscript describes a case of BBS and discusses the role of appropriate incision technique and post incision care for the reduction of incidence of BBS among patients with a newly inserted PEG tube.Case Presentation: A fifty years old lady with recurrent Nasaopharyngeal Carcinoma presented with a localized neck abscess secondary to pahryngeo-pleural fistula. In view of the large collection size, a decision was made to divert the patient’s oral intake via a feeding gastrostomy to allow for healing of the fistula. A PEG tube was successfully inserted via endoscopic guidance. How-ever, gastrostomy was complicated with localized tenderness surrounding the insertion site at one week post insertion. Further investigations revealed BBS which was treated successfully solely by a creative endoscopic approach. Fortunately, the patient was able to use the PEG tube actively for a short period to facilitate fistula healing and was subsequently removed after six months with no other complications.Conclusion: Good principles of insertion coupled with good post insertion care will contribute to the reduction in the incidence of BBS

Malignant melanoma is a potentially lethal neoplasm. Although more than 90% of melanoma is cutaneous in origin, occasionally it manifests as a secondary deposit without evidence of primary lesion. We describe a rare case of malignant melanoma involv-ing the right submandibular lymph node, with negative fluorodeoxyglucose uptake on positron emission tomography. The pa-tient underwent right submandibulectomy and right modified radical neck dissection type II before being referred for oncological treatment