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1 Hepatic and Gastro-Intestinal Manifestations of Volumetric Overload Shocks (VOS) Causing ARDS , Ahmed Ghanem
Substantial physics and physiological evidence with clinical relevance and significance currently exists that affirms Starling's law is wrong (Figure 1) [1-3]. Evidence that volumetric overload shocks (VOS) [4-7] cause the acute respiratory distress syndrome (ARDS) is also available [8]. These VOS are complications of fluid therapy in surgical patients due to many errors and misconcep-tions on fluid therapy [8] that mislead physicians into giving too much fluids during the resuscitation of shock and prolonged ma-jor surgery [9]. The clinical manifestations of VOS causing ARDS is shown in table 1, among the multiple system and vital organ dysfunctions are the hepatic and gastro-intestinal (GIT) manifes-tations [10-14]. These include hepatic dysfunction with elevated bilirubin, alkaline phosphates and liver enzymes of SGOT [10,11] and delayed recovery of intestinal function or paralytic ileus with nausea and vomiting [12,13]
2 Esophageal Dilatation in Children with Esophageal Strictures, Outcome and Safety at Single Center Experience , Abdulhamid Alhadab, Shaden N AlMahamed, Zahid Arein and Abdelhai Hammo
Objective: The aim of this study is to assess the clinical response, nutritional outcome, and safety of endoscopic esophageal dilatation in pediatric esophageal stricture at KFSH-Dammam, Saudi Arabia.Method: Charts of children between the age of 1 month and 16 years old with esophageal stricture who underwent endoscopic esophageal dilatation at King Fahad specialist Hospital-Dammam over a 5 years period from January 2014 until January 2019, was retrospectively reviewed. Patient’s characteristics, procedure modality for stricture dilatation, clinical response, post dilatation catch up growth, and complications were reviewed and evaluated.Result: A total of 17 patients (median age, 2.7 years were identified. The median follow-up period was 2 years. Post esophageal atresia repair stricture (47.1%) and corrosive esophageal injury (17.6%) were the leading cause of strictures. The main presenting symptoms were dysphagia (88.2%) followed by vomiting (64.7%) and then chronic cough (35.3%). Majority of strictures were short segment < 2 cm in length (70.6%). A total of 74 dilatation sessions were performed with an average of 4.3 sessions per patient. 70.8% underwent balloon dilatation. Complete response was achieved in (70.6%) while partial response in (29.4%). Complications of dilatation including esophageal perforation were reported in 1.3%, and post-dilatation chest pain in 2.7%. The mean weight-for-age z-score improved significantly after ED therapy from -1.8 ± 0.79 SD at presentation to -1.01 ± 0.85 SD (P value = 0.003).Conclusion: Our single centre experience demonstrates that endoscopic dilatation is an effective and safe procedure for symptomatic esophageal stricture in children with different etiology. The choice of dilator device is based on multiple factors with minimal reported complications. Maintaining an age appropriate esophageal lumen by dilatation is very crucial to allow for satisfactory oral intake and promote catch-up growth which is the ultimate goal of dilatation
3 Extracorporeal Detoxification and Immunocorrection in Treatment of Corona Virus Pneumonia Complications , Voinov VA, Ilkovich MM, Kovalev MG and Voinova YV
The new corona virus pneumonia caused by COVID-19 having begun in China, has now reached almost all countries of the world, affecting more than 500,000 people, of which more than 25,000 people have died. Unfortunately, specific measures for both preventing and treating this infection, which has pandemic status, are still lacking, which makes this problem very urgent. In severe pneumonia, acute respiratory distress syndrome (ARDS) develops - toxic pulmonary edema with severe and difficult to correct respiratory failure, which requires an extracorporeal membrane oxygenation (ECMO). Since endotoxemia is the basis for ARDS development, extracorporeal detoxification methods should play a leading role in the treatment of this complication. Moreover, with help of hemosorption, not only detoxification is achieved, but also decontamination (delay and removal of pathogens), and with plasma exchange, the body's immune defense system is restored.
4 Meckel’s Diverticulum: Bibliography Review and Presentation of a Case , Carlos Sanjuan-Sánchez and María G García-Rangel
Meckel ́s diverticulum is the most prevalent congenital anomaly of the gastrointestinal tract, is a true diverticulum because contain of the layers of the intestinal wall. Is usually found within 100 cc of the ileocecal valve, is more frequent in men and children with congenital malformations. The diagnostic of symptomatic diverticulum is rare because there is not a specific clinical sing. Treatment of the symptomatic diverticulum is diverticulectomy or intestinal resection, asymptomatic case is still controversy. We reported the case of a male of 24 years old who had acute abdomen, the management was a laparotomy finding diverticulitis of a Meckel ́s diverticulum. Intestinal resection was the decision in the case with entero-anastomosis in two planes with clinical good respond.
5 Covid-19 Crisis: How Tortuous is the Coronavirus Road Ahead? , Avinash Jayaswal
Covid-19 disease is the third betacoronavirus zoonotic infec-tion affecting humans in two decades, and has been by far the most catastrophic in terms of human lives and economic wreck. The global pandemic that started in the meat market in Wuhan, China, has already claimed 116,000 lives and infected 1,8 million people and counting [1]. The first Indian to test positive for covid-19 was a medical student who had arrived in Kerala from Wuhan at the end of January [2], which is around the same time the first American and the first Korean were tested. The response was mapped out immediately by a group of government officials in Kerala as their experience with the outbreak of Nipah in 2018, a brain-damaging virus originating from bats and transferred to humans, was still fresh [2]. That outbreak was successfully managed despite techni-cal shortfalls. This time they put forward a plan of contact tracing, isolation and surveillance state-wide, until the whole country went into confinement with more than 12,000 cases two months later, in an attempt to curb viral spread.
6 Adult Sigmoido-Rectal Intussusception Presenting as Gangrenous Bowel and Rectal Prolapse: A Rare Presentation , Renu Saini, Urmila Basu, Niraj Kumar, Raj Mithun Degala and Sanjay Kumar Dubey
Intussusception in adults especially sigmoido-rectal intussusceptions is extremely uncommon. In this report we have described a case of sigmoido-rectal intussusception in an elderly gentleman presenting as prolapsed gangrenous bowel who underwent laparotomy and resection anastomosis and made an uneventful recovery. Adult intussusceptions are generally associated with a pathological entity predominantly malignant. Insidious presentation with vague abdominal pain is the usual presentation and emergency presentation as seen in our case with gangrenous prolapsing bowel in the absence of a predisposing etiology is extremely uncommon. While adult intussusception usually requires operative intervention controversy exists with respect to attempted reduction prior to resection.
7 Not Only Helicobacter pylori Lives in Stomach - Case Report , Leandro Bressianini Jurkonis, Carolina Rebello Hilgert, Maria Cristina Figueroa Magalhães and Jean Rodrigo Tafarel
This case report brings attention to an unusual pathogen which can live in the human stomach and cause dyspeptic symptoms, weight loss and typically does not spring as the first hypothesis of medical doctors. The 67-year-old Brazilian man described in this report had a delay in his diagnosis of almost 2 years, until his complaints were resolved, which makes this an interesting case report.
8 Spectrum of Pulsion Esophageal Diverticulum and Approach to the  Management Based on Presence or Absence of Symptoms , Ajeet  Kumar  Lohana;Rajesh  Bansari;Fakhar  Ali  Qazi  Arisar;Wasim Jafri
Introduction: Pulsion esophageal diverticulum (PED) is a rare esophageal disorder. A minority of individuals develops characteristic symptoms, such as dysphagia,; however;, the majority does not produce any symptoms. Progression and requirement of a follow up in asymptomatic diverticulum is not well determined. In this study, the spectrum of presentation and approach to management of PED based on presence or absence of symptoms is determined. Method: In this retrospective study, 28 consecutive patients identified having PED from January 2010 to December 2017. Information regarding clinical spectrum of the disease and treatments were recorded. Patients follow up charts were reviewed to determine onset of new symptoms in asymptomatic individuals and resolution/recurrence of symptoms in symptomatic individuals after respective treatments. Results: Mid esophageal diverticulum (MD) was the most common diverticulum (17/28) (60.7%). 13/28 (46.42%) of individuals were asymptomatic and all of these patients harbor MD of ≤1 cm in size. Over a mean follow up of 14 months none of asymptomatic patient developed new symptoms and/or complications. A total of 15/28 (53.54%) patients were symptomatic, predominantly with dysphagia (10/15) (66.66%) and having Zenker’s Diverticulum (ZD) among 4, MD among 4, Epiphrenic Diverticulum (ED) among 6, and MD+ED among 1 patient. Out of 15 symptomatic patients, one third (5/15) of patients underwent surgical interventions due to persistent troublesome symptoms; another one third (5/15) could not undergo surgical resection despite persistent symptoms because of comorbid condition and patient refusal; and in remaining one third (5/15) of patients the symptoms were fairly controlled with  supportive  treatment  only.  1/5  (20%)  of  symptomatic  individuals  who  underwent  surgery  had  recurrence  of  symptoms  postoperatively. Conclusion: MD type with ≤1 cm may not require treatment or long term follow up. Zenker’s and Epiphrenic Diverticula produce persistent  symptoms  even  if  small.  Two  thirds  of  such  symptomatic  patients  require  surgical  or  endoscopic  resection  because  of  troublesome symptoms; however rest of symptomatic patients can be controlled with supportive treatment without necessitating surgical intervention
9 Perplexity in Diagnosis of Pancreatic Lesions , Tanveer Ahmed
Cystic lesions of Pancreas are always challenging for Gastroen-terologist.  In  the  recent  past  cystic  lesions  of  pancreas  remained  undiagnosed  and  number  of  patients  were  diagnosed  after  sur-gery. But in new era Endoscopic Ultrasound have made it so much easy  and  now  cystic  lesions  of  pancreas  are  diagnosed  easily  and  treated well and surgery is needed only in 10 - 25% patients. Only 20%  cystic  lesions  are  malignant  while  others  are  benign  lesions  so early diagnosis and treatment of cystic lesions is very important in reducing mortality and morbidity in number of patients.
10 Metastatic Renal Epithelioid Angiomyolipoma: An Interesting and Rare Case Report , Jill David,Reginald Chounoune,Alene Wright,Abdul Waheed and Frederick D Cason
Angiomyolipomas are the most common clonal mesenchymal tumors of the kidney. Metastatic renal epithelioid angiomyolipomas (MREA) are a less common variant that are found to have malignant potential. We present a case of a 59-year old female diagnosed and treated for MREA which was initially thought to be a benign renal mass. The patient was being followed with serial abdominal imaging which showed subsequent development of two large abdominal masses. Appropriate surgical intervention was performed, the  patient  tolerated  the  procedure  with  minimal  complications,  and  the  post-operative  microscopic  evaluation  of  biopsied  specimens confirmed the diagnosis of MREA. Unlike commonly benign renal angiomyolipomas, MREA is a highly aggressive lesion. It is imperative for clinicians to identify and differentiate this life-threatening lesion from renal cell carcinoma (RCC). A multimodality treatment approach including resection of tumor and adjuvant therapy may provide optimum treatment for MREA.
11 Acute Pancreatitis Revealing Cystic Dilatation of the Common Bile Duct: A Case Report , Naouel Lemdaoui,Raouf Menoura,Abderraouf Bataiche,Ha-kim Rahmoune,Nada Boutrid and Soumia Satta
Cystic dilatation of the common bile duct (CDCBD) is a rare congenital defect. More than half of the reported cases are pediatric and 80% are involving girls. Its symptomatology is often atypical and it is commonly of incidental discovery and rarely revealed by a severe complication like acute pancreatitis.
12 Identification and Characterisation of Periodicum pradatorius: An Emerging Pathogen of Physicus novicius and Litterae scientific , Rasher Dan,Thomas Thug and Peter Throb
Litterae scientific has, over the last decade in particular, been the subject of escalating insult from anumber of rogue elements; none more insidious than Periodicum  pradatorius[1]. Coinciding with the growth of the internet [2], this opportunistic infectious agent gains access to its intermediary host (Physicus novicius) primarily via Email, though social media platforms have also been implicated [3]. Once established in the hosts’ inbox, the virus either remains dormant until activated by the unwitting host, or neutralised by the hosts’ immune defences (i.e. antispam software).
13 The Challenge to Move the GI Tract , Alfredo Fernandez
One of the most difficult approaches are when we have a patient with any symptoms of abnormal motility in this case the inhibit of bowel movements and reflux of GI tract and the same time the patient suffer of any cardiac arrhythmia and neurological disorder including  any  mood  disturbance.  The  reason  is  because  the  meds  that we can use to improve the motility affect some how the dopa-mine receptors in the brain and heart too. Therefore thousands of patients  can’t  be  able  to  improve  her  multiple  symptoms  of  acid  reflux, gas, constipation and upper - lower dyspepsia then the Man-agement of all those conditions stuck in some matter that neither Surgeons  and  Clinicians  can’t  be  able  to  help  them  and  burden  of  this patients medically and economic too increasing their frustra-tion therefore we need to learn how treat this patients and allow their compliant with this condition management.
14 Pedunculated Giant Gastric Adenoma Embedded in the Entire Duodenum , RB Bayramov, RT Abdullayeva and SE Huseynova
Introduction: Adenomatous polyps of the stomach are uncommon tumors, comprising only 7 - 10% of all gastric polyps. Most gastric adenomas are solitary, pedunculated masses, measuring up to 3 - 4 cm in size, and commonly located in the antrum. Method: We present a patient with a giant pedinculated tubulovillous adenoma with features of moderate dysplasia developed in the middle third of the stomach and embedded in the entire duodenum and obturated it, who was referred to the hospital with clinical manifestations of duodenal obstruction. The correct diagnosis was made preoperatively at the specialized hospital on the basis of CT and upper gastrointestinal endoscopy. Case Presentation: 44-year old female was admitted because if epigastric pain and vomiting. First upper gastrointestinal endoscopy carried out at an unspecialized hospital gave duodenal carcinoma obturating the lumen. Abdominal CT and upper gastrointestinal endoscopy  in  specialized  center  revealed  giant  gastric  adenoma  with  long  and  thick  pedicle  embedded  in  the  entire  duodenum  and  obturated  it.  Middle  segment  gastric  resection  wit  gastro-gastroanastomosis  via  laparotomy  was  carried  out.  The  size  of  the  adenoma’s mass was 118 × 10 × 8 cm, of the pedicle – 8 × 4 cm. Conclusion: The  case  emphasizes  that  such  giant  gastric  adenomas  with  a  long  pedicle  can  be  embedded  in  the  duodenum  and  obturate  it  completely  causing  the  manifestations  of  duodenal  obstruction.  In  unspecialized  hospitals  misdiagnosis  can  be  made.  Middle segment gastrectomy can be a preferential option in the case of middle third location of the giant gastric adenoma.
15 Which is the Role of Locoregional Interventional Procedures for Secondary Hepatic Malignancies? , Roberto Iezzi
In the last decade remarkable advances in cancer care has cre-ated new challenges leading the clinical practice towards a person-alized medicine. Metastatic tumors to the liver continue to be an important health problem, representing the most common malig-nant tumor of the liver. Furthermore, liver is also frequently the sole organ harbouring metastases. Therapy directed at the liver to control or eliminate the predominant or exclusive site of disease should theoretically translate into improved survival. Due to the high incidence most of the available data relate to metastases aris-ing from colorectal primaries and the results obtained with resec-tion of colorectal hepatic metastases provide the most compelling evidence in support of this paradigm.
16 Remdesivir-Gate for COVID-19 , Mina T Kelleni
A full-scale clinical trial of remdesivir used for adult patients admitted to hospital for severe COVID-19 has clearly exposed that remdesivir was stopped early because of adverse events in 18 (12%) patients versus four (5%) patients on placebo. Further, remdesivir was not associated with statistically significant clinical benefits including the time to clinical improvement (hazard ratio 1.23 [95% CI 0.87 - 1.75]). Further, neither a significant mortality difference nor a decrease in viral load over time has been reported as compared to placebo
17 Laparoscopic Groin Hernia Repair: A Systematic Institutional Study , Tuhin Shah;Ashish Prasad Rajbhandari;Bhuban Rijal;Rabin Koirala;Arjana Shakya
Abstract Keywords:Inguinal Hernia; TEP; TAPP; Groin Hernia; Laparoscopic Inguinal Hernia RepairIntroductionIntroduction:Laparoscopic inguinal hernia repair is an option for inguinal hernia repair and is emerging rapidly as more surgeons are using this method and reporting the results.It has gained a key role in inguinal hernia repair with advantages reported in many trials and guidelines. Case Report:This is a retrospective descriptive study conducted in Surgery Department of Nepal Medical College and Teaching Hos-pital, Nepal from November 2017 to April 2019. All patients more than 16 years of age with inguinal hernias were given the choice of laparoscopic or open repair. Those who opted for laparoscopic repair were included in the study. Results:A total of 47 patients were included ranging from 16 to 78 years. There was a male predominance with 40 patients; and TEP (total extraperitoneal) repair was done in 30 while TAPP (transabdominal preperitoneal) repair was done in 17 patients. In 11 patients, we did a combined procedure in the form of Pantaloon hernia in 4, umbilical hernia in 2 and cholecystectomy in 5 patients. In this study, 10 patients had surgical complications, 4 each had peritoneal tear and seroma collection and 2 had SSI. The average total hospital stay was 3.2 (range 2-6) days and we do not report any hernia recurrence in our study. Conclusion:Laparoscopic inguinal hernia repair can be safely considered in a developing country with limited resources after at-taining proper training and expertise.
18 A Study to Evaluate the Efficacy and Safety Measures of Opioid Analgesics in Acute Pancreatitis , S Aravind;G Balaji
Abstract Background: Acute pancreatitis is a sudden inflammation of the pancreas. Occurs in order of frequency including a gallstone impacted in the common bile duct beyond the point where the pancreatic duct joins it; heavy alcohol use; systemic disease; trauma; and, in minor mumps. Acute pancreatitis may be a single event; it may be recurrent; or it may progress to chronic pancreatitis. Method: A prospective study about the efficacy and safety measurement of opioid analgesics in the treatment of acute pancreatitis was held in a tertiary care hospital. Objectives: To study the treatment outcomes of opioid analgesics by using case summaries and discharge medication chart. To assess the safety measures to be followed during the therapy of opioid analgesics. To minimise the ADR`S. Results: During the study it was observed that many patients have been suffered with severe abdominal pain prior to the treatment with opioid analgesics. This severity of pain is far most better after the treatment.
19 Role of Fibroscan and Non Invasive Markers to Assess Hepatic Fibrosis and Steatosis at Initial Presentation of Patients with Hepatitis B , Ankur Shah;Rathi Chetan;Shah Jayshri A
Abstract Objectives: To analyse the Role of Fibroscan (FS) and non-invasive markers to assess hepatic fibrosis and steatosis at initial presen-tation of patients with Hepatitis B. Methods: An observational prospective study of patients with chronic hepatitis B (CHB) evaluated at single Liver Clinic, Mumbai from April 2014-March 2017. Serological markers, transient elastography (fibroscan) for HF, APRI, FIB-4, AST/ALT ratio and E-score were analyzed. Controlled attenuation parameter (CAP) score on fibroscan was used for grading of hepatic steatosis. Patients were categorized into 2 groups: No significant fibrosis (< F2), significant fibrosis (> F2) group. AST/ALT ratio was divided into 2 groups: No significant fibrosis for ≤ 1, significant fibrosis > 1. Results: 178 study patients with male preponderance (68%), had asymptomatic infection, 24 patients were symptomatic; ascites (7), variceal bleeding (11) and hepatocellular carcinoma (8). 139 patients underwent fibroscan, 80 had HS on CAP score. 40/100 patients with normal AST and ALT had significant fibrosis (> F2) on fibroscan. Amongst noninvasive biochemical tools, only FIB-4 had significant correlation with fibroscan, (p < 0.05). The ROC curve areas (AUROC) of FIB-4, APRI and AST/ALT ratio that differentiated patients with significant HF from without fibrosis was 0.704, 0.674, 0.567, respectively. The sensitivity and specificity of FIB-4, APRI and AST/ALT ratio to differentiate patients with significant HF from those without was 42.6% and 92.3%, 72.1% and 60.2%, 29.5% and 83.3%, respectively. Conclusion:Fibroscan and FIB-4 had significant correlation of HS in CHB patients. These can be used as non-invasive modalities to monitor HS in CHB patients.
20 Small Bowel Bleeding Associated with Meckel’s Diverticulum. Complex Diagnosis with Monoballoon Enteroscopy , Jonatán Mendoza Ramírez;Diego Angulo Molina;Javier García Guerrero;Jorge Santín Rivero;Laura Montserrat Bernal López
Abstract Meckel's diverticulum is a congenital diverticulum, which contains intestinal mucosa and ectopic tissue (gastric or pancreatic). The diagnostic accuracy of monoballoon enterosocopy has been reported between 58 - 74% compared to 67% of the endoscopic cap-sule in the evaluation of evident small bowel bleeding. Meckel's diverticulum is rarely diagnosed in adults and is usually associated with complications such as gastrointestinal bleeding, obstruction and diverticulitis (30%). The treatment for symptomatic Meckel's diverticulum is surgical resection, with or without an adjacent bowel segment.
21 EUS Guided Liver Workup Versus Percutaneous Guided in a Community Hospital , Matthew M Eves;Allison Harvey;Michael Lysek;Roshanak Derakhshandeh
Abstract Background and Aims: Previous studies confirm endoscopic ultrasound (EUS) can complete liver biopsy, paracentesis and EGD during one procedure. This study evaluates translating these studies to a community hospital. Results: Mean number of portal triads was 12.7 EUS vs. 12.4 percutaneous (p value 0.89). Mean length of the longest core 0.94 EUS vs. 1.06 cm percutaneous (p value 0.14). Etiology of hepatitis 4/7 EUS vs. 0/4 percutaneous (p value 0.03). Confirmation of cirrhosis 4/6 EUS vs. 1/3 percutaneous. Total cost $1705 EUS vs. $3984 percutaneous. No significant complications occurred. Methods: 17 patients requiring EUS liver biopsy were compared to 17 transcutaneous patients for quality, cost and safety. This included evaluation for varices and diagnostic paracentesis. Conclusion: No significant biopsy sample differences existed. EUS provided better diagnostic information and clearly has economic advantages. The benefits of EUS guided liver workup translate to a community hospital
22 Successful Pelvic Exenteration for T4b Rectal Cancer: A Case Report , GZ Bounab;S Bicha;H Rahmoune; N Boutrid;R Sayoud;H Boutrid;N Lemdaoui
Abstract Pelvic exenteration (PE) or pelvectomy is defined as radical “En Bloc” resection of two or more contiguous pelvic organs, followed by reconstruction or diversion of visceral functions. PE was first reported by Brunschwig in 1948 as a particular and radical surgery for advanced and recurrent cancer and considered as "the most radical surgical attack so far described for pelvic cancer". Its broad indications are curative strategies discussed by a multidisciplinary team; PE must be done “En Bloc” with negative margin status.We report a case of a rectal mucinous carcinoma in a 38 year-old man. The patient benefited radical treatment through total PE with terminal colostomy and urinary diversion (ureterostomy by Bricker's method) with good post-operative outcomes.
23 Evaluation of the Frequency and Factors of Hospital Mortality in Surgery at the Kankan Regional Hospital , Camara Soriba Naby;Camara Alpha Kabinet;Diallo Amadou Djoulde;Balde Oumar Taibata;Balde Abdoulaye Korse;Sanoh Doukara;Toure Aboubacar;Diallo Aissatou Taran;Diallo Biro
Abstract Purpose of the Study: The purpose of this study is to make an analysis on the factors of mortality at the prefecture hospital of Kankan.Materials and Methods: Its was a prospective cross-sectional observational study over a period of 6 months. The target population consisted of all patients admitted to the surgical department during the study period. Introduction: By its very definition, mortality can be defined as the number of deaths that have occurred in a population during a given period. The mortality rate is expressed as a percentage; it is the proportion between the total number of deaths in a given space and the size of the population. Results: The sex ratio of nearly 1.42 (M/F) reflected a strong male prevalence of mortality with a frequency of 20 cases, 59% against 14 women, or 41%. In our study, the hospitalization time was less than 10 days with extremes of 1 to 27 days.The average age of the deceased patients was 41 ± 10 years with extreme ages of 2 years and 81 years. The maximum number of deaths concerns the age group between 50 and over with a percentage of 38.22%.Introduction Conclusion: This study allowed us to understand that most of our deceased patients were due to septic wounds, see generalized sepsis and the chronic poverty of the patients which impacts the adequate management.
24 The Evolving Role and Challenges Faced by Gastroenterologist in the Era of COVID-19 Pandemic and Beyond , Muhammad Kamran;Wasim Jafri
Abstract COVID-19 has had a profound impact on both global economy as well as the healthcare system. The long-term consequences of this contagion are yet to be witnessed. In this perspective, the field of gastroenterology also has an important part to play, as the virus very commonly affects the gastrointestinal tract, including the liver. In this brief review, we will first describe the common gastrointestinal and hepatic manifestations pertinent to COVID-19 and also discuss why the GI tract is frequently involved in this viral disease. Subsequently, we will analyze the constantly changing role of gastroenterologists in terms of their interactions with patients in the out-patients department, ward and endoscopy suite. We will also touch upon the different hurdles being faced by them during these testing times, dealing with the COVID-19 patients and at the same time engaged in an incessant struggle to maintain continuity of care for patients with pre-existing disorders of the digestive system. Finally, we will be discussing the problems and currently being encountered by fellowship training programs throughout the world and will try to provide certain practical solutions to some of them. Our overall aim of writing this review is to highlight the issues faced by present day gastroenterologist, so that concerned authorities and academic societies can offer guidance to alleviate these concerns without compromising standard of care of the patients.
25 Abdominal Attacks May Reveal Hereditary Angioedema! , Naouel Lemdaoui;Nada Boutrid;Hakim Rahmoune;Mounira Amrane;Abderraouf Bataiche;Hala Boutrid
We received a 14-years old girl suffering from recurrent acute attacks of abdominal pain and nausea with facial swelling and la-bial angioedema, reoccurring irregularly since 3 years without a clear trigger. A large panel of radiological and laboratory investigations could not unveil the cause of these episodes, until she was readmitted in the ward during a similar crisis with afebrile abdominal pain, face swelling and a transient crural macular rash.The patient is on her first day of menses and is free from urti-caria or pruritus.This clinical stereotyped sequence is highly suggestive of Here-ditary Angioedema (HAE), the most common type of complement related, non-allergic angioedema; with peritoneal involvement and intestinal swelling revealed by pain and vomiting.
26 SPATZ3 Intragastric Balloon: Efficacy, Fungal Contamination and Complications during the 12 Months of Use , Bruno Queiroz Sander;Oliveira ASB;Maiolini R;Pereira CRT;Sindorf ML;Ferreira CO;Silva MIF;Rosa ED;Barral MCM;Clasen SPAS;Freitas JBA;Benvenuti ECSC;Pessoa DF;Bonates HA;Scoralick MO;Ribeiro MMS;Matos CRQS;Carvalho CAM;Braga KM;Rosado JJS
Introduction: The intragastric balloon is the medical treatment indicated for patients with overweight and obesity, it’s safe and effective with great results all over the world. The presence of fungi on the external surface of the intragastric balloon has been the main cause of silicone fragility and perforation of the balloon, with the need for prosthesis replacement. One of the objectives of this study will be to evaluate the effectiveness of the use of oral anti fungal medication (Nystatin) to try to reduce the appearance of fungi on the surface of the balloon and, thus, try to also reduce the rate of leakage or rupture of the prosthesis, in addition, this study aims to evaluate the effectiveness of Spatz in weight loss, as well as the complications presented during the period of its use. We divided the 268 participants in this study into two distinct groups: In the first group, we mixed Nystatin with the usual balloon filling solution and in the second group, we used only the usual filling solution, without the use of anti fungal. Results: In the group where anti-fungal was placed in the balloon filling solution, a little less than 10% of fungal patency was obser-ved on the surface of the balloon, while in the other group, without the anti-fungal, this prevalence was close to 20%, or that is, almost twice as much. We did not observe significant variations in fungal colonization in relation to the age or gender of the participants in this study. The appearance of ulcers, despite the considerable incidence, was not a problem and, in most cases, it was treated con-servatively. Conclusion: The use of anti fungal mixed with the usual filling solution of the balloon decreases the presence of fungi on its surface and, consequently, decreases the rate of perforation or early rupture of the prosthesis. Spatz proved to be a safe and very effective IGB as an auxiliary method for weight loss. Keywords: SPATZ3; Intragastric Balloon; Fungal
27 Weight Regain after Bariactric Surgery. Endoscopic Suture with Overstitch Use for Gastrointestinal Anastomosis Decrease. Inicial Results: Brasilian Multicenter Study , Bruno Queiroz Sander;Marcelo Pereira Sander;Jimi Scarparo;Felipe Matz;Felipe Ramos;Carlos Henrique Rodrigues Castro;Stephany Roman Farfan;Waldemilson Cleber de Castro Vieira;Hellen Guimarães Sampaio;Edson Portela;Linsmar Dantas Conceição;Diego Paim Carvalho Garcia;Luiz Ronaldo Alberti
A new potential treatment option for weight regain after bariatric surgery is endoscopic suturing with the OverStitch system. The aim of this study was to analyze the weight regain after this procedure in patients who underwent bariatric surgery. There was a significant mean reduction in weight and BMI. There was progressively an increase of Total Body Weight Loss percentage. No complications were observed during or after the procedure. Keywords: Obesity; Gastroplasty; Weight Regain
28 Recurrence of Helicobacter pylori Infection after Successful Eradication Therapy in Egyptian Patients , Mohamed AA Bassiony;Amr T El Hawary;Marwan N Elgohary
Background: Helicobacter pylori (H. pylori), a highly prevalent gastrointestinal organism, infects more than 50% of the global population. It is the most common risk factor for peptic ulcer disease, cancer stomach and gastric lymphoma. Eradication therapy regimens for H. pylori are highly effective. However, bacterial resistance to antibiotics and patients non-adherence to the treatment regimens significantly increased the recurrence rates of H. pylori infection in the last few decades. Patients and Methods: We evaluated and followed up 157 patients for one year after confirmed successful eradication of H. pylori infection. We investigated the patients at 3, 6, 9 and 12 months for recurrence of H. pylori infection using urea breath and stool antigen tests. Study Aim: To assess the prevalence and possible risk factors of H. pylori recurrence in Egyptian patients after eradication therapy. Results and Conclusion: We found a one-year recurrence rate of 19% after successful eradication therapy of H. pylori. The education level of the patients and alcohol consumption were the most significant predictors of H. pylori recurrence. The one-year recurrence rate in our study is high but comparable to those reported in the developing countries most probably due to high rates of re-infection and non-adherence to the preventive measures.
29 Non-Alcoholic Steatohepatitis (NASH): A Critical Stage of Chronic Liver Disease , Ali Mahzari
Endoplasmic Reticulum; TNF-α: Tumour Necrosis Factor Al-pha; IL-6: Interleukin 6; IL-1β: Interleukin 1 Beta; NAFLD: Non-Al-coholic Fatty Liver Disease; NASH: Non-Alcoholic Steatohepatitis; NLRP3: NOD-, LRR- and Pyrin Domain-Containing Protein 3; MCD: Methionine Choline Deficient; TG: TriglycerideNon-alcoholic steatohepatitis (NASH) is a severe and progres-sive stage of NAFLD, in which hepatocyte damage, inflammation and fibrosis are present. Unlike simple hepatic steatosis, NASH may become a more prominent public health issue in the near fu-ture with the potential of becoming the leading indication for liver transplantation.
30 Comparing the Effects of Biofeedback and Posterior Tibial Nerve Stimulation (PTNS) on Dyssynergic Defecation Sings and Symptoms , AR Pakghalb;R Bazaz Behbahani
Background: According to past studies it was proved that the treatment of dyssynergic defecation was by doing treatment exercises to defecate properly with biofeedback, but recent studies have proved that using tibial nerve stimulation plays an important role in treatment and recovery of pelvic floor dysfunctions therefore this study took a look at the comparison of exercise therapy with bio-feedback and posterior tibial nerve simulation in patient’s treatment. Materials and Methods: This study was a randomized clinical trial of 42 patients who complained of hard stool, 30 patient were chosen based on RomeIII criteria and they were put into separate groups of biofeedback and PTNS. And then some factors including, volume and time of balloon expulsion, patients complaints and RomeIII criteria before and after intervention were Investigated and compared. Finding: In both groups symptoms of dyssynergic defecation have decreased compared to before treatment but in quantitative criteria a difference was observedin fever of biofeedback. In quantitative criteria time and volume of balloon expulsion were in favor of biofeedback group (p < 0/05). In qualitative criteria including, hard stool, painful defecation, excessive strain and feeling of incomplete defecation significant changes were observed in both groups (p < 0/05 in following criteria such as, bleeding, number of defecation per week and manual maneuver there were so significant differences in groups (p > 0/05). In relation to quantitative criteria, obstructive defecation changes were significant in favor of PTNS group Conclusion: Using PTNS in dyssynergic defecation is effective. Keywords: Biofeedback; Posterior Tibial Nerve Stimulation; Constipation; Dyssynergic Defecation; Anorectal Dyssynergia; Anorectal
31 Is the Proximal Subtotal Gastrectomy a Better Choice in Selected Patients than Radical Gastrectomy: A Comparison of Morbidity, Mortality and Survival after Surgical Treatment of Proximal Third Gastric Adenocarcinoma , Jagric Tomaz;Jagric Timotej
Background/Aim:The theoretical functional advantages of proximal resection with jejunal interposition could outweigh the higher risk of recurrence in the unfit elderly population. The aim of our study was to evaluate proximal resection as an alternative in selected patients. Methods: Between 1993 and 2009, 161 patients were operated on in our centre for adenocarcinoma of the proximal third of the stomach. They were divided into three groups: PG: proximal resection with jejunal interposition; TH: transhiatal extended total gastrectomy; GT: total gastrectomy. We analysed the postoperative morbidity, 30-day mortality, survival, and quality of life with a questionnaire. Results: The patients in the PG group were significantly older and in worse general condition. The number of harvested lymph nodes was significantly smaller than in the GT and TH groups. There were no significant differences in the distribution of TNM stages be-tween groups. There were no differences in the morbidity and 5-year survival rates between groups. No differences were found in the total scores of the GIQLI questionnaire. Conclusion: Proximal resection should be reserved only for high-risk elderly population with proximal gastric cancer. These resec-tions carry acceptable morbidity and mortality; however, the reconstruction with jejunal interposition does not bring the desired functional benefits.
32 Functional Gastrointestinal Disorders in Children , Rajeev Gupta
Functional gastrointestinal (GI) disorders (FGIDs) are common disorders characterized by recurring GI symptoms that cannot be attributed to structural or biochemical abnormalities [1,2].The common functional disorders seen in pediatric patients are functional dyspepsia, irritable bowel syndrome, functional abdom-inal pain and cyclic vomiting. There other less common conditions as well and these functional gastrointestinal disorders continue to challenge the medical professionals and have a significant emo-tional and economic impact. Functional gastrointestinal disorders (FGIDs) are common, the prevalence of FGIDs has been reported to range between 12% and 29%
33 Gut Dysbiosis, Probiotics and COVID-19 , Andrew P Smith
The impact of COVID-19 is well documented, with over sixteen million people infected and 665,000 deaths [1]. With any infection it is necessary to consider countermeasures which can improve im-mune functioning and the immunological response to vaccination. Our bodies are host to large numbers of bacteria which colonise the skin and the digestive system. These organisms are referred to as microbiota and interest here lies in the gut microbiota. These show large individual variation [2], which may plausibly explain differences in susceptibility to and severity of disease. An abnor-mal gut microbiota is referred to as gut dysbiosis, and this has been shown to be a risk factor for disease. For example, hypertension is linked to gut dysbiosis [3], as is coronary heart disease [4]. Similar-ly, patients with both Type 1 [5] and Type 2 [6] diabetes show signs of gut dysbiosis. Susceptibility to, and the severity of COVID-19 has been shown to be associated with the same diseases that lead to gut dysbiosis.
34 Back to the Future: HLA in Gastroenterology , Hakim Rahmoune;Mounira Amrane;Hadia Ziada-Bouchaar;Dalila Satta;Daoud Zineb;Nada Boutrid
Celiac disease (CD) and inflammatory bowel diseases (IBD) are among the most common gastrointestinal disorders and share strong genetic risks that may predict their diagnosis or even guide their management, particularly the Human Leukocyte Antigen (HLA) system.Historically, various associations between the HLA and autoim-mune diseases were reported since the 1970s, and the HLA is now incriminated in a myriad of diseases including CD and IBD
35 Is there Any Relation between the Age of Patients and the Length of the Small Bowel? How Long is your Patient's Bowel? , Sanguinetti J;Barreiro C;Voliovici E;Bentancor M;Montano D;Anaulina Silveira;Sonia Boudrandi;Enrique Barrios
The causes of bowel resections are very frequent. This can re-sult in the onset of short bowel syndrome (SBS), clinical picture characterized by serious malabsorption. Diarrhea, malnutrition, weight loss, dehydration and electrolyte deficit require in some patients nutritional support for life [1-3].SBS is defined by the 70 to 75% loss of the length of the small bowel or a bowel remnant less than 200cm, but how long is really the small bowel in the living patient?Authors describe that the human small bowel has lost length in its evolution, with dietary changes. The small bowel is a meta-bolically expensive tissue, the consumption of processed food has changed its physiology, pursuant to the already published by Ai-ello and Wheeler in 1995 in “expensive tissue hypothesis” [5]. We could not find trials relating the age of patients with the length of the small bowel [6-8]. Most anatomical and physiological descrip-tions state a length of 7, 8, and even 10 meters
36 Role of Ursodeoxycholic Acid in Lowering Indirect Hyperbilirubinemia in Neonates Under Phototherapy , Behairy El-Sayed Behairy;Magdy Anwar Saber;Rasha Elsayed Hassan;Samira Abd-Elwahab Abd-Elaziz;Haidy Mohammed Zakaria;Gihan Ahmed Sobhy
Introduction: Hyperbilirubinemia is a common benign problem in neonates, however in some circumstances; it may cause bilirubin induced neurological dysfunction. Although phototherapy remains the mainstay of treatment for neonatal jaundice, it has some side effects. Aim: The aim of this study was to assess the additive effect of Ursodeoxycholic Acid (UDCA) in reducing indirect hyperbilirubinemia in neonates under phototherapy. Patients and Methods: This randomized controlled study was performed on 100 newborn with indirect hyperbilirubinemia divided into two groups. Group A: included 50 neonates, received Ursodeoxycholic Acid orally in addition to phototherapy. Group B: included 50 neonates, received phototherapy only. All patients were subjected to detailed history taking, thorough clinical examination and laboratory investigations. Total serum bilirubin (TSB) and direct bilirubin were measured on admission and followed up every 12 hours (h) till serum bilirubin became below 10 mg/dl. Results: The sex, mean age and weight, onset of jaundice and total serum bilirubin at the time of admission were comparable in both groups (P > 0.05). The mean TSB measured at 12h, 24h, 36h and 48h of phototherapy in group A was 13.82 ± 1.11, 11.94 ± 1.60, 10.66 ± 1.52, 9.48 ± 1.33 mg/dl respectively and in group B was 15.15 ± 1.41 at 12h, 13.70 ± 1.25 at 24h, 12.49 ± 1.25 at 36h, 11.47 ± 1.13 at 48h. The TSB levels were significantly lower in the group who received UDCA and phototherapy (P < 0.05). The mean duration under phototherapy till reaching TSB < 10 mg/dl in group A (42.96h) were significantly lower than that in group B (71.52 h) (P < 0.0001). Conclusion: UDCA is considered an effective and safe complementary therapeutic adjuvant in neonatal indirect hyperbilirubinemia.
37 Resolution of Multiple Large Spider Angiomas after Liver Transplantation in Severe Alcoholic Hepatitis , Ankur Jindal;Aditi Gupta
We describe a case of giant cutaneous spider angioma in an elderly male with severe alcoholic hepatitis and its resolution after liver transplantation upon improvement in liver function. Spider nevi are benign vascular lesions mostly seen in patients with decompensated liver cirrhosis. Mostly, these are seen in the superior vena cava distribution and are small with pinhead size central vessel. Giant spider angioma and its resolution post liver transplantation is rarely seen and hence this report.
38 A Study on the Challenges of Diagnosis and Interpretation in the Subject with Intestinal Ganglioneuromatosis , Kadir Bal;Sibel Erdamar;Bilgi Baca;Uğur Korman;Erkan Çağlar
Diffuse intestinal ganglioneuromatosis is hamartomatous polyposis distinguished by a scattered, intramural or transmural proliferation of neural elements involving the enteric plexuses. This condition may involve any segment of the gastrointestinal tract, but the ileum, colon, and appendix are most frequently affected. It is a rare, benign neoplastic condition that has a well known association with multiple endocrine neoplasia type 2b, Cowden syndrome and a rare but documented association with neurofibromatosis type 1. We reported the case of a female patient's history of a neurofibromatosis who presented with chronic diarrhea. On the CT scan of the abdomen, thickening of the wall up to 2 cm, air-fluid leveling and dilatation reaching up to 6 cm at its maximum in the ileal segments and mesentery lymphadenopathies and intraperitoneal effusion were reported. There was not any peculiarity except ileal oedema and erythema on the colonoscopic examination. Endoscopic biopsy specimens obtained from the terminal ileum showed acute inflammation without any definitive findings of Crohn’s disease. Due to intestinal obstruction, the patient underwent surgical resection. Diffuse ganglioneuromatosis was observed in the resected specimen
39 Cost Effective Technique of Removal of Platelets for HLA Crossmatching by Density Gradient Centrifugation , Murali Adiga
Renal transplantation is the most successful treatment option for chronic renal failure patients. But success of this depends on HLA crossmatching between the renal recipient and donor. In this test, RBCs and platelets are removed and only donor lymphocytes are incubated with recipient’s serum and the complement and percentage of dead lymphocytes is documented. More than 5% of dead cells indicates a positive test and is a contraindication for renal transplantation. For HLA crossmatching, platelets must be removed before lymphocytes mixed with serum. Removal of platelets for crossmatching by traditional method is a very expensive procedure till now as commercially available thrombin is very costly, which increases the financial burden of the patients. Therefore, we tried to develop a cost effective technique to remove platelets by density gradient centrifugation in patients and donors visiting the Nephrology department of Kasturba Hospital, Manipal. After removing plasma and red blood cells, cell suspension in MCT vials is centrifuged @ 1000 rpm for 5 minutes using microcentrifuge. After this, supernatant is discarded and cell pellet is resuspended with buffer and again centrifuged @ 1000 rpm for 5 minutes. This step is repeated 4 or 5 times until the cell suspension is completely cleared off platelets. A total of 96 HLA crossmatching tests done on renal transplant patients and donors visiting Kasturba Hospital, Manipal. Out of this, two cases showed 5% platelets even after 5 times centrifugation. When we centrifuged the cell suspension @ 1000 rpm for 5 minutes, less denser platelets remained in supernatant and more denser lymphocytes sediment to the bottom. When this is repeated 4 or 5 times, all the platelets are removed. This is a very cost effective technique compared to commercial thrombin used earlier, which has reduced the cost of HLA crossmatching
40 The Importance of Meticulous Peri-operative Care in Managing High-Risk Patients Undergoing Bariatric Procedures   , Omar S Mansour
Background: Recent advances in laparoscopic and endoscopic technology has led to simplify many bariatric procedures especially laparoscopic sleeve gastrectomy and endoscopic intragastric balloon insertion. Because of the recent high demand for bariatric procedures, there has been a recent trend to perform bariatric procedures by general surgeons and physicians who were not trained to perform such procedures. Many surgeons would refuse to perform bariatric procedures on high risk patients to avoid complications of these elective procedures. Analysis: In this paper, two cohorts of high-risk patients were analyzed, laparoscopic sleeve gastrectomy and endoscopic intragastric balloon insertion groups. All of these procedures were done by the same surgeon and for the purpose of weight loss. All of the selected patients had significant comorbidities that could have led to increased morbidities. Conclusion: High risk bariatric patients carry a significant peri operative risk. Proper preoperative optimization and meticulous perioperative care can reduce post-operative risks and avoid significant post-operative morbidities and potential mortalities. There were no mortalities or any ICU admissions for any of the high and low risk patients
41 COVID-19 and Liver Disease , Ankur Jindal;Rakesh K Jagdish;Aditi Gupta
The coronavirus disease 2019 (COVID-19) was first notify to WHO on December 2019 by china after its eruption in Wuhan, subsequently now it has been noticed globally and WHO Declares it as pandemic on 11-3-2020. Respiratory manifestations are predominant feature of COVID-19, but in severe illness and critical patients multi-organ involvement occurs and results in dismal prognosis. Liver patients are also at great risk of worsening of underlying compensated condition and can develop acute decompensation or exacerbation of liver disease with high morbidity and mortality especially in immunosuppressed state due to advanced liver diseases and some patients on immunosuppressive drugs; e.g. autoimmune liver disease and post liver transplantation. This mini review is about the brief summary of the impact of COVID19 infection on patients of liver diseases and management of COVID in liver patients.
42 The Importance of Meticulous Peri-operative Care in Managing High-Risk Patients Undergoing Bariatric Procedures , Omar S Mansour
Background: Recent advances in laparoscopic and endoscopic technology has led to simplify many bariatric procedures especially laparoscopic sleeve gastrectomy and endoscopic intragastric balloon insertion. Because of the recent high demand for bariatric procedures, there has been a recent trend to perform bariatric procedures by general surgeons and physicians who were not trained to perform such procedures. Many surgeons would refuse to perform bariatric procedures on high risk patients to avoid complications of these elective procedures. Analysis: In this paper, two cohorts of high-risk patients were analyzed, laparoscopic sleeve gastrectomy and endoscopic intragastric balloon insertion groups. All of these procedures were done by the same surgeon and for the purpose of weight loss. All of the selected patients had significant comorbidities that could have led to increased morbidities. Conclusion: High risk bariatric patients carry a significant peri operative risk. Proper preoperative optimization and meticulous perioperative care can reduce post-operative risks and avoid significant post-operative morbidities and potential mortalities. There were no mortalities or any ICU admissions for any of the high and low risk patients.
43 Dietary Therapy in Adult Inflammatory Bowel Disease. Is there a Role in 2020? , Gim Hin Ho;Ee Ling Yeong Hazel
The exact pathogenesis of inflammatory bowel disease (IBD) remains uncertain but has been strongly postulated to be influenced by modifiable non-genetic environmental factors. One of these factors is the dysbiotic alteration in the gut microbiome [1]. As a result, research into the alteration of the microbiome by probiotics [2-5], faecal microbiota transplant [6] and diet as potential therapeutic strategies have gathered pace over the past few years. The principle of these interventions presumes that reconfiguration of the microbiome toward a more “eubiotic” or less proinflammatory profile would lead to a reduction of intestinal inflammation [1]. Diet has been hypothesized to play a role in the pathogenesis in inflammation, with research showing the effect of dietary exposures on the intestinal microbiome as well as mucosal integrity.
44 Analysis of 500 Referrals to a Liver Transplant Surgery Unit at a Tertiary Care Center in India: Are We Saving Enough Lives? , Ashish K Mishra
Objective: Living donor liver transplant (LDLT) is the mainstay of liver transplants (LT) in India. Data on transplant referrals and their outcomes is lacking from the subcontinent. This study is aimed to elucidate the reasons for eligible LT candidates not being able to undergo liver transplant and impact on mortality for such patients. Methods: We analyzed 500 referrals to the LT surgery team between November 2018 to July 2019. Patient particulars, diagnosis, MELD score and plan as advised by the team was noted. A questionnaire was answered individually by each patient or primary caretaker after a minimum waiting period of 4 weeks from the clinic or inpatient visit. Results: LT was advised in 476 (95%) patients. 34 (7%) patients were lost to follow up.58 out of 442 (12%) eventually underwent LT. Of the 57 patients transplanted at our center there was no inpatient mortality. 306/442 (69.2%) patients did not agree for evaluation. 74 patients died during the period of study out of which 34/74 (45.9%) had no donors, 25/74 (33.7%) had no finances and 15/74 (20.2%) lacked both donor and finances. 30/442 (6.7%) patients improved on follow up and did not require LT. Conclusion: We conclude that lack of finances and living/deceased donors are the major impediments for LT in the developing world.
45 Mucin Secreting Poorly Differentiated Rectal Adenocarcinoma with Inguinal Metastasis: Is it Regional or Distant Metastasis? A Case Report and Review of Literature , Montadar Al-Azzawi;Hamed Al-Aamri;Ahmed Redwan;Aamed Al-Araimi;Rashid Al-Alawi
This report presents a case of solitary inguinal metastasis after treatment of rectal cancer by abdominoperineal resection. A 79-year-old Omani man was diagnosed with poorly differentiated mucinous adenocarcinoma of the rectum in March 2015. Metastatic involvement of inguinal lymph nodes (ILN) from rectal adenocarcinoma is unusual presentation, particularly without signs of distant spread to other organ sites. In the current time, ILN involvement, including solitary involvement, is classified as metastatic disease (M). Inguinal mass was totally excised; neoadjuvant radiation therapy and chemotherapy had been also carried out before. Pathological analysis showed poorly differentiated mucinous adenocarcinoma compatible with his rectal cancer. The interesting finding was that this case did not seem to belong to any traditional rectal cancer metastasis pathway. This case is representative and worthy of further study to explore whether there is another rectal cancer metastasis pathway
46 Recent Portal Vein Thrombosis in Liver Cirrhosis: A Case of Success in Reversion of Portal Hypertension , Thales Girardi May;Felipe Fiorin Carmona;Lígia Rodrigues Simonetti;Jéssica Araújo Amparado;Luis Fernando Joaquim;Rafael Lima Kahwage
Portal vein thrombosis is an unusual complication in patients with liver cirrhosis. In the current research of its genesis, an underlying prothrombotic state and a combination of local endothelial factors, family and/or acquired inheritance and other thrombophilic factors are demonstrated. This condition is described as a major cause of portal hypertension, whether the patient has liver dysfunction or not. Clinical and laboratorial diagnosis are complemented with imaging exams and are useful in the early diagnosis, since the treatment directly affects the morbidity and mortality of the disease. We aimed to describe a case of a recent portal vein thrombosis concomitantly with hepatic cirrhosis and thrombophilia. Partial recanalization of the thrombus was achieved with anticoagulant treatment and consequent reversal of signs and symptoms of portal hypertension.
47 Initial Experience of “Mujib Protocol”, Therapeutic Plasma Exchange in Acute on Chronic Liver Failure: A Tribute to Father of the Nation of Bangladesh in his Birth Centennial , Mamun Al Mahtab;Ahmed Lutful Moben;Md Abdur Rahim;Md Ashraful Alam;Sheikh Mohammad Noor-E-Alam;Faiz Ahmad Khondaker;Most Rokshana Begum;Dulal Chandra Das;Md Atikul Islam;Md Zahurul Huq;Musarrat Mahtab;Sheikh Mohammad Fazle Akbar
Acute and acute-on-chronic liver failure (ACLF) is the consequence of acute insult of the liver on the background of underlying compensated chronic liver disease and may result from a wide variety of causes. The short-term mortality may be as high as 65% at 3 months [1]. This is the result of multi-organ failure involving both liver as well as extra hepatic organs as a consequence of bizarre systemic inflammation [2].
48 Spontaneous Bacterial Peritonitis in Cirrhotic Patients: Triggering Receptor Expressed on Myeloid Cells (TREM-1) as a Valid Marker , Nadia A Abdelkader;Waheed Abd El Monsef;Ahmed F Helal;Ghada A Ismail;Dalia H Abdelhamid;Maha M El Gaafary;Khaled Raafat;Yasser A Abd El Razek;Ahmed Fouad Sherief
Purpose: Assessment of Triggering Receptor Expressed on Myeloid Cells (TREM-1) levels in the diagnosis of SBP and effectiveness of treatment among Egyptian cirrhotic ascitic patients. Methods: This was a Prospective case-control study, which was conducted on 60 cirrhotic ascitic patients, and divided into two groups: Group 1: (Control) 30 cirrhotic ascitic patients without SBP Group 2: (SBP) 30 cirrhotic ascitic patients with SBP were admitted to the Tropical Medicine Department at Ain Shams University Hospitals with ascites due to chronic liver disease. All patients were subjected to a history of taking the clinical examination and laboratory investigations including ascitic fluid sampling for biochemical testing, total and predominant cell type, count of bacterial culture, and TREM-1 level. Results: There was a high statistically significant difference between the two groups in the baseline level of TREM-1 while the mean was higher 1280 pg/ml (± 1136.9) with a level range between (580 - 4500 pg/ml) among patients with SBP Than the control group mean 129.9 pg/ml (± 51.9) with a level range between (60 - 250 pg/ml) among. Besides, it was found a statistically significant difference in the level of TREM-1 before and after treatment among patients with SBP. The mean of TREM-1 before treatment was higher 1280.6 pg/ml (± 1136.9) than a mean 376.2 pg/ml (± 78.4) and level range between (260 - 560 pg/ml) after the treatment. Conclusion: TREM-1 is an easy, rapid, and reliable diagnostic tool for SPB which also harbors great value in following up patients with SBP.
49 Survey the Prognostic Factors of Recurrence and Survival in Patients with Colorectal Cancer , Alimohammad Bananzadeh;Ali Daneshvar Jahromi;Amirhossein Emami Meybodi;Seyed Mohammad Kazem Tadayon;Mohammad Rezazadehkermani
Purpose: Recurrence of colorectal cancers is considered to be one of the greatest post-surgical complications that is affected by various factors. This study design to investigate the prognostic factors that affect the recurrence and survival of patients with colon and rectal cancer. Methods: A retrospective study was performed in 380 patients with colon and rectal cancer who underwent surgery; type of surgery, tumor size, differentiation grade, proximal, distal and radial, marginal involvement, total number of excision lymph nodes, number of involved lymph nodes and tumor stage was recorded. Also, the incidence of recurrence and metastasis was recorded during the study. Results: 380 patients with mean age of 57.11 were enrolled to the study. 152 patients with an average age of 57.57 were diagnosed with colon cancer. Recurrence and metastasis occurred in 2 patients (1.3%) and 5 patients (3.3%), respectively. 18 patients (11.8%) died due to colon cancer. 228 patients with a mean age of 56.81 had rectal cancer. Recurrence was seen in 19 patients (8.3%) and metastasis in 33 patients (14.5%). 38 patients (16.7%) died due to rectal cancer. Tumor size and involved lymph nodes were independent prognosis factors of recurrence and metastases of colon cancer. Only involved lymph nodes were associated with death due to colon cancer. Independent prognostic factors of rectal cancer metastasis included albumin and age. The total number of excision lymph nodes was the only predictor factor of tumor recurrence and death in rectal cancer. The median survival time of colon and rectal cancers were 90 and 110 months, respectively. Conclusion: The size of the tumor and the number of involved lymph nodes were independent prognostic factors for recurrence and metastasis of colon cancer. Also, the number of involved lymph nodes was associated with colon cancer related death. In the case of rectal cancer, albumin levels and age predicted metastases. Only total number of excision lymph nodes had reverse relationship with recurrence and rectal cancer related death.
50 Predictors of Difficulty in Laparoscopic Cholecystectomy , Bhupendra Prasad
Laparoscopic cholecystectomy (LC) since its inception in 1987, has dramatically replaced conventional open cholecystectomy. LC has rapidly become the gold standard for routine gall bladder removal. Management of biliary tract disease has evolved from being a major procedure to a relatively safe and tolerable day care procedure today, offering early return to full activity.
51 Study of Vascular Pattern of Squamous Columnar Junction of the Cervix by Flexible Endoscopy with Narrow Band Image , Salwa Samir Anter
The capillaries that are in the stroma below the epithelium. may be visible according to thickness of the overlying squamous epithelium, vascular pattern on the original squamous epithelium often no vascular pattern.
52 Front Line Surgeons during the Covid-19 Pandemic , Bo Chen;Gang Chen;Liguang Zhou;Mitchell S Wachtel;Eldo E Frezza
In December 2019, there has been an outbreak of pneumonia caused by novel coronavirus in Hubei province of China. On 11 February 2020, the World Health Organization (WHO) officially named the new coronavirus Disease 2019 (COVID-19). Despite guidelines, surgeons feel almost as if they are in the middle of a war zone, with pressure on the one hand from the hospital to do at least emergency surgery to avoid merited charges of denial of needed care being countered by pressure from medical colleagues and intensive care units to avoid unnecessary exposure to COVID-19. COVID-19 has disrupted surgical diagnosis and treatment work. The epidemic forces us to reflect on our usual diagnosis and treatment work, including the storage of protective materials, to closely examine the problems of aerosol and pneumoperitoneum during endoscopic surgery, and, perhaps, to think of ways of reducing unneeded surgical procedures. This short communication, from the point of view of surgeons in the United States and China, will attempt to provide guidance for determining when surgical procedures should be performed and how to approach surgery with patients who are either likely to have COVID-19 infections or have actually been shown to be positive by laboratory testing. Soon, we will likely return to the operating room armed with greater wisdom.
53 Spleen Preserving Total Pancreatectomy in a Case of Multiple Pancreatic Neuroendocrine Tumour , Urmila Basu;Renu Saini;Devmalya Banerjee;Gaurav Kumar;Shubhayu Banerjee
One of the most common sites of gastrointestinal neuroendocrine tumour is the pancreas. They are known as Pancreatic neuroendocrine tumour (PNET). The previous incidence rate of 0.43/100,000 has more than doubled in last few decades. Most of the PNETs are clinically silent and show slight male preponderance. 10% of PNETs are functional, associated with genetic syndromes and represent as cystic lesion on radiology. Proper pre-operative work up including endocrine testing, tumour marker study and imaging is necessary to establish the diagnosis. Since they have malignant potential, surgery is the treatment of choice for resectable tumours among the various treatment modalities available. We are presenting a case of 50 years old lady having multiple soft tissue lesions involving distal CBD, head, body and tail of pancreas. She underwent spleen preserving total pancreatectomy with Roux-en-Y hepaticojejunostomy and gastrojejunostomy. Post-operative recovery was uneventful and glycaemic control was achieved with pharmacotherapy. We will discuss the various aspects of PNETs in this report.
54 Choice of Wavelets for Electrogastrogram (EGG) , Gokul M;Pradeep Murugesan
From the research background of corresponding author and co-author shows some promising analysis and interpretation on Electrogastrogram (EGG). EGG is the biological signal of stomach in order to empty the stuffs which was taken by the subjects orally. This signal is sort of bio-electric signal which will clearly depicts the functional information of stomach by capturing its ionic potentials by surface electrodes. These potentials will be influenced by the consumed food, subject’s movement, choice of filter and position of electrode. This EGG acquisition will be helpful in diagnosing stomach activity non-invasively by analysing its characteristics. The ideal and normal EGG pattern holds 3 cycles per minute with low distortion. In order to take this technology forward, EGG is tested with wavelets for compressing the signal to implement the telemedicine technology by transferring the signal from one end to another. There are many compression technique is used for transferring, but each technique has some drawbacks like poor compression ratio, information loss etc. The purpose of this editorial note is to choose the significant and low error wavelet for EGG compression. After this preliminary study (by finding the suitable wavelets), the results are taken for further research by analysing the performance of each wavelet in EGG compression.
55 Endoplasmic Reticulum Aminopeptidase-1 (ERAP-1) Mutations in People with Familial Mediterranean Fever (FMF) Gene Mutations Without Disease , Resat Dabak;Gulbuz Sezgin;Faith Oner Kaya;Feride Sinem Akgun;Oya Bayramicli;Selim Nalbant
Background and Study Aim: To date, especially alterations of genes on exon 10 have been considered in Mediterranean fever (MEFV), but it is not clear whether all these alterations are disease-causing mutations. We studied ERAP-1 gene mutations in people with FMF gene mutations without FMF phenotype. We compared our results with our previous study which we studied ERAP-1 gene mutations in patients with FMF and with ulcerative colitis (which has been shown to have a relation with ERAP-1 gene mutations before). Patients and Methods: This is a retrospective study. We studied ERAP-1 gene mutation in blood samples (had been kept in -70°C before for different studies) from 51 people with FMF gene mutations without FMF disease. Some of these people also were followed for about 5 years whether FMF comes out. Results: There were 10 cases without ERAP-1 mutations at Exon-3 and 6 cases without ERAP-1 mutations at Exon-10. Any ERAP-1 mutations were not obtained in three cases both for Exon-3 and 10. There were 41 ERAP-1 gene mutations at Exon-3 and 48 at Exon-10. Exon-3 mutations were usually Codon 127 mutation for 35 patients whether it was single mutation or with multiple mutations. It was totally different our ERAP-1 mutation in patients with FMF for Exon-3. Because in our previous study, if there were ERAP-1 gene mutations at exon-3, [c.380G>C p.(Arg127Pro)] mutation always existed in patients with FMF Conclusion: As a conclusion, ERAP-1 may be the second needed genetic mutation to produce the disease, 2) Certain ERAP-1 genetic mutation may produce FMF together with certain pyrin gene mutation.
56 Treatment of Biliopancreatic Diseases by Endoscopic Retrograde Cholangiopancreatography. Retrospective Analysis of Twenty-five Years in a Tertiary Reference Center , Raúl A Brizuela Quintanilla;Julián F Ruiz Torres;Juan Y Ramos Contreras;Norberto Alfonso Contino;Jorge García-Menocal Hernández
Introduction: The Endoscopic retrograde cholangiopancreatography (ERCP) is the main therapeutic procedure at the present time like complement of the minimally invasive surgery of the biliary tracts and of the pancreas, non-exempt of complications. Aims: Show the level of competence and performance achieved in the treatment of 14,213 biliopancreatic diseases by ERCP during 25 years at the CNCMA. Methods: Retrospective and descriptive study of 14,462 ERCP records taken from the database of the CNCMA, which were carried out from January 4, 1995 to February 5, 2020. Results: Of 14,462 ERCP records, 14,213 they remained for analysis; 5,148 (38%) male and 8,224 (62%) female, ages 18 to 93 years; 4,548 (34%) diagnostic and therapeutic ERCPs were performed, 8,824 (66%). The primary indication was the study of jaundice in 8,690 (65%) and the main diagnosis was choledocholithiasis (5,799 patients [43%]), followed by malignant bile duct strictures (3,685 patients, [27%]). The most widely used intervention was endoscopic sphincterotomy (6,236) to remove stones (3,267), and the placement of prostheses in the bile duct was frequently followed (3,138). Complications occurred in 449 cases, 348 (4%) during 8824 therapeutic procedures and 101 (2.2%) in diagnoses. There was a mortality of 0.19% (28 patients), 24 (0.3%) in therapeutic procedures and four (0.08%) in diagnoses. Conclusions: Our results demonstrate the high level of competence and performance achieved and the high diagnostic value and therapeutic success of ERCP, with minimal complications.
57 Anatomical Basis of Approaches to Liver Resection , Madhusudhanan Jegadeesan;Ramprasad Jegadeesan
Essential to successful and safe performance of any liver resection is the understanding of anatomical aspects pertaining to liver resection. The different approaches to liver resections reflect the different techniques and surgical maneuvers executed at specific anatomical regions in and around liver. The three approaches to liver resection, as put forth by Claude Couinaud, are the intrafascial, extrafascial and the extrafascial transfissural approach. The later two approaches are essentially dissection of Glissonean pedicles at the hilum of the liver. This Glissonean pedicle approach is facilitated by newer insights into anatomy of liver gained by modern pathological and surgical research. The Glissonean pedicle approach is safe as it achieves inflow control early in the process of liver resection and ontologically sound as it is an anatomical approach. It is also effective when employed during minimally invasive liver resections. Both intrafascial and extrafascial approaches are relevant in specific circumstances of liver resection. This chapter will specifically analyse the anatomical basis that surrounds the approaches to liver resection.
58 Comorbid Risk Factors for an In-Hospital Fatal Outcome of Patients Hospitalized for Covid -19: A Case-control Study , Niculae Ion Nedelcu;Magdalena George;David H Van Thiel
Between 13 March - 31 July 2020, 2,529 Covid-19 cases were discharged from the Victor Babes 490 bed hospital recognized by the government as the primary Covid-19 hospital in the capital, Bucharest. Eighty six of these 2,529 patients died in hospital for a case fatality rate (CFR) of 3.4 % (95% CI: 2.8 % - 4.2 %). The CFR for males was 4.7 % (54/1127) while in women it was 2.4 % (33/1402). The difference between these two rates is statistically significant [(Relative Risk (RR): 2.04; 95%CI: 1.33 - 3.12; p: 0.00083)]. Among the 86 who died, 11 (12.8%) were previously healthy (no reported under lying medical condition), 77 (87.2%) had at least one under lying medical condition, and 47 (54.7%) had two or more under lying medical conditions. The prevalence of each of the individual under lying medical conditions in these 86 patients was as follows: hypertension (68.6 %), diabetes mellitus (40.7%), obesity (33.7%), chronic kidney disease (27.9 %), and COPD (7.0 %). A 1:1 case control study was conducted after matching each case with one control of the same gender and age selected at random from the survivors list. Significant odds for death were identified for the presence of at least 2 under lying medical condition (OR:23.00; 95% CI (4.29 - 478.82);p: 0.0000), ), chronic kidney disease (OR: 9.00; 95% CI(2.41 - 57.41); p: 0.0008), and obesity (Odds Ratio (OR): 6.75; 95%CI (2.53 - 22.59); p: 0.0001). These data suggest that individuals with 2 or more under lying disease processes, and either chronic renal disease or obesity should be included in the list of individuals recommended for priority vaccination with a COVID-19 vaccine to reduce the likelihood of death should they become infected with COVID-19.
59 Infective Esophagitis and Gastric Balloon Case Study , Yasser Al Shehadat
The primary reason for early removal of intra-gastric balloon is nausea, vomiting, stomach cramps and gastro-esophageal reflux which is caused by the defense mechanism of the stomach, as balloon is considered as a foreign body. However, it will subside by the conventional treatments such as PPIs. Another reason for balloon removal is Candida esophagitis. Even though, it is a rare side effect, it is very serious. This is due to the long term use of PPIs after balloon insertion for reducing the primary side effects.
60 Vitiligo Improvement in Patient with Crohn’s Disease Undergoing Treatment with Infliximab , Cardoso Mateus Ricardo;Tavares Isabela Boulhosa;Cordeiro Karina Ferreira;Campos Luciana Teixeira
Introduction: Vitiligo is a skin disease that causes depigmentation due to the destruction of epidermal melanocytes. The etiology of vitiligo is unknown, and it is mainly related to an autoimmune factor, coursing with imbalance of cytokines in the injured areas. Infliximab is an anti-TNF-α antibody that prevents the binding of TNF-α to its receptors, this can cause both a protective effect and an inducing effect on the autoimmunity of vitiligo. Objective: Report a case of improvement of vitiligo after treatment with Infliximab and review the existing literature on this subject. Method: Case report selected due the improvement of vitiligo after the use of Infliximab by means of the analysis of medical records, followed by a bibliographic review in textbooks and Pubmed and Google Scholar databases, which results in a qualitative and exploratory analysis of the literature. Results: Description of the improvement of a patient with vitiligo after six months of treatment with Infliximab used for Crohn’s disease. Conclusion: Anti-TNF-α agents have been a promising method for the treatment of vitiligo, especially in refractory cases. Infliximab, however, has presented controversial results in the literature, such as aggravation of the condition or onset cases. The results of this report raises suspicions about the effects of TNF-α inhibition of vitiligo’s pathophysiology, therefore the role of Infliximab as a treatment form remains questionable.
61 Potential Premalignant Status of Gastric Portion Excluded after Roux En-Y Gastric Bypass in Obese Women: A Pilot Study , Graziela Rosa Ravacci;Robson Ishida;Raquel Suzana Torrinhas;Priscila Sala;Natasha Mendonça Machado;Danielle Cristina Fonseca;Gisele Canuto;Ernani Pinto;Viviane Nascimento;Marina Tavares;Paulo Sakai;Joel Faintuch;Marco Aurelio Santo;Eduardo Guimarães Hourneaux Moura;Ricardo Artigiani Neto;Angela Flávia Logullo;Dan Linetzky Waitzberg
Reagents: Acetonitrile (LC-MS grade), formic acid (FA, LC-MS grade) heptane (MS grade), N,O-bis(trimethylsilyl)trifluoroacetamide (BSTFA) with 1% (v/v) trimethylchlorosilane (TMCS), O-methoxyamine, and pyridine were purchased from Sigma-Aldrich (Germany). Methanol (LC-MS grade) was acquired from JT Baker (Mexico).
62 Holistic Approach to Obesity Management without Strenuous Physical Activity , Jain Richa;Sharma S;Singh Pawandeep
Obesity is epidemic and the underlying cause of various lifestyle related disorders that are the scourge of mankind today. Using integrated medicine approach that combines best practices in Ayurveda and Allopathy to an method that has yielded amazing results of weight reduction coupled with health restoration. The approach involves powerful effects of Oral Food Chelation therapy and has been used in the treatment of 100 patients. What emerged as the primary preventive and curative therapy Diet control along with body mind healing. This method promotes balance and integrates body- mind-soul to provide phenomenal results right from achieving ideal weight with natural ease and maintaining it, to healing emotional pain underlying weight issues. All this and more with absolutely no side effects, supplements and reduced dependency on medicines.
63 Hyper-Reactive Malarial Splenomegaly: A Neglected Disease by the Contemporary World , Oumer Abdu Muhie
Malaria could progress to a chronic form in individuals with partial immunity. Chronic malaria is often characterized by the lack of acute malaria symptoms. Thus, this disorder was considered as asymptomatic carrier state. Hyper-reactive malarial splenomegaly (HMS) is likely the most severe chronic form of malaria. HMS-earlier known as tropical splenomegaly syndrome - has classic manifestations. The manifestations of HMS include, massive splenomegaly, elevated titers of anti-malarial antibodies and polyclonal immunoglobulin M hypergammaglobulinemia.
64 Injury to the Inferior Epigastric Artery Branch Necessitating Re-laparoscopy - An Unusual Cause of Bleeding in Laparoscopic Cholecystectomy , Shresth Manglik;Urmila Basu;Camelia Pal;Pradeep Narayan;Sanjay Kumar Dubey
Bleeding after laparoscopic cholecystectomy can be due to multiple reasons and can lead to significant morbidity and mortality, if not recognized and treated promptly. Bleeding from the cystic artery, ligaments of liver, or from the abdominal wall during the placement of ports are common sources of bleeding in these cases. Injury to the inferior epigastric artery and its branches are more common in gynecological and obstetric surgery and is infrequently reported after laparoscopic cholecystectomy. However, the course of inferior epigastric artery is extremely variable. In this report, we describe one such case that highlights the variability in the course of inferior epigastric artery making it vulnerable to injury.
65 The Future of Gastric Motility Assessment Modalities , Riddhima Banerji
The past decade has witnessed major advances in the understanding of gastric and intestinal motility disorders. In view of the fact that the manifestation of physical symptoms are often not in accordance with the severity of disturbances in gastrointestinal function, it is necessary to develop diagnostic testing modalities which will assist in directing treatment. It is equally necessary for all gastrointestinal function tests to follow protocols that are appropriately standardised and approved. Strikingly, the existence of gastrointestinal dysfunction detected on clinical investigation can significantly influence disease management strategies, in addition to prognosticating response to medical treatment in some diseases (Hoad., et al. 2018; Schwizer., et al. 2002; Holloway, 2006).
66 Nutritional Factors Associated with Complications After Loop Ileostomy Reversal in Patients with Inflammatory Bowel Disease , Jordan A Munger;Tamar B Nobel;Alex Mui;David Chessin;Stephen Gorfine;Daniel Popowich;Joel Bauer
Background: Ileostomy formation is often performed in an acute setting with increased nutritional demands - presumed nutritional recovery has occurred at time of reversal. There is a paucity of data evaluating the effect of nutritional status on serious complications following loop ileostomy reversal in patients with inflammatory bowel disease (IBD). While ileostomy reversal is often considered a routine procedure relatively free of complications, we chose to evaluate our group of patients with IBD having this procedure and explored if measures of nutritional compromise at the time of reversal were associated with post-operative complications. Methods: We retrospectively reviewed 359 patients with IBD who underwent ileostomy reversal. Demographics, clinical characteristics, and laboratory values were compared between patients stratified by serious 30-day post-operative complications. Results: The overall median time to reversal was 13.1 weeks, (IQR 11-16), and this was comparable between those with and without serious complications. The overall serious complication rate was 22/359 (6.1%). Patients with serious complications had lower median albumin at time of reversal (3.3 vs 3.8; p = 0.049), higher incidence of anemia (68.4% vs 37.5%, p = 0.013) and greater interval decrease in BMI from time of ileostomy creation to closure (-2.1 vs -0.6; p = 0.03). Multivariate modeling demonstrated that for each integer increase in albumin, the odds of serious complication decreased by 59% (OR 0.41, 95% CI 0.20-0.83). Conclusions: IBD patients are at unique increased risk for nutritional compromise. Patients with malnutrition may be at increased risk of serious complications following ileostomy reversal. Surgeons should consider routine assessment of nutritional status prior to surgery and some patients may benefit from delay for optimization prior to ileostomy reversal.
67 Mini Evaluation Methods in Medical Pedagogy , Lasaad Gharbi;Dhouha Bacha;Wael Ferjaoui;Gati Asma;Sana ben Slama;Ahlem Lahmar
A comprehensive literature search was done over a period of 19 years from 2000 to 2019. Databases from Pubmed, Google Scholar, The National Library of Medicine (MEDLINE) and the Cochrane Library were searche using the following keywords: Medical pedagogy, evaluation, mini method, Mini-Clinical Evaluation Exercise (Mini CEx), mini peer assessment tool (Mini PAT), DOPS (Direct Observation of Procedures), Mini PAT, Mini The objective structured clinical examination (Mini OSCE), Mini viva and the following boolean operators.
68 A Child with Acute Abdomen Due to Torsion of a Wandering Spleen , Antonietta Giannattasio;Marco Maglione;Francesca Di Candia;Domenico Massa;Enzo Coppola;Marianna De Marco;Anna Marcella Giugliano;Vincenzo Tipo
Wandering spleen is a rare clinical entity characterized by splenic hypermotility resulting from laxity or maldevelopment of the suspensory splenic ligaments. The spleen can “wander” or migrate into various positions within the abdomen. Clinical presentation of a wandering spleen is variable, ranging from an asymptomatic, incidentally detected, abdominal or pelvic mass to an acute abdomen secondary to splenic torsion. Diagnosis in an emergency setting can be challenging as it is a rare cause of acute abdomen and does not determine any symptoms until splenic torsion has occurred. We present a case of pediatric ectopic, torsed spleen presenting as acute abdomen, effectively managed by splenectomy.
69 Why Surgeons Should Continuously Revise their Basic MedicalKnowledge and be Always Medically Updated , Omar S Mansour.
Recently, there has been a significant change in our clinical and surgical practice in order to safely cope with the new COVID-19 pandemic. Many new hospital protocols have been implemented and continuously updated in order to avoid added morbidities and complications from catching COVID-19 infection by non-COVID-19 patients. This includes all patients undergoing different treat-ments, whether they were inpatient or outpatient, for other un-related surgical or medical conditions, acute or chronic. Surgeons and physicians should be quite competent in managing high risk patients undergoing complex surgery
70 Role of Laparoscopic Mini Gastric Bypass Surgery in the treatment of Type 2 Diabetes Mellitus , (Maj Gen) Atul K Sharma
It has been more than twenty years since the observation that type 2 diabetes (T2DM) was found to resolve as a corollary of bar-iatric surgery, which was done essentially for the management of morbid obesity. It has also been shown that diabetes and its relat-ed complications reduce significantly after gastric bypass surgery and that the glycemic control in these patients is long lasting [1]. Today such surgeries are even being conducted in patients with a lower BMI (27.5 to 32.4) in Asian populations who have poor glycaemic control
71 Postoperative Crohn’s Disease and Relapse Risk Factors: A Single Centre Experience , Srdjan Markovic, Slobodan Sreckovic, Branimir Zogovic and Petar Svorcan
Introduction and Aim: Surgical intervention is an unavoidable companion for majority of patients with Crohn’s Disease (CD). In this study we determine with Crohn’s Disease (CD). Methods: 50 CD patients with at least one surgical resection were assessed retrospectively. Patients underwent clinical (CDAI) and endoscopic (Rutgeerts) assessments at the Department of Gastroenterology and Hepatology, University Hospital “Zvezdara” on av-erage 36 months after their operation. Age at diagnosis, gender, smoking status, duration of CD before resection, presence of peri-anal disease, colonic involvement, length of resected segment, type of anastomosis, concomitant immunomodulators and biologics (anti-TNF) were reviewed as potential risk factors for clinical and endoscopic recurrence. Data were analysed using univariate and multivariate logistic regression analyses. Results: 74% of patients had clinical remission and 40% of patients had endoscopic remission. Patients in clinical remission were significantly younger than patients that relapsed. Termino-lateral anastomosis resulted in higher remission rates, 66% compared to 25% of patients with termino-terminal anastomosis. Anti-TNF therapy was crucial for maintenance of clinical remission. Older age at diagnosis and extensive small bowel resection were risk factors for endoscopic recurrence based on multivariate logistic regression analysis. Conclusion: Older age at the time of diagnosis, lack of biologics postoperatively, latero-lateral or termino-terminal anastomosis as well as extensive resection were high risk factors for relapse in postoperative CD patients.
72 Short Term Outcome of Saccharomyces boulardii impact the Quality of Life in Patients with Inflammatory Bowel Diseases: A Multicenter, Double Blind, Placebo-Controlled Trial , Srdjan Markovic, Nikola Panic, Branimir Zogovic, Ana Kalaba, Marijana Jankovic, Tamara Knezevic Ivanovski, Dino Tarabar and Petar Svorcan
Introduction:Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) have high burden on quality of life. Dietary supplements such as probiotics have been shown to have beneficial effects on the course of IBS and IBD. So far, Saccharomyces bou-lardii is the only probiotic yeast with a documented health promoting profile. Aim of the Study: The main aim of the study is to investigate the effects to quality of life in patients with IBD in remission as well as patients with mild to moderate ulcerative colitis (UC) and Crohn disease (CD) when treated with Saccharomyces boulardii. The secondary aim is to investigate the safety of the probiotic preparation in patients with IBD. Methods: This is a double-blind, placebo-controlled study. Adult subjects who satisfied the Rome IV criteria and had colonoscopy in the last six months were randomised into two groups: conventional IBD therapy with probiotic Saccharomyces boulardii (Bulardi 500) or placebo for one-month. Patients completed the WPAI-GH Questionnaire, Visual Analogue Productivity Scale, Therapy Satis-faction Questionnaire, SIBDQ, before initiating probiotic and shortly after completing one-month therapy. Results: Patients reported improvements in the quality of their personal and professional lives following the use of Saccharomyces boulardii. Saccharomyces boulardii has a safe profile. Some effects are similar to those caused by placebo. Conclusion:Saccharomyces boulardii has many positive effects in patients with inflammatory bowel disease. Longer treatment and endoscopic assessments are needed for objective assessment of the effects of Saccharomyces boulardii.
73 Study of Infectious Diarrheas, in Transylvania - Romania , Liana Monica Deac
“Diarrhea” is an alteration in a normal bowel movement characterized by an increase in the water content, volume, or frequency of stools. Acute diarrhea of infec tious etiology, often referred to as gastroenteri tis and is typically associated with clinical signs and symptoms including: nausea, vomiting, abdomi nal pain and cramps, bloating, flatulence, fever, passage of bloody stools, tenesmus, and fecal urgency. Infectious diarrheal diseases are the second leading cause of morbidity and mortality worldwide. It is the diarrhea we have also found out, during a large 3 yeas study 2017 - 2020 in Transylvania-Romania. 3577 number of cases were transmitted during this time by the 12 territory sanitary polices, to the Epidemiology Department from the Public Health Center Cluj. These were mostly diagnosed by the territorial family doctors in the region and more than 20%, have need hospitalization, for several days, be-cause of the mentioned disease disorders 3 children died during this time, because of severe complications. The detected infectious microbial etiology were determined in authorized laboratories, in which it was identified: Shigella spp, Salmonella spp, Campylobacter spp, and Yersinia spp. or Rotavirus Giardia, and Fungi species. Most number of cases appeared in children, followed by elderly or adult people, as quantified number of determination. In light of these data, acute diarrheal illness had to be considered a major public health issue against which control efforts are needed. Public health surveillance and response in the field of infectious acute diarrhea include obligatory strategies of infection control.
74 High Technologies in Global Pandemic SARS II Covid-19 and in the Future , Jose Luis Mosso Vazquez
Technology is facing SARS II Covid 19 to prevent and treat SARS II Covid-19 in global pandemic. The most useful product developed in short time up today are vaccines thanks to genetic manipulation. Many countries are building new vaccines against coronavirus to prevent infections and reduce high mortality on humans in short time as never seen. Telemedicine, robotics, and virtual reality tech-nologies are being used every day to reduce and improve social distance, isolation, lockdown, fear, as aftermaths also. Telemedi-cine is being used with mobile or smartphones as one of the most important tools to make fast diagnosis sending texts as brief clini-cal history, medical images as CT scanners, X Rays, MRI and other medical data to be shared with specialist.
75 Tympanic Membrane Perforation in a Patient with COVID-19 , Fatemeh Dehghani Firouzabadi1, Mohammad Dehghani Firouzabadi1, Fatemeh Moosaie, Niyoosha Yoosefi, Sara Ramezanpour, Sepideh Babaniamansour, Saeedeh Rafiee, Maryam Roomiani, Hesam Jahandideh
Background: The outbreak of coronavirus disease 2019 (COVID-19) has become a global crisis, as the World Health Organization declared COVID-19 as a global pandemic. Perforation of tympanic membrane (TMP), followed by remission of COVID-19, is a rare presentation of this infection, which can cause hearing loss. Case Report: We report a critical case of COVID-19 in an elderly woman without any past medical history. She was admitted to the hospital with a rare, but serious presentation of TMP after one week of remission from COVID-19 infection. Otoscopy of ear revealed clear external auditory canal and central perforation in the pars tensa with regular margins occupying the posteroinferior quadrant. Audiogram showed conductive hearing loss of 20dB in the air bone gap. Computed tomography scan (axial view) with thin cuts of the temporal bone revealed well pneumatized mastoid regions without any density or secretion and normal middle ears without any density or secretion. After 2 months, tympanoplasty without mastoidectomy was performed and she recovered totally and the TMP healed and an audiogram performed 2 months later normalized. Conclusion: This case emphasized the importance of regular follow-ups for patients with COVID-19 and highlighted the need for attention to unusual presentations, such as of otorrhea, otalgia, and a sensation of fullness in the ear.
76 Treatment of Hepatitis Viruses; Costly and Inaccessible , Oumer Abdu Muhie1* and Habtewold Shibru2
Hepatitis viruses B (HBV) and C (HCV) are major causes of liver diseases worldwide generally and in developing countries specifically. More than 70 million of the world population is estimated to be infected with hepatitis C virus. The World Health organization (WHO) has planned to eliminate HCV from the globe by the year 2030 [1]. Similarly estimated 240 million people were infected by HBV by 2005 globally
77 Smartphones in 2011 for Telemedicine in Emergency Surgery and 7 Years Later , José Luis Mosso Vázquez1,2* and Enrique Jesús Rodriguez3
Objective: Demonstrate the utility of Mobile phones for Telemedicine in emergency surgery. Surgeon shared patient ́s medical re-cord, pictures and videos with anesthesiologist, scrub nurses to prepare on time operating room and surgical tools before emergence surgery. Methodology: In the preoperative, surgeon made medical text and images with a mobile phone of each patient in emergence service and send this information to anesthesiologists and scrub nurses. In the intraoperative an assistant made pictures of surgical field. In the postoperative surgeon made pictures of organs or tissues removed and share all information with physicians of emergence service also. 77 cases were recorded with this technique. Results: Anesthesiologists evaluated77 cases in the preoperative where images from the patient ́s mouth, teeth, neck size and ana-tomical surgical regions were enough to be evaluated. With aware patient state, endotracheal tube size and preparation of medica-tion for general or regional anesthesia were evaluated also thanks of medical pictures and data. Surgeon sent anesthesiologist a summary of medical record of each patient by messages, pictures and videos. Pictures resolution was enough to evaluate airways of each patient to select the correct endotracheal tube size. Conclusion: Pictures resolutions were enough to prepare adequate surgical and anesthesiologist tools in the preoperative to avoid lost time in the intraoperative. The first significant conclusion is for the quality of surgical attention for patients because we can reduce intraoperative complications such as bleedings and losing time for intubations. Otherwise, with smart phones we improve traditional medical relationship between surgeons, anesthesiologist, scrub nurse, interns, residents, undergraduate students, and emergence team. The cost benefit of this project is the reduction of surgical complications as bleeding and short surgical time. In this technique, we add technology with smart phones inside traditional communications between physicians, sending us medical data of patients in the preoperative 7 years later, mobile phones generations have been improving emergence in surgery communications and in Telemedicine with high resolutions of medical images and videos. Up today, early 2021, smartphones demonstrate the po-tential into SARS II, Covid-19 Global Pandemic. Videoconference, social media are the powerful technology in the humankind hands.
78 GERD Pathophysiology, Diagnosis, Management and Treatment with a Focus on Speech Therapeutics , Shmuel Golfeyz* MD and Aviva Bamshad CCC-SLP
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered diseases worldwide. Symptoms vary widely among patients and can lead to decreased quality of life. Though much has been published regarding medical GERD treatment, there is a paucity of literature on the topic of speech therapeutics as an alternative, or in addition to, standard treatment options. This review article focuses on highlighting current literature on this subject matter and providing a thorough overview of GERD. Further research and study into the utility of speech therapeutics in the treatment of GERD is necessary to help determine which therapeutic techniques are the most effective treatment options.
79 MUC1 Expression in Gastric Adenocarcinomas: Its Prognostic Significance and Clinicopathological Correlation , Nisha Raj1, Ashok Kumar2, Praveer Rai3 and Ram Nawal Rao4*
Background: Gastric adenocarcinoma, a biologically heterogeneous disease that involves numerous genetic and epigenetic altera-tions. MUC1 (Mucin-1) acts as an oncoprotein is a membrane associated glycoprotein, has a role in protecting gastric epithelial cells from a variety of external insults which causes inflammation and carcinogenesis. It also functions in cell signaling pathway leading to the upregulation of cyclin D1. In this study, we evaluated the prognostic significance of MUC1 in gastric adenocarcinoma and its association with clinicopathological parameters. Methods: A total of 70 patients of gastric and gastroesophageal adenocarcinoma were enrolled in to this study. MUC1 protein expres-sion were evaluated by immunohistochemistry using MUC1 antibody on formalin fixed paraffin embedded tissue samples. Results: Out of 70 cases, there were 43(61.4%) males and 27(38.6%) females with a mean age of 54.71 ± 1.78 years. Tumors in an-tropyloric region 33(63.4%) formed the major bulk. Moderately differentiated adenocarcinoma was predominant in 30(42.8%) cas-es followed by poorly differentiated 26(37.2%) and well differentiated type 14(20%). MUC1 positivity rate was observed in 47.2% of cases. Frequency of MUC1 positivity was higher in cases with intestinal type tumors 22(55%). MUC1 positivity was significantly associated with advanced age, gender, smoking, histological subtypes and with lymph node metastasis (p < 0.05).We did not find significant correlation of MUC1 expression with tobacco chewer, tumor site, tumor differentiation, Lymphovascular invasion (LVI), perineural invasion(PNI) and TNM staging (p > 0.05). Conclusion: MUC1 gene was highly expressed in patients with gastric adenocarcinoma in our study. These findings may of prognos-tic value and may give some insight in therapeutic decision-making.
80 Bowel Surgery Audit in a small County/District Hospital , SA Naqvi*
The need of Clinical audit has been increased in the last two decades, as it is required for the accreditation process in every healthcare system. Data collection and analysis are excessively ti-me-consuming in everyday practice. The primary aim of our study was to evaluate the colorectal work at small hospital with out ICU facilities, monitoring of our clinical practice and outcome in difficult circumstances and to evaluate the outcome of colorectal surgeries in a small hospital. The second purpose was to obser-ved mortality rates in this small unit to compare with international standards.
81 Symbiotic Treatment Improve IBS Symptoms and Quality of Life: Placebo-Controlled Study , Bazzi Nagham1, Bazzi Mariam2, Hallal Hadi1, Lakkis Remie1, Akoush Hassan1, Saad Wajih1, AlKhatib Amani1 and Hallal Mahmoud3*
Background:Irritable bowel syndrome (IBS) is a chronic and functional gastrointestinal dysfunction characterized by altered bowel movement and abdominal pain and has a complicated etiology. Probiotics are the novel therapy based on better understanding of the disease pathology. Patients and Methods: We conducted a control-placebo study, 157 subjects enrolled in this study, and followed up for 6 months, divided into three groups to compare the effect of probiotics and placebo on IBS patients. Results: Probiotics significantly decreased the IBS symptoms, it normalized bowel movement. Conclusion: Probiotics could be the gold standard for IBS treatment.
82 Impacts of Perianal Crohn's Disease on Quality of Life and Work Productivity , Dorra Trad*
Background: Few data exist on quality of life (QoL) and the socio-professional impact in patients with perianal Crohn's disease, especially in Tunisia, probably because the patient-doctor relationship is mainly focused on obtaining clinical, biological and endo-scopic remission of the Crohn disease (CD). Our study aimed to evaluate the impacts of perianal Crohn's disease on QoL and work productivity. Methods: A prospective cross-sectional study including patients with CD followed in the Gastroenterology department of Habib Thameur hospital between July and August 2020 was performed. QoL as well as professional impact were compared in patients with perianal Crohn's disease and controls without perianal symptoms. Results: Thirty two patients were included. Mean age was 38.28 years [18 - 60] and the sex ratio was 1. Perianal lesions were ob-served in 15 patients (44% of cases). By calculating the HADS score, anxiety and depression were found in 22% and 19% of patients, respectively. Mean fatigue score was 3.75 [1 - 9]. Mean SF-36 score was 64.18 [37 - 98]. Mean SIBDQ score was 49.09 [29 - 64]. The significant impact of CD on QoL attested by an SIBDQ score < 40 was observed in 22% of cases. The average IBD-Disk score was 41.66 [3 - 88]. Severe functional impairment was predominantly associated with body image and sleep quality in 53% and 47%, respectively. Regarding the impact of CD on work productivity, only 41% of patients had paid work at the time of inclusion. CD was responsible for an overall average decline in productivity estimated at 56% and an average restriction of 45% of usual daily activities. By comparing the QoL scores according to the presence or not of perianal manifestations, we found a statistically significant link be-tween perianal Crohn’s disease and the field of mental health of the SF-36 score (p = 0.03). Regarding the impact of perianal Crohn’s disease on professional activity, there was a statistically significant association between the mean rate of activity restriction and the presence of perianal manifestations (p = 0.04). Conclusion: It appears that CD is a source of impaired QoL and psychological discomfort with reduced work productivity. Com-prehensive care involving a gastroenterologists, occupational physicians and psychologists is sometimes necessary in these young patients. The presence of perianal manifestations seems to influence negatively mental health and professional activity.
83 APRI Score and Conventional Liver Ultrasonography Accurately Evaluate Liver Fibrosis in Hepatitis C Patients in an African Hospital Setting , Raïssa Nana Sede Mbakop1, Mathurin Pierre Kowo1*, Firmin Ankouane Andoulo1, Antonin Wilson Ndjitoyap Ndam1, Jean Roger Mouliom Tapouh2, Jean Claude Mballa Amougou2, Patricia Guekam Ouamba1, Samuel Nko’o Amvene2 and Oudou Njoya1
Background: In Cameroon, some non-invasive methods used in the assessment of liver fibrosis in chronic hepatitis C (CHC) such as liver stiffness or biomarker panels such as FibroTest® and Fibrometer ® are expensive and/or not easily accessible. However, the Aspartate aminotransferase-Platelet Ratio Index (APRI) and conventional liver ultrasonography are readily available and can be used in this resource-limited setting.Aim of the Study: The aim of this study was to evaluate the diagnostic performance of APRI and conventional liver ultrasonography in the assessment of liver fibrosis in patients with CHC in Cameroon. Materials and Methods: We conducted a retrospective study at the Yaoundé University Teaching Hospital in Cameroon. CHC patients ≥ 18 years seen at this center from January 2015 to December 2017 with available results of FibroTest® were included in this study. APRI was calculated for each patient and liver ultrasonography findings were obtained from patient files. The diagnostic accuracy of APRI and liver ultrasonography was assessed using the area under the receiver operator curve (AUROC). The sensitivities, specifici-ties, and predictive values of various cut-offs of APRI in detecting significant fibrosis and cirrhosis were determined using FibroTest®as the standard. Results: 81 patients were included with a mean age of 60.3 ± 9.3 years. The mean viral load was 6.02 ± 0.62 logIU/ml. APRI was strongly correlated to FibroTest® (r = 0.52, p < 0.001). APRI’s AUROCs in diagnosing liver fibrosis were 0.766 and 0.774 for significant fibrosis and cirrhosis respectively. Practically, an APRI > 0.5 had a sensitivity of 75.4% and a positive predictive value (PPV) of 88.5% for significant fibrosis. APRI > 2 was 97.7% specific for cirrhosis and had a PPV of 93.8%. An irregular liver surface was highly spe-cific for cirrhosis (p = 0.004). The diagnostic accuracy for liver cirrhosis significantly increased when APRI was combined with US liver surface parameters (AUROC 0.802, p = 0.005). The combination of irregular liver surface and APRI ≥ 0.73 was 97.7% specific for cirrhosis. Conclusion: APRI score is useful in identifying patients at the main endpoints of hepatitis C-related fibrosis, especially when com-bined with ultrasound, and could be a potentially valuable tool in staging and appropriately managing patients with CHC in limited resource settings.
84 Can be Protective Effect Melatonin against covid-19 Induced Gastrointestinal and Liver Damage? , Ahmet Özer Sehirli1*, Tuğrul Çakır2, Cebrail Akyüz3 and Serkan Sayiner4
Since enzymes such as transmembrane serine protease 2 (TMPRSS2) and angiotensin converting enzyme-2 (ACE2) responsible for the invasion of the SARS-CoV-2 virus, known as COVID-19, are also expressed in the gastrointestinal system and liver. The virus also infects these tissues. Inflammatory pathways are activated by the impairment of T cell activity, especially with increasing free radicals. As a result of the activation of these pathways, cytokine expression increases and this situation causes inflammation-mediated tissue injury. Besides, it is known that the agents used during treatment cause damage to the liver and gastrointestinal system. Therefore, it is thought that melatonin, which is an antioxidant and anti-inflammatory feature released from the pineal gland, may prevent gastrointestinal system and liver damage that will occur during COVID-19 and its treatment. Also, considering that COVID-19 has a more destructive effect on people with immunodeficiency (although this rate is between 1 in 8,500 and 1 in 100,000 among symptomatic individuals), it is a strong possibility that melatonin, which has a pleiotropic immunomodulator feature, may also be beneficial on the liver and gastrointestinal tissue.
85 Timing of Bariatric Surgery in Liver Transplant Recipients; A Comprehensive Systematic Review , Thamer Kassim, Haitam Buaisha, Jonathan Gapp, Jahnavi Koppala, Ryan Walters, Rajani Rangray* and Sandeep Mukherjee
Background and Objectives: Rising obesity rates with an associated increased prevalence of nonalcoholic steatohepatitis (NASH) have become a leading cause of end stage liver disease (ESLD). This excess weight poses particular challenges in the care of liver transplant (LT) patients. We conduct a systematic review to investigate the most safe and feasible timing to undergo bariatric surgery in patients with end-stage liver disease undergoing liver transplant. Methods: We performed a literature search on studies reporting BS associated with LT in adults. There was no enough comparable information to conduct a metanalysis. A systematic review was conducted. Results: BS prior to LT: Eight retrospective studies with small groups of patients (n: 6 - 78) examined BS prior to LT. Most of these studies suggest that this approach is relatively safe, efficacious and carries a low complication rate. However, one larger study suggested that BS (mainly RGYB) prior to LT may be associated with higher delisting rates or deaths prior to LT. Simultaneous BS and LT: Most of the reported studies are limited in their sample size and follow up duration. They showed improvement in obesity related complications and resulted in effective and durable weight loss. BS after LT: Six studies were reported with overall 43 patient. Improvement in the metabolic comorbidities following BS were noted and no early mortality was reported with respect to BS. Overall complication rates were higher than nontransplant population. Effects on immunosuppression were minimal with no reported graft rejection. Conclusion: BS performed before, after, or simultaneously to LT seems to be an acceptable option for obese patients with ESLD.