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Indexed Journal

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;UÄŸur Korman;Erkan ÇaÄŸlar
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*, TuÄŸrul 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.
86 Abdominal Pain May Unmask Subtitle Sickle Cell Traits   , Nada Boutrid, Mounira Amrane, Naouel Lemdaoui, Belkacem Bioud and Hakim Rahmoune
A young adolescent girl was consulting for recurrent abdominal pain crisis with severe emesis, fatigue and cephalalgia.These episodes occurred more than four times during the last few months and the patient had several biological investigations and a myriad of imaging studies; all of them being within the nor-mal limits.A thorough history and a complete physical examination did not reveal additional findings; but hemoglobin electrophoresis un-masked abnormal hemoglobin S at 39% of total hemoglobin.A second blood sample confirmed this sickle cell trait; a full fa-milial screening is ordered and the patient was counseled about preventive measures and referred to the hematology outpatient clinics.
87 Nursing Diagnoses in Promoting the Quality of Life of Patients with Crohn's Disease   , Andreza de Andrade Pinto, Lucas Resende Aniceto, Laurindo Pereira de Souza and Marcia Guerino de Lima
Objective: To identify the basic human needs involved and to implement the nursing diagnoses to the patient with Crohn's disease, to expose the sociodemographic profile and to present the quality of life of these patients. Methods: This is a cross-sectional and descriptive field research, with a quantitative-qualitative approach in the city of Cacoal/Rondônia (Brazil). The sample was of the intentional type composed of 8 individuals with medical diagnosis of Crohn's disease. Data collection was performed in August 2017 through the adapted "Inflammatory Bowel Disease Questionnaire". Results: Showed a higher prevalence in the fourth (37.5%) and fifth (37.5%) decades of life, female predominance (62.5%) and white skin color (50%). It is noted that the highest rates of poor quality of life found after applying the questionnaire are reported in emotional aspects and systemic aspects, both of which refer to 12.5% of the sample. The study found that the quality of life of Crohn's patients is classified, mainly, as good. Conclusion: The primary nursing diagnoses in the treatment of Crohn's disease are: imbalanced nutrition, diarrhea, dysfunctional gastrointestinal motility, risk for dysfunctional gastrointestinal motility, risk of injury, impaired comfort, acute pain, disturbed sleep pattern, fatigue, anxiety, overload stress and impaired mood regulation.
88 The Effect of Water Flushing Pump during Colonoscopy in Adenoma Detection Rate. (Retrospective Study)   , Assaf Moushira, Khalil Ali, Matar Rasha, Lakis Remi, Mroue Ahmad and Hallal Mahmoud
Background/Aims: The adenomatous colorectal polyps are known to be the precursors lesions of colorectal cancer. The aim of our study was to determinate whether the use of water pump in colonoscopy significantly improve the prevalence of polyps and rate of adenoma detection and therefore could be recommended in every endoscopy unit for potentially more effective cancer prevention. Methods: All endoscopy and pathology reports of adult patients underwent colonoscopy at Zhumc between June 2017 and June 2018 were studied retrospectively. The water pump introduced in 15th December 2017. Data were compared between two groups: pre and post installation of pump with six months margin. Results: 1006 eligible patients (mean age 56, male to female ratio 1:1) of which 532 in the pre-pump group and 474 in the post-pump group with similar baseline characteristics were compared concerning prevalence of polyps and rate of adenoma detection. Prevalence of polyps was 36% in the pre-pump group versus 38% in the post-pump group with no statistical significant difference between the two groups: (P = 0.662). Rate of adenoma detection was 26.2% for the first group versus 27.1% for the second group with again no significant difference between the two groups: (P = 0.82). Mean number of polyps of less than 5 mm were also compared between the two groups with no significant difference. The chi square test was performed for comparison between results. Conclusion: The use of water pump had no effect on the detection of adenomatous lesions. On the other hand, with the use of water pump the procedure is faster, easier and therefore more effective in means saving time and effort and achieving the same results.
89 All Sinus in Natal, Always Pilonidal? , Vishal Soni and Megha Sanghvi
A 26-year-old Army man with a pre-operative clinical diagnosis of Pilonidal Disease was found to have a long lateral track extension intra-operatively. Surgery was abandoned and the patient was subjected to further radiological, microbiological and histopathological tests for etiology. After extensive work up, he was subjected to surgery with an excision of about 25 cm track and primary closure of the wound. He made uneventful recovery with excellent wound healing. Final histopathology report showed it to be Non-granulomatous Inflammation, without any hair elements due to which we would like to term it as a case of Idiopathic Natal Sinus (INS) and not a Pilonidal Disease. 4 year follow up has shown no recurrence.
90 Comfortable Glue Injection Therapy , Subramanian Ponniah and Zaid Md Nafe
N-butyl-2-cyanoacrylate glue injection therapy is a well known very effective therapeutic method for gastric variceal bleed, all over the world, over two decades. The injection catheter preferably 23gauge size, 7 Fr and 240 cm length, is first filled with distilled water and the amount of dead space is determined. Depending on the size and extent of the gastric varix, the approximate quantity of glue required to completely obliterate the varix is decided.   In many centers, three glue injection catheters are kept ready and three or four 2 ml syringes each filled with 0.5 ml glue and 0.5 ml lipiodol and one 2 ml syringe with distilled water of volume equal to the dead space, are taken to inject successively till the gastric varix gets hardened upon palpation with catheter. Since the glue gets polymerized very rapidly, it has to be injected very faster to prevent the needle getting clogged at the tip, followed finally by a very faster injection with distilled water. Injecting the glue faster may cause serious complications in few individuals, like portal vein embolism, cerebrovascular embolism, pulmonary embolism and splenic or pancreatic infarction. To prevent this systemic embolization the glue is injected faster in smaller quantities multiple times.
91 Laparoscopic Total Gastrectomy for Gastric Cancer: Does Body Mass Index Matter?   , Akile Zengin, Yusuf Murat BaÄŸ, Mehmet Can Aydin, Kuntay Kaplan, Fatih Sumer and Cüneyt Kayaalp
Aim: The effect of increased body mass index (BMI) on the intraoperative complications and short-term outcomes of laparoscopic total gastrectomy (LTG) is controversial. We aimed to evaluate the influence of BMI on intraoperative and early postoperative outcomes in patients with LTG for gastric cancer (GC). Methods: Thirty-six patients who underwent LTG for GC were included in the study. The patients were divided into two groups as normal weighted (BMI = 18.5 - 24.9 kg/m2, n = 23) and overweighted-obese (BMI ≥ 25 kg/m2, n = 13). Preoperative and intraoperative data, postoperative outcomes were retrospectively analyzed and compared between the two groups. Results: The preoperative data were similar between the groups except for BMI. The median preoperative carcinoembryonic antigen (CEA) level (3.6 ng/ml to 1.9 ng/ml, p = 0.07) was higher in the overweighted-obese group, but the difference was not significant. There were six conversions (26%) in the normal weighted group, while no conversion was observed in the overweighted-obese group (p = 0.06). But conversion reasons were not associated with high BMI. The rate of intraoperative complications (23% to 8.6%, p = 0.32) was higher in the overweighted-obese patients, although this difference was not significant. Conclusion: Although the intraoperative complication rate and the conversion rate differed between the groups, BMI had no significant effect on intraoperative and early postoperative outcomes in patients who underwent LTG for GC.
92 Maintenance Treatment of Eosinophilic Esophagitis   , Bruno Queiroz Sander, Christian Follador Melado, Helen Brum Barcellos, Edson Portela, Adilson Renato Veríssimo, Aline Damasceno de Avance, Guilherme Camarotti de Oliveira Canejo, Flávio Rogério Hoerlle, Tiago Alves de Moura, Rolando Edward Marca Oliveira, José Alberto da Silva, Joao Marcelo Guimarães Marques, Amanda Torres Coelho, Paulo Ricardo Ramos Mendonça Filho, Erson Ramires Alves Barbosa, Lincoln Cruz Dantas, Raielly Coutinho Barbosa, Carlos Henrique Rodrigues Castro, Felipe Antonio de Rezende, Francisco Eduardo Moraes de Oliveira, Alexandre Salomão de Barros oliveira, Leonardo Teixeira Rodrigues and Jonas Pinto Vieira
Eosinophilic Esophagitis is a chronic, immunologically mediated pathology characterized by eosinophil infiltrates in the esophageal mucosa, causing dysfunction of the organ. It can affect any age group, being more common in young people and with other atopics such as asthma, food allergy and allergic rhinitis. The symptoms presented by the patient can range from manifestations of gastroesophageal reflux, abdominal pain, to dysphagia and food impaction. The diagnosis is made through upper digestive endoscopy with biopsies demonstrating eosinophilic infiltrate greater than 15 eosinophils per field. This article has as main theme the treatment of maintenance of eosinophilic esophagitis, aiming to contextualize medical professionals with the therapeutic options used and the impact on clinical improvement and histological remission. Theoretical research started from non-experimental methodology, through literature review on the subject in recent years. The practical guidelines for the therapy of Eosinophilic Esophagitis should involve multidisciplinary follow-up with specialized professionals, such as gastroenterologist, nutritionist and allergist, being based on pharmacological and dietary measures. Dietary treatment consists of the identification of specific food allergens through tests or the empirical elimination diet of potentially more allergenic food groups. Clinical management includes an initial course with proton pump inhibitors. Topical corticosteroids (Fluticasone or Budesonide) are medications capable of reducing the eosinophilic inflammatory response and inducing histological and clinical improvement. Systemic courses of oral corticosteroids, such as Prednisone, may be necessary in patients with significant symptomatology. Endoscopic treatment, through esophageal dilation, is indicated in cases of symptomatic esophageal stricture. The choice of therapy will depend on the clinical picture, the histological analysis and the reported symptoms, as well as the preference of the physician, the patient and the costs.
93 Smartphones and Tablets as Endoscopic Surgical Trainers , José Luis Mosso Vázquez, David Gallardo Ceja, Ivan Alvarez Martínez, Jesus Antonio Gaytan, Viviana Dolores, Luis Zararía Ramón, Edmundo García Valle, Sara del Carmen Santos Dimas, Luis Ignacio Magaña Olguin, Gregorio Tomás Obrador Vera and José Luis Mosso Lara
Objective: We present hold graspers for tablets and smartphones as surgical trainers and the experience of this system training in one session with 5 residents of surgery. Methodology: We designed an acrylic base of 25 cm length, 12 cm width and 2 cm of thickness. We install on this base a commercial tablet and smartphone holder (Specific for windshields). To the center and in the back of the holder we attached a horizontal arm, 22 cm large and 1.5 cm width, 2 holes end with 1 cm each in diameter (Holder for smartphones) and 30 cm lengths for tablets, getting the total systems 30 cm height and 25 cm width (See figure 1 and 2). 5 residents of surgery in the first year of residency at the Regional Hospital number 25 of the IMSS participated in 2010 (See figure 3). They trained just one session. They perform the following tasks, to grasp 4 acrylic cubes and 2 acrylic tubes with right grasper and place it to the left grasper and then place into a hole, the second task is performed knots. Results: Remarkable decreasing time in both tasks are shown in graph 1 and 2. Resident 2 and 3 performed 11 tasks more with remarkable results showing in graph 3 and 4 in a second session. In the beginning, training represents a degree of difficulty but later, warming up decreases time. Conclusion: Surgical simulators need tablets and smart phones as endoscopes. The systems are easy to use and install. New generations as undergraduate students, residents, fellowships and surgeons are potential users. Up to this day, mobile’s technology has developed in the last generation high resolution and new applications. Camera integrated permits us to become mobiles in zero-degree scope. With this experience residents used this trainer by 4 months all weekend after guards. We will design new trainers for new students’ generations in future works and we started the program of laparoscopy in the school of medicine at the Universidad Panamericana in 2010 with this experience. This simulator is useful for warming up for laparoscopic surgeons before real endoscopic surgeries on humans also.
94 Gastrointestinal Complications Post COVID-19 Infection Can be Quite Challenging and Variable in Nature , Omar S Mansour
Since the breakout of COVID-19 infection, our surgical practice had changed dramatically due to the fast spread of the SARS-COV-2 virus [1]. Although COVID-19 infection is usually a respiratory disease, it was reported before that it can present as DIC (disseminated intravascular coagulation) especially in life threatening infections [2]. It has also been reported that gastrointestinal symptoms can present in around 80% of hospitalized patients with severe COVID-19 infections [3]. In my colorectal clinic, I reviewed few COVID-19 patients suffering from co-existing or post COVID-19 gastrointestinal complications. Few had exacerbating of already diagnosed conditions, while others had new onset diseases and symptoms. Most of these patients had a variety of different GI complications that lasted for more than 6 weeks post COVID-19 infection diagnosis confirmed with PCR testing
95 Safety and Efficacy of ERCP Performed on Elderly and Very Elderly Patients in a Low Volume Provider Endoscopy Unit: Results from a Monocentric Retrospective Study with Control Group , Francesco Panzera*, Marina Rizzi, Letizia D’Ambrosio, Maria Filippina Dilorenzo and Berardino D’Ascoli
ERCP is one of the most challenging and high-risk endoscopic procedures. The incidence of biliary tract pathologies is growing with an age-related trend and progresses as the population ages.   Both the age-related outcomes and the volume-related outcomes for ERCP are still debated and incompletely understood. Experts generally agree that the lower the volumes of ERCP provided, the higher procedure-related complication and failure rates are expected. Some studies showed that ERCP in elderly patients is comparable in terms of efficacy and safety to ERCP in younger patients. However, these data generally concern studies made in referral centers and high-volume providers of ERCP. This study analyzes the performance of ERCP when it is performed on elderly and very elderly patients in a low-volume center of biliary endoscopy
96 Endoscopic Diverticulectomy with Platelet-Rich Plasma of Intraluminal Duodenal Diverticulum , Vicente Lorenzo-Zúñiga*, Vicente Moreno de Vega and Jaume Boix Valverde
Background: Procedure-related bleeding remains a common complication after endoscopic diverticulectomy of intraluminal duodenal diverticulum (IDD). The optimal endoscopic approach to IDD has not been established. Platelet-rich plasma (PRP) has proven biological properties to reduce risk of bleeding. Materials and Methods: The authors describe a novel technique in which endoscopic diverticulectomy was performed with prior submucosal injection of PRP (IRB approval PT-16-002). Case Report: A 62-year-old woman with a large IDD like a “windsock” underwent endoscopic diverticulectomy with PRP obtained from a sample of patient’s blood. IDD was resected with EMR technique using a standard polypectomy snare. No immediate or delayed bleeding was noted. Follow-up endoscopy 3 months later revealed complete mucosal healing and open communication to the distal duodenum. Conclusion: Endoscopic diverticulectomy with PRP is an option in patients with IDD
97 Perforated Gastric Ulcer Repair in the COVID-19 Pandemic Era; A Case Report and Literature Review , Afiq Aizat R, Ida Nadiah AF, Noor Shairah MB, Yahya MA and Mohd Firdaus Che Ani*
Perforated gastric ulcer (PGU) is a relatively common cause of peritonitis in elderly on long-term NSAIDS. Treatment algorithm however differs from center to center on managing this condition. Plenty of recommendations available on the literature at the moment to guide young surgeons in how to best manage patient in such situations. We are sharing our experience in managing case of a 76-years-old lady with perforated gastric ulcer who presented in septic shock during COVID-19 pandemic. We aim to highlight the process in decision making on timing of the surgical exploration and intervention and the factors that guide clinicians on the decision making
98 The Role of Gut Microbiota in Gastrointestinal Disease , Riddhima Banerji
Multiple studies have demonstrated that microorganisms in the gut play a key role in maintaining the normal function of the gastrointestinal tract. They are a diverse group of organisms which share an intricate relationship with the gut and one another, thereby helping to maintain a delicate physiological balance. Changes in the internal, cellular or external environment can disrupt this balance and result in pathological changes and disease. The last decade has witnessed important developments in the understanding of the role of gut microbiota in the genesis of gastrointestinal disease. The recent pandemic has underscored their significant function. Therefore, it is vital that research in this crucial area continues
99 Giant GIST of the Stomach Masquerading Gigantic Cyst Located in the Upper Part of the Peritoneal Cavity , Ramiz B Bayramov*, Ramila T Abdullayeva and Simara E Huseynova
Gastrointestinal stromal tumors (GISTs) are uncommon when compared to all gastrointestinal neoplasms but are the most common (80 - 85%) and specific mesenchymal tumors of the gastrointestinal tract. GISTs often present solid tumors and are rarely predominantly cystic. This report presents a case of a large exophytic cystic GIST in 61-year-old woman who was referred to specialized oncologic clinic from an unspecialized hospital with a suspicion of huge pancreatic cystic lesion based on CT imaging. A multidisciplinary meeting including gastrointestinal surgical oncologists, endoscopists and radiologists was held before operation and gastric GIST with cystic appearance was highly doubtful as a definite preoperative clinicoradiologic diagnosis. Radiologically other cystic lesions were less doubtful. Taking into consideration the possible clinicoradiological diagnosis surgery was planned. At laparotomy a large exophytic cystic mass was found to be attached by a thin (3.0 cm in diameter) stalk to the greater curvature of the stomach at the level of its upper third. No infiltration into the surrounding structures was observed. The cyst was very mobile and did not attach to adjacent anatomical structures by adhesions. The lowermost pole of the lesion was at the level lower than umbilicus. The size of the mass was 18 × 17 × 10 cm. Wedge resection of the greater curvature of the stomach along with the cystic mass and the adherent greater omentum was performed. Pathology confirmed spindle cell tumor. Mitotic index was ≤ 5/50 HPFs and the tumor cells demonstrated positivity for CD117 on immunohistochemical staining. The histological features together with the immunohistochemical profile of the tumor cells were consistent with the GISTs. The tumor was accepted as GIST of the stomach with high risk of recurrence according to the generally accepted classifications. Patient was administrated imatinib for 12 months and during the 16 months’ postoperative period no local recurrence or metastases were detected
100 Asymptomatic Primary Biliary Cirrhosis Revealed by Non Convulsive Status Epilepticus , Oumerzouk Jawad*, Louhab Nissrine, Chraa Mohamed and Kissani Najib
We report the case report of a 71-year-old patient admitted for confusional syndrome. The electroencephalogram showed electrical signs in favor of a status epilepticus with a slowing of the background activity and recording of numerous epileptic spike-wave discharges, quasi-continuous and rhythmic. The ionogram showed hepatic cholestasis with hepatocellular insufficiency: GGT = 71 ui/l (7 - 50), PAL = 196 ui/l (32 - 91), ASAT = 61 ui/l (15 - 41), ALAT = 38 ui/l (14 - 54), total bilirubin = 35 mg /l (3 - 12), direct bilirubin = 8 mg/l (1 - 5), hyperammonemia = 126.2 mol/l (11 - 51) with TP = 66%, TCA = 42/33 and hypoalbuminemia = 23 g/l (35 - 50). The immunological assessment showed the positivity of the antinuclear antibodies (titer> 320) and of the anti-mitochondria antibodies (IFI), with negative anti-LKM1 and anti-smooth muscle antibodies. The patient received symptomatic treatment of hepatic encephalopathy, combined with an antiepileptic treatment based on levetiracetam 500 mg, twice a day, and treatment with azathioprine 50 mg, twice a day, combined with ursodeoxycholic acid. Regular monitoring did not record a relapse. In conclusion, a non-convulsive status epilepticus in an elderly patient with biological cholestasis should suggest the diagnosis of PBC
101 Effects of COVID-19 on Living Donor Liver Transplantation , Quratulain Soomro, Sikandar Aziz Afridi, Abdul Wahab Dogar, Kaleem Ullah, Azam Shoaib and Bilal Ahmed
Background and Aims: The novel Coronavirus (COVID-19) pandemic with rapidly rising number of cases and high mortality massivelyaffectedlivingdonorlivertransplantationinPakistan.Thestudyaimsatprovidinganinsightintothetransplantationineraofpandemic,its effectson LDLT inpostoperative period. Methods:AllthepatientslistedforLDLTatPAQSJIMSfromMarch1sttoJune30th2020werere-evaluatedforLDLT,afteraninitialcompletehalt andmortalityof3, in termsof CTP,MELD,COVID PCRandCTchest,for resumption of transplantation servicesandwere closelymonitoredpostoperatively. Results: 54 patients with Child C, MELD above 15 and negative PCR/HRCT underwent LDLT. 6 (5 recipients and 1 donor) out of 70listed, testedpositiveonPCR,weredeferredfromsurgeryandfollowed.Majorityofrecipientsweremalesintheirfortiestosixties,withnormalBMI,nocomorbidities,andunderwentLDLTforchronicviralhepatitiswithdecompensatedcirrhosis(HBV+HDV,HBV,HCV)andunresectablehepatocellularcarcinoma.Postoperatively 5Recipients(nodonors)werediagnosedwithSARSclinically,4testedpositiveonPCRand1hadCTfindingshighlysuggestiveofCOVIDinfection.Mortalitywas2/5,causedbyMOFinpatientwithprolongedillness,andsudden cardiac death inarelatively wellpatient. Conclusion: In conclusion, COVID 19 can have an atypical clinical presentation in postliver transplant patients, patients may bepre-symptomaticorasymptomaticandcanhavecardiacarrhythmias.SymptomaticpatientsmaynotnecessarilyhavePositivePCRs,HRCTfindingsshouldbeconsideredinallsymptomaticpatients,beforelabellingthemCOVIDnegativebasedonPCR.StrictlyfollowingSOPs can reduce transmissionof COVID-19
102 Detection of Human Intestinal Parasites in Commonly Consumed Fresh Leafy Vegetables in Al-Baha Region, Saudi Arabia , Eman M Hussein*, Nawal M Osman, Sarah A Al-Harbi, Ahlam S Al Abbad, Noof A Alghamdi, Raghad A Alghamdi, Lama M Alkhediwi, Safa S Al Zahrani, Yakin H Alhaddad and Ala A Atta
Introduction: Ingestion of contaminated fresh leafy vegetables had an important role in the transmission of several intestinal parasitic diseases. Objectives: This study aimed to identify human intestinal parasites in commonly consumed fresh leafy vegetables in Al-Baha Region, Saudi Arabia. Methodology: In the current study, 400 leafy vegetable samples collected randomly from the supermarkets and open-aired markets at different times of the year in Al-Baha city were examined to detect the frequency of contamination with human intestinal parasites. Sediments and supernatants of concentrated washing solution of vegetables were examined after stained by iodine and modified Ziehl-Neelsen. Results: The leafy vegetables contaminated with intestinal parasites were 41% (164/400). The most contaminated leafy vegetables were spinach, red radish, watercress and lettuce with 58.3%, 57.5%, 55% and 50%, respectively, while the less contaminated were mint and cabbage with 16.6% per each. Green onions, parsley, dill, celery, leek and coriander were contaminated with 40%, 37.5%, 33.3%, 31.2%, 25% and 21.9%, respectively. Contaminated leafy vegetables collected from open-air markets was 41% compared to 33% of that were collected from supermarkets. These results were statistically significant. About 122 leafy vegetables out of 164 (74.3%) were contaminated with helminths. Taeniid eggs and Strongyloides larvae were the most common with 18.3% (30 leafy vegetables per each). About 141 leafy vegetables out of 164 (85.9%) were contaminated with pathogenic human intestinal protozoa. Cryptosporidium oocysts and Giardia lamblia cysts were the most commonly found with 48 (29.3%) and 35 (21.3%), respectively. The highest prevalence was in spring (45.5%) and the lowest was in summer (33.3%). These results were statistically significant. Conclusion: Control measures should include treatment of irrigation water, municipal wastewater, treatment of infected persons and mass education of the persons in contact with fresh leafy vegetables to avoid a greater health risk from handling and consuming these vegetables
103 Specimen Quality of Transanal Total Mesorectal Excision (TaTME) , Soterios George Panousopoulos*, Panayiotis Lazarides, Georgios Panousis, Doukakis Paradellis, Nikolaos Boltsis and Constantinos Mavrantonis
Introduction: Total mesorectal excision of the rectum (TME), has been the gold standard of rectal cancer treatment since its introduction in the 1980s, greatly improving oncologic outcomes for rectal cancer patients. Minimally invasive adapatations of TME have proved to be non-inferior to the open technique. For tumors of the distal third of the rectum, however, TME continues to present significant difficulty. The advent of transanal surgery has led to Transanal Total Mesorectal Excision (TaTME), in an effort to better facilitate complete excision, while preserving the desired oncologic results. Aim: In this study we present our experience with TaTME in 52 cases of rectal cancer patients, who were treated at our department. Patients and Methods: Between March 2018 and December 2020, 52 patients underwent TaTME for rectal cancer, performed by a single surgeon and surgical team. Pathology reports were compared to those of 48 patients who underwent laparoscopic TaSE TME by the same team between 2012 and 2019. Circumferential Resection Margin (CRM), and completeness of TME, were considered. Results: Combined, in the TaTME group, “complete” and “nearly complete” TME specimens were documented in 92.3% of cases. In the TaSE group, the combined “complete” and “nearly complete” specimens were 89.6% (no statistical significance- p = 0.804844). In the CRM involvement investigation, pathology reported 46 cases (88.5%) of free CRM, and 6 cases (11.5%) of involved CRM in the TaTME group (n = 52). In the TaSE group (n = 48), there were 41 cases (85.4%) of free CRM and 7 cases (14.6%) of involved CRM (no statistical significance- p = 0.678986). Conclusion: Our experience with TaTME shows that it is an acceptable TME procedure, delivering excellent results as far as operative quality is concerned. Although hampered by a steep learning curve, it seems that TaTME is safe and efficient enough when performed in a specialized setting, and at least non-inferior to other TME approaches as far as specimen quality is concerned.
104 Exercise Solutions for the Optimal Metabolic Control of Type 2 Diabetes , Xanya Sofra* and Sheetal Badami
Treating physicians have consistently recommended exercise to either prevent diabetes or de-escalate symptomatology. Diabetic complications, however render physical activity undesirable or unattainable. These involve: hypothyroidism leading to substantial weight gain; perpetual fatigue due to accumulation of white adipose tissue serving as fat storage, and inadequate supply of brown fat to generate energy; accumulated toxicity causing hormonal imbalance that increases hunger; chronic pain and wounds on extremities associated with diabetic neuropathy, etc. Recent research with an effortless exercise method has demonstrated enhanced fitness and T3 increase, juxtaposed by decreased inflammation, an optimal relationship between leptin and ghrelin that control appetite, and a significant decrease of visceral fat along with VLDL, the very low density lipoprotein that carries triglycerides to the tissues. We measured the fasting and postprandial glucose and insulin of 21 diabetics and 20 prediabetics respectively, pre and post twenty treatments. There was a statistically significant decrease in both fasting and postprandial glucose and insulin for all subjects who also exhibited increased skeletal muscle mass, normalized T3 levels, decreased visceral and overall fat, along with reduced CRP, advocating diminished inflammation. Dyslipidaemia appeared to subside as denoted by suppressed levels of triglycerides contrasted by elevated HDL.
105 Successful Endoscopic Sub Mucosal Resection (ESMR) for Treatment of Carcinoid Tumor with Central Adhesion in Posterior Wall of Duodenum , Seyed Reza Fatemi, Naghmeh Salarieh*, Shabnam Shahrokh, Shirin Haghighi and Seyed Ali Fatemi
Duodenal carcinoids are rare form of neuroendocrine tumors with tend to invade the submucosa, during the early stages. Recently, endoscopic resection of neuroendocrine tumors of the duodenum is increasingly performed as an alternative to conventional surgery. Although, a few reports have described the use of endoscopic resection of duodenal carcinoids, it is still a challenging treatment especially for bulbar carcinoids. We performed endoscopic Sub mucosal resection (ESMR) for a case of carcinoid in posterior wall of bulb with central adhesion. Although the tumor was located in the 2nd and submucosa layer, R0 resection was performed without complication in this case. ESMR thus is a safe and effective treatment for duodenal carcinoids less than 10 mm in diameter even with adhesion.
106 An Analysis of Gastroentereopancreatic Neuroendocrine Tumours at a Tertiary Care Hospital in Southern India , Vinay K, Balaji Jayasankar* and Sonali V Huilgol
Introduction: There is limited data available on epidemiology and clinicopathological patterns of gastroenteropancreatic neuroendocrine tumours (GEP NET) in India. Due to increased availability of advanced endoscopic and radiological imaging, the diagnosis of benign and incidentally identified lesions has also increased over the past decades. Curative surgery is often not feasible since most patients present with metastases at diagnosis. We sought to study the demographics and the behaviour of the tumour. Methods: The present study is an ambispective study of 25 patients diagnosed to have GEP NETs, treated at over a period of 5 years. Our study focussed on the distribution, epidemiology, treatment and outcomes. Results: The mean age of presentation was 51 years with a female preponderance of 52%. Most common site of origin was pancreas (56%) followed by duodenum (32%). Abdominal pain (68%) was the most common clinical presentation followed by vomiting (8%). 17 patients underwent surgery or endoscopic resection. 8 patients underwent medical management. All 25 patients survived and discharged from hospital after respective treatment. There were no deaths recorded in these patients during the hospital stay, however on follow up 5 patients reported mortality in a span of 18 months. Conclusion: The majority of GEP NET will benefit with a timely surgical intervention along with a sustained medical management. A more robust epidemiological study will help us to understand the burden of this disease better amongst our population.
107 Right Hepatectomy in Post Bariatric Surgery Living Donor: Case Report , Manoj Gupta*, Bhushan Bhole and KR Vasudevan
Background: Hepatic steatosis is one of the most common causes of an increasing prevalence of non-alcoholic fatty liver disease (NAFLD) [1]. NAFLD is one of the most common causes of chronic liver disease. Weight reduction by bariatric surgery can prevent the progression of NAFLD to chronic liver disease. Case Report: Liver donor was 50 year old female who donated for her husband. She was having past history of laparoscopic sleeve gastrectomy and her recent BMI was more than 35. On evaluation, USG abdomen was normal. MR fat estimation showed 3 - 5% fat fraction in her right and left lobe (Picture 1). Ct volumetric analysis showed adequate remnant and graft volume. Liver biopsy analysis showed 5 - 7% fat fraction without any sign of portal inflammation or fibrosis (Picture 2). During operation her liver was looking normal with adequate volume and remnant, Right lobe was taken out without middle hepatic vein. She tolerated procedure well. Her post-operative recovery was uneventful. Patient also recovered well. Conclusion: There are not enough similar studies, this case report has shown that in selected cases, post bariatric surgery obese person can also be considered for liver donation safely, though larger studies needed to confirm it.
108 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]
109 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
110 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.
111 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.
112 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.
113 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.
114 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.
115 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
116 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.
117 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.
118 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.
119 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).
120 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.
121 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.
122 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.
123 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
124 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.
125 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.
126 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.
127 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.
128 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
129 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.
130 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.
131 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.
132 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.
133 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
134 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
135 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.
136 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.
137 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
138 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.
139 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%
140 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.
141 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
142 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
143 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.
144 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.
145 A Study on the Challenges of Diagnosis and Interpretation in the Subject with Intestinal Ganglioneuromatosis , Kadir Bal;Sibel Erdamar;Bilgi Baca;UÄŸur Korman;Erkan ÇaÄŸlar
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
146 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
147 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
148 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.
149 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.
150 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.
151 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.
152 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
153 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.
154 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].
155 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.
156 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.
157 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.
158 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.
159 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.
160 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.
161 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.
162 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.
163 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.
164 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.
165 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.
166 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.
167 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.
168 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).
169 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.
170 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.
171 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.
172 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).
173 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.
174 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.
175 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.
176 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
177 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
178 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.
179 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.
180 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.
181 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.
182 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.
183 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
184 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.
185 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.
186 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.
187 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.
188 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.
189 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.
190 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.
191 Can be Protective Effect Melatonin against covid-19 Induced Gastrointestinal and Liver Damage? , Ahmet Özer Sehirli1*, TuÄŸrul 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.
192 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.
193 Abdominal Pain May Unmask Subtitle Sickle Cell Traits   , Nada Boutrid, Mounira Amrane, Naouel Lemdaoui, Belkacem Bioud and Hakim Rahmoune
A young adolescent girl was consulting for recurrent abdominal pain crisis with severe emesis, fatigue and cephalalgia.These episodes occurred more than four times during the last few months and the patient had several biological investigations and a myriad of imaging studies; all of them being within the nor-mal limits.A thorough history and a complete physical examination did not reveal additional findings; but hemoglobin electrophoresis un-masked abnormal hemoglobin S at 39% of total hemoglobin.A second blood sample confirmed this sickle cell trait; a full fa-milial screening is ordered and the patient was counseled about preventive measures and referred to the hematology outpatient clinics.
194 Nursing Diagnoses in Promoting the Quality of Life of Patients with Crohn's Disease   , Andreza de Andrade Pinto, Lucas Resende Aniceto, Laurindo Pereira de Souza and Marcia Guerino de Lima
Objective: To identify the basic human needs involved and to implement the nursing diagnoses to the patient with Crohn's disease, to expose the sociodemographic profile and to present the quality of life of these patients. Methods: This is a cross-sectional and descriptive field research, with a quantitative-qualitative approach in the city of Cacoal/Rondônia (Brazil). The sample was of the intentional type composed of 8 individuals with medical diagnosis of Crohn's disease. Data collection was performed in August 2017 through the adapted "Inflammatory Bowel Disease Questionnaire". Results: Showed a higher prevalence in the fourth (37.5%) and fifth (37.5%) decades of life, female predominance (62.5%) and white skin color (50%). It is noted that the highest rates of poor quality of life found after applying the questionnaire are reported in emotional aspects and systemic aspects, both of which refer to 12.5% of the sample. The study found that the quality of life of Crohn's patients is classified, mainly, as good. Conclusion: The primary nursing diagnoses in the treatment of Crohn's disease are: imbalanced nutrition, diarrhea, dysfunctional gastrointestinal motility, risk for dysfunctional gastrointestinal motility, risk of injury, impaired comfort, acute pain, disturbed sleep pattern, fatigue, anxiety, overload stress and impaired mood regulation.
195 The Effect of Water Flushing Pump during Colonoscopy in Adenoma Detection Rate. (Retrospective Study)   , Assaf Moushira, Khalil Ali, Matar Rasha, Lakis Remi, Mroue Ahmad and Hallal Mahmoud
Background/Aims: The adenomatous colorectal polyps are known to be the precursors lesions of colorectal cancer. The aim of our study was to determinate whether the use of water pump in colonoscopy significantly improve the prevalence of polyps and rate of adenoma detection and therefore could be recommended in every endoscopy unit for potentially more effective cancer prevention. Methods: All endoscopy and pathology reports of adult patients underwent colonoscopy at Zhumc between June 2017 and June 2018 were studied retrospectively. The water pump introduced in 15th December 2017. Data were compared between two groups: pre and post installation of pump with six months margin. Results: 1006 eligible patients (mean age 56, male to female ratio 1:1) of which 532 in the pre-pump group and 474 in the post-pump group with similar baseline characteristics were compared concerning prevalence of polyps and rate of adenoma detection. Prevalence of polyps was 36% in the pre-pump group versus 38% in the post-pump group with no statistical significant difference between the two groups: (P = 0.662). Rate of adenoma detection was 26.2% for the first group versus 27.1% for the second group with again no significant difference between the two groups: (P = 0.82). Mean number of polyps of less than 5 mm were also compared between the two groups with no significant difference. The chi square test was performed for comparison between results. Conclusion: The use of water pump had no effect on the detection of adenomatous lesions. On the other hand, with the use of water pump the procedure is faster, easier and therefore more effective in means saving time and effort and achieving the same results.
196 All Sinus in Natal, Always Pilonidal? , Vishal Soni and Megha Sanghvi
A 26-year-old Army man with a pre-operative clinical diagnosis of Pilonidal Disease was found to have a long lateral track extension intra-operatively. Surgery was abandoned and the patient was subjected to further radiological, microbiological and histopathological tests for etiology. After extensive work up, he was subjected to surgery with an excision of about 25 cm track and primary closure of the wound. He made uneventful recovery with excellent wound healing. Final histopathology report showed it to be Non-granulomatous Inflammation, without any hair elements due to which we would like to term it as a case of Idiopathic Natal Sinus (INS) and not a Pilonidal Disease. 4 year follow up has shown no recurrence.
197 Comfortable Glue Injection Therapy , Subramanian Ponniah and Zaid Md Nafe
N-butyl-2-cyanoacrylate glue injection therapy is a well known very effective therapeutic method for gastric variceal bleed, all over the world, over two decades. The injection catheter preferably 23gauge size, 7 Fr and 240 cm length, is first filled with distilled water and the amount of dead space is determined. Depending on the size and extent of the gastric varix, the approximate quantity of glue required to completely obliterate the varix is decided.   In many centers, three glue injection catheters are kept ready and three or four 2 ml syringes each filled with 0.5 ml glue and 0.5 ml lipiodol and one 2 ml syringe with distilled water of volume equal to the dead space, are taken to inject successively till the gastric varix gets hardened upon palpation with catheter. Since the glue gets polymerized very rapidly, it has to be injected very faster to prevent the needle getting clogged at the tip, followed finally by a very faster injection with distilled water. Injecting the glue faster may cause serious complications in few individuals, like portal vein embolism, cerebrovascular embolism, pulmonary embolism and splenic or pancreatic infarction. To prevent this systemic embolization the glue is injected faster in smaller quantities multiple times.
198 Laparoscopic Total Gastrectomy for Gastric Cancer: Does Body Mass Index Matter?   , Akile Zengin, Yusuf Murat BaÄŸ, Mehmet Can Aydin, Kuntay Kaplan, Fatih Sumer and Cüneyt Kayaalp
Aim: The effect of increased body mass index (BMI) on the intraoperative complications and short-term outcomes of laparoscopic total gastrectomy (LTG) is controversial. We aimed to evaluate the influence of BMI on intraoperative and early postoperative outcomes in patients with LTG for gastric cancer (GC). Methods: Thirty-six patients who underwent LTG for GC were included in the study. The patients were divided into two groups as normal weighted (BMI = 18.5 - 24.9 kg/m2, n = 23) and overweighted-obese (BMI ≥ 25 kg/m2, n = 13). Preoperative and intraoperative data, postoperative outcomes were retrospectively analyzed and compared between the two groups. Results: The preoperative data were similar between the groups except for BMI. The median preoperative carcinoembryonic antigen (CEA) level (3.6 ng/ml to 1.9 ng/ml, p = 0.07) was higher in the overweighted-obese group, but the difference was not significant. There were six conversions (26%) in the normal weighted group, while no conversion was observed in the overweighted-obese group (p = 0.06). But conversion reasons were not associated with high BMI. The rate of intraoperative complications (23% to 8.6%, p = 0.32) was higher in the overweighted-obese patients, although this difference was not significant. Conclusion: Although the intraoperative complication rate and the conversion rate differed between the groups, BMI had no significant effect on intraoperative and early postoperative outcomes in patients who underwent LTG for GC.
199 Maintenance Treatment of Eosinophilic Esophagitis   , Bruno Queiroz Sander, Christian Follador Melado, Helen Brum Barcellos, Edson Portela, Adilson Renato Veríssimo, Aline Damasceno de Avance, Guilherme Camarotti de Oliveira Canejo, Flávio Rogério Hoerlle, Tiago Alves de Moura, Rolando Edward Marca Oliveira, José Alberto da Silva, Joao Marcelo Guimarães Marques, Amanda Torres Coelho, Paulo Ricardo Ramos Mendonça Filho, Erson Ramires Alves Barbosa, Lincoln Cruz Dantas, Raielly Coutinho Barbosa, Carlos Henrique Rodrigues Castro, Felipe Antonio de Rezende, Francisco Eduardo Moraes de Oliveira, Alexandre Salomão de Barros oliveira, Leonardo Teixeira Rodrigues and Jonas Pinto Vieira
Eosinophilic Esophagitis is a chronic, immunologically mediated pathology characterized by eosinophil infiltrates in the esophageal mucosa, causing dysfunction of the organ. It can affect any age group, being more common in young people and with other atopics such as asthma, food allergy and allergic rhinitis. The symptoms presented by the patient can range from manifestations of gastroesophageal reflux, abdominal pain, to dysphagia and food impaction. The diagnosis is made through upper digestive endoscopy with biopsies demonstrating eosinophilic infiltrate greater than 15 eosinophils per field. This article has as main theme the treatment of maintenance of eosinophilic esophagitis, aiming to contextualize medical professionals with the therapeutic options used and the impact on clinical improvement and histological remission. Theoretical research started from non-experimental methodology, through literature review on the subject in recent years. The practical guidelines for the therapy of Eosinophilic Esophagitis should involve multidisciplinary follow-up with specialized professionals, such as gastroenterologist, nutritionist and allergist, being based on pharmacological and dietary measures. Dietary treatment consists of the identification of specific food allergens through tests or the empirical elimination diet of potentially more allergenic food groups. Clinical management includes an initial course with proton pump inhibitors. Topical corticosteroids (Fluticasone or Budesonide) are medications capable of reducing the eosinophilic inflammatory response and inducing histological and clinical improvement. Systemic courses of oral corticosteroids, such as Prednisone, may be necessary in patients with significant symptomatology. Endoscopic treatment, through esophageal dilation, is indicated in cases of symptomatic esophageal stricture. The choice of therapy will depend on the clinical picture, the histological analysis and the reported symptoms, as well as the preference of the physician, the patient and the costs.
200 Smartphones and Tablets as Endoscopic Surgical Trainers , José Luis Mosso Vázquez, David Gallardo Ceja, Ivan Alvarez Martínez, Jesus Antonio Gaytan, Viviana Dolores, Luis Zararía Ramón, Edmundo García Valle, Sara del Carmen Santos Dimas, Luis Ignacio Magaña Olguin, Gregorio Tomás Obrador Vera and José Luis Mosso Lara
Objective: We present hold graspers for tablets and smartphones as surgical trainers and the experience of this system training in one session with 5 residents of surgery. Methodology: We designed an acrylic base of 25 cm length, 12 cm width and 2 cm of thickness. We install on this base a commercial tablet and smartphone holder (Specific for windshields). To the center and in the back of the holder we attached a horizontal arm, 22 cm large and 1.5 cm width, 2 holes end with 1 cm each in diameter (Holder for smartphones) and 30 cm lengths for tablets, getting the total systems 30 cm height and 25 cm width (See figure 1 and 2). 5 residents of surgery in the first year of residency at the Regional Hospital number 25 of the IMSS participated in 2010 (See figure 3). They trained just one session. They perform the following tasks, to grasp 4 acrylic cubes and 2 acrylic tubes with right grasper and place it to the left grasper and then place into a hole, the second task is performed knots. Results: Remarkable decreasing time in both tasks are shown in graph 1 and 2. Resident 2 and 3 performed 11 tasks more with remarkable results showing in graph 3 and 4 in a second session. In the beginning, training represents a degree of difficulty but later, warming up decreases time. Conclusion: Surgical simulators need tablets and smart phones as endoscopes. The systems are easy to use and install. New generations as undergraduate students, residents, fellowships and surgeons are potential users. Up to this day, mobile’s technology has developed in the last generation high resolution and new applications. Camera integrated permits us to become mobiles in zero-degree scope. With this experience residents used this trainer by 4 months all weekend after guards. We will design new trainers for new students’ generations in future works and we started the program of laparoscopy in the school of medicine at the Universidad Panamericana in 2010 with this experience. This simulator is useful for warming up for laparoscopic surgeons before real endoscopic surgeries on humans also.
201 Gastrointestinal Complications Post COVID-19 Infection Can be Quite Challenging and Variable in Nature , Omar S Mansour
Since the breakout of COVID-19 infection, our surgical practice had changed dramatically due to the fast spread of the SARS-COV-2 virus [1]. Although COVID-19 infection is usually a respiratory disease, it was reported before that it can present as DIC (disseminated intravascular coagulation) especially in life threatening infections [2]. It has also been reported that gastrointestinal symptoms can present in around 80% of hospitalized patients with severe COVID-19 infections [3]. In my colorectal clinic, I reviewed few COVID-19 patients suffering from co-existing or post COVID-19 gastrointestinal complications. Few had exacerbating of already diagnosed conditions, while others had new onset diseases and symptoms. Most of these patients had a variety of different GI complications that lasted for more than 6 weeks post COVID-19 infection diagnosis confirmed with PCR testing
202 Safety and Efficacy of ERCP Performed on Elderly and Very Elderly Patients in a Low Volume Provider Endoscopy Unit: Results from a Monocentric Retrospective Study with Control Group , Francesco Panzera*, Marina Rizzi, Letizia D’Ambrosio, Maria Filippina Dilorenzo and Berardino D’Ascoli
ERCP is one of the most challenging and high-risk endoscopic procedures. The incidence of biliary tract pathologies is growing with an age-related trend and progresses as the population ages.   Both the age-related outcomes and the volume-related outcomes for ERCP are still debated and incompletely understood. Experts generally agree that the lower the volumes of ERCP provided, the higher procedure-related complication and failure rates are expected. Some studies showed that ERCP in elderly patients is comparable in terms of efficacy and safety to ERCP in younger patients. However, these data generally concern studies made in referral centers and high-volume providers of ERCP. This study analyzes the performance of ERCP when it is performed on elderly and very elderly patients in a low-volume center of biliary endoscopy
203 Endoscopic Diverticulectomy with Platelet-Rich Plasma of Intraluminal Duodenal Diverticulum , Vicente Lorenzo-Zúñiga*, Vicente Moreno de Vega and Jaume Boix Valverde
Background: Procedure-related bleeding remains a common complication after endoscopic diverticulectomy of intraluminal duodenal diverticulum (IDD). The optimal endoscopic approach to IDD has not been established. Platelet-rich plasma (PRP) has proven biological properties to reduce risk of bleeding. Materials and Methods: The authors describe a novel technique in which endoscopic diverticulectomy was performed with prior submucosal injection of PRP (IRB approval PT-16-002). Case Report: A 62-year-old woman with a large IDD like a “windsock” underwent endoscopic diverticulectomy with PRP obtained from a sample of patient’s blood. IDD was resected with EMR technique using a standard polypectomy snare. No immediate or delayed bleeding was noted. Follow-up endoscopy 3 months later revealed complete mucosal healing and open communication to the distal duodenum. Conclusion: Endoscopic diverticulectomy with PRP is an option in patients with IDD
204 Perforated Gastric Ulcer Repair in the COVID-19 Pandemic Era; A Case Report and Literature Review , Afiq Aizat R, Ida Nadiah AF, Noor Shairah MB, Yahya MA and Mohd Firdaus Che Ani*
Perforated gastric ulcer (PGU) is a relatively common cause of peritonitis in elderly on long-term NSAIDS. Treatment algorithm however differs from center to center on managing this condition. Plenty of recommendations available on the literature at the moment to guide young surgeons in how to best manage patient in such situations. We are sharing our experience in managing case of a 76-years-old lady with perforated gastric ulcer who presented in septic shock during COVID-19 pandemic. We aim to highlight the process in decision making on timing of the surgical exploration and intervention and the factors that guide clinicians on the decision making
205 The Role of Gut Microbiota in Gastrointestinal Disease , Riddhima Banerji
Multiple studies have demonstrated that microorganisms in the gut play a key role in maintaining the normal function of the gastrointestinal tract. They are a diverse group of organisms which share an intricate relationship with the gut and one another, thereby helping to maintain a delicate physiological balance. Changes in the internal, cellular or external environment can disrupt this balance and result in pathological changes and disease. The last decade has witnessed important developments in the understanding of the role of gut microbiota in the genesis of gastrointestinal disease. The recent pandemic has underscored their significant function. Therefore, it is vital that research in this crucial area continues
206 Giant GIST of the Stomach Masquerading Gigantic Cyst Located in the Upper Part of the Peritoneal Cavity , Ramiz B Bayramov*, Ramila T Abdullayeva and Simara E Huseynova
Gastrointestinal stromal tumors (GISTs) are uncommon when compared to all gastrointestinal neoplasms but are the most common (80 - 85%) and specific mesenchymal tumors of the gastrointestinal tract. GISTs often present solid tumors and are rarely predominantly cystic. This report presents a case of a large exophytic cystic GIST in 61-year-old woman who was referred to specialized oncologic clinic from an unspecialized hospital with a suspicion of huge pancreatic cystic lesion based on CT imaging. A multidisciplinary meeting including gastrointestinal surgical oncologists, endoscopists and radiologists was held before operation and gastric GIST with cystic appearance was highly doubtful as a definite preoperative clinicoradiologic diagnosis. Radiologically other cystic lesions were less doubtful. Taking into consideration the possible clinicoradiological diagnosis surgery was planned. At laparotomy a large exophytic cystic mass was found to be attached by a thin (3.0 cm in diameter) stalk to the greater curvature of the stomach at the level of its upper third. No infiltration into the surrounding structures was observed. The cyst was very mobile and did not attach to adjacent anatomical structures by adhesions. The lowermost pole of the lesion was at the level lower than umbilicus. The size of the mass was 18 × 17 × 10 cm. Wedge resection of the greater curvature of the stomach along with the cystic mass and the adherent greater omentum was performed. Pathology confirmed spindle cell tumor. Mitotic index was ≤ 5/50 HPFs and the tumor cells demonstrated positivity for CD117 on immunohistochemical staining. The histological features together with the immunohistochemical profile of the tumor cells were consistent with the GISTs. The tumor was accepted as GIST of the stomach with high risk of recurrence according to the generally accepted classifications. Patient was administrated imatinib for 12 months and during the 16 months’ postoperative period no local recurrence or metastases were detected
207 Asymptomatic Primary Biliary Cirrhosis Revealed by Non Convulsive Status Epilepticus , Oumerzouk Jawad*, Louhab Nissrine, Chraa Mohamed and Kissani Najib
We report the case report of a 71-year-old patient admitted for confusional syndrome. The electroencephalogram showed electrical signs in favor of a status epilepticus with a slowing of the background activity and recording of numerous epileptic spike-wave discharges, quasi-continuous and rhythmic. The ionogram showed hepatic cholestasis with hepatocellular insufficiency: GGT = 71 ui/l (7 - 50), PAL = 196 ui/l (32 - 91), ASAT = 61 ui/l (15 - 41), ALAT = 38 ui/l (14 - 54), total bilirubin = 35 mg /l (3 - 12), direct bilirubin = 8 mg/l (1 - 5), hyperammonemia = 126.2 mol/l (11 - 51) with TP = 66%, TCA = 42/33 and hypoalbuminemia = 23 g/l (35 - 50). The immunological assessment showed the positivity of the antinuclear antibodies (titer> 320) and of the anti-mitochondria antibodies (IFI), with negative anti-LKM1 and anti-smooth muscle antibodies. The patient received symptomatic treatment of hepatic encephalopathy, combined with an antiepileptic treatment based on levetiracetam 500 mg, twice a day, and treatment with azathioprine 50 mg, twice a day, combined with ursodeoxycholic acid. Regular monitoring did not record a relapse. In conclusion, a non-convulsive status epilepticus in an elderly patient with biological cholestasis should suggest the diagnosis of PBC
208 Effects of COVID-19 on Living Donor Liver Transplantation , Quratulain Soomro, Sikandar Aziz Afridi, Abdul Wahab Dogar, Kaleem Ullah, Azam Shoaib and Bilal Ahmed
Background and Aims: The novel Coronavirus (COVID-19) pandemic with rapidly rising number of cases and high mortality massivelyaffectedlivingdonorlivertransplantationinPakistan.Thestudyaimsatprovidinganinsightintothetransplantationineraofpandemic,its effectson LDLT inpostoperative period. Methods:AllthepatientslistedforLDLTatPAQSJIMSfromMarch1sttoJune30th2020werere-evaluatedforLDLT,afteraninitialcompletehalt andmortalityof3, in termsof CTP,MELD,COVID PCRandCTchest,for resumption of transplantation servicesandwere closelymonitoredpostoperatively. Results: 54 patients with Child C, MELD above 15 and negative PCR/HRCT underwent LDLT. 6 (5 recipients and 1 donor) out of 70listed, testedpositiveonPCR,weredeferredfromsurgeryandfollowed.Majorityofrecipientsweremalesintheirfortiestosixties,withnormalBMI,nocomorbidities,andunderwentLDLTforchronicviralhepatitiswithdecompensatedcirrhosis(HBV+HDV,HBV,HCV)andunresectablehepatocellularcarcinoma.Postoperatively 5Recipients(nodonors)werediagnosedwithSARSclinically,4testedpositiveonPCRand1hadCTfindingshighlysuggestiveofCOVIDinfection.Mortalitywas2/5,causedbyMOFinpatientwithprolongedillness,andsudden cardiac death inarelatively wellpatient. Conclusion: In conclusion, COVID 19 can have an atypical clinical presentation in postliver transplant patients, patients may bepre-symptomaticorasymptomaticandcanhavecardiacarrhythmias.SymptomaticpatientsmaynotnecessarilyhavePositivePCRs,HRCTfindingsshouldbeconsideredinallsymptomaticpatients,beforelabellingthemCOVIDnegativebasedonPCR.StrictlyfollowingSOPs can reduce transmissionof COVID-19
209 Detection of Human Intestinal Parasites in Commonly Consumed Fresh Leafy Vegetables in Al-Baha Region, Saudi Arabia , Eman M Hussein*, Nawal M Osman, Sarah A Al-Harbi, Ahlam S Al Abbad, Noof A Alghamdi, Raghad A Alghamdi, Lama M Alkhediwi, Safa S Al Zahrani, Yakin H Alhaddad and Ala A Atta
Introduction: Ingestion of contaminated fresh leafy vegetables had an important role in the transmission of several intestinal parasitic diseases. Objectives: This study aimed to identify human intestinal parasites in commonly consumed fresh leafy vegetables in Al-Baha Region, Saudi Arabia. Methodology: In the current study, 400 leafy vegetable samples collected randomly from the supermarkets and open-aired markets at different times of the year in Al-Baha city were examined to detect the frequency of contamination with human intestinal parasites. Sediments and supernatants of concentrated washing solution of vegetables were examined after stained by iodine and modified Ziehl-Neelsen. Results: The leafy vegetables contaminated with intestinal parasites were 41% (164/400). The most contaminated leafy vegetables were spinach, red radish, watercress and lettuce with 58.3%, 57.5%, 55% and 50%, respectively, while the less contaminated were mint and cabbage with 16.6% per each. Green onions, parsley, dill, celery, leek and coriander were contaminated with 40%, 37.5%, 33.3%, 31.2%, 25% and 21.9%, respectively. Contaminated leafy vegetables collected from open-air markets was 41% compared to 33% of that were collected from supermarkets. These results were statistically significant. About 122 leafy vegetables out of 164 (74.3%) were contaminated with helminths. Taeniid eggs and Strongyloides larvae were the most common with 18.3% (30 leafy vegetables per each). About 141 leafy vegetables out of 164 (85.9%) were contaminated with pathogenic human intestinal protozoa. Cryptosporidium oocysts and Giardia lamblia cysts were the most commonly found with 48 (29.3%) and 35 (21.3%), respectively. The highest prevalence was in spring (45.5%) and the lowest was in summer (33.3%). These results were statistically significant. Conclusion: Control measures should include treatment of irrigation water, municipal wastewater, treatment of infected persons and mass education of the persons in contact with fresh leafy vegetables to avoid a greater health risk from handling and consuming these vegetables
210 Specimen Quality of Transanal Total Mesorectal Excision (TaTME) , Soterios George Panousopoulos*, Panayiotis Lazarides, Georgios Panousis, Doukakis Paradellis, Nikolaos Boltsis and Constantinos Mavrantonis
Introduction: Total mesorectal excision of the rectum (TME), has been the gold standard of rectal cancer treatment since its introduction in the 1980s, greatly improving oncologic outcomes for rectal cancer patients. Minimally invasive adapatations of TME have proved to be non-inferior to the open technique. For tumors of the distal third of the rectum, however, TME continues to present significant difficulty. The advent of transanal surgery has led to Transanal Total Mesorectal Excision (TaTME), in an effort to better facilitate complete excision, while preserving the desired oncologic results. Aim: In this study we present our experience with TaTME in 52 cases of rectal cancer patients, who were treated at our department. Patients and Methods: Between March 2018 and December 2020, 52 patients underwent TaTME for rectal cancer, performed by a single surgeon and surgical team. Pathology reports were compared to those of 48 patients who underwent laparoscopic TaSE TME by the same team between 2012 and 2019. Circumferential Resection Margin (CRM), and completeness of TME, were considered. Results: Combined, in the TaTME group, “complete” and “nearly complete” TME specimens were documented in 92.3% of cases. In the TaSE group, the combined “complete” and “nearly complete” specimens were 89.6% (no statistical significance- p = 0.804844). In the CRM involvement investigation, pathology reported 46 cases (88.5%) of free CRM, and 6 cases (11.5%) of involved CRM in the TaTME group (n = 52). In the TaSE group (n = 48), there were 41 cases (85.4%) of free CRM and 7 cases (14.6%) of involved CRM (no statistical significance- p = 0.678986). Conclusion: Our experience with TaTME shows that it is an acceptable TME procedure, delivering excellent results as far as operative quality is concerned. Although hampered by a steep learning curve, it seems that TaTME is safe and efficient enough when performed in a specialized setting, and at least non-inferior to other TME approaches as far as specimen quality is concerned.
211 Exercise Solutions for the Optimal Metabolic Control of Type 2 Diabetes , Xanya Sofra* and Sheetal Badami
Treating physicians have consistently recommended exercise to either prevent diabetes or de-escalate symptomatology. Diabetic complications, however render physical activity undesirable or unattainable. These involve: hypothyroidism leading to substantial weight gain; perpetual fatigue due to accumulation of white adipose tissue serving as fat storage, and inadequate supply of brown fat to generate energy; accumulated toxicity causing hormonal imbalance that increases hunger; chronic pain and wounds on extremities associated with diabetic neuropathy, etc. Recent research with an effortless exercise method has demonstrated enhanced fitness and T3 increase, juxtaposed by decreased inflammation, an optimal relationship between leptin and ghrelin that control appetite, and a significant decrease of visceral fat along with VLDL, the very low density lipoprotein that carries triglycerides to the tissues. We measured the fasting and postprandial glucose and insulin of 21 diabetics and 20 prediabetics respectively, pre and post twenty treatments. There was a statistically significant decrease in both fasting and postprandial glucose and insulin for all subjects who also exhibited increased skeletal muscle mass, normalized T3 levels, decreased visceral and overall fat, along with reduced CRP, advocating diminished inflammation. Dyslipidaemia appeared to subside as denoted by suppressed levels of triglycerides contrasted by elevated HDL.
212 Successful Endoscopic Sub Mucosal Resection (ESMR) for Treatment of Carcinoid Tumor with Central Adhesion in Posterior Wall of Duodenum , Seyed Reza Fatemi, Naghmeh Salarieh*, Shabnam Shahrokh, Shirin Haghighi and Seyed Ali Fatemi
Duodenal carcinoids are rare form of neuroendocrine tumors with tend to invade the submucosa, during the early stages. Recently, endoscopic resection of neuroendocrine tumors of the duodenum is increasingly performed as an alternative to conventional surgery. Although, a few reports have described the use of endoscopic resection of duodenal carcinoids, it is still a challenging treatment especially for bulbar carcinoids. We performed endoscopic Sub mucosal resection (ESMR) for a case of carcinoid in posterior wall of bulb with central adhesion. Although the tumor was located in the 2nd and submucosa layer, R0 resection was performed without complication in this case. ESMR thus is a safe and effective treatment for duodenal carcinoids less than 10 mm in diameter even with adhesion.
213 An Analysis of Gastroentereopancreatic Neuroendocrine Tumours at a Tertiary Care Hospital in Southern India , Vinay K, Balaji Jayasankar* and Sonali V Huilgol
Introduction: There is limited data available on epidemiology and clinicopathological patterns of gastroenteropancreatic neuroendocrine tumours (GEP NET) in India. Due to increased availability of advanced endoscopic and radiological imaging, the diagnosis of benign and incidentally identified lesions has also increased over the past decades. Curative surgery is often not feasible since most patients present with metastases at diagnosis. We sought to study the demographics and the behaviour of the tumour. Methods: The present study is an ambispective study of 25 patients diagnosed to have GEP NETs, treated at over a period of 5 years. Our study focussed on the distribution, epidemiology, treatment and outcomes. Results: The mean age of presentation was 51 years with a female preponderance of 52%. Most common site of origin was pancreas (56%) followed by duodenum (32%). Abdominal pain (68%) was the most common clinical presentation followed by vomiting (8%). 17 patients underwent surgery or endoscopic resection. 8 patients underwent medical management. All 25 patients survived and discharged from hospital after respective treatment. There were no deaths recorded in these patients during the hospital stay, however on follow up 5 patients reported mortality in a span of 18 months. Conclusion: The majority of GEP NET will benefit with a timely surgical intervention along with a sustained medical management. A more robust epidemiological study will help us to understand the burden of this disease better amongst our population.
214 Right Hepatectomy in Post Bariatric Surgery Living Donor: Case Report , Manoj Gupta*, Bhushan Bhole and KR Vasudevan
Background: Hepatic steatosis is one of the most common causes of an increasing prevalence of non-alcoholic fatty liver disease (NAFLD) [1]. NAFLD is one of the most common causes of chronic liver disease. Weight reduction by bariatric surgery can prevent the progression of NAFLD to chronic liver disease. Case Report: Liver donor was 50 year old female who donated for her husband. She was having past history of laparoscopic sleeve gastrectomy and her recent BMI was more than 35. On evaluation, USG abdomen was normal. MR fat estimation showed 3 - 5% fat fraction in her right and left lobe (Picture 1). Ct volumetric analysis showed adequate remnant and graft volume. Liver biopsy analysis showed 5 - 7% fat fraction without any sign of portal inflammation or fibrosis (Picture 2). During operation her liver was looking normal with adequate volume and remnant, Right lobe was taken out without middle hepatic vein. She tolerated procedure well. Her post-operative recovery was uneventful. Patient also recovered well. Conclusion: There are not enough similar studies, this case report has shown that in selected cases, post bariatric surgery obese person can also be considered for liver donation safely, though larger studies needed to confirm it.
215 All that Glitters is Not Gold: Non-Oncological Elevation of CA-125 , Hakim Rahmoune, Nada Boutrid, Soumia Satta, Hala Boutrid and Naouel Lemdaoui
Genital, and particularly adnexal lesions are not uncommon, and may masquerade different diagnoses, sometimes unexpected.A sharp approach of this condition should lead to a step-wised assessment, especially for adolescent patients, keeping in mind the socio-epidemiological context of the local population.We present a very ludic and peculiar case of an ovarian cyst with ascites in a teenager.We admitted a girl aged 13 with a previous history of a pro-longed, 6-month secondary amenorrhea associated with fever and subacute pain at the right lumbar region.A prompt and complete investigation reveals a mid-size ovarian cyst at right with localized, (reactive) ascites. Concomitant biology depicts highly elevated inflammatory biomarkers (C Reactive Protein, CRP and Erythrocyte Sedimenta-tion Rate, ESR) along with a dramatic increase of the Cancer Anti-gen-125 (CA-125).Finally, TB-Interferon is positive, and Tuberculin skin test is as high as 19 mm of diameter.
216 A Case Report on Alprazolam Induced Pedal Edema , Clement Kabakama, Aneena Suresh, Abdul Rafey Usmani and Zahra D Khan
Alprazolam induced pedal edema is a rare entity. Alprazolam acts at several sites within the central nervous system, including the limbic system and reticular formation effects which may be mediated through GABA (A) sub unit receptor system where by leading to increase in neuronal membrane permeability to chloride ions enhances the inhibitory effects of GABA. We report a case of a 70 year-old-female patient with complaint of difficulty in breathing, tiredness and palpitations. She was later diagnosed with congestive heart failure. On the third day patient had complaint of difficult in sleeping and was prescribed alprazolam. The following day, during the ward round, odema was reported and alprazolam was stopped and reported as an ADR through spontaneous reporting form of an adverse drug reaction. During Hospitalization the Prognosis of the patient to withdrawal of the causative agent was done and the Patient her swollen left leg, managed with loop diuretic. Hence forth we report a rarely incidence of alprazolam inducing pedal edema.
217 Biochemical Significance of Biomaterials Based on the Chitin-Chitosan Axis , Tamar Farraj, Mariam Ajam, Sevgi Gençosman, Deniz Ceylanli, Ahmet Özer Åžehirli and Serkan Sayıner
Chitin is the second most available polysaccharide in nature after cellulose. It is found abundantly in the exoskeleton of arthropods such as insects, crabs, lobsters, and its presence in the fungi cell wall. The deacetylation of Chitin yields the formation of Chitosan, which has multiple exceptional properties. These include biocompatible, biodegradable as well as anti-microbial characteristics. Chitin and its biopolymer Chitosan have been a subject of research for their potential use in biomedical application. Their interesting properties meet the criteria needed to be used as biomaterials, especially in tissue engineering. This review explains the biochemical significance of biomaterials based on the chitin-chitosan axis by showing the biochemical structure and the properties of the Chitin and Chitosan, which include biodegradability, anti-inflammatory, anti-oxidant and some other beneficial properties which make Chitosan a very functional biomaterial that can adapt with living mammalian cells and induce their proliferation. We mention their use in the biomedical field as biomaterial, with a particular focus on Chitin and Chitosan-based scaffolds in tissue engineering (chitosan hydrogels and chitosan sponges), scaffolds in wound dressing (chitosan films, porous chitosan nanofiber membranes, and chitosan-based sutures), and some other chitin/chitosan-based materials. In fact, besides being biocompatible and biodegradable, they also display some other properties that allow them to be formed as scaffolds, using various methods, including lyophilization, freeze gelation, and gas foaming. Their non-toxic, soft and flexible properties will give them advantageous characteristics for their use as hydrogels. Their porous structure, antibacterial and hemostatic characteristics will make them ideal biomaterials for wound dressings and sponge materials in tissue engineering. Chitin/chitosan-based biomaterials have also proven significance in Veterinary medicine with their high nutritional characteristics that should be present in animals' diets. Additionally, it was also recognized for its high biomedical importance that has been used widely in medicine. Chitin and chitosan-based biomaterial are thus a revolutionary discovery in the biomedical field, as they improved the performance of biomaterials by being natural substitutes to the petrochemical products precedents and renewable and environmentally friendly.
218 Paradoxical Additional Role of SGLT2 Inhibitors Beyond Glycosuria in Controlling Obesity, NAFLD Treatment, Pancreatic β Cell Protection Besides Therapy for Diabetes Mellitus, CVOT and Renoprotection-A Minireview , Kulvinder Kochar Kaur, Gautam Allahbadia and Mandeep Singh
Earlier we had reviewed how obesity is assuming an endemic/pandemic proportions resulting in escalating incidence as well as prevalence associated with escalating worldwide incidence of metabolic syndrome (MetS) with non-alcoholic fatty liver disease (NAFLD), that is correlated with enhanced morbidity. We tried to detail how probiotics, L-carnitine (LC), nicotinamide ribose (NR) combination, along with apical sodium dependent bile acids transporter (ASBT) or volixibat and silybin, vitamin D, allyl isothiocyanate (AITC), might aid in treating and understand the etiopathogenesis of NAFLD, besides role of Astragaloside IV. Having reviewed sodium-glucose cotransporter 2 (SGLT2) inhibitors earlier for better glycaemic control and cardiovascular outcome (CVOT) and renoprotective actions here we conducted a minireview on how SGLT2 inhibitors have demonstrated certain magical actions beyond glycosuria for Diabetes mellitus (DM) control, in treating obesity, protective action on pancreatic β cells and how they are another efficacious therapy for NAFLD specifically in the ones who have developed diabetes mellitus (both type 1 and 2).
219 Perceptional Barriers in Hepatitis C Therapy: A Cross-Sectional Assessment of the Patients from Khyber Pakhtunkhwa Pakistan , Muhammad Daud*, Saima Mehboob, Bushra Gul and Waheed Ullah
Objective: To determine the perception of local resident patients regarding chronic hepatitis C infection using the BIPQ (brief illness perception questionnaire). Materials and Methods: This Observational, cross-sectional study was performed in two hospitals, selected from two districts of KPK (Khyber Pakhtunkhwa), a tertiary care hospital from District Peshawar, and a secondary care hospital from District Charsadda. Patients with chronic Hepatitis C (HCV RNA positive through PCR analysis), of age ≥ 18 years, mentally sound, and lacking any major comorbidities were included in the study. The study duration was 1 year lasting from January 2018 to December 2018. Patients were recruited through non-probability Convenience sampling and face-to-face interviews for duration of 10 - 15 minutes were conducted in the outpatient departments of each hospital. Descriptive statistics were used to describe the demographic characteristics of the study participants and the scoring of BIPQ. Kolmogorov-Smirnov test was used for determining the normality of the data. Inferential statistics (Mann Whitney U test and Kruskal-Wallis tests) were used for comparative analysis of study variables. Spearman’s rho correlation was used to check the association between the BIPQ item scales and overall score. Binary logistic regression was applied to identify the predictable variables responsible for overall threat or benign condition of the patients. Results with P ≤ 0.05 were considered statistically significant. Microsoft Excel 2016, and IBM SPSS V.21.0 were used for data analysis and interpretation. Results: A total of 550 patients were approached for participation but only 525 patients showed consented for inclusion in the study (95.45% response rate). Mean age of the participants was 43.94 (11.90) years. Majority were females with a frequency of 301 (57.4%) and out of these, stay at home wives were 294 (56%). Most of the patients were of lower middle age i.e. 31 - 45 years. Illiteracy was high among the participants 426 (81.1%). Patients who were daily wages job workers (DWJWs) were 127 (24.2%), and those who had previously experienced some kind of failed HCV therapy were 197 (37.5%) (Table 1). BIPQ results showed that Patients had the highest Concern score with a Mean (SD) of 8.09 (2.09); followed by Treatment control, 7.92 (2.13); and lowest on the Coherence item scale, 2.92 (1.85). According to the instructions, the overall sum score of BIPQ was calculated, which was found to be 43.35 (13.15) Mean (SD), and it also showed an internal consistency of α = 0.859 (Table 2). Females showed higher emotional representation and lower Coherence than males with p ≤ 0.05. Daily wages job workers (DWJWs) showed higher concern (p ≤ 0.05). Treatment-experienced patients scored less on treatment control (p = 0.029) and high on disease chronicity (p ≤ 0.01) when compared with newly diagnosed HCV patients (Table 3). BIPQ Overall score showed significant strong and positive correlation with Consequences (r = 0.822, p ≤ 0.01), identity (r = 0.816, p ≤ 0.01), and strong negative correlation with treatment control (r = -0.715, p ≤ 0.01) and Your-control r = -0.700, p ≤ 0.01 (Table 4). On the basis of Overall score (Total score = 80), patients were divided into the final two categories for research purpose. Patients who scored 0 - 40 were labeled “Benign” (i.e. having good perception, less threat), and those with a score ranging from 41 - 80 were labeled “Threat” (i.e. Bad perception, higher threat). Binary logistic regression of these two categories with independent study variables indicated that only failed previous treatment experience of the patients had a significant effect on the overall patients’ perceived threat of the disease, χ2(1) = 1.587, p < 0.05, (95%CI: 1.096, 2.296). Regarding the most probable source of infection most patients (79.23%) were unable to identify any transmission risk factor for Hepatitis C. Some of the participants (8.5%) indicated that unsterilized dental practices as the cause of their infection. Some pointed out mental stress, pollution, and spiritual reasons as a cause of infection (Figure 1). Conclusion: Patients lacked information and understanding of the causality and transmission of risk factors of HCV infection and they showed high concerns for their lives and families. Previously failed HCV treatment experiences altered the patients’ perceptions negatively as they were doubtful of the success of modern more effective drugs available.
220 Prevalence and Predictors of Gallbladder Stasis among Patients with Cholelithiasis , M Ravikiran, Usha Dutta, Anish Bhattacharya, Kuldeep Solanki, GR Verma, Sanjay Chaudhuri, Rakesh Kochhar, B Nagi and Kartar Singh
Background: GB stasis is an important cofactor in the pathogenesis of gallstones and gallbladder cancer. The prevalence and predictors of GB stasis among patients with GS in a high incidence area for GBC like North India is not known. Aims: To determine the prevalence of gallbladder stasis among patients with GS using cholescintigraphy and to identify clinical, demographic and radiological predictors of GB stasis. Methods: Patients with GS were prospectively evaluated for demographic, anthropometric, dietary and clinical parameters. Ultrasonography assessment for number and size of stones and to exclude associated malignancy/polyp was done. Gallbladder Ejection Fraction (GBEF) was assessed using HIDA scan after ingestion of fatty meal. GBEF of £ 35% was considered as evidence for GB stasis. Predictors of GB stasis were identified by univariate followed by multivariate analysis. Results: 120 patients with GS were studied (mean Age 46 ± 13 years; 80% F). Majority (92%) were symptomatic, dyspepsia (78%), biliary colic (70%), postprandial discomfort (70%), fat intolerance (31%) or jaundice (5%). Ultrasound showed multiple GS in 73%. The median EF was 40% (range 0 - 95%). 47% (56/120) had GB stasis {non-visualized GB (39 cases) or low EF (17 cases)}. The median EF in the multiple GS group was lower than in single GS group [35% vs 52%; (p = 0.021)]. Patients with single GS were more likely to have good EF (> 75%) than multiple GS group [12/33 (36%) vs 10/87 (12%); p = 0.002]. GB stasis was found more often in the multiple GS group than single GS [45/87 (52%) vs 11/33 (33%) (p = 0.07)]; among poor SES than upper SES group [44/84 (52%) Vs 12/36 (33%), (p = 0.05)]; in those with postprandial discomfort than those without [44/84 (52.4%) Vs 12/36 (33%), (p = 0.05)] and in those of sub-Himalayan belt than those from Punjab and Haryana [18/28 (64%) vs 38/92 (41%); p = 0.03]. Independent risk factors for stasis were postprandial discomfort (OR = 2.7; p = 0.03), belonging to sub-Himalayan belt (OR = 4; p = 0.007), poor SES (OR = 3.2; p = 0.014) and multiple GS (OR = 2.4; p = 0.05). Conclusion: Gallbladder stasis is present in 47% of patients with GS. Independent predictors of GB stasis are presence of multiple GS, poor SES and post-prandial discomfort and in those belonging to states of sub-Himalayan belt.
221 Predictors of Difficult Cholecystectomy , Nagendra Prasad Anipindi
Background: Laparoscopic cholecystectomy (LC) is one of the most commonly performed laparoscopic surgeries worldwide. There is no uniform consensus as to predictors of pre-operative difficult gall bladder and conversion to open cholecystectomy. Few indicators have been proposed but may not be applicable in all cases leaving a room for intra-operative surprises. In this study, we evaluated the indicators for pre-operative difficult cholecystectomy and possible conversion to open cholecystectomy. Methods: A prospective observational study of patients who underwent LC from 2009 to 2016 was done. A retrospective analysis of possible factors responsible for conversion from laparoscopic cholecystectomy to open cholecystectomy was performed. The statistical analysis was done using chi-square test. Results: Out of 415 cases, 368 (88.7%) patients underwent successful laparoscopic cholecystectomy while 47 (11.3%) patients were converted to open cholecystectomy. These 47 patients constituted the study cohort. Males constituted 62%. Average age was 51.34 years ± 10.3 years. Abdominal pain was seen in 93.5%, tenderness in 81%, palpable mass in 25.5% and fever in 60% of patients. Raised total leucocyte count was seen in 78.7% and altered liver function tests in 66% of patients. Increased gall bladder wall thickness was found in 91% and pericholecystic fluid collection was seen in 27.5%. Dilated Common bile duct was found in 17% patients. Acute cholecystitis with obliterated Calot’s triangle was seen in 49% followed by dense adhesions, empyema and xanthogranulomatous cholecystitis. Conclusion: The most common cause of conversion to open cholecystectomy was presence of dense adhesions obliterating the anatomy at Calot's triangle. Difficult LC can be predicted based on clinical, laboratory and imaging parameters. All said and then, a difficult gall bladder can still be encounter on the operative table in the absence of the above findings. Hence every case should be treated on its individual merit and one should always be ready for difficult dissection.
222 Infrared Coagulation for Treatment of Internal Hemorrhoids in Otherwise Healthy Patients and Specific Condition (A 5 Year Follow Up) , Seyed Reza Fatemi, Behzad Hatami, Naghmeh Salarieh, Azam Farahani, Seyed Ali Fatemi, Sania Alizadeh2 and Mahdi Heydari Monfared
Background: Infrared coagulation (IRC) is one of nonsurgical office-based modalities for treatment of internal hemorrhoids. Although until recently, rubber band ligation (RBL) has mainly been considered as first-line therapy, it sounds that IRC can be used as first choice in treatment of grades I-III internal hemorrhoids, especially in certain conditions including pregnant and cirrhotic patients. Methods: Our study was conducted prospectively and 220 patients including 190 otherwise healthy, 20 cirrhotic Child-Pugh class B or C and 10 pregnant patients, 46% female and 53% male, with symptomatic internal hemorrhoids grades II or III underwent IRC in total 660 sittings over a 3- month period of treatment. Early and late complications and outcome of patients were monitored during a period of 5-year follow-up. Results: Out of 220 patients just 85.8% experienced some short time post-procedure symptoms. The most common complaint was feeling of mild pressure or discomfort in anal canal (42.7%) occurred within 24 hours to 10 days after procedure and completely resolved thereafter. The other complaint was trivial bleeding during defecation (23.2%) for few days after procedure. The post procedure complaints in pregnant and cirrhotic patients were not different from otherwise healthy patients. Among 220 patients treated by IRC, only 33 patients (15%) experienced recurrence of symptoms predominantly as rectal bleeding during long-term follow-up. The majority of relapses occurred within one year after procedure (81.8%). Unexpectedly, the relapse rate in pregnant and cirrhotic patients were similar to otherwise healthy patients. Overall success rate of this modality for treatment of early internal hemorrhoids in long-term follow-up was 85%. Conclusion: IRC is a simple, swift, convenient and repeatable procedure with good safety index and high success rate for treatment of grades I-III internal hemorrhoids that can be conducted in outpatient setting for otherwise healthy patients as well as pregnant and cirrhotic patients. It can even be regarded as first -line therapy.
223 Surgical Management of Hepatobiliary Complications in Sickle Cell Disease. Literature Review , Salah Termos, Afaq Mahmoud Alkhalil, Hassan Al-Jafar, Ali Alqatan, Nijmeh Hammoud, Ahmad Essam Almulla, Fahad Alabdulghani and Mohammad Alhunaidi
Sickle cell disease (SCD) is a common hemoglobinopathy that results in vasoocclusive crisis with abnormal endothelial interactions causing repeated ischemia and reperfusion injuries, inflammation and endothelial dysfunction. This pathophysiologic process can affect multiple organs in the body leading to serious medical disorders. Liver disease is an important factor of morbidity and mortality in patients with SCD. It is most commonly affected due to sickle hepatopathy, an umbrella term for a variety of acute and chronic pathologies that can be manifested in several clinical conditions that range from benign hyperbilirubinemia to an overt liver failure. Management of this disease poses diagnostic and therapeutic dilemmas. Surgical treatment of hepatobiliary complications in SCD patients will be outlined in this review.
224 SARS 2-Covid-19 Social Impact, in a Remote Indigenous Village in the Alpine and Southeast of Mexico , José Luis Mosso Vázquez, Dejanira Mosso Lara and Jonathan Joshua del Real
Goal: Describe the impact of COVID-19 in “El Tepeyac, an indigenous community of Mè’Phàà people situated in the southeast region of Guerrero, México. Methods: We obtained permission from local meet with the community to provide critical information regarding the COVID-19 pandemic. We made a survey to get population statistics in the last year, we donated oximeters, thermometers and fast covid-19 tests in order to enhance diagnostic capabilities of the community. We provided direct assistance to the community for 3 days, during which we utilized the assistance from a Mè’Phàà translator. Results: Since the time that the SARS-CoV-2 virus was detected in February 2020 up until today May 12, 2021, there have been 0 deaths and 0 infected with SARS-CoV-2 in El Tepeyac. No citizens were infected the disease in the period lasting from February 2020 to May 13, 2021. The El Tepeyac village has 325 citizens as of December 31, 2020. Few of them use face cloth masks, none of which were classified as N95 masks. Little to no assistance was offered by local healthcare institutions for the prevention and treatment of COVID-19. Conclusion: There are no reported infections or deaths from COVID-19 in El Tepeyac. It is suggested that the transmission of COVID-19 was prevented due to social distancing in addition to the distance between other communities. The community El Tepeyac is separated from other communities by more than 15 kilometers. The small size of these communities and relative isolation from areas of higher population density is also a possible reason for the minimal impact of COVID-19 on this community.
225 Large Gastritis Cystica Polyposa Treated with EMR Polypectomy in Patient without History of Gastric Surgery , Seyed Reza Fatemi, Behzad Hatami, Naghmeh Salarieh, Azam Farahani, Seyed Ali Fatemi, Sam Ali Zadeh2 and Mahsa Molaei
Gastritis cystica polyposa (GCP) is a rare inflammatory disease of the gastric remnant that usually develops after partial gastrectomy. It is defined by the presence of polyps on anastomotic gastric junction mucosa, at histopathological examination, by the presence of mucosal and submucosal cysts with foveolar hyperplasia. The disease is characterized by the frequency of gastro-intestinal bleeding and possibility of carcinomatous association. The endoscopic examination of a 51-year-old female without history of gastric surgery revealed a protruding lesion in the greater curvature of the middle third area of stomach. The lesion was 25 mm in size. Polypectomy was performed with snare base method and submucosal stalk injection, with endoscopic impression of hyperplastic polyp, without any complications. Histopathological findings were consistent within gastritis cystic polyposa (GCP).
226 Foetal Organ Implantation into Adult Animals: A Model for In Vivo Culture of stem cells? , Coulic Véry, Novikov VN1, Mboti F and Delrée P
Background: Presently stem cell implantations are more and more developed and applied in clinics as alternative and complementary solutions to adult organ transplantation because of the growing demand and capacities to provide these interventions, while lack of donors is patent. But some limitations of stem cell use remain (for instance integration within the recipient organism of engineered tissues and organoids obtained in vitro from stem cells). The use of foetal organ implantation into adult animals may be an alternative for in vivo study of stem cell development and evaluation of the host participation to this process. The objectives of this work were o try different foetal organ implantations into adult animals (part I) and to evaluate their use for repairing experimental lesions of some adult organs (part II). Material and Methods: Part I: In > 650 experiments on rats and mice, different sites of foetal organ syngeneic implantation were proposed. Physiological (electric activity, motor and secretion activity) and morphological (per illumination, ultrasound and magnetic imaging, optic and electron microscopy) methods were used for implant development evaluation during up to 12 months. Part II: Foetal heart and foetal digestive organs were tested for both oesophagus circular defect and heart thermic lesion repair (38 and 29 rats). Trials with foetal pancreas implantation were provided in rats with diabetes induced by Streptozotocin and/or protein deficit and in a small pilot group of diabetic patients. Result: Part I: After a “dedifferentiation” phase, foetal organ implants could grow following ontogenetic pattern but - at least in our experimental conditions - some of them were not able to re-organize as a whole functional adult organ. The factors enhancing or limiting the organoid formation are considered. Part II: Foetal heart implants were proved to enhance heart lesion morphological and functional repair. Foetal oesophagus, stomach or intestine fragments combined with chitosan flaps ensured a complete restoration of the oesophagus wall after oval or segmental resection. Implantation of foetal pancreas was able to reverse Streptozotocin induced diabetes and to prevent chronic glucose disorders following protein deprivation in rats. In patients temporary positive influence was noted. Conclusion: Implantation of different foetal organs into syngeneic adults may constitute a valuable model for theoretical studies of in vivo stem cell differentiation and organoid growth. The ear implantation site deserves special attention. Some interesting applications are possible and worthwhile to be discussed and developed.
227 Being Vegetarian: A Boon for Good Health , Surya Kant, Priyanka Jain and Nandini Dikshit
It is very correctly said by Albert Einstein that “Nothing will benefit human health and increase chances for survival of life on Earth as much as the evolution vegetarian diet”. Human body is technically the most advanced and complicated machine. Like any other machine it also requires fuel to function. Food that is consumed by humans act as a necessary fuel and provides energy for the body to function in a normal manner. For a machine to function properly it requires right kind of fuel for which it is designed. If you put diesel into a petrol car it will not function properly rather it will give you lot of trouble. Likewise, incorrect food and eating habits can give rise to ailments. The evaluation of the records regarding vegetarianism specifically focused on ancient Indian culture. The perspective of Jainism and Buddhism express that vegetarianism was supported entirely based on the concept of nonviolence against the animals that was a rule for both Jainism as well as Buddhism. As explained in the yogic thought, the concept of Saatvik food [1] mainly defines the responsibility of the food to purify the human mind and maintain the calmness that increases the body potential and maintain the health factor of the human body. Satvik foods mainly involve ingredients that are cultivated within the country and mainly constitute vegetarian food.  The vegetarian food chart mainly involves heterogeneous composition that includes certain individual restrictions and certain biased practises as it imposes complete exclusion of all forms of foods that are extracted from animals. The particular diet has the characteristics of a healthy eating habit that include regular consumption of legumes, fruits and vegetables that includes nuts and grains, each of which are independently associated with positive health outcomes. Though specific diet patterns influence the control of chronic diseases such as the regular consumption of vegetarian food helps in reducing their saturation of blood level which includes a controlled level of cholesterol and blood rich in fibre, nutrients including ascorbic acid and manganese and copper. However, the consumption of vegetarian food can generate suboptimal consumption of specific nutrients that need to be taken into account while using the supplement. Additionally, there are non-dietary factors that contribute to the consumption of vegetarian food regularly which mainly involves physical activity and avoidance of practices such as alcohol consumption.
228 Blood Oxygen Saturation and Pulse Rate Comparatives Measures with Wrist Smartwatch and Oximeter Monitoring , José Luis Mosso Vázquez
Goal: We present 145 comparative statistical measures monitoring blood oxygen saturation BOS and pulse rate PR, monitoring with wrist smartwatch and oximeter in 145 randomized surgical outpatients 16 months after Mexican pandemic started. Method: We set up wrist smartwatch on the right wrist and oximeter in the right index to monitoring PR and BOS in 145 randomized patients during examination in a tertiary Hospital at the Mexican Social Security in Mexico City. Results: Remarkable results show a great difference between blood oxygen saturation measured by wrist smartwatch and oximeter because oximeter measured with large rank and smartwatch a short rank demonstrated with standard deviation and line regression in statistical analysis. Conclusion: Internet of Medical Things is a potential technology in hospitals, homes and much more in global pandemic. With our results we demonstrate a great different result among two wearable devices. Physicians most choose the best brand carefully to make the best medical decision for patients.
229 Beyond the Bowel: Granulomatous Renal Pseudotumor in Crohn’s Disease. Is it Possibly an Extra-Intestinal Manifestation? , Siew Yi Ching and Gim Hin Ho
Extra-intestinal manifestations (EIMs) occur in patients with inflammatory bowel disease (IBD). Renal EIMs are uncommon. Even more rare are granulomatous renal pseudotumors in IBD patients. We report a possible case of renal EIM presenting as a granulomatous renal mass in a patient with Crohn’s disease.
230 What Flexner Report did to Our Medicine After 100 Years of Implantation? , Huang Wei Ling
Recently, the author is felling that we are starting a new phase of medicine due to her research in Brazil, that she concluded that the energy patterns of our patients have changed to less energy standard. In the article written by the author (2021) entitled Is the Population in the World the Same as in the Past? she is explaining the reasons that our population is changing the energy pattern and becoming all classified as immunosuppressed and not immunocompetent as she showed in the article Are We Vaccinating Immunocompetent or Immunocompromised People for COVID 19?
231 Hepatitis B Sero-Conversion Rates among HIV Positive Children Immunized with Pentavalent Vaccine in Bamenda Health District, Cameroon , Lem Edith Abongwa, Forwang Lisette Nkengbeza, Clauvis Yengo, Signang Alberic and Mabeyonga Berenice Fokong
Background/Aims: Immunosuppression caused by the human immunodeficiency virus (HIV) alters the pathogenesis of the hepatitis B virus (HBV) infection thereby increasing HBV prevalence. Globally, HIV and HBV remain major public health concerns. Immunization is an effective method of preventing childhood infection. This cross-sectional study aimed at assessing the effectiveness of the pentavalent vaccine in the prevention of HBV transmission in HIV-positive children. Methods: Children who gave their assent with the consent of their parents/guardians were recruited into the study. Socio-demographic information was collected using a close-ended questionnaire. Serum samples were used to test for serological markers of HBV. One hundred and fifty-six children were enrolled between March and July 2020. Data analyses were done using SPSS version 23.0. Results: The age range of the participants were 0.8 months to 15 years with a mean ± standard deviation of 9.6 ± 3.8 years. The prevalence of HBV among the study participants was 2 (1.3%), and it was insignificantly (p = 0.25) higher in females (2.1% vs 0.0%) compared to their male counterparts. As concerns age group, <6years recorded the lowest prevalence 0 (0.0%) and this was insignificant (P = 0.88). HBV prevalence was highly significant (p = 0.001) among children whose parents/guardians were positive 2 (15.4%) for HBV Conclusion: The use of the pentavalent vaccine is effective in preventing HBV and all babies born to HBV-positive pregnant women should be followed up to ensure that they receive the monovalent vaccine at birth and 4 weeks after birth alongside all the required vaccines.
232 Reversal of Alcoholic Fatty Liver in Patients with Acute Pancreatitis - A Prospective Observational Study , Venkatesh Kasi Arunachalam*, Thambidurai Sadasivam, Rupa Renganathan, Gopinath Periaswamy, Haleema Sherene, Rajesh S, Rajesh Kumar Varatharajaperumal and Sriman Rajasekaran
Purpose of the Study: Fatty liver is a reversible condition characterized by the accumulation of triglycerides within the hepatocytes. The prime way to reverse the fatty liver includes abstinence from alcohol, dietary modifications, and regular exercise. Our study aimed to assess the reversal of alcoholic fatty liver in patients with acute pancreatitis. Materials and Methods: One hundred five patients with acute pancreatitis were included in our study. The liver attenuation index was calculated in a plain scan, and fatty infiltration was quantified. All the patients with fatty infiltration were divided into an alcoholic and non-alcoholic subgroup. The LAI was calculated in the follow-up CT scan in these patients with fatty infiltration, and reversal of fatty liver was calculated along with the time. Results: Among 105 patients with acute pancreatitis, 32 had fatty liver. In these 32 patients, alcohol was the cause of acute pancreatitis in 18 patients. Follow up CT scan was done in 40 % of the patients with fatty infiltration. Out of 10 patients with fatty infiltration in an alcoholic subgroup, eight patients showed reversal of fatty liver in 4 days to 16 weeks, and all these patients were abstinent from alcohol from the time of admission. Conclusion: Abstinence from alcohol is the mainstay in the reversal of alcoholic fatty liver, and it will take at least four weeks for the complete reversal of the alcoholic fatty liver disease.
233 The Mused Entrails-Gastroenterology and Hepatic Disease , Anubha Bajaj
Gastroenterology is a division illustrating the disorders of gastrointestinal tract and hepatobiliary system. Gastrointestinal tract extends from oral aperture to the anus along with an interconnecting alimentary tract which may be incriminated by several congenital or acquired disorders. For cogent diagnosis and treatment, the speciality entails the performance of several diagnostic and therapeutic interventional procedures such as upper gastrointestinal endoscopy, colonoscopy, oesophagogastroduodenoscopy (EGD), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) or tissue sampling from hepatic parenchyma
234 Terlipressin Induced Reversible Valvular Dysfunction in a Cirrhotic Patient for Living Donor Liver Transplant: Case Report , Manoj Gupta and K R Vasudevan
Terlipressin, a vasopressin analogue, has known cardiac side effects e.g. arrhythmias, reduced left ventricular ejection fraction, non ST elevation myocardial infarction. However, to the best of our knowledge reversible valvular insufficiency with pulmonary hypertension with terlipressin has never been described in the literature in cirrhotics. As in the present case it was reversible therefore definitive treatment i.e. liver transplantation should not be deferred in this subgroup of patients.
235 Importance of Nutritional Evaluation in Transplant Patients Awaiting Lung Transplantation , Sevan Çetin Özbek and Fatma Perim Türker
Nutritional status of lung transplant candidates is important both before and after transplant. Early assessment of nutritional status is necessary to identify individuals with malnutrition/at risk of malnutrition and to prevent complications, manage the catabolic process and provide optimal nutrition. In this article, it is aimed to draw attention to the importance of nutritional evaluation before lung transplantation. By reason of today, there is still a need to increase malnutrition awareness, prevent malnutrition and spread interdisciplinary work all over the world. Malnutrition and obesity, considered, a malnutrition, have negative consequences for the patient, health professionals and the economy. These are encountered with deterioration of organ systems, increase in hospital stay-cost-re-admission, in morbidity and mortality. For this reason, determining the nutritional problems of the patients from the first admission to the hospital is the key point in predicting the problem from the beginning and producing a solution accordingly. In particular, the nutritional status of lung transplant candidates affects short and long-term factors such as post-transplant complications, length of hospital stay and mortality, post-discharge care and re-admission to the hospital.
236 CRISPR Genome Editing: A Boon to Medical Science , Hemshankar Laugi
CRISPR, an acronym for Clustered Regularly Interspaced Short Palindromic Repeats, is one of the major discoveries in the field of medical science. It is a type of bacterial adaptive immunity used to fight against bacteriophages. It is a type of memory. Whenever a virus attacks a bacterium for the first time, it creates a memory which is used to fight with that virus if it attacks the second time. In this system, small guide RNAs (crRNAs) are employed for sequence-specific interference with invading nucleic acids. CRISPR-Cas comprises a genomic locus called CRISPR that has short repetitive elements (repeats) separated by unique sequences (spacers), which can originate from mobile genetic elements (MGEs) such as bacteriophages, transposons, or plasmids
237 Chronic Diarrhoea: Scenario in Indian Vis-à-Vis Western Children , Suraj Gupte
Background: Chronic diarrhoea, defined as diarrhoea of 2 weeks or more duration, is a common problem in Indian children. Until recently, this remained ambiguous if the approach to its diagnostic evaluation and management warranted to be the same as followed in the western countries. Objective: To focus on the current etiologic profile of chronic diarrhoea in childhood in India and highlight the major differences between the profile encountered in Western children. Design: The review is based on author’s extensive experience in chronic diarrhoea in children in India spread over the past four decades and the information available in the English medical literature. Salient Features: Aetiology of chronic diarrhoea in resource-limited settings is exhaustive. Nonetheless, only a few conditions such as protein-energy malnutrition (PEM), iron-deficiency anaemia (IDA), intestinal parasitosis (giardiasis, ancylostomiasis), and excessive consumption of soft drinks monopolise the situation. Coeliac disease, inflammatory bowel disease, and cystic fibrosis do occur but less frequently. This picture sharply contrasts with the pattern dominated by celiac disease, cystic fibrosis and inflammatory bowel disease in the Western children. Conclusion: A good idea about the pattern of aetiology of chronic diarrhoea in different regions together with an individualised approach and an adequate follow-up is likely to resolve a large majority of the diagnostic problems in chronic diarrhoea in paediatric practice. Treatment depends on the aetiological condition. With the evolving socioeconomic and living conditions, futuristic changes in the aetiological pattern in India are expected in future. As the nutritional status improves and gut parasitic infestations get controlled, the pattern may slowly move towards the one that is seen in the western countries.
238 Nutrition Therapy a Cardinal and Unmapped Aspect in Liver Transplantation: A Review , Neha Bakshi and Kalyani Singh
Managing nutrition status is challenging among Liver transplant patients. Symptoms of liver failure like ascites and low albumin levels represent demo in nutrition status assessment. Despite this, malnutrition is prevalent in more than 80% of pre-LT patients. Malnutrition has been associated with poor surgical outcomes; therefore, the need for aggressive nutrition therapy before and after the liver transplant is crucial. Hence, this review aims to accentuate the need for nutrition interventions to devise a nutrition therapy plan in all the phases of Liver transplant.
239 Clinical Burden Related to Surgically Placed Feeding Enterostomy. A Single Center Study , Muhammad Shadab Khan, Syeda Sarah Batool, Shah Muhammad, Jahangir Farman Ali, Haider Mendhi and Abdaal Waseem Khan
Objective: To determine the incidence and severity of postoperative complications following surgically placed feeding enterostomy. Introduction: Enteral nutrition is more advantageous compare to other forms of nutritional supplements. Enteral feeding tube placement is a relatively common general surgery procedure but there has been little standardization in their surgical technique and postoperative care. The aim of this study is to review indications, complications, and clinical burdens related to feeding tube placement and its long-term use. Materials and Methods: Head and neck and upper gastrointestinal cancer patients presented in Sindh institute of urology and transplantation’s Oncology center from November 2017 till October 2020 were reviewed retrospectively. Details reviewed from patient’s files at the time of initial admission and subsequent follow ups during study period. All data was collected as per Proforma requirement in retrospective manner while maintaining strict confidentiality protocol according to institutional Ethical review board protocol. Collected data was analyzed for results using SPSS version 23.0. Results: During this study period, a total of 116 patients underwent feeding enterostomies in our institute. Male patients were 51.7% and mean BMI was 17.86 ± 2.43. The mean age at the time of surgery was 44.22 ± 14.02 years. Out of total 63 patients (54.3%) develop complications. According to Clavein dindo classification 28.4% minor while 25.8% major complications were noted. Subgroup analysis showed that complications were more common in the feeding jejunostomy group with a statistically significant P-value. Conclusion: Understanding the clinical burden and complications related with feeding tubes will help in minimizing associated morbidity and mortality. Feeding gastrostomy because of low clinical burden and complications should be preferred over feeding jejunostomy where possible.
240 Molecular Crosstalk amongst Anti-Orexigenic Ghrelin and Adenosine Monophosphate-Activated , Akanksha Singh
Ghrelin has proved to be a crucial mediator in stimulation of obesity. It elevates appetite by eliminating the action of GHS-R1a of neurological NPY/AgRP thus enhancing orexigenic activity. Such negative effects had been neutralized by the production of auto-ghrelin antibodies which are self-catalytic neutralizing the obese conditions by directly targeting AMPK active site which is known to stimulate appetite. Suppression of AMPK thus playing a central role might stimulate the activation of GHS-R1a thus leading to controlled release of ghrelin hormone. In this study, when mice were fed with high calorie diet exposed to the anti- ghrelin antibodies prepared by ELISA technique, after few hours, anti- ghrelin showed maximum activity thus decreasing ghrelin levels originally present. The study mainly focusses on the determining the interaction occurring between obese mediated ghrelin molecule and AMPK.
241 The Remodeled Ossein-Fibrous Dysplasia , Anubha Bajaj
Fibrous dysplasia is a benign bone lesion demonstrating intramedullary fibro-osseous proliferation occurring on account of modified osteogenesis. Fibrous dysplasia was initially scripted by Lichtenstein and Jaffe in 1942 and chronicled as “Jaffe-Lichtenstein syndrome” [1]. Fibrous dysplasia was also designated as osteitis fibrosa or generalized fibrocystic disease of bone. Fibrous dysplasia can incriminate a singular bone, denominated as monostotic fibrous dysplasia or multiple bones, termed as polyostotic fibrous dysplasia.
242 Do Statins Therapy Included as Rationale Treatment and Management for Rheumatic Heart Disease: A Case Report , Clement Kabakama, Abdul Rafey Usmani and Zahra D Khan
Rheumatic Heart Disease (RHD) is an autoimmune response to group A-streptococcus infections of the upper respiratory tract which may result in carditis or inflammation of the mitral and aortic valves if left untreated. Rheumatic Heart Disease causes an acute generalized inflammatory response and an illness that affects certainly parts of the body mainly Heart, Joints, Brain and skin, Patients with Rheumatic Heart Disease are often severally unwell and they are in great pain and require Hospitalisation. Despite of that it has been postulated streptococcal infection seems to play an important role for clinical presentation shows a streptococcal pharyngitis but streptococcal cellulitis has never been implicated, common feature is a painful migratory arthritis which is present in approximately 80% of patients. There is a link with class-I human leukocyte antigens (HLAs) which has been found. However, evidence which exists suggests that elevated immune complex levels in blood samples from patients with RHD are associated with HLA-B5. Recently it has been estimated that 33.4 million people worldwide have rheumatic heart disease and that 300,000 - 500,000 new cases of rheumatic fever occur annually, with 230,000 deaths resulting from its complications at the same Time at the same time, The World Heart Federation non-communicable disease action plan, developed for the World Health Assembly in 2013, called for a 25% reduction in premature mortality from RHD by the year 2025. This case report discusses about management and prevention of further complications due to rheumatic heart disease.
243 Assessing the Knowledge and Practice of Water, Sanitation and Hygiene (Wash) among Female College Students , Deevena Jemima, Neelam Kumari, Nandini Dikshit and Surya Kant
It is very rightly said that abode of a health mind is always a healthy body. To maintain good health the most basic requirement however is to have a clean and safe environment. In spite of the widespread use of water purifiers and filtration devices majority people do not have access to clean water for drinking, cleaning and washing. School and college going students mostly have improper eating habits and mostly do not practice proper sanitization. Therefore, they are most prone to infections and if we inculcate the habits of properly washing, sanitization and use of clean and safe water in this age group it will lead to the development of healthier youth population. Clean and safe environment is therefore every child’s birth right. Children who follow good hygiene practices have a healthy life and subsequently develop a robust constitution. WASH stands for universal access to water, sanitation and hygiene which is programme initiated by UNICEF that has a profound socio-economic impact. After the COVID pandemic struck a lot of awareness was propagated regarding the importance of hand hygiene, despite that three billion people worldwide, that includes millions of school-going children, have no access to hand washing facilities with soap water. The most vulnerable and affected are those living in rural areas, urban slums, disaster-prone areas and belonging to low socio income countries. This awareness is of utmost importance in COVID era since COVID infection spreads in three different ways, by contaminated person, by contaminated air and by contaminated objects. To curtail the spread of infection spread by contaminated objects it is very essential to practice proper sanitization and hand hygiene. Water, sanitation and hygiene practices play an important role in the prevention and transmission of many communicable diseases. In the wake of COVID-19 it is important that these practices be maintained along with proper food safety and sanitation procedures to prevent the spread of illness. Water is the main cause of various communicable diseases. There are 4 types of water related diseases namely, water borne, water washed, water based and water related vector borne. Water related diseases are those diseases that spread by contaminated water like typhoid, water watershed diseases are those diseases that are spread by not following proper sanitization and hygiene like worm infestation, water based diseases are those that propagate by pathogens based in water like schistosomiasis whereas vector borne diseases like dengue are cultivated near dirty and unsterile water bodies. By following proper methods of sanitisation and keeping self as well as the surroundings clean a good number of these diseases can be nipped in the bud. Provision of clean water for drinking and bathing will not solely prevent infection if proper sanitization techniques are not followed. Therefore, importance of washing and staying clean is of utmost importance for a healthy living. Hygiene and sanitation is specifically important for girls because they are highly susceptible to catch infections such as urinary tract infection and other genital infections. If women follow proper hygiene and they are provided safe access to clean water infections and death amongst infants and mothers will come down by one fourth of their actual number. Females who are mostly involved in cleaning and sanitization of their houses should specifically be made more aware of these practices in order to have a healthy family life. Therefore, this study in young college going females is a means to gauge the quality of basic awareness of hygiene practices in the community.
244 Anal Sphincter Repair for Fecal Incontinence. Experience from a Secondary Care Center , Torres Carlos, Gil Dina, Torres Douglas and Salinas Pedro
Background: Fecal incontinence (FI) is a chronic and debilitating condition that carries a significant health, economic, and social burden. This disease is characterized by the frequency of episodes and the consistency of the feces. The aim of this study was to review our experience with overlapping sphincteroplasty to assess its efficacy on the surgical treatment of fecal incontinence. Methods: Retrospective study was conducted for all patients who underwent overlapping sphincteroplasty in our institution from April 2007 to May 2017, for Fecal Incontinence with defects sphincter, at the Hospital Sor Juana Ines de la Cruz. All patients had evidence of a sphincter defect during physical examination, which was confirmed by Endoanal Ultrasound. Follow-up data were gathered from outpatient clinic visits and were obtained last office visit. The patients with fecal incontinence were asked Cleveland Clinic Florida Fecal Incontinence score (CCFFISW) Wexner score was registered preoperatively and 6 weeks postoperatively were collected. Results: We performed twenty one overlapping sphincteroplasty for patients with fecal incontinence during a study period of ten years. Patients mean age was 56.95 years ± 14.95, range (25 - 78). The etiologies were 11 patient’s Obstetric injury (52.38%), Diabetes Mellitus six patients (28.57%), anorectal surgery 3 patients (14.28%) and one patient who had traumatic rectal impalement (4.76%). The mean of CCFFIS Score Wexner decreased from 19.19 (range 17 - 20) to 9 (range 5 -18) after sphincteroplasty, with improved quality of lifestyle 12 months after procedure, even young patients affirmed to have sexual function improved. The median follow-up time was 12 (range 6 - 24, ± 14.38) months. Postoperative wound dehiscence partial was the most common complications after sphincteroplasty in 15 patients (71.42%). Only one patient went another hospital and undergone to terminal colostomy. One patient failed sphincteroplasty, and after one year had undergone a repeat. Conclusion: The overlapping sphincteroplasty is an effective treatment of choice for fecal incontinent patients with defects sphincter. This procedure still has a positive role to play in the management of fecal incontinence and has low costs when are compare with another surgical procedure for fecal incontinence.
245 Gluten and Autism: A Common Leak? , Nada Boutrid, Mounira Amrane and Hakim Rahmoune
In 1825, the French Jean Anthelme Brillat-Savarin wrote, in Physiologie du Goût, ou Méditations de Gastronomie Transcen- dante: «Tell me what you eat and I will tell you what you are» [Dis- moi ce que tu manges, je te dirai ce que tu es.] [1]. There is mounting evidence unmasking the origins of the pecu- liar association between celiac disease (CD) and autism spectrum disorders (ASD), in adult as well as in pediatric populations [2]. Actually, we should highlight the shared pathophysiological role of the digestive microbiota and the intestinal hyperperme- ability in these two conditions.
246 Analysis of Variceal Bleeding Recurrence Rate After Various Interventions in Extrahepatic Portal Hypertension , Ismailov SI, Devyatov AV, Babadjanov A Kh, Tuksanov AI and Boyko EV
Purpose: To conduct a comparative analysis of the incidence rate and period of gastric and esophageal varices bleeding recurrence associated with extrahepatic portal hypertension after different interventions. Materials and Methods: The study included 131 patients with various forms of extrahepatic portal hypertension; who underwent operative therapy of extrahepatic portal hypertension in the Republican Specialized Scientific and Practical Medical Center of Surgery named after academic V. Vakhidov (RSSPMCS) for the period from 2006 to 2020. Most patients were adolescents (41.2%) and young age (45.0%). Total gastroesophageal basin disconnection was performed in 57 (43.5%) patients, portosystemic shunting - in 51 (38.9%) patients, and endoscopic interventions - in 23 (17.6%).  Results: The comparative incidence rate of bleeding recurrence showed that the most effective intervention is portosystemic shunting. Significantly low efficiency is observed after endoscopic interventions, in which the incidence of hemorrhagic syndrome is 65.2% on average after 13.5 ± 2.9 months. While after a total disconnection of the gastroesophageal collector, a relapse-free course was noted in 35.1% (p = 0.014) of cases lasting 25.9 ± 4.4 months (p < 0.05), which in terms of timing did not differ significantly from relapses after portosystemic shunting - 41.4 ± 8.2 months, but significantly lower in the occurrence of variceal bleeding during decompression operations - 17.6% (p < 0.001).  Conclusion: The most effective surgical intervention is portosystemic shunting with a bleeding recurrence freedom rate in 82.4% (p = 0.014) of patients. The most long-term recurrence period is within 41.4 months (p < 0.05), and with a 5-year persistent remission in 75.0% of patients. After disconnection operations, bleeding recurrence was noted in 35.1% of patients; the recurrence period averaged 19.6 months.
247 In a Wonderful and Furious World , Boris I Yaremin
Without a doubt, we live at a time when the importance of medical science has increased many times over, and even people far from science have involuntarily joined its mysteries. Medicine has become newsmaker number 1 again. But medical science itself is changing. New pathogenetic mechanisms, points of drug use, issues of forecasting and analysis of big data - these issues have received a qualitatively new impetus. Any war is an absolute evil, but we remember what a powerful impetus was given to science and industry by the Second World War.
248 How Can We Treat Gastroesophageal Reflux Without Doing Surgery? , Huang Wei Ling
The author decided to write this article, in solidarity with one specific patient who had a complication after a gastroesophageal reflux surgery. This patient performed the surgery by video laparoscopy and had a bowel perforation without having been suspected by the surgeon at the time of the surgery. According to Hippocrates, father of medicine, in one of his quotes said, “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or chemist’s drugs” [1].
249 Physiological Bases of Hypertension , Lebedeva VD*, Pastukhova OA and Sokolov DE
Many different theories of the pathogenesis of hypertension have been created, but the true mechanism of its course remains unclear to this day. The article discusses the concept of hypertension as a neurosis of the higher autonomic centers, which is transformed into a metabolic syndrome.   The processes occurring during hypertension in the body are regulated by the autonomic nervous system. Inhibition of the noradrenergic system and a decreased level of noradrenaline in the blood are associated with an increase in blood pressure and lead to the activation of the cholinergic system. This activation causes impaired blood flow and damage to the vascular endothelium, which contributes to arterial hypertension.
250 Future Perspective of Nutrition in Gastro Intestinal Disease , Neha Bakshi
Nutrition Therapy is imperative in the treatment of gastrointestinal (GIT) disorders irrespective of the causative factors. However, we need enormous efforts in the research area to find out solutions to the nutrition challenges faced during the treatment of GIT disorders. Non Alcoholic Fatty Liver Disease (NAFLD) is a public health concern globally, the worldwide prevalence of NAFLD is 25% [1]. Lifestyle modification by managing diets to correct obesity/overweight has scientifically shown improvement histologically and can be proven beneficial beyond the drug therapy for high risk NASH patients [2]. It is recommended to develop strategies at the community level for both preventive and curative interventions to combat the predictive higher prevalence of cirrhosis from NASH in next 20 years [3].
251 Eosinophilic Esophagitis , Aimun Raees and Wasim Jafri
Eosinophilic Esophagitis (EoE) is a long-standing, relapsing immune-mediated esophageal disorder, facilitated by atopy, resulting in dysphagia and esophageal strictures. The prevalence has been leaping in the last few decades consistent with the enhanced understanding of the disease. It occurs in people from all ages but children and young males are especially affected. A wide spectrum of factors has been associated with it, including genetic and environmental risk factors. In atopic individuals, interaction of allergens with the esophageal epithelium generates a T-helper cells type2 driven immune response, which leads to the activation of inflammatory cytokines which in turn induce various genes causing formation and recruitment of eosinophils as well as mast cells setting in a chronic inflammatory process. Diagnosis is made on typical clinical, endoscopic and histological factors. Therapeutic modalities range from dietary restriction to corticosteroid therapy. Endoscopic intervention may be needed for patients presenting with esophageal strictures. Recently, biological agents have also been under trials for its treatment but there is no FDA approved drug therapy available as yet. It is a relatively new disorder that is constantly under evolution in terms of diagnostic and therapeutic fields.
252 Gastric Cancer, Linitis Plastica. EUS FNA Core Biopsy Technique as a Fast and Valuable Diagnostic Method Comparable to FNB , Seyed Reza Fatemi, Behzad Hatami, Naghmeh Salarieh, Azam Farahani, Seyed Ali Fatemi, Shahram Ebadi and Pardis Ketabi Moghadam
A fifty-year-old man was referred with progressive abdominal pain accompanying with anorexia and weight loss. Upper endoscopy was considered as a helpful procedure for the patient. Upper endoscopy revealed increased mucosal fold thickness due to decreased expansion in body and fundus with multiple erosions, in favor of mural infiltration compatible with diffuse type of gastric cancer, multiple standard biopsies were taken but pathology was reported negative. Abdominal CT-SCAN was done and it was highly suspicious of malignancy, so bite on bite biopsies were performed again. Pathology report was negative for the second time. Eventually, EUS-FNA was done, full thickness of all layers of stomach with multiple lymph nodes were noticed in EUS. With 22 G needle, FNA with slow-pull and multiple pass technique was performed to obtain many and sufficient core samples for cellblock cytology was taken. Pathology report was adenocarcinoma with signet ring cells.as a result, EUS-FNA was an accurate procedure for diagnosing gastric cancer.
253 Therapeutic Pathomorphosis After Thermochemoradiotherapy of the Rectal Cancer , S Yu Ignatenkov, I Yu Kudryavtsev, KA Kuzminykh, OA Skugareva and EA Dobrosotskaya
Rectal cancer is one of the most common malignant tumors of the gastrointestinal tract. Recent studies have shown the high efficiency and impact of neoadjuvant chemoradiotherapy on the number of sphincter-preserving surgeries, and local regional control. The article provides a review of the oncological literature in Russia devoted to the efficacy and safety of preoperative chemoradiation therapy against the background of hyperthermia in the treatment of locally advanced stage II-IV rectal cancer. In addition, the degree of therapeutic pathomorphosis in 59 patients of the Kaluga oncology clinic is considered, among whom 35 patients received radiosensitization only with chemotherapy and 24 patients additionally underwent local hyperthermia. The thermal radiation component use in combined treatment allows achieving an increase in the number of medical pathomorphosis of the III-IV degree.
254 Strategies to Increase Colorectal Cancer Screening Rates in Moderate-Risk Population: A Systematic Review , Iure Kalinine F Souza MD PhD, Luiza A Diniz, Érico Henrique A de Morais, Raquel M Carvalho, Rayane Elen F Silva, Camila G Mendes MSc and Eduardo Angelo Braga MD PhD
Evidence from randomized intervention studies indicates that colorectal cancer (CRC) screening is effective in reducing mortality. Thus, this systematic review is aimed to evaluate the factors associated with the success of strategies that increased the adherence to CRC screening tests by medium-risk patients. We grouped each strategy in clusters according to its interventions. Two articles addressing screening by recommendation/education of medical professionals presented an increase of 12.4% and 2.2 times more chance of patients completing screening tests; three resorted to recommendation/education of non-medical health professionals or assistant researchers, in which compliance went from 1% to 29% and 1.6 times more chance of following it through; four used recommendation/education of trained members of the community, in which there were an increase from 6.6% to 26.4%; two provided free FOBT kits available at post offices and pharmacies, in which the increase was of 29.8% to 30%; one sent pamphlets/invitations by mail or inviting patients by phone, in which growth varied from 1.1% to 13.7%; three educated the population via multimedia, which increased the rate to 14% or 15%; five used a mix of interventions, resulting in a growth from 1.7% to 76.9%. The rate increase in adherence to CRC screening tests relates to the guidance provided by a trained multidisciplinary team. Also, the patient-centered clinical method attends to the patient's singularities and thereby uses the best screening methodology based on updated scientific evidence for each population. Moreover, sending personalized newsletters and strengthening contact with patients via phone call/multimedia also increase success chances.
255 Nonalcoholic Fatty Liver Disease: Approaches in the Development of Obstetric Complications in the Pregnant Women with Overweight , Lina Bahniy, Svitlana Heryak and Nataliya Bahniy
Among the pathological conditions that are factors threatening the course of pregnancy, a special place is occupied by disorders of lipid metabolism. According to the WHO, 90% of overweight women develop early manifestations of hepatic steatosis at the age of 20 - 25, which leads to non-alcoholic steatohepatitis over the next five years of life. Therefore, overweight women are at risk for the development of obstetric and perinatal complications, in the genesis of which a significant role is given to metabolic disorders in the liver. The rationale for the planned study is the fact that the category of pregnant women with impaired lipid metabolism is progressively increasing. A significant number of studies have been devoted to this issue in pregnant women in accordance with disorders of lipid metabolism, metabolic syndrome, diabetes mellitus and their complications associated with arterial hypertension, and so on. However, the authors did not pay attention to the role of the liver in lipid metabolism and the risk of developing steatosis and non-alcoholic steatohepatitis at a young age, which may worsen the course of pregnancy and childbirth. At the same time in the special literature there are no works, in which the pathogenetic mechanisms of functional disorders of the liver in women with impaired lipid metabolism and features of pregnancy and childbirth in this pathology have been studied.
256 Peculiarities of Myocardial Remodeling in Young Obsessive Women with Arterial Hypertension , EG Mutalova, LI Galikhanova and EG Jamlikhina
Background/Aims: Overweight and obesity play a significant role in the development of many noncommunicable diseases, leading to a reduction in life expectancy and adversely affecting its quality. A number of studies have proven a close relationship between high blood pressure and abdominal obesity. In adult patients, it has been proven that obesity leads to an increase in the mass of the left ventricular myocardium, impaired myocardial function, which are significant predictors of unfavorable outcomes of cardiovascular diseases. The aim of the study was to investigate left ventricular (LV) structural changes in overweight and obese young women with arterial hypertension (AH). Design and Methods: In the study, according to inclusion criteria, 108 young women of 18 - 45 years old were included. Three groups were identified: the women with obesity without AH, the women with obesity and 1st degree of AH, the women with obesity and 2nd degree of AH. All patients underwent anthropometry (height and weight) with calculation of body mass index (BMI), echocardiography was performed according to a standard procedure with calculation of LV structural indexes. The LV geometry phenotypes were determined. Results: Echocardiography LV dimensions (posterior wall thickness, interventricular septal thickness, diastolic and systolic LV diameter), as well as LVM and LVMI were higher in obese women compared to control group. LV hyper-trophy (LVH) developed in 61,9% obese patients without AH and in 76,4% and 78,1% patients with obesity and AH. Normal LV geometry was found in 23,8% patients with obesity, concentric remodeling - in 14,3% cases, 35,7% patients had concentric LVH, and 26,2% - eccentric LVH. In obese patients with 1st degree of AH the distribution of various types of LV remodeling was as follows: 17,6%/6%/52,9%/23,5%, respectively, and in obese patients with 2nd degree of AH - 12,5%/9,4%/53,1%/25%, respectively. Conclusion: Since young age overweight and obesity are risk factors for LVH and the development of various LV geometry phenotypes. Markers of myocardial remodeling is an affordable way of early cardiovascular risk stratification in overweight and obese young women.
257 Mobile Computing Devices for Laparoscopic Training Education. Comparative Millennial and Z Generation Experience , José Luis Mosso Vázquez, Paula Loyola Nieto, Eduardo Brenner Muslera and Renata Moreno Cordero
Purpose: To conduct a comparative analysis of the incidence rate and period of gastric and esophageal varices bleeding recurrence associated with extrahepatic portal hypertension after different interventions. Materials and Methods: The study included 131 patients with various forms of extrahepatic portal hypertension; who underwent operative therapy of extrahepatic portal hypertension in the Republican Specialized Scientific and Practical Medical Center of Surgery named after academic V. Vakhidov (RSSPMCS) for the period from 2006 to 2020. Most patients were adolescents (41.2%) and young age (45.0%). Total gastroesophageal basin disconnection was performed in 57 (43.5%) patients, portosystemic shunting - in 51 (38.9%) patients, and endoscopic interventions - in 23 (17.6%).  Results: The comparative incidence rate of bleeding recurrence showed that the most effective intervention is portosystemic shunting. Significantly low efficiency is observed after endoscopic interventions, in which the incidence of hemorrhagic syndrome is 65.2% on average after 13.5 ± 2.9 months. While after a total disconnection of the gastroesophageal collector, a relapse-free course was noted in 35.1% (p = 0.014) of cases lasting 25.9 ± 4.4 months (p < 0.05), which in terms of timing did not differ significantly from relapses after portosystemic shunting - 41.4 ± 8.2 months, but significantly lower in the occurrence of variceal bleeding during decompression operations - 17.6% (p < 0.001).  Conclusion: The most effective surgical intervention is portosystemic shunting with a bleeding recurrence freedom rate in 82.4% (p = 0.014) of patients. The most long-term recurrence period is within 41.4 months (p < 0.05), and with a 5-year persistent remission in 75.0% of patients. After disconnection operations, bleeding recurrence was noted in 35.1% of patients; the recurrence period averaged 19.6 months.
258 Clinical Case of Severe Bilateral Associated Pneumonia with Sars-Cov-2 Viral Infection , Boryshevska-Lohin Olena A, Ahii Vladyslava I, Peresta Yurii Yu, Akar Stanislav Y, Lohoida Olha L and Hanbarov Nikita P
Coronavirus infection spreads rapidly and is transmitted from person to person by airborne and contact-household means. A positive PCR test for Sars-Cov-2 is required for a definitive diagnosis. However, MSCT is a sensitive and specific method of diagnosing coronavirus lung disease as the most common manifestation of infection. In addition, in patients at high risk for Covid-19, signs of viral pneumonia in pulmonary MSCT may precede negative PCR results. on their own experience and observations in the diagnosis of severe respiratory syndrome Sars-Cov-2 draw attention to the need to perform MSCT of the chest in patients at high risk and clinical manifestations of Covid-19 associated pneumonia, despite the initial negative results of PCR tests.
259 Clinico-Pathological Characteristics of Colorectal Cancer among Young Subjects Aged 30 and Under in Tropical Areas: Retrospective Comparative Study Over Ten Years of Clinical Practice in Cameroon , Ankouane Andoulo, Kowo Mathurin, Atenguena Obalemba Etienne, Ndjitoyap Ndam Antonin William, Bekolo Winnie, Dontsi Donrielle, Eloumou Bagnaka Servais Fiacre
Introduction: In sub-Saharan Africa, colorectal cancer (CRC) affects nearly 39.2% of young people aged 20-45 years. Epidemiological data are scarce. The aim was to describe the clinico-pathological characteristics of CRC in young subjects aged 30 years and under. Patients and Methods: Retrospective study, conducted from January 1 to May 15, 2020, on a collection of data from the records of patients who were under patient care for histologically confirmed CRC in the hepato-gastroenterology, digestive surgery and medical oncology departments of ten hospitals in the cities of Yaounde and Douala-Cameroon, from January 1, 2009 to December 31, 2019. Patients were divided into two groups for comparison: the group comprising subjects aged 30 years and under at the time of diagnosis and the group including subjects aged over 30 years. Results: A total of 153 patients followed for histologically confirmed CRC were included, of which 67 were 30 years old and under (43.8%) and 86 were older than 30 years (56.2%). The average age of those 30 years and under was 25.5 ± 4.2 years (10 - 30 years). Anaemia (65.7% vs. 48.8%; OR: 2.0 [1.0 - 4.1]; p = 0.03), abdominal mass (29.9% vs. 17.4%; OR: 2.0 [0.9 - 4.6]; p = 0.07), and occlusive syndrome (16.4% vs. 7.0%; OR: 2.6 [0.8 - 8.5]; p = 0.06) were more prevalent in the 30 years and under group. The general condition was impaired (WHO stage II to IV) in 92.5% of those 30 years and under (OR: 16.4 [5.6 - 51.7; p < 10-5). Risk factors for CRC were rare in those aged 30 years and under, notably alcoholism (7.5% vs 43.0%; OR: 0.1 [0.0 - 0.3]; p < 10-5) and smoking (3.0% vs 10.5%; OR: 0.3 [0.0 - 1.4]; p = 0.06). The average time from symptom onset to diagnosis was 8.6 ± 4.4 months for those 30 years and under vs. 9.4 ± 5.2 months (p < 10-5). The left colon was the specific site in those 30 years and under (16.4% vs. 4.7%; OR: 4.0 [1.1 - 16.0]; p = 0.03). Ulcerated adenocarcinoma (86.6%) was more frequent in those aged 30 years and under 43.3% vs. 27.9% (OR: 2.0 [1.0 - 4.1]; p = 0.04). Well- and moderately-differentiated forms were unfrequently found in patients aged 30 years and under (19.4% vs. 34.9%; OR: 0.5 [0.2 - 1.0]; p = 0.03 and 11.9% vs. 38.4%; OR: 0.2 [0.0 - 0.5]; p < 10-5, respectively). TNM stage II was the most common in both groups. Liver and lung metastases were found approximately equally in both groups. Conclusion: CRC in young subjects aged 30 years and under is very common in the tropical areas. Some well-known risk factors do not appear too involved. The alteration of the general state seems to be present at the time of diagnosis. Anaemia, abdominal mass and occlusive syndrome are quite common. The left colon is involved in more than 80% of cases. The adenocarcinoma is ulcerated and of variable differentiation.
260 Lavender (Lavandula latifolia) Explicits High Efficiency in Old Aged Chronic Piles Patient , Bihari L Gupta
Lavender (Lavender latifolia) was given to a dying 86 years old woman who had been suffering from piles for the last 45 years with an emerged fistula of more than 6 inches which used to bleed daily. She stopped taking drugs prescribed by physician as they were not performing effects due to resistance to drugs. In such a situation the patient was feeling severe pain in stomach and more bleeding in stools. The alternative treatment was performed by an oral intake of 5 drops of lavender in 5 ml of water three times a day along with a teaspoonful of each of Diegene, Liv-52 (Himalaya) and multiple vitamins syrup. About 18 gms of proteins in the form of Horlicks was also given to the patient. After 10 days of treatments the patient condition became stable resulting in complete stoppage of blood in the stools and also relieved from the stomach pain. It was also observed the patient recognized every person of the family confirming a best function of gut-brain axis which is disturbed by specific overgrowth of bacteria. In conclusion it may be proved that lavender kills the microbes in the gut, relieves from pain and maintains a good homeostasis between gut and brain. It may be a potential alternative in treating piles even in chronic condition.
261 Pancreatic Ascites in a Cirrhotic Patient, a Case Report , Renata Gizani de Moura Leite, Anna Paula Mendanha da Silva Aureliano, Sara Cardoso Paes Rose, Luana Dantas Barbosa and Liliana Sampaio Costa Mendes
Pancreatic ascites (PA) is a rare cause of ascites and usually appears as consequence of chronic pancreatitis. It results from an excess of exudative intraperitoneal fluid, rich in amylase and proteins, commonly originated from a pseudocyst or pancreatic duct disruption. Patients typically present mild abdominal pain, hyporexia, and sense of fullness. The diagnosis is characterized by high levels of amylase (above 1000 U/L), proteins (above 3 g/dl) and low serum ascites albumin gradient - SAAG (< 1.1 g/dl) at the ascitic fluid. The objective of this study is to report a case of a cirrhotic patient with the diagnosis of pancreatic ascites and discuss it laboratory and imaging findings, as well the main causes and treatments for this case. PA is a rare entity and either more, when occur in a cirrhotic patient. The management of cirrhotic ascites is different when there is PA. The clinicians should be aware of this possibility.
262 To What Extent is Human Behavior Genetically Determined? , Hemshankar Laugi
Research has revealed that almost every human body cells possess the same DNA sequence. Despite this fact, these cells get specialized to perform different functions. Some cells become cardiac cells and others nerve cells, carrying out their distinct functions. This is because the environment affects gene expression [1]. Let’s suppose the twins reside in a different environment. They prepare a same dish. However, they taste it differently depending on the tastiness of individual appetizers, desserts and casseroles, which may be similar. Likewise, only genes can’t determine physical traits like height, blood pressure, etc. The combined interaction of multiple related genes with environment is supposed to determine a particular trait.
263 Should Everyone Eat Gluten-Free? What does the Scientific Data Say? , Emel Öktem Güngör and Sevan Çetin Özbek
oday, changing the dietary habits of the individual to a gluten-free diet during the treatment process of Celiac disease (CD), wheat allergy (WA), non-celiac gluten sensitivity (NCGS), irritable bowel syndrome, autism, and neurological, psychiatric, and rheumatological diseases reduces the symptoms of the diseases. On the other hand, the gluten-free diet is presented as a healthy choice by the popular media. This has led to an increase in gluten-free food alternatives in the market. A long-term gluten-free diet in healthy individuals is associated with problems, such as uncontrolled weight gain, diabetes, and vitamin and mineral deficiencies. This review aims to question the effects of a gluten-free diet on health in healthy individuals. While the beneficial effects of gluten in the treatment of some diseases are supported by the literature, there is not enough evidence to support the positive effects of a gluten-free diet in healthy individuals in line with the relevant objective. Raising awareness of the community about the potential risks of adopting a gluten-free diet in individuals who do not have a gluten-related disease is possible through education emphasizing healthy and sustainable nutrition.
264 Surgical Haemorrhoidectomy is Still the Gold Standard Treatment for Prolapsing Hemorrhoids , Omar S Mansour
There has been a recent surge in upper and lower gastrointestinal diseases in the last two years, probably secondary to COVID-19 infection and the recent tight social restrictions. Many of these diseases are limited to the anorectal area, specifically anal pain and bleeding secondary to anal fissures and haemorrhoids [1]. Haemorrhoidal disease can be treated conservatively in most cases. Complicated haemorrhoids can present with either prolapse, bleeding or with varying degrees of incontinence. Bleeding haemorrhoids can be treated with ligation or banding of haemorrhoids and ligation of the feeding haemorrhoidal arteries. This relatively new and moderately effective technique does not fully remove the causing pathology, the haemorrhoids. Drs. Milligan and Morgan developed the open hemorrhoidectomy technique in the UK in 1937. This surgical procedure was invented mostly for second, third- and fourth-degree hemorrhoids. The most common postoperative complication in the postsurgical-hemorrhoidectomy patients is severe throbbing pain. Closed hemorrhoidectomy was developed in the United States by Drs. Ferguson and Heaton in 1952 as a modification of the Milligan-Morgan procedure. The closed technique is similar to the open technique but the wounds are closed with absorbable sutures. A recent meta-analysis showed that the closed technique (Ferguson’s) is superior to the open hemorrhoidectomy operation (Milligan-Morgan) in terms of reducing post-operative complications like bleeding, severe pain. The Ferguson’s technique was also proven to be associated with faster wound healing [2].
265 Inflammatory Bowel Disease in the Elderly in the Context of COVID-19. What do we know so? , Carlos Henrique Rodrigues Castro, Caroline Rodrigues Castro, Jackson Santos dos Reis, Ewerton Naves Dias, Claudio Roberto Tavares Pereira, Camila Neto da Silveira and Luiz Ronaldo Alberti
Over the last few decades, several authors have demonstrated the relationship of the interaction of the immune system in a pathway called the “gut-brain axis,” with implications both for the local immune response and for the systemic modulation of inflammatory mediators. The hypothesis that the underlying inflammatory disease contributes to the pathogenesis of SARS-CoV-2, and consequently patients with inflammatory bowel disease (IBD) may theoretically be at increased risk of infection and mortality, is still controversial. With the increase in the diagnosis of IBD in patients over 60 years of age, the increased concern in the context of the SARS-CoV-2 pandemic was evident, as elderly patients have comorbidities that could raise the risk of worsening the progression of the infection and unfavorable clinical outcomes. Thus, a survey of the literature to date was carried out to understand the implications of IBD in the context of the SARS-CoV-2 pandemic.
266 Vanishing Bile Duct Syndrome due to Valproic Acid: A Rare Case , Jean Rodrigo Tafarel, Isabela Busto Silva, Isadora Busto Silva, Luiz Augusto Fanhani Cracco, Vanessa Martins Torres and Larissa Uhlmann Wendling
Vanishing bile duct syndrome (VBDS) is a rare acquired condition, described by the progressive loss of intrahepatic bile ducts, leading to ductopenia and cholestasis. It can be associated with adverse drug reactions, cancer, and autoimmune liver diseases. The diagnosis is confirmed when there are less than 50% of the bile ducts on histopathological analysis. The prognosis is variable and it is depends on the etiology of the bile duct injury. We report a case of a 47-year-old man with chronic cholestatic condition associated with the use of valproic acid, in which the investigation confirmed VBDS in the histopathological analysis.
267 Misdiagnosis of Intestinal Tuberculosis as Crohn’s Disease: A Case Report and Literature Review of Parametric Predictive Models , Moussaoui Safa, M Zakhama, M Moussaoui, A Guediche, I Jemni, N Ben Chaabène and L Safer
In recent years, the incidence of Crohn's disease (CD) has been increasing worldwide, especially in areas where tuberculosis (TB) is prevalent. Due to similar manifestations, distinguishing between Crohn’s disease (CD) and intestinal tuberculosis (ITB) is quite challenging.  Herein, we report the case of a 25-year-old man who presented with recurrent partial bowel obstruction, whose initial diagnostic work-up suggested stenosing Crohn disease 3 years ago. He had been previously treated with mesalazine and corticosteroids. After undergoing surgical treatment, histopathological findings revealed the diagnoses of intestinal tuberculosis instead.  We combined our case report with parametric predictive models reviewed in the literature to evaluate their diagnostic accuracy for our case. We found that using these models could lead to a better differentiation between these two entities.
268 Pembrolizumab in the Treatment of Metastatic Gastric Cancer , Rakhimov R Radmir, AA Izmailov, ON Lipatov, AV Sultanbaev, KV Menshikov, AF Nasretdinov and VA Surovyatkin
The incidence of stomach cancer has been declining over the past decade, but unfortunately it is still the fifth most common disease with the third death rate among cancers. Diagnosis of stomach cancer usually occurs at the stage of neglect and incurability (stages III - IV), in the early stages (I - II stages) clear symptoms do not appear. 25% of patients have advanced gastric cancer, the other 25 - 50% progress to metastatic gastric cancer. The prognosis is especially poor for patients who have not responded to 1 line of chemotherapy. In the United States in 2012, 54.5% of patients received second and third lines. Five-year survival rate is 30% among all stages. In recent years, new drugs have emerged in the treatment of stomach cancer that needs to be studied. Pembrolizumab demonstrated efficacy in PD-L1-positive advanced gastric/gastroesophageal junction cancer in the first-, second-, and third-line setting in KEYNOTE-062, KEYNOTE-061, and KEYNOTE-059, respectively.   In KEYNOTE-062, median follow-up was 11 months, median OS (pembrolizumab vs. chemotherapy) was 17 months versus 11 months (HR, 0.69; 95% CI, 0.49-0.97), median PFS was 3 months versus 6 months (HR, 1.09, 95% CI; 0.79-1.49), ORR was 25% versus 38%, and median (range) DOR was 19 months (1+ to 34+) versus 7 months (2+ to 30+).
269 Acute Pancreatitis: Review Article , Jesús Velázquez Gutiérrez and Morella Vargas Useche
Acute pancreatitis (AP) is defined as an acute inflammatory process of the pancreas which can compromise other organs and tissues. The diagnosis requires at least 2 of the following characteristics: moderate to severe abdominal pain, accompanied by nausea and vomiting; biochemical evidence of pancreatitis and/or imaging evidence through dynamic computed tomography (DCT) and/or magnetic resonance imaging (MRI) of the pancreas. It is the most common acute gastrointestinal disease that requires hospital admission, with a favorable evolution in most cases (80%). However, necrotizing pancreatitis can develop in up to 20% of patients and is associated with significant rates of early organ failure (38%). Metabolic disorders and fasting compromise the nutritional status which could aggravate the course of the disease, therefore the route of administration of nutritional therapy has been shown to have an impact on the evolution of patients. There is now a better definition of which AP patients need aggressive nutritional therapy.
270 Use of Plasmapheresis: Acute Pancreatitis Due to Hypertriglyceridemia: Case Report , Danny Fernado Silva Cevallos, Diana Evangelista Barragan, Mirella Barrera Rivera, Casar Arreaga Perez, Angelica Zarate Zapata and Fernando Silva Michalon
Hypertriglyceridemic pancreatitis (PATG) is described as an uncommon cause with an incidence that ranges from 2 to 4% of cases, generates significant morbidity and mortality between 40 per 100,000 inhabitants in a western population [1,2]. There are several pathophysiological mechanisms that explain the appearance of pancreatitis caused by hypertriglyceridemia, one of them is the direct toxic role of free fatty acids on pancreatic tissue and another widely accepted mechanism is chylomicron-mediated vascular obstruction, given the decrease in the gene expression of lipoprotein lipase (LPL) [3]. The American Society for Apheresis (ASFA) indicates the use of plamapheresis when there is severe pancreatitis, when triglyceride levels exceed more than 2000 mg/dl and when there is no satisfactory response to first-line treatment; the success of the treatment is based on a decrease in triglycerides below 500 mg/dl to achieve the goal of using plasmapheresis [4]. In this case, it was demonstrated that the timely assessment of the patient was essential to make treatment decisions in the appropriate time with a favorable response to it.
271 Clinical Case of a 14-Year-Old Boy with Abdominal Stem-Shaped Twisted Necrotizing Vascular Malformation , Yu Yu Sokolov, SV Stonogin, EE Bibikova, EA Tashirova and Zh R Omarova
Lymphatic malformations (LM) are benign neoplasms that form as a result of impaired formation of embryonic lymphatic sacs during embryogenesis. A 14-year-old boy was admitted to the department of infectious diseases with complaints of fever, weakness, abdominal pain, sore throat and loose stools. Previously, the patient had complaints of abdominal pain for a year; ultrasound examination of the abdominal cavity was performed repeatedly, in which no pathological changes were detected. The patient underwent laparoscopic appendectomy; During the revision of the abdominal cavity, a space-occupying lesion emerging from the mesentery of the ascending colon and twisted around the vascular pedicle by 3 turns was revealed. Education removed. Histological and immunohistochemical examination confirmed the diagnosis of lymphatic-venous malformation.
272 uncomPreliminary Evaluation of Possibilities for Determination of Optical Density of Venous Blood Plasma for Diagnosis in Emergency Abdominal Surgery , Andrii I Shurma, Fedir V Grynchuk and Artem V Motric
Background/Aims: The basis of laboratory diagnosis in emergency abdominal surgery is to determine the number of leukocytes and their forms, the content of C-reactive protein. But the results of such studies are nonspecific. With unclear clinical symptoms, this creates the preconditions for diagnostic errors. Therefore, the search for new diagnostic tools that would allow for a quick, accurate assessment remains relevant. Therefore, the aim of the study was to pre-evaluate the diagnostic possibilities of determining the optical density of venous blood plasma in the infrared range for emergency abdominal surgery. Methods: 42 patients were examined. Among them were: liver abscess - 4 cases, acute phlegmonous appendicitis with periappendicular abscess - 4, acute phlegmonous appendicitis with diffuse peritonitis - 5, acute phlegmonous appendicitis without complications - 8, acute phlegmonous cholecystitis without complications - 5, perforation of gastroduodenal ulcer with diffuse peritonitis - 5, acute adhesive intestinal obstruction without complications - 4, acute catarrhal appendicitis without complications - 3, acute catarrhal cholecystitis without complications - 4 cases. At patients on admission to hospital venous blood from an ulnar vein was collected. Measured the optical density of venous blood plasma on a spectrophotometer SF-4A in the wavelength range l = 2.0 - 20.0 μm. The measurement results were compared with the results of the removed organs histological examination. The control group consisted of 11 patients who had no destructive changes in organs and complications: 4 patients with adhesive intestinal obstruction, 3 patients with acute catarrhal appendicitis, 4 patients with acute catarrhal cholecystitis without complications. Results: We found in the infrared spectrum a number of maxima of the values of the blood plasma optical density, which are localized at wavelengths l = 3.1, 3.5, 4.3, 6.1, 6.7, 9 and 17.5 μm. Indicators of optical density at these wavelengths differed in different diseases and complications. For analysis and comparison, patients were also divided into groups: with abscesses, with diffuse peritonitis, with phlegmonous changes of organs without complications (appendicitis, cholecystitis) and control (no organ destruction). In this comparison, it was found (Figure) that at wavelengths l = 3.1, 6.1, 6.7, 9 and 17.5 μm, the optical density indices differ with specific regularities. In particular, each time in patients from the control group the parameters were statistically significantly (p < 0.05) lower than in patients with inflammatory-destructive pathology. In addition, the indicators differ in patients with diffuse peritonitis, abscesses and uncomplicated phlegmonous appendicitis and cholecystitis. Conclusion: 1. Patients with acute surgery have specific maxima of optical density of venous blood plasma in the infrared region at wavelengths l = 3.1, 3.5, 4.3, 6.1, 6.7, 9 and 17.5 μm. 2. Indicators of optical density of blood plasma at wavelengths l = 3.1, 6.1. 6.7, 9, 17.5 microns differ, depending on features of the main disease and complications and have the general laws at perforation of hollow bodies, abscesses, diffuse peritonitis, phlegmonous changes of bodies without complications. 3. The study of optical density is a promising area for improving the diagnosis in emergency abdominal surgery.
273 Surgery and Sickle Cell Disease , Alexander Forero-Torres, Francisco Reinoso Lozano, Fuad López Fernández and Santiago Valderrabano González
Sickle cell anemia is considered the most common inherited red blood cell disorder. Patients with SCD present a very particular physiological response to surgical and anesthetic stress, and due to the chronic clinical manifestations, they are a perioperative challenge. Since neonatal screening campaigns and prevention and treatment of this disease crises have been carried out, these patients have increased their survival, reaching adulthood and manifesting chronic organic dysfunctions that may require surgical treatment [1]. Surgery in patients with SCD raises an unique challenges due to the chronic manifestations of their disease and especially their physiological response to surgical stress and anesthesia. The perioperative management of the patient with SCD is of vital importance to minimize the appearance of complications associated with surgical interventions, and it is essential to create multidisciplinary teams that offer adequate perioperative management of these patients.
274 Synovial Sarcoma of the Liver - A Case Report , Geethanjali Sundaram, Rajkumar Ramasamy, Venkatesh Kasi Arunachalam, Sangita Sharma Mehta and Sriman Rajasekaran
Synovial sarcoma is an uncommon malignant mesenchymal neoplasm that usually occurs in extremities. Rarely have they been reported in the head and neck, pericardium, lungs, liver, and retroperitoneum. The term synovial sarcoma is a misnomer because the tumor doesn’t arise from synovial tissue. It was once believed to recapitulate synovium, but the cell of origin is still unclear. We report a case of synovial sarcoma of the liver in a 55-year-old male, presented to our hospital with a history of abdominal discomfort and weight loss.
275 The Role of SPECT/CT in the Detection of Meckel’s Diverticulum , FJ Nasirova
Meckel´s diverticulum is considered a true because contain of all layers of the intestinal wall. Тhere is a "rule of two". Meckel's diverticulum most often seen at 2 years of age and 2 times more common in males, is present in 2% of the population, often contains 2 ectopic tissues (gastric and pancreatic), is 2 inches long, is situated 2 feet from the ileocecal valve. The main clinical signs of Meckel’s diverticulum are: melena, pain in the right lower quadrant of the abdomen, volvulus, intestinal obstruction. Surgery removal of diverticulum is recommended for bleeding develops. We reported the case of 20 children who had melena, the management was a scanning with Technetium99m - pertechnetate in the detection of Meckel´s diverticulum.
276 Practical Use of Oral Rehydration Solutions and their Implementation in ERAS Protocols (Literature Review) , Bihniak PI, Gomon ML and Krenov K Yu
Introduction: Volemic therapy has been paid much attention in the ERAS program, in particular the use of fluids before surgery has been liberalized, the effectiveness of chewing gum has been proved, the early removal of drains and probes has been recommended (which facilitates the intake of fluids and food through the mouth in the postoperative period). The most common electrolyte disorders in the postoperative period is sodium and fluid retention (due to the fact that the operative stress stimulates secretion of antidiuretic hormone), hypokalemia (exchange for hydrogen ions during acidosis compensation, insufficient admission, "invisible losses" in hemolysis, polyuria, diabetes insipidus syndrome, for instance in neurosurgery or sub-compensation of existing diabetes mellitus. The aim of the study was to reveal the influence of preoperative rehydration therapy on patients' functional indicators in early postoperative period. Methods: 73 elective patients of the surgical department of Starokostiantyniv Central District Hospital were examined. The first group consisted of patients receiving "traditional" preoperative preparation (control group) n = 33. Patients of the second group received IONICA oral rehydration mixture as a preoperative preparation in the amount of 20 ml/kg the day before surgery, n = 40. Results: The first group (n = 33) consisted of patients with “traditional” preoperative preparation, the average age of patients was 43.2 ± 18.3, the second group consisted of patients with preoperative preparation, which included the ORM (oral rehydration mixture) IONICA (n = 40), the average age of patients was 46.3 ± 11.4. Functional and laboratory indicators were defined before surgery and in 24 hours, and the day of peristalsis recovery was also determined. There was no significant difference between the studied indicators on the first day; the only exception was the glucose level, which was significantly lower in the ORM group in 24 hours compared to the “standard” therapy group. Besides, despite the absence of significant differences in the peristalsis recovery in the control group, it occurred on 2.9 ± 0.7, compared with the ORM group: 2.7 ± 0.6 day. Conclusion: ORT is a simple, affordable and effective method to correct hydro-electrolyte balance disorders in elective surgical patients.
277 The Effectiveness of Primary Syndromic Diagnosis in Diseases of the Upper Gastrointestinal Tract Using the Information System “Electronic Polyclinic” in Comparison with the Validated Questionnaire GSRS , Katkova Anastasiya Veniaminovna and Mishlanov Vitaly Yuryevich
The aim of the study was to compare the results of primary syndromic diagnosis of diseases of the upper gastrointestinal tract using the gastroenterological module of the computer program "Electronic polyclinic" and the validated questionnaire GSRS. The material of the study was 20 patients with non-neoplastic diseases of the upper gastrointestinal tract and the control group consisted of 20 persons who were recognized as healthy according to the results of the medical examination of certain groups of the adult population on the basis of the Ministry of Health's order of the Russian Federation dated October 26, 2017 No. 869 n. All respondents were interviewed using 2 questionnaires: GSRS and the gastroenterological module of the interactive system "Electronic Polyclinic". Statistical analysis of the results was performed using the software package Statistica 10.0. Despite the slightly greater sensitivity of some symptoms of diseases of the upper gastrointestinal tract, obtained during an interactive examination using the computer program "Electronic polyclinic" than when using the GSRS questionnaire, the accuracy of their assessment was low (30 - 55%). Due to the syndromic principle, the accuracy of the diagnostic process has increased, to a greater extent when using the automated system "Electronic Polyclinic": the sensitivity of the method was 80% and the specificity - 90%; when using the GSRS questionnaire, the operating characteristics were 65% and 75%, respectively. According to the results obtained, a conclusion was made about a higher effectiveness of primary syndromic diagnosis when using the gastroenterological module of the computer program "Electronic Polyclinic" in comparison with the use of the GSRS questionnaire due to an increase in the number of detailed symptom-questions in the interactive questionnaire, up to 15 within one syndrome, taking into account the coefficients of significance every symptom.