1 Radiological Focal Enteritis as a Presentation of Accidental Fishbone Ingestion , Mira Damounya1, Safi Khuri1,2*
Accidental Foreign body ingestion is not an uncommon medical problem. Of all foreign bodies ingested, Fishbones are the most common, yet most pass the alimentary tract unnoticed. Gastrointestinal complications, such as hollow viscus perforation may develop in less than 1% of cases. Diagnosis is usually challenging and depends on a combination of detailed history and physical examination, along with radiological findings. Two cases of non-radio-opaque fishbone ingestion with localized small bowel perforation presented radiologically as focal enteritis are reported here.
2 Dimensions of Reproducible Malignant Transformation as Brain Infiltration by Glioma , Lawrence M Agius1*
Frameworks of operability and dysregulation are paramount considerations in the evolutionary history of a malignant glioma in particular as further emphasized by the embryonic nature of characterization of the cells of origin of a given neoplasm. It is in terms of evolving constitution that the infiltrated surrounding brain tissue of a malignant glioma recapitulates the derivative nature of oncogenesis with its multi-varied dimensions of spread into the surrounding tissues as support and inducing influence in oncogenesis. Radio-nuclides are parametric models that attempt directing suppression primarily of such infiltrative margins of malignant gliomas, as well exemplified by models of generation and duplication of the malignant transformation process from the initial stage of conception to the culmination as infiltrative margins of a given malignant glioma. The main aim in this review is to clarify to some extent the involvement of infiltrative phenomena on the part of malignant gliomas and also of malignant neoplasms as a whole in the essential lesion progression. The dynamics of progression are direct derivative processes that impact also the growth and further infiltration of “normal” brain tissue or stroma. Indeed, the infiltrative phenomenon is a principal mechanism in the further progression of glioma genesis per se.
3 Isolated Type Immunoglobulin G4 Sclerosing Cholangitis: The Misdiagnosed Cholangiocarcinoma , Safi Khuri
Over the last two decades, Immunoglobulin G4 (IgG4) related disease (IgG4-RD), also known as IgG4 related sclerosing disease or IgG4 associated disease has become a well-known medical problem, with increasing incidence. IgG4-RD is defined as a systemic disease characterized by inflammation and fibrosis of the affected tissues [1,2]. Inflammation usually occurs during the early phase of the disease, whereas fibrosis develops later when diagnosis is delayed. Although it is well known as an immune mediated disease, and there is a growing evidence that the disease is an autoimmune in nature, the precise pathogenesis is yet to be known. It usually results in pseudo tumorous swelling of the affected organs, along with high levels of serum IgG 4 plasma cells [3,4]. The affected tissues usually share similar pathological features, with dense lyphoplasmacytic infiltrate rich in IgG4-positive plasma cells being the hallmark findings [2]. IgG4-Slerosing Cholangitis (IgG4-SC), also known as IgG4 associated cholangitis, is the biliary system manifestation of the IgG4-RD. IgG4-SC is known as a recent type of sclerosing cholangitis that differs from primary sclerosing cholangitis [5]. Previously, cholangitis was classified into two types: primary, which is usually idiopathic, and secondary, which could be due to bile duct stones, cholangiocarcinoma, congenital biliary disorders or postoperative bile duct injury [6]. Nowadays, three types are identified with the emergent of the IgG4-SC type, the most common type, as the third one. IgG4 SC is usually associated with type 1 autoimmune pancreatitis (AIP-1) (the proto type of IgG4 RD) in more than 90% of cases. Due to this close association, they are sometimes collectively called sclerosing pancreatocholangitis. IgG4 SC may present in different manners; either as tumorous mass due to segmental bile duct involvement, which should be differentiated from extra-hepatic cholangiocarcinoma, or as a diffuse sclerosing process mimicking primary sclerosing cholangitis [7,8]. Diagnosis of isolated type IgG4 SC is very challenging, and usually misdiagnosed as cholangiocarcinoma, especially IgG4-SC types 1, 3 and 4. Due to differences in biological behaviors, treatment options and survival, it is of immense important to differentiate between these diseases.
4 Cross-Cultural Adaptation and Measurement Properties of the Arabic Version of the Modified Cinccinati Knee Rating System? (MCKRS) , Khaja AF1*, Al-Samhan A1, Hussain AA1, Al-Awadh M1, Mandani OW1, Hanna SS1
Objectives: The Modified Cincinnati Knee Rating System (mCKRS) was designed as an outcome measure to help clinicians gather information about the clinical and functional outcomes of patients after knee surgery. It applies to various knee conditions. Design: Our goal was the translation of the mCKRS to the Arabic language followed by the investigation of its psychometric properties as well as test of its floor/ceiling effects, validity, reliability, and internal consistency. Method: Fifty-seven patients participated in two occasions at the baseline and the follow-up after 2 weeks. We tested for internal consistency with Cronbach’s α. We calculated Spearman’s correlation as a means of estimating construct validity in comparison to the Arabic Knee injury and Osteoarthritis Outcome Score (KOOS). Also, the responsiveness of the mCKRS questionnaire was measured by calculating the standardized response mean (SRM). Results: Overall, the Arabic mCKRS at the baseline had a Cronbach’s α of 0.792, and 0.820 at the follow-up, which was very high and internally consistent. Intra Class correlations (ICC) indicated that the mCKRS questionnaire is reliably reproducible, while Standardized Response Mean (SRM) of the questionnaire with 1.30. This illustrates a high degree of sensitivity regarding the change. Also, we observed a strong correlation with Arabic KOOS (r = 0.760, p < 0.001), indicating that the construct validity was good. Also, all the subscales, except swelling, proved to have a high correlation with Arabic KOOS (r > 0.70). We did not observe any major floor and ceiling effect among all responses. Conclusion: From the results of the study, we can confidently say that the Arabic version of the mCKRS is reliable for diagnosis of knee injuries and produces results similar to those of the original English version.
5 Editor's Note: Journal of Surgery Research and Practice , Dr. Safi Khuri, M.D. Editor-in-Chief
Dear Readers and Authors, It is my pleasure to introduce you to the new and exciting Journal of Surgery Research and Practice. The journal encourages established, but mainly young authors to consider submitting their latest articles, especially surgical papers that may be considered for publication. A variety of surgical issues are covered by the journal, including General Surgery, Surgical Oncology, Vascular Surgery, Cardiac Surgery, Thoracic Surgery, Plastic Surgery, Orthopaedic surgery, Trauma and Acute Care Surgery, and other types of surgical topics. The journal has fully entered the electronic era for submission and access, and it has successfully published its first issue in the year 2020. The editorial board team consists of leading researchers, who have made significant contributions to highly acclaimed studies and papers. Together we will strive to transform the Journal of Surgery Research and Practice into one of the leading journals in the field of surgery. I am honored to take on the role of Editor-in-Chief of this developing and ground breaking journal. It is our priority as editors, to expediently reply with feedback and decisions regarding the papers submitted to us by our potential authors. This paper deals with many topics and covers a wide range of interests on the surgical spectrum. I have always enjoyed delving into journals with diverse areas that keep the average surgeon on the edge of their seat, as opposed to single-specialty journals. I hope you enjoy exploring the innovative nature of the papers that will compose our journal each couple of months as much as I will enjoy editing them. Yours Truly, Dr. Safi Khuri, M.D. Editor-in-Chief
6 Socialization and Social Work as a Facilitator for Surgery Practice: A Sociological Link , Mohammad Taghi Sheykhi1*
Sociology as a science studying and investigating different matters from various perspectives. It looks at surgery practice highly followed and accompanied by in favor of the elderly people from the age of 65 and over. Social work as a necessity for all age groups, especially the elderly, bridges between the potential clients and patients to the medical and surgical resources. Many clients do not much know their health needs and conditions. Social work practice diagnoses the public health conditions of clients; referring them to medical centers for further diagnosis and practice. However, social work practice practice has contributed to longer life expectancy for the elder people, and the result of which is the existence of 29% people of 65 years and older in Japan. Many other European countries with advanced social work systems, have brought about high%age of their older people, simply through medications and surgical practices in case necessary. Therefore, countries must mind it to invest more on social work to pave the way towards surgery practice and other improvements in health conditions. Surgery practice is at all levels, and for all people regardless of social class, gender, religion, race etc. As all the means are available, and medical facilities have advanced, medical referrals are increasing day by day. To achieve it well and in a satisfactory way, it needs to be in parallel with social work. Practice of social work eventually leads to normal life.
7 Chronic Sigmoid Volvulus Necessitating Pelvic Colectomy: A Case Report and Review of the Literature , Aliyu S1, Ningi AB2*
The Viennese Pathologist, Von Rokitansky, first reported the volvulus of the colon in 1896. Volvulus of the colon is said to occur when a bowel loop and its mesentery twist on a fixed point at its base. It occurs at segments of the colon where a large segment is mobile and is supported by a mesentery with a narrow base at fixation. This anatomical placement allows for axial rotation. Although, colonic volvulus usually occurs in the sigmoid or cecum, it may happen at any segment of colon. Synchronous volvulus of the sigmoid and cecum, or sigmoid and ileum may occur. Recurrent episodes of abdominal distension, constipation and abdominal pain are the most striking symptoms (the so-called sigmoid volvulus triad). The pain is generally a mild colicky type. Symptoms usually resolve with passage of flatus, rather than faeces, or following a diagnostic barium enema. Recurrent sigmoid colon volvulus is a common phenomenon, rather than a rarity and open surgical intervention is the norm in Africa, rather than endoscopic detortion. The twisted sigmoid colon in Africans is thickened, hypertrophied, with a long and thickened mesocolon and dilated mesenteric vessels. Pelvic colectomy is preferred in patients from rural areas because, they are easily lost to follow up, only to present with a gangrenous or compound volvulus; significantly increasing surgery related morbidity and mortality. No sufficient data has been found on systematic review of papers from Nigeria highlighting the paradigm shift for surgical resection over non operative procedures. The aim of this review is to investigate the extent of recurrent sigmoid colon volvulus and the role of surgical resection of sigmoid colon in African patients.
8 Challenging Pancreato-enteric Anastomosis during Whipple Procedure: How to Overcome this Problem? , Kenan Hallon1*, Subhi Mansour1, Ameer Farah1, Safi Khuri1,2
Among the complications following Pancreato-Duodenectomy (PD), Post-Operative Pancreatic Fistula (POPF) is the most common complication. Different techniques and adjuncts for safer anastomosis were suggested, mainly for small caliber main pancreatic duct, none can completely eliminate the risk of leakage. Recently, we have introduced a new technique, using a Seldinger approach for small caliber main pancreatic duct. Since then, we have used this maneuver several times with encouraging results.
9 Inherent Brain Problems , Andrew Hague1*
Humans were formed when their brains changed. They gained technical skills and lost communication skills. The result was violence far in excess of all other creatures and damage has been inflicted on everything from our planet to ourselves. At last, mass communication by technology may compensate for inherent inadequacy if we learn to manage ourselves.
10 Increasing Elderly People in Need of Surgery Practice: A Sociological Appraisal , Mohammad Taghi Sheykhi1*
World population is in a transition in recent decades leading to aging people of both genders, but more of women. More elderly people worldwide much owes to the development of science and technology, research in medical field, development of surgical practice, development of the auxiliary science of social work especially in developed countries. Many factors in an integrated manner have contributed to more longevity and higher life expectancy. Sociology as a science of appraises the new phenomenon of the elderly and the factors responsible in this regard. In developed countries where social work intervenes, and gives warnings to the aging people, guide those in need, to clinics and hospitals, it is a great job to the elderly people. People at the age of 60 and over, are usually worn out needing hospitalization and surgeries. In the developed world, it easily happens so, and the surgery practice usually extends life span and further longevity. That is why in countries like Japan, life expectancy for women extended to 87 years for females in 2020 [1]. On the other hand, in many parts of the developing world where hospital facilities are poor, the elderly people are not insured and there is not enough social work facilities in practice, the elderly patients cannot easily receive the medications needed. That is why they do not have long lives as the industrial countries have. Yet, as the new generations of aging people being educated with higher expectations, they expect more medical facilities, better food, better housing, more income and so on. Under such atmosphere, governments must plan for higher standards of such facilities.
11 Migration of Mesh through Trans-Rectal Route: An Unusual Complication of Laparoscopic Inguinal Hernia Repair , Avtar Pachauri1*, Harvinder Singh Pahwa1, Awanish Kumar1
Majority of inguinal hernia repairs today, open or laparoscopic, are performed with mesh tension-free repair. The introduction of mesh, though beneficial, poses its own gamut of postoperative problems; mesh migration being the most unusual, increases morbidity and financial burden. Only a handful of cases of mesh migration have been reported in literature. Here we report the first case to our knowledge, of mesh migration through rectum developing 2 years postoperatively. The mesh was removed manually and the patient was managed conservatively and discharged. This case highlights the importance of recognising mesh migration as a complication of hernia repair and thus we suggest that all the cases of mesh migration should be reported and further research should be done to find out the cause of this occurrence and thereby taking necessary steps to prevent its incidence.
12 Pandemic as an Ideological Dead End of Modern Medicine , Igor Klepikov1*
For most people on our planet, the beginning of the current COVID-19 pandemic was a complete surprise and looks like a sudden disaster. However, experts do not have the right to argue in this way, since the cause of this disaster has long been known to medicine. Moreover, similar epidemics of this infection have already been observed in the recent past, had a very similar scenario, but with less coverage of the population and territories. The identity of the causative agent of today’s pandemic with the two previous outbreaks, SARS in 2002-2004 and MERS in 2012-2013, is even reflected in the terminology – CoV, CoV-1 and CoV-2 [1]. The above information contradicts the surprise factor in the current pandemic. Medicine has already had experience in combating the spread of coronavirus infection and could provide and develop a set of measures and therapeutic and preventive measures in the event of the return of such phenomena. There was enough time for this, especially since outbreaks of infection were repeated. In addition, in the last couple of decades, there has been an increase in the proportion of viral lesions among patients with Acute Pneumonia (AP) [2]. The annual number of such diseases in the world was estimated at 200 million cases [3]. The latter indicator was 4 times higher than the overall indicator of the current pandemic, but this situation was not accompanied by an epidemiological and social boom, as in the current period. But it should be emphasized that this is not just about quantity. If in previous years the total indicator reflected the number of cases, today this figure shows the number of infected people, many of whom do not develop the disease.
13 Brief Facts about COVID-19 (SARS-CoV-2) , Sorush Niknamian1*
Coronaviruses are a group of related viruses that cause diseases in mammals and birds. In humans, coronaviruses cause respiratory tract infections that can range from mild to lethal. Mild illnesses include some cases of the common cold, while more lethal varieties can cause SARS, MERS and COVID-19. The outbreak was identified in Wuhan, China, in December 2019, declared to be a Public Health Emergency of International Concern on 30th January 2020 and recognized as a pandemic on 11th March 2020. Coronaviruses are the subfamily Orthocoronavirinae, within the family of Coronaviridae, order Nidovirales and realm Riboviria. They are enveloped viruses with a positive-sense single-stranded RNA genome and a nucleocapsid of helical symmetry. The genome size of coronaviruses is approximately from 26 to 32 kilobases. Coronaviruses were first discovered in the 1930s and Human coronaviruses were discovered in the 1960s. The earliest ones studied were from human patients with the common cold, which were later named human coronavirus 229E and human coronavirus OC43. Other human coronaviruses have since been identified, including SARS-CoV in 2003, HCoV NL63 in 2004, HKU1 in 2005, MERS-CoV in 2012 and SARS-CoV-2 in 2019. Most of these have involved serious respiratory tract infections.
14 Failed Substance Profiles of Anti -Tumor Immune Responses , Lawrence M Agius1*
The proportionality of evidential reappraisal of dynamics of turnover allow for a permissiveness within systems of non-reactivity as borne out by the non-participation of an inflammatory milieu within the tumor lesion. As such, the incongruent involvement of whole clones of subse T-lymphocytes allows for the involvement and applicability of a reactive immune response dictated by systems of progressive increment and as further promoted by the participation of individuality of single lymphocytes. It is to be realized that anergic states are an evolutionary series of steps towards a dysfunction of lymphocytes that fail to respond to staged increase of proliferating tumor cells within a non-inflammatory milieu.
15 Surgical Management of an Intercostal Artery False Aneurysm Due to a Stab Wound , Hadhri Saif El Hak1, Ben Jmaà Hèla1*, Gueldich Majdi1, Ben Saida Fatma1, Ziadi Arwa1, Rebei Mohamed1, Dammak Aiman1, Frikha Ime1
Pseudo-aneurysm are due to arterial wall disruption leading to the formation of a perfused sac that communicates with the arterial lumen. This entity remains at highly significant risk of rupture. The majority of cases are presenting as haemothorax. Intercostal artery pseudo-aneurysms are extremely rare, most of them were associated with surgical interventions or blunt thoracic trauma, only one case was reported after a knife stabbing wound. We describe the case of a young male patient who was stabbed with a knife in his posterior left chest side and was first operated to evacuate a contained hematoma only to re-consult after 20 days for a pulsatile mass which proved to be an intercostal artery pseudo-aneurysm. The patient was successfully surgically managed and was discharged 4 days after the surgery.
16 Comparison of Outcomes in Pancreaticogastrostomy versus Pancreaticojejunostomy in Patients Undergoing Pancreaticoduodenectomy , Vimalakar Reddy1*, Mustafa Hussain Razvi1, Bhavya Manosila1, Mohan Narasimha1, Ramesh Ardhanari1
Introduction: The postoperative mortality and morbidity after pancreaticoduodenectomy with pancreaticogastrostomy and pancreaticojejunostomy is controversial. Aim of the study: Primary aim was comparison of Post-Operative Pancreatic Fistula (POPF) rate in PG vs PJ. Secondary aim was mortality rate between PG vs PJ. Method: A retrospective analysis of data of 74 patients who underwent pancreaticoduodenectomy with either pancreaticogastrostomy or pancreaticojejunostomy from June 2012 to June 2014. Statistical analysis done using un-paired ‘t’ test, chi square test, fischer’s exact test appropriately. Result: Out of 74 pancreaticoduodenectomy cases. Pancreaticogastrostomy was done in 44(59.5%) cases and pancreaticojejunostomy done in 30(40.5%) of cases. Among them 20(27.16%) patients developed pancreatic fistula of which 9(12.16%) belonged to pancreaticogastrostomy group and 11 (15%) belonged to pancreaticojejunostomy group (p=0.708). Grade A fistula occurred in 8 (10.8%) patients, grade C fistula in 1(1.35%) patient in the pancreaticogastrostomy compared with grade A fitula in 11(15%) patients in the pancreaticojejunostomy group.Significant post pancreaticoduodenectomy haemorrhage [3 patients(6.8%) (p=0.0001)] and mortality [3 patients(6.8%)] was seen in PG group. No significant difference in median hospital stay was (PG=11.1±2.78 vs PJ= 10.4± 3.1) seen in either group (p=0.305). Conclusion: There was no significant difference in pancreatic fistula rate and hospital stay in either groups. However grade a fistula was more in pancreaticojejunostomy group. Significant mortality was seen in pancreaticogastrostomy group though they were not related to pancreatic fistula.
17 IVF Outcomes of Microdose Flare-up, GnRH Antagonist and Long Protocols in Patients Having a Poor Ovarian Response in the First Treatment Cycle , Hassan Mumtaz1*, Shahzaib Ahmad2, Farrukh Zaman3, Aamir Ghazanfar4
Objectives: To compare the outcome of patients assumed to be poor responders before their first cycle of IVF and treated either microdose flare-up or GnRH antagonist protocols with patients stimulated by long GnRH protocol and had a poor ovarian response with a low yield of the oocyte after their first IVF cycle. Study Design: Retrospective cohort study. Place and Duration of Study: Department of Obstetrics and Gynecology from September 2014 to February 2019. Methodology: Patients treated with the first cycle of IVF and diagnosed as poor responders after ovarian stimulation were evaluated according to the treatment protocol, including microdose flare-up (Group 1: 136 patients), GnRH antagonist (Group 2: 105 patients), and long GnRH agonist (Group 3: 77 patients). Results: Basal FSH level was significantly lower in group 3 compared to other groups (p<0.05). The number of oocytes retrieved, the number of metaphase II oocytes were similar between groups, although the mean AFC was significantly higher in group 3 than in group1 and 2 (p<0.05). Clinical pregnancy rates per patient were higher in group 3 (22.9%) than in group 1 (13.7%) and group 2 (14.4%), but the difference was not statistically significant (p=0.214). The live birth rate per patient was statistically higher in group 3 (21.4%) as compared to other groups (9.7%, 10.3%, respectively; p<0.05). Conclusion: Long protocol may be an option in poor responders undergoing IVF. Ovarian reserve markers are essential factors with stimulation protocol for the success of IVF in poor responder patients.
18 Impact of the COVID-19 Pandemic on Gallstone Disease: Experience at a High-Volume Center , Joaquin Fernandez-Alberti1*, Nicolas Panzardi1, Mariano Bregante2, Rafael Jose Maurette2, Jorge Diego Bogetti2, Daniel Enrique Pirchi3
Background: Diagnostic delay associated to COVID-19 pandemic led patients to present with more advanced conditions than usual. The aim of this study was to analyze Laparoscopic Cholecystectomies (LC) performed for acute gallstone-related disease during the pandemic and to compare them with two control groups. Methods: All LC performed between April and July 2020 (Group 3: G3) were analyzed and compared with LC performed in the same period in 2019 (Group 2: G2) and 2018 (Group 1: G1). Results: In G3 80 LC were performed, of which 36 (45%) were due to acute disease, while in G1 of 192 LC 45 (23.44%) and in G2 of 234 LC 37 (15.81%) were due to acute disease (p <0.01). Time from symptom onset until hospital consultation was longer during the pandemic (G3: 3.8 days vs 2.87 days for G1 and 2.26 days for G2; p <0.05). Mean operative time in minutes was also longer: 78.56 (SD ± 31.6) for G3, 57.69 (SD ± 26.5) for G1 and 63.51 (SD ± 29.4) for G2 (p <0.01). Discussion: We observed a significant delay in hospital consultation due to acute gallstone-associated disease resulting in more advanced cases requiring increased operative time for their resolution.
19 With the Advance in the Techniques of Hemostasis, Is it Necessary to Use Drain Routinely in Thyroid Surgery? A Comparative Study , Husham Salman Abdulkareem1, Zainab Taher Ibrahim2, Muntadher Muhamed Jawad1, Sadq Ghaleb Kadem3*
Prophylactic drainage after thyroid surgery, many surgeons have routinely used it to prevent post thyroidectomy cervical hematoma. With advances in surgical methods of hemostasis, the rate of post thyroidectomy cervical hematoma has decreased significantly to about 0.1%. The aim of this study is to evaluate the outcome of thyroidectomy with drain vs no drain, while we achieved the hemostasis by an Ultrasonic scalpel in all cases. We conducted this study in Al-Shiffa general hospital, Basrah, Iraq, during the period from January 2016 to January 2018. Eighty patients with different thyroid pathologies and candidates for total or near total thyroidectomy have been included; forty patients were undergoing thyroid surgery with drain in the period during 2016. We compared the results with results of a selected similar characteristics group of forty patients that undergo thyroid surgery with no drain in the period during 2017. The results of this study show that, the patients with no drain reported a significant shorter mean duration of surgery in comparison to patients with drain (53.13±14.16 and 60.49±7.78 minutes) respectively, P-value = 0.01. In addition, patients with no drain also reported a significant shorter mean duration of hospital stays in comparison to patients with drain (24±4.16 and 48±9.29 hours). Respectively, P-value = 0.001. Most patients with no drain reported mild level of pain score compared to patients with drain, 32(80%) and 11(27.5%) respectively, with significant statistical difference: P-value = 0.001. Three patients (7.5%) developed seroma in patients with drain, while in patients with no drain, the seroma was reported in 4 patients (10%) with no significant statistical difference between 2 groups (P- value = 692). No cases of cervical hematoma, postoperative bleeding, wound infection or mortality were reported during this study. In conclusion, using advanced energy devices like ultrasonic scalpel for hemostasis in thyroid surgery, the drain should not be used routinely. The routine drainage may increase postoperative pain, prolong duration of surgery and postoperative hospital stay.
20 Impact of the COVID-19 Pandemic on Gallstone Disease: Experience at a High-Volume Center , Joaquin Fernandez-Alberti1*, Nicolas Panzardi1, Mariano Bregante2, Rafael Jose Maurette2, Jorge Diego Bogetti2, Daniel Enrique Pirchi3
Background: Diagnostic delay associated to COVID-19 pandemic led patients to present with more advanced conditions than usual. The aim of this study was to analyze Laparoscopic Cholecystectomies (LC) performed for acute gallstone-related disease during the pandemic and to compare them with two control groups. Methods: All LC performed between April and July 2020 (Group 3: G3) were analyzed and compared with LC performed in the same period in 2019 (Group 2: G2) and 2018 (Group 1: G1). Results: In G3 80 LC were performed, of which 36 (45%) were due to acute disease, while in G1 of 192 LC 45 (23.44%) and in G2 of 234 LC 37 (15.81%) were due to acute disease (p <0.01). Time from symptom onset until hospital consultation was longer during the pandemic (G3: 3.8 days vs 2.87 days for G1 and 2.26 days for G2; p <0.05). Mean operative time in minutes was also longer: 78.56 (SD ± 31.6) for G3, 57.69 (SD ± 26.5) for G1 and 63.51 (SD ± 29.4) for G2 (p <0.01). Discussion: We observed a significant delay in hospital consultation due to acute gallstone-associated disease resulting in more advanced cases requiring increased operative time for their resolution.
21 Computed Tomographic Finding of Hepatic Portal Venous Gas in a Patient with Perforated Sigmoid Adenocarcinoma: Case Report , Amir Obeid1*, Sa’d Sayida1, Suheil Artul2, Wisam Abboud1
Hepatic Portal Venous Gas (HPVG) is a rare entity which may require emergent surgical intervention. Detection is usually obtained by various radiological techniques such as plain radiological imaging, Ultrasonography (US) or Computed Tomography (CT) scan. Recognition of portal venous gas is predominately seen in conditions such as mesenteric ischemia and colitis. Portal venous gas alone is usually secondary to an underlying disease which requires surgical intervention. The outcome of the disease is dependent upon the pathology of the underlying cause. In this case, portal venous gas was an incidental finding during computed tomography which was performed for further investigation in an elderly patient with a perforated obstructing bowel tumor.
22 Negative Pressure Wound Therapy: The Experience of Our Surgery Department , Fatma Ben Saida1*, Chaker Jaber1, Nadia Azabou1, Khadija Soumer1
Introduction: The negative pressure wound therapy NPWT is a simple technique using negative pressure which aims to heal different types of wounds in different kinds of surgeries.The purpose of our study is to evaluate the results of this therapy on patients who have had delayed wound healing in cardiac, vascular or thoracic surgery. Methods: It is a retrospective review, from 2009 to 2021, including 31 patients , hospitalized in the thoracic and cardiovascular surgery department of Abderrahman Mami hospital of Ariana – Tunisia. Data were collected on patient cardiovascular risk factors, primary diagnosis, intervention, site of the wound, duration of the therapy, number of NPWT dressing implemented, the inflammatory assessment, the microorganism found and the evolution after the NPWT. Results: The mean age was 61 years with a maximum of 78-year-old-patient and minimum of 24 (Range 24 Year Old-78 Year Old) There were 23 male and 8 female patients with the following risk factors and comorbidities: Diabetes (70,59%), Smoking (47,06%), Hypertension (41,17%), Dyslipidemia (29,41%). Five patients presented with mediastinitis after coronary by-pass and five others had an infected scarpa but the bypass was preserved. Ten (10) cases presented with critical limb ischemia and have had distal revascularization of the limb by bypass associated to trans metatarsal amputation. Six patients presented with diabetic foot ulceration. Four of them had limb revascularization. Four patients had a complex thoracic wound after lung biopsy for tuberculosis (1 case), lobectomy for purulent pleurisy (1case); resection of a tumor in the chest wall (1 case), pneumonectomy for adenocarcinoma (1 case). One patient had NPWT on lower limb aponeurotomy wound. The average duration of NPWT was 17 days with a maximum of 30 days and minimum of 5 days (range 5 days-30 days). The frequency of the dressing change varies from 3 to 5 days with the use of one to six dressings per patient. Wound closure was obtained in 28 patients. Three patients had major amputation for poor vascular supply. Conclusion: The application of NPWT in multiple surgeries have shown promising results. It helps rapid wound healing and can reduce morbidity and mortality in patients with severe wound infections. It also lower surgical reinterventions and reduces hospital stay.
23 Intraoperative Pathophysiological Changes and Therapeutic Interventions in Patients Undergoing On-pump Cardiac Surgery May be Risk Factors for the Development of Post-operative Delirium in the Cardiac Intensive Care Unit: A Prospective Observational Study , Abdallah Halahla1*, Aidah Alkaissi1, Wael Sadaqa1
Introduction: Delirium after cardiac surgery is a common complication in cardiovascular intensive care units. Estimated incidence rates are approximately 30% to 73%. Delirium is an acute organic syndrome characterized by inattention, disorientation, along with global cognitive impairment and disturbance in consciousness. Post-operative delirium is typically characterized by a varying rate and can be associated with either increased or decreased psychomotor activity. Delirium after cardiac surgery to be quite distinct from other forms of delirium for the following reasons: Different surgical populations have different medication profiles, require different anesthesia techniques thus pharmacological triggers of delirium will vary depending on the surgery, the use of cardio-pulmonary bypass in cardiac surgeries requires special consideration since its use is associated with Post-operative effects on neurotransmitter function and an increase in delirium. Research has shown that predictors of delirium appear vary depending on the surgery type and the levels of various biomarkers for delirium. Identification of risk factors of delirium is important for positive Post-operative outcomes. Aim: The aims of this study are to investigate whether intra-operative events and therapeutic interventions affect the risk of Post-operative delirium in patients undergoing cardiac surgery in the ICU and to determine the incidence of and risk factors for delirium in patients undergoing cardiac surgery. Material and methods: A descriptive analytical study design used; study performed at cardiac surgery units at three hospitals in Palestine. Sixty patients who underwent elective cardiac surgery are subsequently admitted to cardiac surgical ICU are enrolled into this study. A detailed clinical report form was created to collect pertinent data in order to determine the effect of pre-operative, intra-operative and post-operative variables on delirium. All subjects are screened for delirium using the RASS and CAM?ICU test once daily and all those who tested positive were thereafter designated as cases and the other subjects are deemed controls. Results: The percentage of patients who developed delirium right after the operation were 75.9% (41/54) of the targeted sample, the percentage continued to drop until it reached 3.7% (2 patients) in the second and third day. No relation could be detected between delirium and the demographic variables (education, smoking status, gender, marital status and age) and no relation could be detected between delirium and the pre-operative factors. Intraoperative, total amount of midazolam/mg in control group 3.31±0.398 compared to 2.41±0.135 in delirium group, p= 0.051, (59% confidence level) and the result shows that those who did not suffer from delirium Post-operative have had higher amount of midazolam. There was a significant difference at (90% confidence level) in the total amount of morphine/mg in control group (no delirium) 8.85±1.04 compared to delirium group 7.93±0.45 (p= 0.085), those who received more morphine intra-operatively where more likely not to develop delirium after the surgery. The variable with significant relation to delirium was the use of atropine (90% confidence level) as those who seemed to use more atropine were significantly less likely to develop delirium, as in control group (not delirium) 3 (23.1%) patients received atropine compared to delirium group 1 (2.4%), p= 0.062. Regarding temperature (95% confidence level) those patients who had low grade or high temperature 19(46.3) in delirium group compared to 0(0%) in the control group (p= 0.01) were significantly more likely to develop delirium. This result indicates that low grade or high temperature Post-operative is a precipitating factor for delirium. Post-operatively, bolus doses of morphine/mg (95% confidence level) as in the control (not delirium) M(SD) 0.00±.000 compared to 1.17±0.308 in the delirium group, p= (0.001) those patients who received morphine where significantly more likely to develop delirium Post-operatively. Regarding the Sequential Organ Failure Assessment score (SOFA) (90% confidence level) as those patients who scored higher SOFA in the delirium group 5.56±0.191were more likely to develop delirium compared with control group (not delirium) 4.85±0.390, (p= 0.083). This result indicates that higher SOFA was a precipitating factor for delirium. Hyperactive type of delirium was seen in 22/41 patients (54.7%) while 11/41 patients (25.9%) had hypoactive delirium and 6/41 (13%) patients had mixed delirium. Conclusion: A compelling percentage of cardiac surgical patients encountered delirium in ICU, broadly in its hyperactive form. Few modifiable risk factors have been determined that could lower the probability of post cardiac surgical ICU delirium. One should contemplate the use of midazolam, morphine and atropine intra-operative as protective drugs for Post-operative delirium. Low and high grade fever, Post-operative morphine usage and augmenting of SOFA score are precipitating factors for Post-operative delirium.
24 SARS-CoV-2 in Peritoneal Fluids. Our Point of View after a Short Review of Literature , Salvatore Greco1, Nicolò Fabbri2*
One of the most interesting topics concerning SARS-CoV-2 infection is about the theoretical transmission of the virus during surgery. The virus is transmitted mainly through respiratory droplets containing the viral particles: these are usually exhaled by the infected subject when coughing, sneezing or simply talking and the amount of viral particles released is greater as the infection process goes one. Regardless the gastrointestinal involvement in the case of infection, that may be present in different percentages of cases (12.5% in our cohort of patients), any kind of invasive approach could hypothetically cause the aerosolization of viral particles and potentially lead to the contamination of the operating room [1-3]. In this respect, recent studies have focused on the unknown role covered by some invasive procedures like laparoscopic surgery: Seeliger, et al., reported the absence of viral RNA in the peritoneal samples of 5 patients, analyzed throughout RT-PCR assay; also an Indian study by Gaba, et al., on 11 biological samples from 8 patients (7 wound swabs, 2 peritoneal fluids and 2 tissue specimens) did not identify the viral genome in any of the samples considered [1,2]. Similar results were recorded in an interesting work by a group of polish researchers on 65 peritoneal samples in pregnant women tested positive for SARS-CoV-2 infection and in another study from Bahrain on 5 peritoneal samples, all tested negative for the viral detection. The potential role of peritoneal swabs in the alternative detection of SARS-CoV-2 RNA during surgery is a point of discussion in the current literature but the amount of studies concerning this topic is still too small to get to any kind of conclusion [4]. We discussed about the reliability of peritoneal tests in one of our previous works dedicated to this particular aspect of the disease concluding that caution is still required in case of surgery with COVID-19 inpatients; moreover, the current literature does not allow to understand whether handling biological fluids of such patients is completely safe or not and much attention should be provided during either invasive or mini-invasive procedures [5]. Based on the studies cited above, it would seem that peritoneal fluids are somehow spared from viral penetration, but for all the intrinsic limitations of these findings and the small size of the samples considered, further specific studies are still needed in order to define the actual role of biological fluids’ samples.
25 Giant Adrenal Myelolipoma as a Cause of Chronic Abdominal Pain: Abdominal Pain due to Giant Myelolipoma , García-Orozco Víctor Hugo1*, López-Yerena Iván2, Solar-Aguirre Carlos3, Ibarra-Ocampo Carlos M3, Castillo-Montero Alan-G4
Adrenal myelolipomas are a benign and infrequent tumor, with adipose and hematopoietic composition; generally asymptomatic, in which the size varies from a few millimeters to some large ones that cause symptoms due to compression (mainly chronic and diffuse abdominal pain). We present the case of a 54 year old male patient with a long-term clinical course characterized by chronic abdominal pain, constipation and progressive volume increase, a large retroperitoneal mass was observed in the computerized tomography, so he underwent surgery for tumoral resection obtaining histopathological result of adrenal myelolipoma.
26 Diffuse Sclerotic Metastatic in Carcinoma Prostrate , Manjeet Kumar1*, Kirti Rana2, Sanjeev Chauhan2
An 82 years old male presented with lower urinary tract symptoms with swelling feet. On examination he had palpable urinary bladder and hard nodular prostate. Blood investigations were Hb 15.6 gm%, TLC 7600/mm3, Urea 40, creatinine 1.9, PSA 5200 ng/dl. X-ray pelvis and skull suggested sclerotic lesions in pelvic bones and skull. He was catheterized and prostate biopsy was done. Prostate biopsy suggested adenocarcinoma prostate Gleason’s score 4+4. He was started on LHRH antagonist and Docetaxel based chemotherapy for metastatic carcinoma prostate. Skeletal metastases comprise almost 70% of all malignant bone tumours, and are associated with a variety of cancers. Carcinoma Prostate is the most common cancer in males. In our part of India, radiological investigations like bone scan, PSMA PET scan are not available. Thereupon diagnosis is made clinically and with X-ray, CT scan and MRI. Diagnosis with X-ray is easy, quick and freely available. With this clinical image, we believe that history, clinical examination, X-ray pelvic bones and skull are still useful for diagnosing and follow up in carcinoma Prostate ((Fig. 1).
27 Palliative Bilio-Digestive Anastomosis for the Treatment of Bile Duct Obstruction Due to Pancreatic Head Tumors: Techniques and Therapeutic Results , Diakité SY1*, Camara FL1, Camara SN1, Baldé H1, Barry H1, Barry AM1, Doumbouya B1, Sow Z1, Baldé AK1, Camara AK1, Diallo AD1, Touré A1, Diallo AT1, Diallo B1
Introduction:  Biliary-digestive anastomosis are a fistulization between the bile ducts and the digestive tract that aims at permanent drainage of bile to the digestive tract in case of obstruction at the lower bile duct. The objective of our study was to describe the main techniques and postoperative results of biliary-digestive anastomoses in the treatment of pancreatic head tumors in the visceral surgery department of the Donka national hospital. Material and Methods: This is a descriptive cross-sectional study for 5 years duration from January 01, 2014 to December 31, 2019 which focused on the records of patients who underwent bilio-digestive anastomosis for pancreatic head tumors. Results: The frequency of biliary-digestive anastomosis was 0.38% (N=24). The mean age was 43.75 years with a male predominance of 54.17% (n=13): sex ratio 1.18. The clinical picture was dominated by jaundice, dark urine and stool discoloration in all cases. Abdominal Computed Tomographic (CT) scan and Ultrasound (US) were the reference examinations. The indications were tumors of the head of the pancreas 100% (n=24). The approach was median supra-umbilical in all cases. The types of anastomosis were dominated by choledochodenal anastomosis 54.16% (n=13) followed by cholecysto-jejunal 20.83% (n=5) and choledoco-jejunal 16.67% (n=4). The postoperative course was simple in 56% (n=14). Morbidity was 20% (parietal suppuration 12%, anastomotic biliary leakage 8%), and postoperative mortality 24% (n=6). The average hospital stay was 12.70 days. Conclusion: Due to the lack of endoscopic and angiographic methods for biliary drainage in our hospital, the bilio-digestive anastomosis keep their place in the palliative treatment of the tumors of the head of the pancreas in our context of practice.
28 A Young Healthy Female with Idiopathic Extensive Subcutaneous Emphysema Occurring in Neck, Mediastinum, Left Arm, Peritoneal and Retroperitoneal Spaces: A Case Report , Abdalrahman T Albader1*, Mishal M Almutairi2
A case of a young healthy female patient with idiopathic extensive subcutaneous emphysema in neck, mediastinum, left arm, peritoneal and retroperitoneal spaces. The patient presented to the emergency department and then admitted to the ward for monitoring of vitals signs, evaluation and manage her accordingly. The patient had a surgical intervention to release emphysema. She improved significantly post-surgery. She stayed in hospital for a total of 10 days. Then, the patient was followed in outpatient clinic weekly for a total of 4 weeks. She was completely asymptomatic with no new issues since discharge.
29 Allocation of Extra Surgical Staff in Surgical Assessment Unit (SAU) - An Effective Strategy for Improvement? , Muhammad Ali1*, Rute Castelhano2, Sherwin Ng2, Anwar Owais3, Roderick Alexander3
Background: SAU is a recognized model of care in managing acute surgical patients, but limited resources and growing workload are affecting its efficiency. This study aimed to assess if the allocation of an extra registrar in surgical assessment unit would increase its efficiency. Methods: We routinely record patient arrival, triage, junior doctor (house officer/senior house officer) and senior doctor review (registrar) times in our SAU. Data was collected retrospectively for all general surgical patient waiting times and number of patients discharged in June/July 2018 over 20 days. In the second part of the study, after allocation of a second duty registrar during peak times (14:00-18:00hrs), data was prospectively collected for the same parameters during June/July 2019. In both cycles of study, the data was collected from Monday to Friday between (08:00-20:00 hours). This allowed us to compare both sets of data fairly. We statistically analysed the data using 2 tailed t tests. Results: The total number of patients in 1reg and 2reg studies were 182 and 196 respectively. In the 1reg group, the mean waiting times from patient triage to senior doctor review and junior to senior doctor review were 154 and 121 minutes respectively. These times were 110 and 75 minutes respectively in the 2reg group. Statistical analysis revealed that waiting times were significantly shorter (p=0.001, P=0.0003) in the 2 reg group. The number of patients discharged in 1reg and 2reg groups were 77 and 103 respectively (p=0.01). The patient triage times by nursing staff and junior doctor review times were not statistically different in both groups. Conclusion: The allocation of a second registrar in surgical assessment unit allows earlier senior review and decision making which decreases the patient waiting time and increased number of patient discharges thereby improving quality of care provided to the patients.
30 Laminin 511-E8 Fragment Improves Second-Degree Burn Wound Healing in a Rat Model , Jiraroch Meevassana, Manita Attasuriyanan, Apasee Sooksamran, Jade Wititsuwannakul, Papatson Boonsongserm, Supitcha Kamolratanakul, Nichakarn Ekprachayakoon, Kevin J Hamill, Apiwat Mutirangura, Apichai Angspatt
Background: The rate of re-epithelialization is the primary determinant of the morbidity and mortality in patients with severe burn injuries. Laminin ⍺5β1γ1 (LM511) is an extracellular structural protein that can support epithelial cell adhesion and migration. LM511-E8 is a functionally minimal form of LM511 with an efficacy similar to that of the full-length protein. To investigate whether treatment of burn wounds with the LM511-E8 fragment improves wound closure in a rat second-degree burn wound model. Methods: Second-degree burn wounds were produced in vivo on the backs of rats. The rats were separated into saline-treated control and LM511-E8-treated groups (n=9 per group), which were imaged on day 0 and on days 7, 14, 21 and 28 post-injury. Tissue sections were processed for histological and immunochemical examination and scored based on the overall pathology, epithelialization and presence of cytokeratin 10 and 14. Results: Burn wound healing improved in the LM511-E8-treated group compared with that in the control group from 7-28 days post-wounding (P < 0.01). The re-epithelialization of the LM511-E8-treated group was significantly faster than that of the control group at 7-28 days post-injury, with the largest improvement observed on days 7 and 14 (P < 0.001). The overall pathological score of the LM511-E8-treated group was higher than that of the control group at 14-28 days post-injury; maximum improvement was observed on days 14 and 21. Conclusion: The use of LM511-E8 is a promising therapeutic option for managing second-degree burns.
31 Subacute Management of Ruptured Lung Hydatid Cysts in Pediatrics , Salma Abed Samamqa, Ali Khalid Salah, Shaimaa Awawdeh, Amer Y AbuRumaila, Mohammad Eid Al Mohtasib, Yousef Abu Asbeh
Background: The aim of this observational, retrospective study was to review and describe clinical presentations and subacute management of patients with complicated Pulmonary Hydatid Cysts (PHC) and its outcome. Cases Preview: Six patients, suffering from 10 lung hydatid cysts, with a mean age of 10 years (3-15) year old, of these six patients, there were three males and three females, the most common presentation was ruptured hydatid cyst in four of the cases, all of them were associated with liver hydatid cysts, there were no other organ involvement, the cysts size was ranging from 2.5-10 cm, with mean size of 5 cm. The presenting symptoms were fever, dry cough, shortness of breath, chest pain on the affected side, hemoptysis, recurrent chest infection, hematemesis and vomiting, we didn’t witness any anaphylactic episodes in our study. All the patients were managed surgically after stabilization period range from 2 days- 2 months, there were no intra or post-operative complications, patients were extubated on day 1 post op and the patients were discharged on day 5-8 post-operative on albendazole, with no mortality. Conclusion: The subacute management of ruptured hydatid cyst results were promising in terms of minimal intra and post-operative complications if presented at all, shorter hospital stay and rapid return to daily activities, early extubation with no need to mechanical ventilation, with no need to rush for an urgent surgery with unstable patient with it’s possible complications, this approach was safe, reliable and successful.
32 Sigmoid Colon Cancer in an Irreducible Scrotal Hernia Case: A Combined Surgical Laparoscopic and Inguinal Approach and Review of the Literature , Luciano Onofrio1, Danilo Cafaro2, Lorenzo Asciore1, Maria Diana Fidanza1, Francesco Iarrobino1, Gianfausto Iarrobino1
Inguinal hernia and colorectal cancer, considered individually, are very common pathologies; their simultaneous manifestation in the same patient, on the other hand, is a rare condition and even more the presentation in the form of a complication (bleeding, intestinal obstruction, etc.). We report an 86-year-old man case of incarcerated sigmoid colon carcinoma diagnosed in the emergency department preoperatively and treated with elective laparoscopic surgery, combined with an inguinal approach. Literature review (last 30 years) was applied to analyzed variability and open questions in the management of this particular pathologic combination.
33 Two Cases of Pemphigus Foliaceus with Severe Pruritus and Elevated IgE Levels , Jingfang Zhang1,2, Liu Yang1,2, Yamin Zhang1,2*, Juan Tao1,2
We report the clinical characteristics and management of two patients with severe PF, who presented with extreme pruritus and high IgE levels. Both the two patients had common characteristics as follows They were all diagnosed as PF and presented with chronic eczematous lesions The patients all accompanied with intense pruritus and were resistant to diversified forms of antihistamines. Furthermore, the level of IgE antibody in their serum was significantly increased Their skin lesions were accompanied with Staphylococcus aureus infection by secretion culture After the diagnosis of PF was made, methylprednisolone (1.5 mg/kg) and antibiotics were administered, which rapidly induced remission and the levels of Dsg1 and IgE in the serum were significantly declined. The possible role and mechanism of IgE elevation in these two cases were also discussed
34 A Case of Giant Esophageal Gastrointestinal Stromal Tumor that was Successfully Resected without Neoadjuvant Treatment , Bayan Hemedat1, Enas Hroub1, Isra’ Badarin1, Hazem Ashhab2, Mo’taz Alnatsheh3, Mohammad Mohtasib4, Yousef Abuasabah5*
A 27-year-old male from Gaza was admitted to the Gastroenterology department with complaints of progressive dysphagia. An endoscopic examination shows submucosal gastric mass at the Gastro-Esophageal (GE) junction. Physical examination was normal. There was no abnormalitie found in laboratory examinati ons, including hematologic and biochemical analyses. A whole abdominal enhanced Computed Tomography (CT) scan revealed a solid mass with a smooth border and hypervascularity at the gastro-esophageal junction. Endoscopic ultrasound guided fine needle biopsy was performed, pathologic diagnosis of the submucosal tumor was GIST. The patient was considered for neoadjuvant immunotherapy, but then he is excluded due to logistic considerations. The patient underwent distal esophagectomy and proximal gastrectomy, complete resection was performed and the specimen was sent for histopathology. The diagnosis of an esophageal GIST with negative margins was confirmed by histological investigation of the resected specimen. Spindle-shaped tumor cells were discovered in the tumor. CD34 and DOG1 were shown to be positive in the tumor cells by immunohistochemistry. In 50 high-power fields, the mitotic index was less than 5 mitotic figures. There were no postoperative complications. The patient was discharged 5 days after the surgery and has been doing well since then. A repeat endoscopy upper GI and a CT scan of the whole abdomen will be scheduled during the next follow-up visit to exclude any kind of recurrence or metastases. We present this unusual case to show the potential of surgical resection in patients with large esophageal GISTs without preoperative imatinib treatment, especially when the patient is unable to receive neoadjuvant treatment for some reason, as long as we can achieve complete resection without rupture and with a clear margin.
35 Adipose-Derived Stem Cells: Isolation and Utilization within Regenerative Medicine and Cosmetic Procedures , Gillian Bello1, Vincent S Gallicchio1*
Adipose-derived stem cells are a promising tool for the future of reconstructive surgeries, regenerative therapies and cosmetic procedures. Their ability to be safely, efficiently and cost-effectively isolated from extracted subcutaneous fat tissue makes them a favorable option for plastic surgeons, who often routinely perform liposuction procedures that provide adequate samples for stromal vascular fraction isolation. The differentiation potential of adipose-derived stem cells is vast and limited only in a developmental potential when compared to embryonic stem cells. Their utilization within clinical trials can be seen in procedures ranging from soft tissue and bony reconstruction, wound and burn healing, peripheral nerve regeneration and cosmetic procedures like skin rejuvenation and breast augmentations. The results from these trials provide evidence that supports future use of these stem cells within these fields of medicine.
36 A Rare Case of Peritoneal Tuberculosis in a 21 Years Old Male Patient , Garritano C1*, Godoy F2, Fonseca J2, Cruz LM2, Oliveira M2
Tuberculosis is among the top 5 causes of death from infectious disease caused by Mycobacterium tuberculosis, it most frequently affects the lungs, although it can compromise the digestive tract, genitourinary, peritoneum, pleura, bones, lymph nodes and meninges, composing the group of extrapulmonary tuberculosis. Peritoneal involvement is the most common form of abdominal type representing 0.1 to 0.7% of all tuberculosis cases. With nonspecific symptoms, without of laboratory findings that would guide the search for Mycobacteria and imaging tests that overlap common in other pathologies, the diagnosis is difficult. In Abdominal Computed Tomography, ascites, smooth peritoneal thickening, densification of the mesentery root, lymphadenomegaly with central necrosis or calcification are observed. Laparoscopy with the biopsy and collection of ascitic fluid is used as a method for diagnosis. The mortality of abdominal tuberculosis can reach 15% and perforation of intestinal loops, malnutrition, anemia, hypoalbuminemia are the main complications. We present the case of a patient presenting recurrent umbilical hernia, whose diagnosis of peritoneal tuberculosis was made during surgery.
37 Successful Surgical Management of a Traumatic Dissection of Internal Carotid Artery , S El Hadhri1*, M Gueldich1, S.Kallel2, A Zaidi2, D Ayman1, BJ Hela1, I Frikha1
Introduction: Blunt carotid artery dissection is relatively rare and different from spontaneous dissections. Ischemic stroke is the main complication with high morbidity and mortality rates. Case report: We report the case of a 32 years old man who had a polytraumatic injury and was admitted in our emergency unit. Injuries of the head and a dissection of the right internal carotid artery were identified on CT. The patient was then successfully management and had surgical repair of right internal carotid artery and head injuries. Conclusion: Management of blunt carotid dissection is challenging; in fact, no guidelines are actually available. Treatment should be conducted quickly after trauma and could be conservative, endovascular or open.
38 Post Traumatic Stress Disorder (PTSD) Following Craniomaxillofacial Trauma - A Five Year Retrospective Study , Colonel (Dr) Priya Jeyaraj1*
Introduction: The psychological and psychiatric derangements as well as psychosocial impact that craniomaxillofacial trauma can have upon patients, often goes undetected, ignored and unaddressed. This can adversely affect the mental and physical well-being of the patient, leading to a lifetime of severe debility and incapacitation. Methods: This retrospective study examined the incidence, severity, predictors and likely predisposing factors for development of PTSD among 378 patients treated for craniomaxillofacial trauma at a tertiary care centre, over a five-year period. It correlated the likelihood of development of PTSD with the mode of injury sustained and analysed the management protocols employed and outcomes achieved. Results: 31% of the patients demonstrated a positive diagnosis for PTSD and were managed for the same. Self-inflicted maxillofacial trauma patients exhibited the highest risk for developing PTSD, followed by victims of natural disasters, combat associated trauma victims (blast and ballistic injuries), followed thereafter by physical assault and RTA victims. Depending upon the severity of PTSD exhibited by the different patients, counselling, psychotherapy, and/or pharmacotherapy were employed. Discussion: Careful screening of craniomaxillofacial trauma victims for features of PTSD cannot be overemphasized. Timely and effective management of the same can go a long way towards successful rehabilitation of these vulnerable group of patients. Surgical management of orofacial injuries should integrate case management that addresses psychosocial sequelae as it is not only necessary to restore the integrity of the anatomy and function, but also to provide psychiatric support and therapy for patients experiencing symptoms of PTSD caused by traumatic events.
39 Preoperative Lateral Laxity in the Extensor Position and Intraoperative Medial Soft Tissue Release Affect Postoperative Ligament Balance in Osteoarthritis Knees Undergoing TKA in Women , Manabu Hino1,3, Shuji Nakagawa2, Hiroaki Inoue1, Yuta Fujii1, Kenta Kaihara1, Kenji Takahashi1, Yuji Arai2*
Purpose: Adequate ligament balance is important for long-term outcomes after Total Knee Arthroplasty (TKA). We retrospectively evaluated preoperative factors and intraoperative medial soft tissue release techniques that affected adequate ligament balance after TKA for varus knee. Method: One hundred knees with Osteoarthritis (OA) in women were included. X-rays were taken preoperatively and postoperatively with varus and valgus stress in the extension and flexion positions. Knees were postoperatively, classified as stable (n=49) or laxity (n=51). Results: Factors associated with adequate ligament balance include joint inclination angle of varus at extension, and superficial Medial Collateral Ligament (sMCL) release. Postoperative ligament balance was significantly associated with preoperative joint inclination angle of varus at extension of 7°. Conclusion:  Preoperative lateral laxity in the extensor position under stress X-ray and sMCL release may affect postoperative ligament balance. A 7° preoperative lateral joint inclination may be useful in predicting postoperative ligament balance.
40 A Rare Vascular Complication in a COVID-19 Patient: A Case Report of Free-Floating Carotid Thrombus , Ben Saida Fatma1*, Jaber Chaker1, Soumer Khedija1, Bousnina Mouna1, Azabou Nadia1, Jemel Amine1
It is now admitted that Coronavirus is related to vascular complications especially thrombotic ones. Mechanism of thrombotic complications is not fully understood. Free-floating carotid thrombus is a rare condition and it has been found in numerous cases of COVID-19 patients. Data related to management of this floating clot is limited. Anticoagulation remains an important pillar of treatment. We report is this work, a case of a 59-year-old male, hospitalized twice for management of COVID-19 infection in January and March 2021. A free-floating carotid thrombus was discovered and a medical treatment was initiated.
41 Soft Tissue Sarcoma in a Malignancy Prone Patient: An Update , Badr M I Abdulrauf1*, Basma Mogharbel2, Afnan Altowaireb2, Abrar Aljunaid3
It is possible to encounter a patient who might have more than one type of a primary malignant tumor. The literature supports increasing tendencies for subsequent development of malignancies within same individual. A case example of a young woman is given who was diagnosed with a pleomorphic Liposarcoma, while she is been followed up for metastatic ductal breast carcinoma and with a past history of treated acute lymphoblastic Leukemia. As per our review, various associations of malignant conditions are encountered, but are more likely to be metachronous rather than synchronous. The duration between diagnosing a second and third malignancy tends to be relatively short. Soft tissue sarcoma as a synchronous malignancy has been shown to be associated with breast cancer more often. Patients diagnosed with new subsequent malignancy including soft tissue sarcomas must be managed holistically and with full measures; as per current data, their prognosis is not necessarily poorer than regular cancer patients.
42 Soft Tissue Sarcoma in a Malignancy Prone Patient: An Update , Badr M I Abdulrauf1*, Basma Mogharbel2, Afnan Altowaireb2, Abrar Aljunaid3
It is possible to encounter a patient who might have more than one type of a primary malignant tumor. The literature supports increasing tendencies for subsequent development of malignancies within same individual. A case example of a young woman is given who was diagnosed with a pleomorphic Liposarcoma, while she is been followed up for metastatic ductal breast carcinoma and with a past history of treated acute lymphoblastic Leukemia. As per our review, various associations of malignant conditions are encountered, but are more likely to be metachronous rather than synchronous. The duration between diagnosing a second and third malignancy tends to be relatively short. Soft tissue sarcoma as a synchronous malignancy has been shown to be associated with breast cancer more often. Patients diagnosed with new subsequent malignancy including soft tissue sarcomas must be managed holistically and with full measures; as per current data, their prognosis is not necessarily poorer than regular cancer patients.