General surgery clinical research

In this clinical study hyperbaric ropivacaine in spinal anaesthesia for lower limb and hip surgery was evaluated and results obtained were compared with those using hyperbaric bupivacaine. Methodology: Two hundred patients scheduled for lower limb and hip surgery were randomly divided into two groups of 100 patients each. These patients received a spinal injection of either 3ml (15mg) of 0.5% hyperbaric ropivacaine or 3ml (15mg) of 0.5% hyperbaric bupivacaine using 25G Quincke type spinal needle. The parameters studied were -onset and total duration of sensory block, onset and total duration of motor block, quality of intraoperative anaesthesia, hemodynamic alterations, and any intraoperative and postoperative complications. Results: The mean onset of sensory block (6±1.3min vs. 3±1.1min; p value<0.05) and motor block (13±1.6min vs. 9±1.3min; p value< 0.05) was significantly slower in ropivacaine group as compared to bupivacaine group. The total duration of sensory block was significantly shorter in ropivacaine group (160±12.9min) than in bupivacaine group (260±16.1min; p value <0.05). The mean duration of motor block was also shorter in ropivacaine group compared to bupivacaine group (126±9.2min vs. 174±12.6min; p value<0.05). Conclusion: The quality of anaesthesia was excellent in both the groups. In conclusion, a solution of ropivacaine (hyperbaric) can be used for spinal anaesthesia and is comparable with hyperbaric bupivacaine in terms of quality of block, but has shorter recovery profile.

Inguinal hernia repair is among the most commonly performed surgeries across the globe. Lichenstein's tension-free technique of open hernioplasty remains the gold-standard, and laparoscopic techniques have gained popularity over recent decade. Giant inguinal hernias that extend below the midpoint of the inner thigh are uncommon, challenging to manage and are more prone for post-operative complications. There is no standard treatment protocol or surgical procedure designated for the management of giant hernias which are associated with grossly disrupted local tissue architecture and compromised tissue integrity and dynamics. Large volumes of omentum and bowel make up the contents of the hernia sac, which with the natural pathological processes involved, further complicate the management. This care report and review of literature aims to elucidate a clear management protocol for Giant Inguinal Hernias.

The renal vein normally is located in front of the aorta. However may course posterior to the aorta. This variation is of importance during procedures in the retroperitoneal region. The objective of this study was to investigate the incidence of the retro – aortic left renal vein. A total of 13 cadavers and 10 visceral blocks were used for the study in the laboratory of Morphology of the University of Pamplona. In two cadavers, three renal veins were found to bind and give rise to a common venous trunk corresponding to the left renal vein passing behind the aorta abdominal (retro-aortic) and ending at the inferior vena cava at the level of the fourth vertebra lumbar. Knowledge of anomalies of left renal vein is essential for radiologists, endocrinologists, fertility specialists, urologists and surgeons, in determining the feasibility of complication-free surgical interventions

Penetrating diaphragmatic rupture sometimes poses a diagnostic challenge. We describe two cases due to
stab wounds that were identified by M-mode ultrasonography, which showed lesser motion of the left
hemidiaphragm compared to the right. We recommend that the addition of M-mode ultrasonography to
focused abdominal sonography in trauma (FAST) examination will help clinicians reach the correct
diagnosis in cases of suspected penetrating diaphragmatic rupture.

To evaluate syringe pressure irrigation of the surgical wound to decrease its infection after appendectomy, we designed a randomized control trial at the Emergency Department of Mexico City General Hospital, including 350 patients with acute abdomen suggestive of appendicitis, without any other infection clinically evident. The trial was randomized into 2 groups. Group I patients received prophylactic systemic antibiotics before surgery. Group II patients received the same prophylactic systemic antibiotics plus syringe pressure irrigation of the surgical wound with 300 ml of saline solution using a 20-ml syringe with 19-gauge intravenous (IV) catheter to measure the incidence of postoperative wound infection. In our results, 283 patients had appendicitis. Of these, 188 were uncomplicated (66.4%) and 95 (33.6%) were complicated. Of the complicated cases, 40 were assigned to group I, and of these, 29 (72.5%) developed wound infection. In group II there were 55 patients and only 9 (16.3%) developed wound infection after syringe pressure irrigation [p ‫؍‬ 0.000001; 95% confidence interval (CI) ‫؍‬ 0.02-0.22]. We conclude that syringe pressure irrigation of the surgical wound after appendectomy contributes significantly to decrease the incidence of postoperative wound infection in complicated cases. It is a cheap, safe, and accessible method in any surgical room.

Introduction: According to WHO it is estimated that ~56
million pregnant women are anaemic, among which 75-80
% have iron deficiency anaemia. Even the most optimal diet
is not sufficient to meet the increased iron demands in pregnancy,
therefore iron supplementation is a must during pregnancy.
The first choice in the treatment is oral iron because
of its effectiveness, safety, and lower cost. However there are
problems with oral intake such as poor compliance. Hence a
predetermined dose of parental iron given intermittently may
have an advantage. Keeping this in mind, this study has been
designed to compare the efficacy of daily oral iron supplementation
and fixed schedule of intravenous iron sucrose given in
pregnancy for anaemia prophylaxis.
Material and methods: 200 patients between 16 – 20 weeks
of gestation with singleton pregnancy and Hb level 8-11 gm/
dl attending antenatal OPD were recruited and devided in two
groups. Group A was given oral iron tablets containing100mg
of elemental iron. Group B was given a total of 1000 mg of intravenous
iron sucrose divided into five doses of 200 mg each
at weekly intervals. Estimation of haemoglobin was started 4
weeks after commencement of iron therapy and then repeated
every 4 weeks till 36 weeks of gestation, pre-delivery and
postpartum.
Results: Haemoglobin repeated at term and postpartum did
not show significant difference in the two groups. In group
A incidence of nausea and vomiting was significant while in
group B incidence of superficial thrombophlebitis was significant.
Conclusion: The increment in haemoglobin with iron sucrose
was comparable with oral iron. No significant differences
were found in immediate postpartum maternal haemoglobin
levels. Side effects noted in the study were minimal.

Introduction: Clinical teaching is the most ancient of the methods of teaching students. It is one of the most, rather the most, important tool available for the teachers to impart knowledge to the medical student. It remains to date at the heart of medical training. However it is not being fully exploited and most often a clinical class becomes nothing more than an extended theory lecture class. There is lack of structure in clinical teaching .There is no inter unit or intra departmental coordination which will allow the students to see all kinds of cases through their student career. The feelings of the patients are not taken into account and neither a consent taken from them before starting a clinical class. Some of the lacunae in the present clinical teaching can be addressed by introducing a structured ,feedback based system.

Acute Appendicitis remains the most common surgical emergency of the abdomen, and though it can present at any age, usually occurs in children and young adults. Despite tremendous advancements is surgical technique, the peritonisation of the stump of the appendix remains a challenge and is especially more so when the base is perforated, gangrenous, or sloughed out. In these conditions, surrounding tissues are compromised and cannot be relied upon to heal thoroughly, with a high rate of morbidity, including the dreaded fecal fistula. The adjacent cecum, thickened and indurated by the inflammatory process is also liable to ischemia, making the management challenging when the base of the appendix is involved in the pathology, which fortunately is a rare occurrence. Here is reported the case of a young male patient with appendicitis with a sloughed base, and a review of literature regarding the ideal management of the condition.

Fistulas are communicating tracts between two surfaces, linking structures and planes that should, under normal circumstances, not be in dialogue. They may be congenital or acquired and are most commonly associated with the gastrointestinal and ano-rectal territories, where they link two different organ systems internally, or track outwards, creating a communicating channel between the internal viscera and the skin surface. Vaginal fistulas on occasion result from perineal tears due to traumatic delivery, or less commonly, infection or non-healing of the episiotomy wound, and are of the rectovaginal or vesicovaginal variety. Very rarely, the channel from the vagina tracks to an opening in the skin. This is the report of a patient who developed the rare vagino-cutaneous fistula following a normal vaginal delivery with episiotomy, and review of the limited literature available about the peculiar entity, so rare that
no previous reports of vagino-cutaneous fistulas developing after vaginal delivery with episiotomy could be found.

Objectives: To describe the association and relationship of the clinical manifestations and the metabolic
changes in a case of asymptomatic Celiac Disease (CD), Primary Hyperparathyroidism (PHPT) and
Plummer-Vinson Syndrome (PVS).
Methodology: A case report presenting a 37-year old female, with a 3 - year progressive lower back pain
(LBP), fatigue and history of anaemia, and referred to Rafidia medical centre. No suggestive symptoms
of malabsorptive disease were observed. Detailed clinical assessment revealed proximal myopathy,
sever osteoporosis, normal calcium and phosphorus, elevated alkaline phosphatase and parathyroid
hormone level.
Results: Left parathyroidectomy was done, followed by sever hypocalcemia non-responding to oral
calcium. Serological and endoscopic screening for Celiac Disease was positive and associated with
oesophageal web. Treatment with gluten-free diet (GFD), oral calcium and oral iron yielded remarkable
clinical biochemical and radiological improvement.
Conclusion: Celiac Disease is asymptomatic for long time, and forms the underlying cause of
osteoporoses and anaemia. The associated Primary Hyperparathyroidism makes osteoporosis more
sever. Plummer-Vinson syndrome is frequently associated with celiac disease.

Surgery is establishing research Hubs in low-and middle-income countries (LMICs). The aim of this study was for the Hubs to prioritize future research into areas of unmet clinical need for patients in LMICs requiring surgery. Methods: A modified Delphi process was overseen by the research Hub leads and engaged LMIC clinicians, patients and expert methodologists. A four-stage iterative process was delivered to prioritize research topics. This included anonymous electronic voting, teleconference discussions and a 2-day priority-setting workshop. Results: In stage 1, Hub leads proposed 32 topics across six domains: access to surgery, cancer, perioperative care, research methods, acute care surgery and communicable disease. In stages 2 and 3, 40 LMICs and 20 high-income countries participated in online voting, leading to identification of three priority research topics: access to surgery; outcomes of cancer surgery; and perioperative care. During stage 4, specific research plans to address each topic were developed by Hub leads at a priority-setting workshop. Conclusion: This process identified three priority areas for future research relevant to surgery in LMICs. It was driven by front-line LMIC clinicians, patients and other stakeholders representing a diverse range of settings. The results of the prioritization exercise provide a future framework for researchers and funders.

Antecedentes: No se cuenta con un estudio previo que permita evaluar la formación del residente de cirugía general en un hospital enfocado al trauma.

Objetivo: Evaluar el papel que desempeña el trauma abdominal penetrante en la formación del residente de cirugía general.

Material y métodos: Pacientes con trauma abdominal penetrante durante un año. Las variables analizadas fueron: causa de la lesión, tipo de laparotomía, rol desempeñado por el residente ayudante/cirujano, órganos lesionados, tratamiento establecido, complicaciones y mortalidad. Estudio descriptivo, transversal. Análisis con porcentajes como medidas de resumen y Chi cuadrado de Pearson para obtener la diferencia significativa.

Resultados: 203 pacientes sometidos a laparotomía, 109 heridas por arma de fuego y 105 por arma blanca. Se realizaron 139 laparotomías terapéuticas, 49 no terapéuticas y 15 cirugías de control de daño. 24 fueron por residente de primer año, 85 por los de segundo año y en 94 actuaron los de tercer año. De 272 lesiones, 184 lo fueron en víscera hueca, 78 en órgano sólido y 10 lesiones vasculares; se tuvieron 28 complicaciones postquirúrgicas, siendo las más comunes sepsis (8 pacientes) y cinco infecciones del sitio quirúrgico.

Conclusiones: Durante la formación del cirujano es importante el desarrollo de las habilidades técnicas en la sala de operaciones y el manejo integral del paciente con trauma abdominal desde su ingreso a la sala de urgencias. No se han establecidos parámetros claros en cuanto al número de pacientes que deben ser evaluados ni el número de procedimientos quirúrgicos que se deben realizar durante la formación un residente.

Background
A major deterrent to providing qualitative surgical care in developing countries is the lack of
adequate facilities and severe shortage of human resources. Therefore, most of the surgical
workforce in rural areas and urban slums predominantly includes general practitioners with little
formal training in providing surgical care. There is a need for constant review of patients’ care
in this setting with the aim of improving service delivery and conforming to the internationally
acceptable standard of practice.
Materials and methods
A 5-year descriptive retrospective study, from January 2007 to December 2011, of general
surgery cases at State Specialist Hospital Ikere-Ekiti (Nigeria) was carried out.
Results
A total of 80 patients underwent 85 surgical operations. Most of them (86.2%) had ward
admission for a mean duration of 4.6±1.4 days. The most frequent elective operation was
hernia repair [66 (77.7%)]; whereas that of emergency was appendectomy [seven (8.2%)]. Other
operations included lumpectomy [three (3.5%)], hydrocelectomy [two (2.4%)] and orchidectomy
and laparotomy [three (3.5%) each]. All patients received postoperative antibiotics, with 71.3%
receiving two or more antibiotics. Fifteen (18.8%) patients had surgically excised specimens
with no histopathological evaluation. Only four (5%) patients were followed up beyond 4 weeks.
No mortality was recorded.
Conclusion
Surgical volume was grossly low and there is a need for the government to equip secondary
healthcare centres with basic facilities and strengthen surgical capacity for maximum utilization
and improved quality of care. Periodic training programmes for general practitioners to ensure
strict adherence to the international best practices will be helpful. In addition, health education
should be available for everyone to reduce sociocultural-related problems.

Background: End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods: This study comprised an analysis of GlobalSurg-1 and-2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle-and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results: In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6⋅9 per cent) from low-HDI, 254 (15⋅5 per cent) from middle-HDI and 1268 (77⋅6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57⋅5, 40⋅9 and 35⋅4 per cent; P < 0⋅001) and subsequent use of end colostomy (52⋅2, 24⋅8 and 18⋅9 per cent; P < 0⋅001) in low-compared with middle-and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3⋅20, 95 per cent c.i. 1⋅35 to 7⋅57; P = 0⋅008) after risk adjustment for malignant disease (OR 2⋅34, 1⋅65 to 3⋅32; P < 0⋅001), emergency surgery (OR 4⋅08, 2⋅73 to 6⋅10; P < 0⋅001), time to operation at least 48 h (OR 1⋅99, 1⋅28 to 3⋅09; P = 0⋅002) and disease perforation (OR 4⋅00, 2⋅81 to 5⋅69; P < 0⋅001). Conclusion: Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone.

There are many respiratory diseases in small animals, as well as the possibilities of diagnoses, as laboratory and radiographic exams, bronchoalveolar lavage and biopsies. This research aimed at assessing the results of transdiaphragmatic paraxiphoid thoracoscopies in pulmonary biopsies of thirteen clinically healthy dogs. Under general anesthesia, each dog was insufflated with 30ml kg-1 of air in each hemithorax; two trocars were placed between the xiphoid appendix and the
costal arch through the diaphragm. An endoscope was introduced by the first portal; while the second portal was used to allow access to the nippers in the biopsy forceps. Then, these nippers were removed and replaced by chest tube drainage. During the procedures, respiratory frequency, heart rate, oxygen saturation, arterial pressure and central venous pressure (CVP), hemogasometric parameters were checked. Within 48 hours after the surgery, drains were or drain was removed, with minimal production of air and/or liquid. In conclusion, this is a fast and safe technique, which
is free of trans and post surgical complications, thus allowing the collection of sufficient material for pulmonary histological evaluation.

Introduction Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as postoperative analgesia by the Enhanced Recovery After Surgery Society. Recent studies have raised concerns that NSAID administration following colorectal anastomosis may be associated with increased risk of anastomotic leak. This multicentre study aims to determine NSAIDs’ safety profile following gastrointestinal resection.

Methods and analysis This prospective, multicentre cohort study will be performed over a 2-week period utilising a collaborative methodology. Consecutive adults undergoing open or laparoscopic, elective or emergency gastrointestinal resection will be included. The primary end point will be the 30-day morbidity, assessed using the Clavien-Dindo classification. This study will be disseminated through medical student networks, with an anticipated recruitment of at least 900 patients. The study will be powered to detect a 10% increase in complication rates with NSAID use.

Ethics and dissemination Following the Research Ethics Committee Chairperson's review, a formal waiver was received. This study will be registered as a clinical audit or service evaluation at each participating hospital. Dissemination will take place through previously described novel research collaborative networks.

Objective: To find out the different presentations of tuberculous mastitis and to highlight the importance of tuberculosis as a cause of breast disease in young unmarried girls. Study Design: Case series Place and Duration: The study was conducted in Surgical unit-I, Rawalpindi General Hospital, RMC and Railway Hospital, IIMC over a period of 8 years from Materials and Methods: All female patients of any age presenting with lump/ulcer in the breast, multiple sinuses or cold abscess with clinical/FNAC suspicion of chronic granulomatous mastitis were included in the study. A Proforma was designed containing bio-data, clinical history and examination details regarding name, age, marital and lactational status. Investigations included routine hematological tests like CP, ESR, blood complete examination, erythrocyte sedimentation rate in all patients and biochemical tests as indicated during the course of therapy, ultrasonography of the breast, fine needle aspiration cytology (FNAC) and histopathological evaluation.

The most common variable of the muscle biceps brachii is the presence
of supernumerary heads. The aim of this case report is to describe the
presence of a third head of the muscle biceps brachii and its clinical significance. The anatomical variations described were found during routine dissection conducted in the laboratory of Morphology of the University of Pamplona in two male cadavers, embalmed of 75 and 59 years respectively. Measurements were taken using a Vernier caliper. Topographic details of the variations were examined, recorded and photographed. They have been described compression of the brachial artery, median nerve, musculocutaneous nerve between the supernumerary heads of muscle biceps brachii, your knowledge is of interest to clinicians, specialists; and health professionals in order to achieve diagnoses, procedures and safer and efficient rehabilitations.

Introduction
Hematic biometry is the most used laboratory exam in the emergency room in every general or trauma hospital.

Objective
To analyze and compare the levels of hemoglobin, hematocrit, platelets, leukocytes, and neutrophilia in both pre-surgical and post-surgical levels in penetrating abdominal trauma patients.

Material and Methods
This is a descriptive and prospective study in patients with penetrating abdominal trauma that underwent exploratory laparotomy. The variables analyzed were: age, gender, type of trauma, presurgical and post-surgical count of hemoglobin; hematocrit; platelets; leucocytes; neutrophilia; perioperative bleeding, mortality, and hospital stay.

Results
Of 508 patients studied, only 93 patients were included. The mean of age was 29.6 years old. 87 patients were males. 32 patients (34.4%) were SW injured whereas 61 (65.6%) were GW injured. According to the type of trauma: 78 patients (83.9%) underwent therapeutic laparotomy, 11 patients(11.8%) underwent non-therapeutic laparotomy, and 4 patients (4.3%) underwent damage control
surgery. There were differences between pre-surgical and post-surgical levels, with major levels in presurgical means.

Discusión
Presented values, represent the beginning of a major and multi-institutional study to show real and reliable values that we can expect in a patient with penetrating abdominal trauma during pre-surgical and post-surgical time. We cannot conclude that these data are conclusive; however these data can guide on the levels that we can expect in a multi-institutional study with a major number of patients.

Pilonidal sinus disease is a complex condition that causes both discomfort and embarrassment to sufferers. Direct cost through absence from work is high. Controversy still exists regarding the best surgical technique for its treatment in terms of minimizing disease recurrence and patient discomfort. Thus, we conducted this study to evaluate the results of rhomboid excision and Limberg flap reconstruction in the surgical treatment of pilonidal sinus disease. This prospective study included 81 patients who had pilonidal sinus and were treated by the rhomboid excision and Limberg flap. The mean follow–up was 18 months and all patients were satisfied with the procedure. There were lower complication rates, minimal discomfort, patients discharged in 2-3 days and only two recurrences. The authors recommend the Limberg Flap procedure for pilonidal sinus disease. It is effective, with short hospitalization, low recurrence rate and shorter time off work. Introduction Pilonidal sinus disease is a common medical condition that accounts for almost 15% of anal suppuration and is responsible for significant morbidity [1]. It is usually seen in young adults [2]. Males are affected more frequently than females by a ratio of 3:1, probably due to their more hirsute nature [3]. The origin of pilonidal sinus disease is not fully understood. There are many theories associated with its pathogenesis: The most important are the acquired and the congenital theories. However, the majority of opinion favors the acquired theory, which postulates that the sacro-coccygeal pilonidal infection originates in the natal cleft hair follicle that has become distended with kera

Background: End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods: This study comprised an analysis of GlobalSurg-1 and-2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle-and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results: In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6⋅9 per cent) from low-HDI, 254 (15⋅5 per cent) from middle-HDI and 1268 (77⋅6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57⋅5, 40⋅9 and 35⋅4 per cent; P < 0⋅001) and subsequent use of end colostomy (52⋅2, 24⋅8 and 18⋅9 per cent; P < 0⋅001) in low-compared with middle-and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3⋅20, 95 per cent c.i. 1⋅35 to 7⋅57; P = 0⋅008) after risk adjustment for malignant disease (OR 2⋅34, 1⋅65 to 3⋅32; P < 0⋅001), emergency surgery (OR 4⋅08, 2⋅73 to 6⋅10; P < 0⋅001), time to operation at least 48 h (OR 1⋅99, 1⋅28 to 3⋅09; P = 0⋅002) and disease perforation (OR 4⋅00, 2⋅81 to 5⋅69; P < 0⋅001). Conclusion: Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone.

The aim of this study was to evaluate the plasma concentration of diclofenac sodium (DS) in dogs submitted to diclofenaco phonophoresis and to evaluate if phonophoresis induces greater absorption of this drug in dogs. Five dogs were used in eight different groups at different times: One group received oral administration of 40mg of DS per dog and seven groups received topical application of emulgel DS. The topical application area was 20cm2. A continuous ultrasound frequency of 1MHz and intensity of 0.4W cm-2 was used. Blood collections were performed before the treatment (T0), and 1h (T1) and 4h (T2) after ultrasound application for all groups. DS concentrations in plasma were measured by high performance liquid choramatohraphy (HPLC). There was significant increase of DS plasma concentration only at T1 in the oral administration group. It was not possible to detect any concentration of DS in the plasma of dogs after topical application of DS, even after DS phonophoresis. The facil...

This is the first case report of an adult who had spontaneous reduction
of ileoileal intussusception occurred after punching to the abdomen.
A 40-year-old man was brought to our emergency department
by ground ambulance due to pounding and punching a few hours ago.
Physical examination showed multiple dermabrasions on his face, abdomen,
and lower extremities. All other examinations were unremarkable
except that of mild abdominal pain. Laboratory results gave no
clues. On abdominal x-ray, paucity of intestinal gas, pseudomass and
surrounding gas appearances were visible. No nausea or vomiting occurred
during observation. His abdominal pain resolved gradually. On
the 24th hour after admission, control computed tomography showed
that the findings of intussusception disappeared. He was discharged
after 1 day of observation. Outpatient follow-up did not show any abnormality.
We suggest that, in patients with mild to moderate trauma,
even if the patient has mild abdominal pain, physicians should rule
out invagination. Computed tomography is the suggested imaging modality.
These patients should be kept in close follow-up. If symptoms resolve
and intussusception findings disappear in computed tomography,
no further treatment is required.

Background We investigated the utility of the red cell distribution width (RDW) in diagnosing acute mesenteric
ischemia (AMI) in patients with abdominal pain.
Methods The patients were divided into two groups in this retrospective case–control study: patients with AMI and
patients with abdominal pain who did not require urgent surgery. Venous blood was collected from the patients upon
admission to the emergency department, and abdominal computed tomography angiography was performed. The
RDW and hematological and biochemical parameters of the groups were compared. The primary outcome was AMI
among the patients with abdominal pain. The secondary outcome was mortality, complaint period, and size of
ischemia/necrosis among the AMI patients.
Results The RDW, white blood cell lactate dehydrogenase, and blood urea nitrogen of the patients with AMI were
significantly different from those of the control group. When the average RDW (15.04 %) of the patients with AMI
was used as a cut-off value, the sensitivity, specificity, positive likelihood ratio (?LR), and negative likelihood
(-LR) were 40.8 %, 81.2 %, 2.17, and 0.73, respectively. When patients with AMI and anemia were included in the
group, the sensitivity and specificity values did not change. There was no relation between the RDW and mortality,
size of the ischemia/necrosis, and complaint period. Furthermore, there was no significant difference in the average
RDW between the patients with ischemia/necrosis in the small intestine only and those with ischemia/necrosis in the
colon.
Conclusion The RDW on admission is of marginal help to diagnose AMI among patients with abdominal pain.

Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as postoperative analgesia by the Enhanced Recovery After Surgery Society. Recent studies have raised concerns that NSAID administration following colorectal anastomosis may be associated with increased risk of anastomotic leak. This multicentre study aims to determine NSAIDs&#39; safety profile following gastrointestinal resection. This prospective, multicentre cohort study will be performed over a 2-week period utilising a collaborative methodology. Consecutive adults undergoing open or laparoscopic, elective or emergency gastrointestinal resection will be included. The primary end point will be the 30-day morbidity, assessed using the Clavien-Dindo classification. This study will be disseminated through medical student networks, with an anticipated recruitment of at least 900 patients. The study will be powered to detect a 10% increase in complication rates with NSAID use. Following the Research Ethics Committee Chair...

The aim of this study was to evaluate the plasma concentration of diclofenac sodium (DS) in dogs submitted to diclofenaco phonophoresis and to evaluate if phonophoresis induces greater absorption of this drug in dogs. Five dogs were used in eight different groups at different times: One group received oral administration of 40mg of DS per dog and seven groups received topical application of emulgel DS. The topical application area was 20cm². A continuous ultrasound frequency of 1MHz and intensity of 0.4W cm-2 was used. Blood collections were performed before the treatment (T0), and 1h (T1) and 4h (T2) after ultrasound application for all groups. DS concentrations in plasma were measured by high performance liquid choramatohraphy (HPLC). There was significant increase of DS plasma concentration only at T1 in the oral administration group. It was not possible to detect any concentration of DS in the plasma of dogs after topical application of DS, even after DS phonophoresis. The facilitation of transdermal penetration by ultrasound has not been verified under the protocol specified in this research.

The "port-site metastasis" represents a tumor recurrence that develops in the abdominal wall within the scar tissue of the insertion site of one or more trocars, after laparoscopic surgery, not associated with peritoneal carcinomatosis. This last aspect is central because in the literature some isolated cases are reported, but most cases are associated with peritoneal carcinomatosis. The first case in the literature dates back to 1978 and in the literature, the incidence varies from 1% to 21%, although most published research reports a very small number of patients. Currently, the incidence in a specialized cancer center is consistent with the incidence of recurrence on a laparotomy scar. Possible mechanisms for cell implantation at the port site are direct implantation into the wound during forced, unprotected tissue retrieval or from contaminated instruments during tumor dissection; the effect of gas turbulence in lengthy laparoscopic procedures, and embolization of exfoliated cells during tumor dissection or hematogenous spread. Probably, however, the triggering mechanism is necessarily multifactorial. To date, the only significant prognostic factor in patients diagnosed with port-site metastasis is the interval between laparoscopy and the diagnosis of the port site: in fact, patients who develop the port site within 7 months after surgery have a generally worse prognosis, as well as port-site metastasis are more frequent in advanced cancers and the presence of ascites. To reduce the risk, the following measures are proposed in the literature: 1) Select the patient who does not have a metastatic oncologic condition or friable cancerous masses or lymph node spread or attached external or intracystic vegetations, preferring well-localized, benign or low-malignant or otherwise intact tumors; 2) Use wound protectors and use of protective bags (or endo bag) for tissue retrieval; 3) Peritoneal washing with heparin, to prevent free cell adhesion, or washing with cytocidal solutions. Evaluate the utility of using Povidone-iodine, Taurolidine (which has anti-adhesion activity and decreases proangiogenic factors), and chemotherapy products; 4) Avoid removing pneumoperitoneum with trocars in place; 5) Avoiding direct contact between the solid tumor and the port site; 6) Prefer laparoscopy to laparotomy, if possible; 7) Avoid the use of gas or direct CO2 insufflation, although in literature the point is controversial and deserves more attention and study, as the initial hypothesis that CO2 increased the invasion capacity of tumor cells (in vitro and in vivo) has been refuted several times. Insufflation of hyperthermic CO2 and humidified CO2 leads to a better outcome in patients with a malignant tumor who undergo a laparoscopic procedure compared with normal CO2 pneumoperitoneum; 8) Comply with surgical protocols and techniques by updating one's surgical skills, as it has been demonstrated, as already reported here, the presence of cancerous cells on instruments, washing systems and trocars (in particular, on the trocars of the first operator). Suturing all layers of the abdominal wall decreases the risk of the port site; 9) Avoid excessive manipulation of the tumor mass during the surgical/operative procedure.

Background: The purpose of this study was to develop a large incisional hernia pattern made on an animal that is clinically relevant, to design a new original surgical technique to repair abdominal wall defect, and to evaluate its effectiveness, aiming to apply it on patients. Methods: Physical examination and ultrasound scan was performed at fixed intervals at 3, 7, 14 and 30 days. Postoperative complications were followed. To evaluate the resistance of the repair, the swine model went through gestation and given birth process. Results: There are the following situations: wound infection, enteric fistula, stoma, or retraction of the abdominal wall, when direct synthetic mesh repair is inadequate. Biological meshes may be placed to achieve abdominal wall reconstruction, but they are associated with a high recurrence risk. The good result is based on the flap properties of biocompatibility and incorporation into the surrounding tissue. If some surgeons questioned the flap repair, which would not provide the required resistance, the reinforcement with the mesh would ensure it. The advantage of using the flap directly into the defect reduces the risk of infection. Mechanical test of abdominal rectus muscle across the repair site was performed and no test is better than the gestation and given birth process. Conclusion: The technique accomplishes the reconstruction of a functional dynamic abdominal wall via the antilogous vascularized tissue flap and the mesh insertion, which will reinforce the repair. We recommend it due to the fast tissue regeneration and resistance to pressure forces on different physiological acts.

Fistulele anastomotice în chirurgia digestivă reprezintă o complicaţie gravă, care poate duce la decesul pacientului. Identificarea unor probe paraclinice de laborator care să permită diagnosticul precoce al fistulelor ar permite optimizarea managementului pacientului. Noi am efectuat un studiu prospectiv pe 100 pacienţi cu cancer, operaţi pe tubul digestiv, între mai 2016 şi decembrie 2017, în Clinica I de Chirurgie Generală şi Oncologică a Institutului Oncologic din Bucureşti (IOB). Urmărirea postoperatorie a inclus determinarea proteinei C reactive (PCR), monitorizarea numărului de leucocite (Ld) din cavitatea peritoneală (din produs biologic recoltat de pe tubul de dren), asociat cu numărul de leucocite din sânge (Ls) la toţi pacienţii cu sau fără fistulă digestivă. În funcţie de valorile acestor probe biologice şi de evoluţia clinică, în cazuri selecţionate s-au asociat alte explorări paraclinice pentru confirmarea diagnosticului. Datele obţinute au arătat că la pacienţii cu fistule digestive are loc o creştere rapidă şi o menţinere la valori ridicate a PCR şi a leucocitelor din cavitatea peritoneală, la care s-a asociat şi o creştere a leucocitelor din sânge. Modificările apar cu aproximativ două zile înainte de apariţia semnelor clinice şi a confirmării lor prin probe imagistice (ecografie, computer tomograf).