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Abstract Book

All abstracts were published as they were prepared by authors.

XVII Annual Meeting of the European Society of Surgery Malta 2013

Abstracts Book

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XVII Annual Meeting of the European Society of Surgery – Malta 2013

INDEXCutajar C.L.; THE HISTORY OF MEDICINE IN MALTA: OPENING SESSION.; 6Session BARIATRIC SURGERY 7 Luigi Schiavo, Giuseppe Scalera, Alfonso Barbarisi PRE- AND POSTOPERATIVE NUTRITIONAL CONSIDERATIONS TO BETTER MANAGE BARIATRIC SURGERY PATIENTS. 8Gabriele De Sena, MD - Renato Sergio, MD - Vincenza Capuozzo, MD – Giovanni Giordano, MD - Francesco Iovino, MD - Giuseppe Scalera, MD PROPOSAL OF A BARIATRIC SURGERY UNIT: OUR EXPERIENCE 9Session UPPER GI SURGERY AND UPPER GI CANCER 10Jo Etienne Abela, Godfrey LaFerla; THREE-STAGE OESOPHAGECTOMY FOR END-STAGE ACHALASIA; 11Christian Petkov; HOW TO DIAGNOSE AND OPERATE SMALL BOWEL TUMORS; 12

GIST: EXPERIENCE OF OUR SURGERY CENTER; 13Omar Sadieh,MD MRCS-Mahmoud Khashashneh MD MRCS-Nedal Shawagfeh,MD- Loai Bani Essa INCIDENTAL FINDING OF GALLBLADDER CARCINOMA. 14Dr K. Chircop, Dr S. Aquilina, Dr A. Mizzi; PERCUTANEOUS BILIARY DRAINAGE AND STENTING. THE FIRST AUDIT REPORT OF THE MALTESE EXPERIENCE; 15Lemaire J, Rosiere A, Bertrand C, Demoor V, Michel; SPLENECTOMY FOR MASSIVE SPLENOMEGALY (MS); 16Jo Etienne Abela, Mark Schembri; THE ANTERO-POSTERIOR APPROACH FOR LAPAROSCOPIC SPLENECTOMY IN SPLENOMEGALY; 17Ms Elaine Borg, Dr Doriella Galea, Dr Stephanie Azzopardi, Mr Mark Schembri; AUDIT ON PATIENTS’ PREFERENCE REGARDING SAME-DAY DISCHARGE POST-LAPAROSCOPIC CHOLECYSTECTOMY AT MATER DEI HOSPITAL; 18Session SAFETY IN THE OPERATING THEATRE 19Cutajar C.L.; OPERATING ROOM ERRORS; 20N Suleyman, E Williams, I Sagriotis, D L Stoker; WAITING TIME FOR LAPAROSCOPIC CHOLECYSTECTOMY AT A LONDON DISTRICT GENERAL HOSPITAL; 21N M Suleyman, J Wright; AN AUDIT OF POST-OPERATIVE PRESCRIBING AT A LONDON DISTRICT GENERAL HOSPITAL; 22Farhana Akter, Aneela Hameed, Mansoor Akhtar, Ayman Hamade; PREVENTION OF SURGICAL SITE INFECTION; 23Andrey Kudryavtsev, Valery Kryshen, Artem Breus; SAFETY MAINTAINING AFTER LAPAROSCOPIC STRANGULATED HERNIA REPAIR; 24Session THE ACUTE ABDOMEN 25František Vyhnánek; TRAUMA DAMAGE CONTROL SURGERY; 26Salvatore Guarino, Antonio Catania, Salvatore Sorrenti, Deborah Maria Giusti, Matteo Nardi, Carlo Di Marco, Grazia Savino, Enrico De Antoni; BLUNT TRAUMAS. MANAGEMENT OF INTRABDOMINAL INJURIES IN A UK MAJOR TRAUMA CENTER; 27Session COLO-RECTAL SURGERY AND PROCTOLOGY 28Gallo G, Ferrari F, Carpino A, Sena G, Silipo D, Vescio G, Sammarco G, Sacco R; WHAT’S THE FUTURE FOR THE MILLIGAN-MORGAN’S TECHNIQUE? 29Gallo G, Carpino A, Ferrari F, Ammendola M, Sena G, Vescio G, Sammarco G, Sacco R; THE SLIDE : OUR EXPERIENCE; 30Melnik Idit MD, Oleg Dukhno MD, Ornit Cohen M.MED Sc ,Dimitry Goldstein MD, Boris Yoffe MD FACS; WHEN TO GO SINGLE? A COMPARISON BETWEEN SINGLE PORT AND THE TRADITIONAL MULTIPORT TECHNIQUE FOR COLON RESECTIONS. 31Tikfu Gee, Emad H Aly; SCARLESS SURGERY!! SINGLE INCISION LAPAROSCOPIC SURGERY (SILS) - AN ALTERNATIVE SURGICAL APPROACH OF MINIMALLY INVASIVE SINGLE PORT SURGERY IN COLORECTAL SURGERY; 32Pierpaolo Sileri , Luana Franceschilli, Federico Perrone, Ilaria Carolina Ciangola, Ilaria Capuano, Federica Giorgi, Achille Lucio Gaspari; LAPAROSCOPIC VENTRAL RECTOPEXY FOR INTERNAL RECTAL PROLAPSE USING BIOLOGICAL MESH:A CRITICAL APPRAISAL AFTER 100 CASES; 33Session EMERGENCY SURGERY AND TRAUMA; 34Obondo CA, Moussa O, Muthukumarasamy G, White RD, McBride K, Bhat R, Beverage E, Brennan JC, Holdsworth R.; CLINICAL OUTCOMES OF ENDOVASCULAR TREATMENT IN CHRONIC SYMPTOMATIC MESENTERIC ISCHAEMIA; 35O. Sadieh, Asem Ghasoup,MD MRCS-Mahmoud Khashashneh,MD MRCS-Isamil Marey,MD-Adala Al Anzi,Abeer Al Anzi THE OUTCOME OF PATIENTS WITH BLUNT CHEST TRAUMA AND PULMONARY CONTUSION. 36Mrktich Mrktichyan, Hovhannes Sarkavagyan, Tigran Khachatryan, Armen Khanoyan, Artak Manukyan, Artur Sardaryan, Hayk Kikoyan; TRAUMATIC RUPTURE OF THE DIAPHRAGM; 37Kryshen V.,Kudriavtchev A.; TAPP MODIFYING TECHNIQUE FOR STRANGULATED INGUINAL HERNIA; 38Baras R. Karakas, M.D.1 , Aslinur Sircan-Kucuksayan, M. S.2, Gulsum uzlem Elpek, M.D. Prof. 3, Murat Canpolat, PhD. Prof. Dr.2; ASSESSMENT OF THE INTESTINAL VIABILITY BY DIFFUSE REFLECTANCE SPECTROSCOPY ON ISCHEMIA-REPERFUSION INJURY IN THE RAT; 39Marvan J., Bačová J., Antoš F., Fanta J.; SPECIFIC ISSUES IN THE MANAGEMENT OF AN ACUTE ABDOMEN IN PSYCHIATRIC PATIENTS; 40Dobbs T, Aveyard N, Bratby M, Hormbrey P; DEEP VEIN THROMBOSIS - HAVE YOU CONSIDERED MAY-THURNER SYNDROME? 41Session UPTODATE ON ENDOCRINE SURGERY 42Camenzuli C., Micallef A., Sammut Henwood K., Betts A.; DEMOGRAPHICS AND INCIDENCE OF THYROID CANCER: A POPULATION STUDY; 43Camenzuli C., Cassar N., Psaila J., Attard A.; USE OF CLOSED DRAINS UNDER SUCTION AFTER HEMITHYROIDECTOMY- A PRELIMINARY REPORT OF A RANDOMIZED CONTROLLED TRIAL. 44

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Nicola PALESTINI, Enrico BRIGNARDELLO, Milena FREDDI, Marco GALLO, Alessandro PIOVESAN, Guido GASPARRI; 45IMPACT OF SURGERY ON SURVIVAL IN ANAPLASTIC THYROID CARCINOMA. A CASE SERIES OF PATIENTS REFERRED TO A SINGLE INSTITUTION BETWEEN 1999-2012; G.Gallo; G.Tomaino; N.Innaro; R.Sacco; IONM: OUR EXPERIENCE; 46Marcin Barczynski, Aleksander Konturek, Małgorzata Stopa, Wojciech Nowak; SCREENING FOR PRIMARY HYPERPARATHYROIDISM IN ELDERLY PATIENTS BEFORE THYROID SURGERY: RESULTS OF A RETROSPECTIVE COHORT STUDY WITH FIVE-YEAR FOLLOW-UP.; 47Cherenko S., Larin O., Tovkay O.; DIFFERENT OPTIONS OF ENDOSCOPIC ADRENALECTOMY FOR DIFFERENT ADRENAL LESIONS: LESSONS FROM EXTENSIVE PERSONAL EXPERIENCE; 48Session DECISION MAKING AND TRADE-OFFS IN SURGERY 49Arthur Felice, MD, MSc. FRCS Ed, FEBS.; PROCESSES IN CLINICAL DECISION MAKING; 50Kevin Cassar; THE ROLE OF NON INVASIVE IMAGING IN CLINICAL DECISION MAKING AT A VASCULAR ONE STOP CLINIC; 51Jo Etienne Abela;MANAGEMENT OF COMPLICATIONS OF ACUTE SEVERE PANCREATITIS - INVITED TALK; 52Patrick Zammit; PREDICTION OF SUPERFICIAL BLADDER CANCER DISEASE PROGRESSION USING ARTIFICIAL NEURAL NETWORKS; 53Miroslav Jirik 1, Miroslava Svobodova 2, Hynek Mirka 3, Vladislav Treska 2, Jan Bruha 2, Vaclav Liska 2; LIVER SEGMENTATION AND VOLUMETRY FROM PREOPERATIVE CT IMAGES, MANUAL AND SEMIAUTOMATIC ESTIMATION; 54Noel Cassar, Joseph Debono; PREDICTING AXILLARY LYMPH NODE METASTASIS PREOPERATIVELY TO AVOID UNNECESSARY AXILLARY SURGERY? 55Rumyana Rumenova Smilevska, Andres Garcia Marin, Asuncion Candela Gomis, Valentin N. Rodriguez, Maria Mingorance Alberola, Elena Martinez Guerrero, Miguel Morales Calderon, Salvador Garcia Garcia; EARLY VS. DELAYED CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS EVIDENCE VS. EXPERIENCE; 56Ms Elaine Borg, Dr Adrian Mifsud, Ms Josephine Psaila; FEEDING POLICY FOR ACUTE SURGICAL ADMISSIONS; 57Gyorgy Lazar, Zsolt Simonka, Attila Paszt, Szabolcs Abraham, Janos Tajti; LAPAROSCOPIC AND OPEN SURGICAL TREATMENT OF COLITIS ULCEROSA - A RETROSPECTIVE ANALYSIS; 58Session POSTGRADUATE SURGICAL TRAINING 59Kevin Cassar; PROFESSIONALISM IN SURGICAL POSTGRADUATE TRAINING; 60Stroman L, Johnston M, Arora S, King D, Darzi A; CHANGES IN THE SURGICAL TEAM MODEL TO IMPROVE JUNIOR DOCTOR SUPERVISION: AN INTERVENTION STUDY; 61N. Pavia, S. Grixti, M. Brincat, O. Tsar, I. Knyazev, J. Mamo; EFFECT OF LAPAROSCOPIC SIMULATION TRAINING ON GYNAECOLOGICAL SURGERY; 62Angeliki Lintzeri, Xanthi Agrogianni, Ioannis Lintzeris; THE ROLE OF RADIOFREQUENCY ABLATION IN SURGERY TREATMENT; 63Session MISCELLANEUS SURGICAL TOPICS 64Darmanin M, Umana E, Debono J; MRI RESULT AND TREATMENT OUTCOME IN BREAST CANCER PATIENTS; 65Alexander Manchea; CORONARY SURGERY IN THE OVER 70’S: SHORT AND LONG-TERM OUTCOMES. IS IT WORTHWHILE? 66Ms E. Borg, Prof K. Cassar; PROSPECTIVE STUDY OF MANAGEMENT AND OUTCOME OF INPATIENT DIABETIC FOOT ULCERS AND GANGRENE ACCORDING TO WAGNER›S CLASSIFICATION IN A TERTIARY HOSPITAL IN MALTA; 67Hannah King, Amanda Rea, Nick Kalson, Georgios Akritidis, Bimbi Fernando, Fiona Mint, Seraphim Patel; QUALITY OF CONSENT DOCUMENTATION FOR MAJOR SURGICAL PROCEDURES REFLECTS THE OUTCOME OF THE CONSENT PROCESS; 68Gordon Caruana-Dingli; IMPROVING THE AESTHETIC OUTCOME OF BREAST CANCER SURGERY; 69Joseph Galea, Alexander Manche; GENERAL SURGICAL COMPLICATIONS FOLLOWING CABG; 70Ian Said, Kevin Cassar; IS DEEP TISSUE BIOPSY CULTURE SUPERIOR TO SUPERFICIAL SWAB CULTURE IN THE EVALUATION AND TREATMENT OF DIABETIC FOOT INFECTION? 71Aaron Casha,Alexander Manche, Ruben Gatt, Marilyn Gauci, Pierre Schembri Wismayer, Marie-Therese Camilleri-Podesta, Joseph N Grima; IS THERE A BIOMECHANICAL CAUSE FOR SPONTANEOUS PNEUMOTHORAX? 72Lara Sammut, Annalisa Montebello, Gianluca Bezzina, Ali Virk, Gerald Busuttil; AN AUDIT OF URINARY TRACT INFECTIONS AT THE UROLOGY UNIT AT MATER DEI HOSPITAL, MALTA; 73Max Mifsud, Kevin Cassar; RANDOMISED CONTROLLED TRIAL OF ELECTRICAL CALF MUSCLE STIMULATION IN INFRAINGUINAL BYPASS SURGERY; 74Poster Session 75Asem Ghasoup,MD MRCS, Omar Sadieh,MD MRCS- Mahmoud Khashashneh MD,MRCS-Ismai Marey,MD-Nedal Shawagfeh,MD,Adala Al Enzi,Abeer Al Enzi EARLY MARKERS OF ACUTE RESPIRATORY DISTRESS SYNDROME IN SEVERE TRAUMA PATIENTS. 76Borasi Andrea, Bossotti Maurizio, Bona Alberto, Bellomo Maria Paola, Manfredi Silvio, LAPAROSCOPIC APPROACH TO ACUTE APPENDICITIS: OUR 8 YEARS EXPERIENCE AND COST ANALYSIS. 77Butyrsky Olexandr, Dubovenko Viktor, Govorunov Igor, Butyrska Iryna, Makeieva NadiiaABOUT OBLIGATORY NECK LYMPH NODE DISSECTION IN PAPILLARY THYROID CANCER. 78Kryshen V., Lyashenko P.; DYNAMICS OF CD -4 LYMPHOCYTES AT PERITONITIS DURING SORPTION DIALYSIS APPLICATION. 79

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Kryshen V., Lyaschenko P.; DYNAMICS OF ENDOGENOUS INTOXICATION DUE TO TRANSMEMBRANE DIALYSIS FOR PERITONITIS. 80Trofimov M.V.; DYNAMICS OF BLOOD SEROTONIN AT PATIENTS WITH BLEEDING GASTRO-DUODENAL ULCER. 81Kryshen V.P, Trofimov M.V.; DYNAMICS OF BLOOD CATECHOLAMINE AT PATIENTS WITH BLEEDING GASTRODUODENAL ULCER. 82Iarynko D.,Trofimov M., Kryshen V.,Iarynko A.; DYNAMICS OF BLOOD TYROSINE AT PATIENTS WITH BLEEDING GASTRODUODENAL ULCER. 83Manafov S.S.,Gerayzade R.B.; COMPARISON OF OPPORTUNITIES OF RADIOLOGICAL METHODS IN ACUTE INTESTINAL OBSTRUCTION CAUSED BY A COMPLICATED EXTERNAL ABDOMINAL HERNIA. 84Manafov S.S.,Gerayzade R.B.; OLE OF ULTRASOUND IN THE SELECTION OF TREATMENT STRATEGY FOR MALIGNANT LARGE-BOWEL OBSTRUCTION (LBO). 85Baris R. Karakas, M.D., S. Halide Akbas, M.D. Prof., Gulsum Ozlem Elpek, M.D. Prof., Fatih CELIK, M.D., Kemal Hakan Gulkesen, M.D., PhD. Assist. Prof., Nurullah Bulbuller, M.D., Assoc. Prof.; THE EFFECTS OF LUTEOLIN ON THE INTESTINAL ISCHEMIA/REPERFUSION INJURY IN MICE. 86Kirien Kjossev, Georgi Gurbev, Evgeni Belokonski, Ivan Teodosiev, Tihomir Atanasov.; IMPACT OF INTRAOPERATIVE COMPLICATIONS IN SURGERY FOR LIVER ECHINOCOCCOSIS. 87Mr. Matthew T. Fenech, Dr. James G Diamond; SILICONE OIL COMPLICATIONS IN RETINAL DETACHMENT REPAIR. 88Mr Noel Cassar, Dr Alistair Bezzina, Mr Ernest Ellul; FEMORAL HERNIA AUDIT AT MATER DEI HOSPITAL 2009-2011. 89Richard Apap Bologna, John Camilleri-Brennan MD, FRCS; PERIPHERAL VENOUS CANNULAS IN GENERAL SURGICAL WARDS: ARE WE FOLLOWING THE GUIDELINES? 90Liska Vaclav 1, Treska Vladislav 1, Daum Ondrej 2, Novak Petr1, Vycital Ondrej 1, Bruha Jan 1, Pitule Pavel 1; TUMOR INFILTRATING LYMPHOCYTES AS PROGNOSTIC FACTOR OF EARLY RECURRENCE AND POOR PROGNOSIS OF COLORECTAL CANCER AFTER RADICAL SURGICAL TREATMENT. 91Mark Portelli, John Camilleri-Brennan MD FRCS; ANALGESIA IN POST-OPERATIVE DAY SURGERY PATIENTS: STANDARDISED REGIME OR INDIVIDUAL VARIATION? 92Ethan Caruana, John Camilleri-Brennan MD FRCS; GENERAL PRACTITIONER REFERRALS TO THE COLORECTAL SERVICE: DO THEY CONFORM TO THE PUBLISHED GUIDELINES? 93K. Zarkov, Chr. Petkov, N. Nickolov, M. Nickolov; ASPECTS OF THE TECHNICAL POSSIBILITIES FOR SPHINCTER PRESERVATION IN ULTRA LOW ANTERIOR RECTAL RESECTIONS. 94Rumyana Rumenova Smilevska, Andres Garcia Marin, Asuncion Candela Gomis, Valentin N. Rodriguez, Maria Mingorance Alberola, Elena Martinez Guerrero, Miguel Morales Calderon, Salvador Garcia Garcia; INFLAMMATORY MARKERS AND ACUTE CHOLECYSTITIS 95Daniel Vella Fondacaro, Richard Apap Bologna, John Camilleri-Brennan MD FRCS; A PROSPECTIVE EVALUATION OF COMPLICATIONS ASSOCIATED WITH PERIPHERAL VENOUS CANNULATION IN SURGICAL PATIENTS. 96Eleanor Borg, Dr. Mark Brincat, Dr. Sarah Grixti, Dr. Norma Pavia, Mr. John Mamo; BLOOD LOSS AND TRANSFUSION REQUIREMENTS IN MYOMECTOMY PATIENTS AT MATER DEI HOSPITAL. 97Hasan Altun, Aziz Bora Karip, Ahmet Yalin Iscan, Kafkas Celik, Umit Akyuz, Birol Agca, Kemal Memisoglu EARLY AND LATE EFFECTS OF NISSEN FUNDUPLICATION SURGERY ON BODY WEIGHT. 98Ioannis Lintzeris, Xanthi Agrogianni, Angeliki Lintzeri; FLUID ADMINISTRATION IN PATIENTS WITH SEPTIC SHOCK. 99N. Pavia, S. Grixti, O. Tsar, I. Knyazev, J. Mamo; THE CHANGE FROM TRADITIONAL BURCH COLPOSUSPENSION TO LAPAROSCOPIC BURCH PROCEDURE. 100N. Pavia, S. Grixti, M. Brincat, O. Tsar, I. Knyazev, J. Mamo; EFFECT OF LAPAROSCOPIC SIMULATION TRAINING ON GYNAECOLOGICAL SURGERY. 101Ioannis Lintzeris,Angeliki Lintzeri,Xanthi Agrogianni,Georgios Chatzoulis,Venetsanos Ponirakos; SURGICAL WOUND INFECTIONS BY GRAM NEGATIVE BACTERIA AND ANTIMICROBIAL RESISTANCE. 102Farrugia A, Cassar K, Attard A, Abela J, Saliba K, Grech R, Mizzi A; ENDOVASCULAR COILING OF SPLENIC ARTERY ANEURYSMS - A SAFE AND EFFECTIVE ALTERNATIVE TO SURGICAL REPAIR. 103Rumyana Rumenova Smilevska, Andres Garcia Marin, Asuncion Candela Gomis, Valentin N. Rodriguez, Maria Mingorance Alberola, Elena Martinez Guerrero, Miguel Morales Calderon, Salvador Garcia Garcia; EARLY VS. DELAYED CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS - EVIDENCE VS. EXPERIENCE. 104Lara Sammut, Annalisa Montebello, Juanita Parnis, Gerald Busuttil; CASE REPORT - SACRAL HERPES ZOSTER: A RARE CAUSE OF ACUTE URINARY RETENTION. 105Xanthi Agrogianni,Angeliki Lintzeri,Georgios Vourliotakis, Venetsanos Ponirakos, Ioannis Lintzeris; CHRONIC PANCREATITIS AND PERSISTENT PLEURAL EFFUSION- AN UNCOMMON CLINICAL ENTITY. 106Dr Michelle Bugeja, Ms Josephine Psaila; A CASE OF STERNOCLAVICULAR SEPTIC ARTHRITIS IN A PATIENT WITH NO PREDISPOSING FACTORS. 107Omari Gibradze, Mamuka Mikadze, David Tevtoradze, Paata Meshveliani; RADICAL DUODENOPLASTY IN THE TREATMENT OF ELDERLY PATIENTS WITH DUODENAL ULCER COMPLICATED BY BLEEDING. 108Supreet Kaur,Gaurav Maheshwari, Iqbal Singh, R P Doley, Atul Joshi, Rajeev Kapoor, JD Wig; EMERGENCY OR ELECTIVE ABDOMINAL SURGERY IN ELDERLY PATEINTS: IS THERE A DIFFERENCE IN OUTCOME? 109Karakaş BR, Aslaner A, Gündüz UR, Çalış H, Karakoyun Demirci R, Öngen AN, Öner OZ, Bülbüller N.; IS THE DISTANCE OF LATERALIZATION IMPORTANT IN THE ASYMMETRIC MODIFIED LIMBERG FLAP PROCEDURE FOR THE SACROCOCCYGEAL PILONIDAL SINUS TREATMENT? 110Sammut M; THE USE OF PROPHYLACTIC ANTIBIOTICS IN SEVERE ACUTE PANCREATITIS. 111Nathania Bonanno, Simon Aquilina; THE ROLE OF C-REACTIVE PROTEIN AND WHITE CELL COUNT IN THE DIAGNOSIS OF ACUTE APPENDICITIS. 112Kibil W, Hodorowicz-Zaniewska D, Kulig J; MAMMOTOME BIOPSY IN DIAGNOSING AND TREATMENT OF INTRADUCTAL PAPILLOMA OF THE BREAST. 113

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Mr Karl Spiteri, Mr Joseph Debono; COMPARISON OF RADIO-GUIDED OCCULT LESION LOCALISATION (ROLL) VERSUS WIRE-GUIDED LOCALISATION (WGL) FOR BREAST CONSERVING SURGERY FOR IMPALPABLE BREAST CANCER. 114Khalid Akbari, Ragai Makar, Vivien NG, Simon Middleton, Daniel McGrath; THE INFLUENCE OF RESECTED SPECIMEN LENGTH AND TUMOUR DIAMETER ON LYMPH NODE HARVEST IN COLORECTAL CANCER. 115Lintzeris Ioannis, Alexiou Ioannis, Dimitriou Maria, Agrogianni Xanthi, Datsis Konstantinos, Perrakis Nikos, Nomikos Iakovos, Papaemmanouil Virginia; ISOLATION AND CHARACTERIZATION PREVALENCE AND ANTIFUNGAL SENSITIVITY OF CANDIDA SPP IN GREEK CANCER PATIENTS OF A SURGICAL UNIT. 116Kate Huntingford, Miriam Sterkel, Jo Etienne Abela; LAPAROSCOPIC INGUINAL HERNIA SURGERY - A SINGLE SURGEON’S EXPERIENCE. 117Lintzeris Ioannis,Alexiou Ioannis,Dimitriou Maria, Agrogianni Xanthi,Datsis Konstantinos, Perrakis Nikos, Nomikos Iakovos, Papaemmanouil Virginia; ISOLATION AND CHARACTERIZATION PREVALENCE AND ANTIFUNGAL SENSITIVITY OF CANDIDA SPP IN GREEK CANCER PATIENTS OF A SURGICAL UNIT. 118

All abstracts were published as they were prepared by authors.

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Authors - Cutajar C.L.; Afiliation - Dept of Surgery, The Medical School, University of Malta.;

THE HISTORY OF MEDICINE IN MALTA: OPENING SESSION.;

Situated in the middle of the Mediterranean sea, Malta has inherited diverse cultures, including those of medi-cine and health, mainly from mainland Europe. It has a long and rich tradition of medical practice particularly dating back to the advent of the Hospitaller Order of St John of Jerusalem. This presentation traces the develop-ment of medicine in the Maltese islands from ancient times to the present day in the context of medical deve-lopments in Europe and elsewhere.

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Session BARIATRIC SURGERY

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Authors: Luigi Schiavo, Giuseppe Scalera, Alfonso BarbarisiAfiliation: Department of Anaesthesiology, Surgery and Emergency Sciences, School of Medicine, Second Uni-versity of Naples, Naples, Italy

PRE- AND POSTOPERATIVE NUTRITIONAL CONSIDERATIONS TO BETTER MANAGE BARIATRIC SURGERY PA-TIENTS.

Introduction: Bariatric surgery is an effective method of weight loss for the treatment of morbid obesity. Most of bariatric candidates are in state of “high calorie malnutrition” and show some dietary deficiency pre-operatively and needs to adjust their diet before they have bariatric surgery. Objectives: The aim of our study is to investigate the vitamin, mineral and trace element deficiency in patients who are considering bariatric surgery. Material and Methods: 10 obese patients (BMI of 40 Kg/m2 or more) undergoing laparoscopic adjustable gastric band or sleeve gastrectomy were analyzed, in addition to a full blood count, lipid profile and others biochemical markers, for the following micronutrient: iron, vitamin B12, folic acid, vitamin D, vitamin A, vitamin E and zinc. All the analysis were performed in a licensed clinical laboratory.Results: The above reported micronutrient screening tests enable us to recognize a pre-existing nutritional con-cerns with a prevalence of 55–70% for vitamin D, 30% for folate, 25 % for zinc and up to 40% for iron.Conclusion: Although an ample energy intake, most of bariatric surgery candidates show some dietary deficiency pre-operatively, with a prevalence for vitamin D, folate, zinc and iron. Therefore, regardless of the bariatric pro-cedure proposed, a comprehensive screening is recommended, ideally in sufficient time to correct deficiencies before surgery. In conclusion, lifelong vitamin and mineral supplementation is influenced not only by the bariat-ric procedure performed but also by the preoperative status.

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Authors Gabriele De Sena, MD - Renato Sergio, MD - Vincenza Capuozzo, MD – Giovanni Giordano, MD - Fran-cesco Iovino, MD - Giuseppe Scalera, MDAfiliation Department of Anaesthesiological, Surgical and Emergency Sciences - Second University of Naples

PROPOSAL OF A BARIATRIC SURGERY UNIT: OUR EXPERIENCE

Introduction. Bariatric Surgery has in a number of clinical studies proven to be the most effective treat-ment method to achieve sustainable weight reduction and to avoid or reverse obesity related complications. Method. Our Bariatric Surgery Unit offers surgical interventions for bariatric patients, predominantly laparo-scopic, it includes a multidisciplinary team of highly trained bariatric surgeons, plastic surgeons, diabetologists, cardiologistd, bariatric nurses, physiotherapists, nutritionists and dieticians.In three years 157 (71 male, 86 fe-male) mean age 37 (16 – 63) patients have addressed to our center; surgery was contraindicated in 35 patients; 122 underwent to baraitric surgery. We placed an indication of gastric banding for 56 patients (BMI 38,8 kg/m2) and of Sleeve gastrectomy for 66 patients BMI 46,2 kg/m2). 113 surgeries were performed whit traditional lapa-roscopy, 9 whit single-port laparoscopy, no one was converted to laparotomy. Diabetes was present in 13% of GB and 34 % of SG. Arterial hypertension was present in 5% of GB and 12 % of SG. Among patients who underwent SG 9 had amenorrhea and/or infertility. Depression, social and emotional issues were found in 36%.Results. About patients who underwent GB in 3 years of follow up they obtainded an excess weight loss (EWL) of 25,87% at 3 months; 34,84% at 12 months; 40, 68 % at 2 years; 42,32 % at 3 years. About patients who un-derwent SG in 2 years of follow up they e obtainded an EWL of 25, % at 3 months; 57,32% at 12 months; 63, 23 % at 2 years. Complications observed for GB were dysphagia 3,16%; esofagiete 1,6 %; Port disconnection 1,34 %; Port infection 1,25%; psychological disorders 0,51%, no slippage; no migration; no exitus. In 3 cases GB was removed laparoscopically. Complications that we observed for SG were dysphagia 2,24%; esofagie-te 2, 41%; anemia 3,10 %; gastric fistula 0,61 %; no exitus. We observed a risolution of diabetes in 46 % of SG and 27% of GB; a whole resolution of amenorrhea and infertility and an improvement of blood pressure.

Discussion. Obesity is a health and social problem because there are interactions of a multitude of societal, psy-chological, and physiological variables that do not allow a simply solution of the problem. According to our expe-rience surgery alone is not effective to solve this social drama. A multidisciplinar approach seems the only way to get not only the weight loss but above all the improvement of quality of life, maximization of independence, and/or the return to a normal life in the community.

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Session UPPER GI SURGERY AND UPPER GI CANCER

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Authors - Jo Etienne Abela, Godfrey LaFerla; Afiliation - Mater Dei Hospital, Malta;

THREE-STAGE OESOPHAGECTOMY FOR END-STAGE ACHALASIA;

Introduction. Achalasia is a complex disorder characterised by an aperistaltic oesophagus and a hypertensive lower oesophageal sphincter.Materials and methods. We present the case of a 64 years old male with a 40 years history of dysphagia culmi-nating in complete oesophageal failure complicated by the sudden emergence of rheumatoid arthritis of the up-per limb joints, bilaterally. The diagnostic process and the patient’s management with jejunostomy feeding and oesophageal clearance followed by three-stage oesophagectomy will be described. The latter will be described in detail with illustration. Alternative surgical techniques and the reasons for not employing them in this case will be described. Results. The patient’s post-operative recovery was uneventful with satisfactory blue-dye and radiological con-trast testing on day 5 and introduction of normal texture diet on day 8. He is well and thriving on follow-up. Conclusion. Three-stage oesophagectomy appears to be safe and effective treatment for end - stage achalasia even in the high-risk patient.

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Authors - Christian Petkov; Afiliation - First Surgical Department, Fifth General Hospital, Sofia, Bulgaria;

HOW TO DIAGNOSE AND OPERATE SMALL BOWEL TUMORS;

Objectives: As usual small bowel tumors are found on table during emergency surgery for bowel obstruction. To diagnose a small bowel tumor before operation is very rare and is a special skill. Aiming to reveal: What may suggest us about a small bowel tumor? What are the diagnostic methods and the algorithm to verify a small bowel tumor? What is the appropriate time for surgery and the radical operation of operation? To assess histopathology and survival. Methods: Clinical exam exhibits in bowel obstruction of different degree. Some had anemia. Diagnostics starts with native X-ray examinations, ultrasound; barium enema and colonoscopy are next step. Barium follow-thro-ugh and CT scan are considered later. Radical operation comprises radical bowel resection and lymph node dis-section along the superior mesenteric vein up to the lower edge of pancreas. Results: For 10 years we operated 18 small bowel tumor patients. Tumor was in mesenterium in 4 cases (leyomy-oma and lyposarcoma) necessitating bowel resection. Invagination in 3 cases. Histopathology: Adenocarcinoma - 5; Carcinoid - 4; Schwanoma -2; Leyomyoma - 2; Lyposarcoma - 2; Inflammatory pseudotumor - 3. Frozen sec-tions of lymph nodes were done in all cases, metastatic found in 2. Removed lymph nodes - 14 to 19 per patient; found metastatic - 2 to 10 in 4 patients. No major morbidity. No perioperative mortality. Detailed survival is pre-sented. Ultrasound may exhibit abdominal tumor. Barium enema and colonoscopy are negative. If small bowel tumor is suggested barium follow-through or CT scan with swallowed and venous contrast medium should be performed for verifications. Histopathology was not and could not be evident before operation. Conclusion: Small bowel tumors are difficult to be diagnosed before operation. Macroscopic view of the tumor is not predictive for malignancy. Negative lymph nodes on express histopathology examination do not exclude malignancy - radical resection with lymphadenectomy should be done.

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Raffaele Costantini, Francesco Caldaralo, Paolo Innocenti; Afiliation - Institute of Surgical Pathology, G. D`Annunzio” University of Chieti, Italy;

GIST: EXPERIENCE OF OUR SURGERY CENTER;

Introduction: The diagnosis of GIST, rare gastrointestinal stromal tumors, is often difficult due to aspecific symp-tom onset in many cases. Surgery is the gold standard therapy, but its outcome largely depends on early diagno-sis. Objectives: The aim of the study is to report the experience of our Surgery Center for GIST cases over 12 years. Material and Methods: GIST cases were retrospectively examined relative to the period January 2000-December 2012, for: sex and age of patients, symptoms, outcome of preoperative instrumental examinations (preoperative diagnosis of GIST: yes, no), localization of GIST, type of intervention, follow-up. Results: 19 patients (43-81 years) proved to have GIST while 1 preoperatively suspected GIST (77 years) was a fal-se positive. Patients were either asymptomatic (14%) or presented aspecific symptoms in various combinations: dyspepsia, abdominal pain, anemia, melena, asthenia, anorexia. Preoperative diagnoses were: GIST in 4 cases (only 3 subsequently confirmed), leiomyoma (n.2), neoplasia (n.13), pancreas carcinoma (n.1). At surgery, GIST localization in the 19 positive patients was: 12 stomach, 3 duodenal, 3 ileal and 1 oesophageal. The false positive was: gastric Schwannoma. Interventions performed were: gastric wedge resection (n.5), Billroth II gastrecto-my (n.9), distal oesophageal resection-oesophagoplastic (n.1), pancreaticoduodenectomy (Whipple procedure)(n.1), videoassisted ileal resection (n.3), de-rotation+duodenal resection (n.1). Three deaths occurred after 1, 9 and 12 months while no recurrence was observed in the remaining cases. Conclusion: Our casuistry confirms the difficulty in the preoperative diagnosis of GIST but also shows the optimal outcome of the surgical approach to treatment of this type of tumor.

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Authors- - Omar Sadieh,MD MRCS-Mahmoud Khashashneh MD MRCS-Nedal Shawagfeh,MD- Loai Bani Essa Afiliation - Princes Raia Hospital Irbid-Jordan , Al Bashir Hospital Amman-Jordan

INCIDENTAL FINDING OF GALLBLADDER CARCINOMA.

Background: Carcinoma of the gallbladder is the fifth most common gastrointestinal malignancy (and the most common of the biliary tract) and is usually discovered accidentally. Gallbladder carcinoma is diagnosed patholo-gically in 0.3-1.5% of cholecystectomy specimens. AIM and Objectives: To evaluate the impact of incidental gallbladder cancer on surgical experience and to esta-blish the overall rate of gallbladder carcinoma. Methods: We retrospectively evaluated all consecutive cholecystectomies performed in our ward from (2007-2012) in order to Determine the incidence of gallbladder carcinoma and to identify common characteristics of this particular group of patients. Results: Of the 580 cholecystectomies performed in our ward from 2007-2012, gallbladder carcinoma was dia-gnosed in six patients (1.03%) but was not suspected prior to surgery in any of them. In accordance with the literature, the occurrence in women (4/6) was higher than in men (2/6). The mean age was 64 years (range 55-90).The most common symptom was abdominal pain; the majority (5/6) had cholelithiasis, and the pathologic report confirmed the diagnosis of adenocarcinoma in all six patients. Conclusions: The overall incidence of unsuspected gallbladder carcinoma in our series was 1.03%. We could not find any common characteristics for this particular group of patients when compared to patients with non-ma-lignant pathology.

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Authors - Dr K. Chircop, Dr S. Aquilina, Dr A. Mizzi;

PERCUTANEOUS BILIARY DRAINAGE AND STENTING. THE FIRST AUDIT REPORT OF THE MALTESE EXPERIENCE;

Background: Biliary obstruction requiring drainage is a common clinical scenario, with the majority of cases being managed endoscopically. Percutaneous intervention performed by skilled radiologists is a well-recognized treatment option, both for failed endoscopy cases and as well as for other specific case scenarios. Aim: This is a retrospective audit to evaluate the local practise with regards percutaneous biliary intervention. Does the local practice compare to the data published internationally? Methods: We performed a retrospective review of the percutaneous biliary interventions performed at Mater Dei Hospital, Malta in the last three years (40 cases). Using the medical imaging database and the individual patients hospital data, the population demographics, procedural indication, technical success, bilirubin shifts, survival curves and complication rates were individually evaluated. Results: Percutaneous biliary intervention is a safe and effective method for treating biliary obstruction. The local practice compares very closely to that published in the international literature.

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Authors - Lemaire J, Rosiere A, Bertrand C, Demoor V, Michel; Afiliation - Surgical Services, Mont-Godinne UniversitY Hospital, University of Louvain;

SPLENECTOMY FOR MASSIVE SPLENOMEGALY (MS);

Objective: Splenectomy for MS (i.e. weight > 1.5kg) is still considered a) to be hazardous and b) to provide poor palliation for haematologic cytopenias. Design: Analysis of the prospective records of 48 consecutive patients (30%) presenting debilitating MS taken out of our series of 161 splenectomy performed for haematologic diseases over the past three decades. Patients: Sex ratio 19F/29M; mean age 62 (median 64, range 26-83). Indications for operation are thrombo or pancytopenia (n=30) associated with major abdominal discomfort (n=40) in the course of lymphoma (n=30), myelofibrosis (n=8), polycythemia vera (n=3), and other rare diseases (n=7: 1 Niemann-Pick, 1 hystiocytosis, 2 microspherocytosis, 1 sideroplastic anemia with hemochromatosis, 1 idiopathic segmental portal hypertension, 1 autoimmune thrombocytopenic purpura). Surgical approach: Splenectomy was performed in 34 patients (71%) through an original oblique incision starting below the left costal margin at the level - and in the axis of the 9th intercostal space and descending toward the umbilicus. A median laparotomy was elected in the remaining 14 patients for less important MS (i.e. weight at 2kg) and/or associated with peritoneal surgery (5 cholecystectomy, 3 vagotomy, 1 left nephrectomy, 1 Nissen, 1 abdominal aortic aneurysma,). For all 48 cases, the splenic artery was ligated at the beginning of operation in order to realize an autotransfusion of the splenic blood content and to decompress the spleen. Results: The normal ratio of body weight to spleen weight in kg is between 250-500; in this study the mean was 32 (median 32, range 6-64). Postoperatively, one patient got abdominal wall hematoma and two had a second look operation 2 and 3 hours after initial surgery for active bleeding in the splenic bed. There was no operative or postoperative death. Mean hospital stay of 11 days (median 10, range 7-20); mean follow up (FU) of 51 months (median 52, range 2-180). Survival by the Kaplan-Meier estimator is interesting: so far 16 patients (33.3%) are alive more than 5 years after surgery compared with 13 deaths during FU (mean 21 months postop, median 22, range 2-41); 5 others have comprehensive FU of 10-10-16-16-18 months, and 14 others were lost after a mean FU of 24 months (median 24, range 2-53). Conclusion: Splenectomy for MS can be achieved with low morbidity and no operative mortality. It results in long term pain relief and improvement of hematologic cytopenias with a reasonable long term survival. However, the poor condition of those patients allows only one surgical attempt to solve the problem.

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Authors - Jo Etienne Abela, Mark Schembri; Afiliation - Mater Dei Hospital, Malta;

THE ANTERO-POSTERIOR APPROACH FOR LAPAROSCOPIC SPLENECTOMY IN SPLENOMEGALY;

Introduction. Laparoscopic splenectomy is usually reserved for small spleens involved in haemolytic disorders such as ITP and hereditary spherocytosis. Its use in malignant disease is still controversial and splenomegaly poses an operative challenge.Materials and methods. We explain the technique of the antero-posterior, artery first technique applied to lapa-roscopic splenectomy for the giant spleen. Two patients (one male and one female, aged 70 and 72 years respec-tively) with rituximab- refractory marginal cell splenic lymphoma became transfusion dependent with recurrent anaemia, leucopenia and thrombocytopenia. Their spleens measured 22 - 25cms on pre-operative imaging. The female patient had, in addition, symptomatic gall stone disease necessitating cholecystectomy (performed just prior to splenectomy). Pneumoperitoneum was achieved through an open umbilical cutdown and porst placed. Having gained access to the lesser sac, the splenic artery was controlled and then the short gastric and inferior polar vessels divided. the patient was then tilted to the right and the diaghragmatic and lieno-renal attachments divided. The pedicle was next slooped and divided with an Endo-GIA stapler after clearance of the pancreatic tail. Results. Operative time was an average of 180 minutes (excluding cholecystectomy). One patient required trans-fusion of one unit packed red cell concentrate intra-operatively. In one patient the spleen would not be mano-uvered into the specimen bag and it was therefore, delivered whole through a left iliac fossa Lanz incision. In the other patient the spleen was morcellated in a bag. Both patients were well after surgery and were discharged on the 3rd post-operative day.Conclusion. It appears that this approach, although slow, is safe and effective for massive splenomegaly. Mor-cellation can still provide an adequate histological specimen.

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Authors - Ms Elaine Borg, Dr Doriella Galea, Dr Stephanie Azzopardi, Mr Mark Schembri; Afiliation - Mater Dei Hospital;

AUDIT ON PATIENTS’ PREFERENCE REGARDING SAME-DAY DISCHARGE POST-LAPAROSCOPIC CHOLECYSTEC-TOMY AT MATER DEI HOSPITAL;

BACKGROUND Day-case laparoscopic cholecystectomy has been implemented in the UK in view of improve-ments in operative and anaesthetic techniques leading to shorter hospital stays. Concerns remain amongst Maltese surgeons regarding the feasibility and acceptability of day-case laparoscopic cholecystectomy in Malta.

AIM The objective of this study is to assess patients’ preference of laparoscopic cholecystectomy to become a day-surgery procedure in Mater Dei Hospital, Malta.METHODA retrospective analysis of 95 patients undergoing elective laparoscopic cholecystectomy in Mater Dei Hospital was carried out during an 8-month period between January and August 2013. The patients’ demo-graphics, and operative details including duration of procedure, intra-operative complications and conversion rate was accessed using iSOFT, Electronic Case Summary and medical files, accessible from the Medical Record Department at Mater Dei Hospital. After the patients were discharged from hospital, a telephone interview was conducted. Their social environment was assessed and the severity of complications including pain, nausea and vomiting was monitored using the 5-point scale. The patients were also asked whether they had a reliable pri-mary healthcare provider and were asked whether they would cope if they were discharged on the same day of the procedure. Reasons to their answers were documented. RESULTS From the 95 patients included in this study, 25 (26%) were male and 70 (74%) female. The average age was 48.5 years (median 50; range: 16-81). On average the duration of the laparoscopic cholecystectomy was 86.2 minutes (range: 40-145). Intra-operative complications were documented in 11 cases (11.6%). The conversion to open cholecystectomy was in 2% of cases.90 patients (94.7%) have a primary healthcare provider/ general prac-titioner (GP). Of these, 67 patients (72%) claim that their GP is readily available. 75 patients (78.9%) claim that they would feel comfortable calling GP to manage post-operative complications. 43 patients (45%) said that they would cope at home if discharged on the same day, whilst 52 (55%) claimed they would not. The predominant reasons why the latter group did not opt for same-day procedure was due lack of adequate pain control, anxiety/fear and better environment at hospital due lack of family support. CONCLUSION The majority of our patients (55%) prefer overnight stay post-laparoscopic cholecystectomy. Patient’s anxiety due lack of community support should be taken into consideration when planning day - case laparoscopic cholecystectomy.

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Session SAFETY IN THE OPERATING THEATRE

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Authors - Cutajar C.L.; Afiliation - The Medical School, University of Malta;

OPERATING ROOM ERRORS;

The health of a patient scheduled for surgery may be compromised by errors occuring in the operating room, usually unexpected but nevertheless foreseable and preventable. Often these are directly related to patient management, such as inappropriate pre- or per-operative medical treatment, or surgery on the wrong side or wrong limb. However, other errors can be extraneous to the surgery itself but attributable to failures directly attributable to short-comings of the operating room personnel. This paper will focus on two aspects, namely, a) equipment-related failures; b) retained surgical sponges and instruments.These are of concern not only becausae they directly impact on patient health, but also because of the medico--legal complications and compensation costs.

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Authors - N Suleyman, E Williams, I Sagriotis, D L Stoker; Afiliation - North Middlesex University Hospital;

WAITING TIME FOR LAPAROSCOPIC CHOLECYSTECTOMY AT A LONDON DISTRICT GENERAL HOSPITAL;

Introduction Index laparoscopic cholecystectomy reduces investigations, life-threatening disease, overall cost and elective waiting times. A 2007 audit found the median wait for cholecystectomy was 5 months and 12 out of 13 patients with acute cholecystitis had elective operations. 4 out of 13 were readmitted whilst on the waiting list. Patients with acute pancreatitis were waiting longer than guidelines advise for ERCP (< 72 hours) and cholecystectomy (< 2 weeks). Guidelines were publicised and discussion of patient eligibility for index laparoscopic cholecystectomy encouraged. A re-audit was conducted. Methods 108 cholecystectomies were performed between October 2012 and March 2013. Retrospective review of elec-tronic records was used to identify waiting times between initial presentation and cholecystectomy +/- ERCP, number of admissions (including operation), length of stay and diagnosis. Findings were then compared against the BSG guidelines. Results The median wait for cholecystectomy from presentation is 146 days. All acute cholecystitis patients had an elec-tive operation (n = 18) and of these, 5 were readmitted whilst on the waiting list. Of 13 patients presenting with gallstone pancreatitis, 3 were readmitted whilst on the waiting list. Patients with acute pancreatitis waited too long for ERCP (median 5 days, range 1-166 days) and cholecystectomy (median 138 days, range 50-277 days). Conclusion Waiting times for cholecystectomy, and ERCP where applicable, have not improved in this hospital despite pre-vious intervention and remain below the BSG targets. Further improvements in service provision are required to meet targets and reduce the morbidity and number of readmissions in this patient group.

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Authors - N M Suleyman, J Wright; Afiliation - North Middlesex University Hospital, London, UK;

AN AUDIT OF POST-OPERATIVE PRESCRIBING AT A LONDON DISTRICT GENERAL HOSPITAL;

Introduction This audit was conducted following difficulties prescribing regular medicines for post-operative patients when on-call. Additionally there was anecdotal evidence of delays in patients receiving regular medications. Currently there is no guidance regarding responsibility for the completion of the drug chart for surgical patients, and thus recording allergies, prescribing VTE prophylaxis and regular medications. Methods Patients who were on regular medications admitted to General Surgery, Urology and Orthopaedics during April 2013 were identified from clinical notes after discharge. The drug chart for the hospital stay in question and cli-nical notes were used to collect data retrospectively from a total of 11 cases. Results 55% of drug chart allergy boxes were completed with a name and signature on the day of surgery. 18% had a 1day delay in completing allergy details. VTE prophylaxis was correctly prescribed and documentation completed without delay in 45% of cases. Regular medications took a mean time of 1.3 days to prescribe and 11% of regular medications were not prescribed at all. Conclusion The safety of post-operative patients was compromised due to the late documentation of allergies, prescribing of VTE prophylaxis and regular medications. Simple, low-cost initiatives could help improve safety of these patients.

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Authors - Farhana Akter, Aneela Hameed, Mansoor Akhtar, Ayman Hamade; Afiliation - QEQM Hospital;

PREVENTION OF SURGICAL SITE INFECTION;

Aims Evaluate current practices in the department of Colorectal Surgery in reducing post-operative surgical site infec-tion. MethodsProspective observational study of 67 elective and emergency colorectal cases in June and July 2012 in a busy district general hospital. Surgical theatre lists and on-call lists were used to identify patients undergoing elective and emergency colorectal surgery. Patients were interviewed and notes studied to identify surgical site infections (SSI) during post-operative stay in the hospital. Telephone calls (consent obtained) were used to identify if pa-tients had developed SSI at home within 30 days of operation. Results Only 1/67 patients were given wound infection advice preoperatively. Intraoperatively 38/67 (56.7%) had tem-perature regulated and 37/67 (55.22%) patients developed hypotension. Postoperatively only 15/67 (22.3%) pa-tients had wound dressings changed aseptically. 22/67 (32.85%) patients developed SSI, 13/22 (59%) of patients with SSIs developed it during stay at hospital, 9/22 (41%) developed infection at home. All patients received antibiotics. ConclusionsSSIs remain a significant problem in all patients following operation. However several measures can be used to reduce incidence of infection. Preoperatively all patients must be given information regarding wound infection and how to identify surgical site infection. Intraoperatively physiological parameters must be monitored, these parameters should be incorporated in the WHO Surgical safety checklist and compliance ensured. Postoperative-ly any dressings changed must be done so aseptically. We have seen that greater than fourty per cent of patients developed infection in the community and required antibiotics and were only identified following telephone consultation. It is thus prudent we ensure a robust follow up of patients take place to identify and treat surgical site infection promptly.

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Authors - Andrey Kudryavtsev, Valery Kryshen, Artem Breus; Afiliation - Dnipropetrovsk Medical Academy, common surgery department

SAFETY MAINTAINING AFTER LAPAROSCOPIC STRANGULATED HERNIA REPAIR;

Introduction: Laparsopic method proposes new and faster technology in strangulated hernia repair. This makes complication risk higher, and thus requires using known methods for their estimation and prevention. Aim of study: to implement objective methods for intra- and post operation complications control. Materials and methods: 46 patients operated using author’s modified TAPP method with one-sided strangula-ted hernia. Soft meshes of average size 10x15 cm were used. Electronic thermometry was used in many cases; programmed relaparoscopy was used in 2 cases. Results and discussion: specific technics modifications were used for all operated patients. Peristaltic grade, bowel glint, bowel temperature measured with electronic thermometer at strangulated and healthy areas were used. Programmed relaparoscopy was used in 2 cases in the 1st and 2nd day of postoperation period as prescri-bed, also in that time sanation of abdominal cavity was performed. All laparoscopic operations were finished by draining abdominal cavity with one or two drainages for period of 2-3 days with control of wound discharge, postoperation temperature curves, bowel peristaltic, flatus and bowel movement. All patients received standard antibacterial therapy. With all above-mentioned, patients operated laparoscopically have usual postoperational period flow with acceptable level of close postoperation complications. All patients were discharged from hospi-tal at standard terms. Conclusion: usage of laparoscopic hernioplastic in cases of strangulated hernia asks for additional safety ma-intaining procedures. These can be operation methodic modifications, intraoperational electrothermometry , programmed relaparoscopy, and more strict control of patient vital functions on the whole.

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Session THE ACUTE ABDOMEN

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Authors - František Vyhnánek; Afiliation - Traumatological Centre, Department of Surgery, University Hospital, 3. Fakulty of Medicine, Charles University, Prague, Czech Republic;

TRAUMA DAMAGE CONTROL SURGERY;

Introduction. Damage control surgery has become well established in the past decade as the surgical strategy to be employed in the unstable trauma patients. The aim of this presentation was analysed trauma patients with damage control surgery to thoracic and abdominal injuries.Material, methods. A retrospective review of 71 victims undergoing emergency department thoracotomy / EDT / or damage control laparotomy / DCL / in a level 1 trauma centre over 11 years period was performed.There were 17 patients with blunt / 6 / or penetrating / 11 / thoracic trauma and 54 patients with blunt abdominal trauma.Results. In 6 victims undergoing EDT to blunt thoracoabdominal trauma was indicated for severe intraabdominal haemorrhage with heart arrest / 3 / or for lung laceration with major vascular haemorrhage / 3 /.From those 4 patients died . Penetrating heart injuries were treated in 11 patients with death in two. Overall mortality rate in EDT was 35 % due to haemorrhagic shock. 54 patients with blunt abdominal injuries were undergoing DCL to severe intraabdominal haemorrhage from solid organs trauma and or with contamination of abdominal cavity from perforation of GIT. Main organ damage included smashed hepatic injuires in 39 cases, splenic injuries in 18, GIT perforation in 11 , 5 with renal injuries, and urinary bladder perforation in 2 patients. From those in 5 were laparotomy combined with thoracotomy for associated severe lung injuries. A total of 40 patients survived / 74 % / and 14 died / 10 within 24 hours and 4 died 1-3 days after trauma. The trauma deaths were causes by severe primary injuries resulting in failure of circulation or craniocerebral injuries.Conclusion. Damage control surgery is the leading surgical strategy in emergency surgery for instable thoracic and abdominal injuries with haemorrhagic shock combined with signs of the „ lethal triad”. Surgeon should selected the rapid reasonable examination before operation and the proper time to perform damage control surgery to control bleeding and decontamination of abdominal cavity.

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Authors – Salvatore Guarino, Antonio Catania, Salvatore Sorrenti, Deborah Maria Giusti, Matteo Nardi, Carlo Di Marco, Grazia Savino, Enrico De Antoni; Afiliation - Department of Surgical Sciences „Sapienza” University of Rome;

BLUNT TRAUMAS. MANAGEMENT OF INTRABDOMINAL INJURIES IN A UK MAJOR TRAUMA CENTER;

Trauma is a leading cause of death in the UK, accounting for over 16 000 deaths per year representing the first cause of death in the population younger than 40 in the Western World and the fourth in the general population. Abdominal blunt traumas represent the 75% of all the blunt traumas. The intra-abdominal injuries typically are caused by a blunt force attributed to collisions between the injured person and the external environment and to acceleration or deceleration forces acting on the person’s internal organs.Spleen is the most frequent injured organ in abdominal blunt trauma, because its peculiar vascularization and anatomical position. The advantage of conservative management for grade I and II has been proved while its value is still debated for grade III and IV. Herby we present the experience on the management of splenic laceration in abdominal blunt trauma in the largest Major Trauma Center in UK with over 2400 trauma admissions per year. The retrospective analysis of the splenic laceration management proved that conservative management in the grade I and II lacerations is safe while for higher grade of splenic laceration, careful multidisciplinary opinion has to be taken for the decision making. The management of these patients represents a challenge and requires expert care from a large number of different specialties to give them the best chance of survival and recovery. Therefore the need of highly specia-lized Trauma Centers with specially trained medic and paramedic team capable to overcome the complexity of these cases.

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Session COLO-RECTAL SURGERY AND PROCTOLOGY

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Authors - Gallo G, Ferrari F, Carpino A, Sena G, Silipo D, Vescio G, Sammarco G, Sacco R; Afiliation - Chair of Clinical Surgery, Magna Graecia University, Catanzaro, Italy;

WHAT’S THE FUTURE FOR THE MILLIGAN-MORGAN’S TECHNIQUE?

Introduction: A variant to realize the hemorrhoidectomy sec. Milligan-Morgan is offered by the system LigaSure PreciseTM (LigaSure). Aim of study: In today’s new minimally invasive technology (HPS, THD slide) and mucoprolassectomy with sta-pler there is a place for the Milligan-Morgan? Material and Methods: The Ligasure Precise is an electrothermal bipolar device constituted by a radiofrequency generator able to perform the synthesis and hemostasis of arterial and venous vessels up to 7 mm in diameter realizing a complete and permanent synthesis of the vascular wall. In our Division of Emergency Surgery 58 pa-tients(45 males and 13 females) with haemorrhoids of grade IV second Goligher and with eroded and bleeding mucosa were subjected to hemorrhoidectomy sec. Milligan-Morgan using the LigaSure Precise. Results: The mean operation time was 12 minutes. The score for postoperative pain according to the numerical scale verbal (VNS) was 6 after 24h and 48h after 5. Hospitalization was on average of 2.8 days (range 2-4).Surgical wounds have healed after a mean of 18.3 days. The return to work occurred after a mean of 10 days. Conclusions: The use of Ligasure Precise has shown significant advantages over the traditional technique: lower operating time, faster healing of wounds,reduced postoperative pain and early return to work. We have disco-vered that in the haemorrhoids of 4th grade with giants and pseudopolypoid nodules, eroded and bleeding mu-cosa, the Milligan-Morgan technique would be better to latest suspension techniques both for the low number of relapses both in consideration that in one of our cases the histologic examination showed an adenoma with high dysplasia.

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Authors - Gallo G, Carpino A, Ferrari F, Ammendola M, Sena G, Vescio G, Sammarco G, Sacco R; Afiliation - Chair of Clinical Surgery, Magna Graecia University, Catanzaro, Italy;

THE SLIDE : OUR EXPERIENCE;

INTRODUCTION: Various methods have been used in recent years for the surgical treatment of hemorrhoidal disease. Is in doubt that treatment with PPH-Stapler has had great resonance compared to the techniques which included the removal of hemorrhoidal`s packages whether performed with radiofrequency whether performed with ultrasound. AIM OF STUDY: The onset of serious complications has led many surgeons to develop and execute less invasive methods. Among these, the THD SLIDE certainly had an important development. MATERIAL AND METHODS: In the Operative Unit of Digestive Surgery of University Magna Graecia in Catanzaro were treated ,in 2012 , with THD SLIDE , 20 patients with hemorrhoidal disease including 14 males and 6 females with an age range 40 to 60 years. Three of the 20 patients had haemorrhoids classified with grade P3E3 according to PATE 2000 and the other 17 patients with grade P4E3. RESULTS: Our results showed a post-operative pain rated with VNS scale of 5.2 . The days of hospitalization were on average 2 except in one case. However there have been some early complications: 3 cases of bleeding ; 2 ca-ses of urinary retention ; 6 cases of thrombosis and 8 cases of tenesmus. Late complications were the following : 4 cases of residual disease , 5 cases of late bleeding and 4 of thrombosis . CONCLUSION: In our experience the THD slide method it was a technique repeatable and safe for patients with prolapse lower than 1.5 cm. However, this tecnique has some limits in terms of recurrence although single no-dule for prolapses greater 1.5 cm and is not recommended in bleeding and pseudopolipoid hemorrhoids with grade IV and with eroded mucosa.

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Authors - Melnik Idit MD,Oleg Dukhno MD, Ornit Cohen M.MED Sc ,Dimitry Goldstein MD, Boris Yoffe MD FACS; Afiliation - Department of General and Vascular Surgery,Barzilai Medical Center, Ashkelon, Israel. Affiliated with the Faculty of Health Sciences, Ben-Gurion University of the Negev.;

WHEN TO GO SINGLE? A COMPARISON BETWEEN SINGLE PORT AND THE TRADITIONAL MULTIPORT TECHNI-QUE FOR COLON RESECTIONS.

Introduction: single incision laparoscopic technique is an emerging modality. Methods: We retrospectively reviewed the charts of all patients who underwent laparoscopic colectomies be-tween October 2010 and December 2012. The cohort was divided into two groups, SILC and MILC, which were compared in terms of their intra-operative and early postoperative outcomes. Each group was then sub-divided according to the type of procedure, each of which was compared separately between SILC and MILC. The intra--operative parameters were total operative time, surgical margin involvement and the number of lymph nodes extracted. The postoperative parameters included length of hospital stay, 30-day readmission, maximum pain score, morbidity, and mortality. Results: Seventy five patients underwent laparoscopic colectomies (SILC-21/ MILC-54). Between the two groups, patient characteristics were not statistically different. A comparison of the groups intraoperative and postope-rative results showed no statistically significant differences. Analyses of each procedure separately showed that when performing RH there was a trend (p = 0.08) of better oncological results with a higher mean number of lymph nodes extracted (23.5 Â± 3.16 vs. 17.19 Â± 6.93). In addition, LOS decreased (5.91 Â± 3.59 vs. 6.48 Â± 1.76, respectively), which was statistically significant (p = 0.05). Conclusions: Single incision approach for bowel resections is feasible and safe. Given our findings, we believe that SILC technique is an effective alternative to MILC when performing RH with the statistically significant be-nefits of lower LOS and better oncological results. However, the efficiency of the technique in LH or AR is still questionable and needs further evaluation.

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Authors - Tikfu Gee, Emad H Aly; Afiliation - General Hospital Kuala Lumpur (GHKL), Malaysia and Aberdeen Royal Infirmary (ARI), Aberdeen, Scotland.;

SCARLESS SURGERY!! SINGLE INCISION LAPAROSCOPIC SURGERY (SILS) - AN ALTERNATIVE SURGICAL APPRO-ACH OF MINIMALLY INVASIVE SINGLE PORT SURGERY IN COLORECTAL SURGERY;

Background. Laparoscopic surgery has become the preferred choice of surgery because of its improved post operative outcomes in pain, recovery phase, duration of hospital stay and cosmetic appearance. Single Incision Laparoscopic Surgery (SILS) is a branch of laparoscopic surgery which utilises either specially designed single multi-channel port or standard ports that are introduced in to a single incision made to the skin. While SILS has succeeded conventional laparoscopic surgery in various procedures with better cosmetic appearances, there is still insufficient evidence to establish its superiority in the other post operative outcomes. Objective and AimsTo compare the effectiveness of SILS in colorectal surgery using standard laparoscopic ports with conventional laparoscopic colorectal surgery in adult patients at four weeks post-surgery. To compare post operative outco-mes between the two methods of surgery. To establish safety and feasibility of SILS using standard laparoscopic ports in colorectal surgery.Method41 cases from January 2010 - December 2011 were reviewed in this retrospective study. Data from board-appro-ved laparoscopy database on Single Incision Laparoscopic Surgery (SILS)-using standard ports and conventional laparoscopic surgery were collected using a data collection sheet. Results were tabulated on Microsoft Excel and analysed using the SPSS 17.0 software. Statistical difference in post-operative outcomes between the two proce-dures were noted and compared.ResultsResults from both colorectal surgeries (Right Hemicolectomy and Anterior Resection) shows that there were no significant differences in post operative outcomes between conventional method and SILS-using standard ports, in terms of age, BMI and operative time. However, post operatively pain score for day 1, 2 and 3 was statistically significant as SILS-using standard ports reported less pain compared to the conventional laparoscopic method.ConclusionSILS using standard laparoscopic ports are safe and feasible in the hands of an experienced laparoscopic colo-rectal surgeon, leaving behind an essentially scarless procedure around the umbilicus. Not only is this method cost effective, it produces a similar cosmetic outcome as the SILS using a single multi-channel port. While better pain outcome was reported with SILS using standard laparoscopic ports, further experience and evidence-based research are necessary to establish its superiority towards conventional laparoscopic surgery.

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Authors - Pierpaolo Sileri , Luana Franceschilli, Federico Perrone, Ilaria Carolina Ciangola, Ilaria Capuano, Fed-erica Giorgi, Achille Lucio Gaspari; Afiliation - Department of Surgery, University of Rome Tor Vergata;

LAPAROSCOPIC VENTRAL RECTOPEXY FOR INTERNAL RECTAL PROLAPSE USING BIOLOGICAL MESH:A CRITI-CAL APPRAISAL AFTER 100 CASES;

Background: Laparoscopic Ventral Mesh Rectopexy (LVR) is constantly gaining wider acceptance as the preferred method of procedure to correct internal as well as external rectal prolapse associated with obstructed defaeca-tion syndrome (ODS) and/or faecal incontinence. This procedure convinces with excellent functional outcomes associated with very little operative risk, even in older and fragile patients. These results are mostly obtained using synthetic mesh. Despite the improvement of the efficacy of the reconstructive procedure with reduction of the recurrence rate there is ongoing debate regarding the possible complications like erosions and infections with the use of synthetic mesh in close proximity of pelvic organs. Some biological meshes may serve as an al-ternative. Very few reports exist on the use of biological mesh for LVR. Therefore, no superiority of one mesh over the other can be established in terms of surgical complications, as well as short and longer term functional outcomes. In this critical appraisal we report our experience with this abdominal, minimally invasive and nerve sparing technique, using porcine dermal collagen mesh.Patients and Methods: Prospectively collected data on laparoscopic ventral mesh rectopexy (LVR) for internal rectal prolapse were analysed. All patients underwent preoperative evaluation with defaecating proctography and/or pelvic dynamic magnetic resonance imaging (MRI), full colonoscopy, anal physiology studies, and endo--anal ultrasound. Surgical complications and functional results of this technique in terms of constipation (expres-sed as Wexner Constipation Score = WCS) and faecal incontinence (expressed as Faecal Incontinence Severity Index = FISI) at 1 week; 1, 3, 6 and 12 months were analysed using Mann-Whitney U-test for unpaired data and Wilcoxon signed rank test for paired data (two-sided p-test).Results: Between April 2009 and April 2013, 100 consecutive patients underwent LVR for internal rectal prolap-se. Two patients were lost during the follow-up and excluded. Mean symptom duration before surgery was 11+/-9 years. Mean operative time was 85+/-40 minutes. Conversion rate to open technique was 1%. There was no postoperative mortality. Overall 16 patients experienced 18 complications (18%), including rectal perforation (1), small bowel obstruction (2), urinary tract infection (8), subcutaneous emphysema (3), wound haematoma (2), sacral long lasting pain (1), and incisional hernia (1). Median postoperative length of stay was 2 days. At the end of the follow-up the FISI score significantly improved to 3+/-2 from preoperative 8+/-3 (p 0.003). Incontinence improved in 86% of the patients and was completely cured in 72%. Similarly, WCS score significantly improved to 7+/-5 from preoperative 18+/-6 (p 0.002). Constipation improved in 92% of the patients and was cured in 80%. No deterioration of continence, constipation or sexual function was observed. Fourteen patients (14%) experien-ced prolapse persistence or recurrence.Conclusions: Laparoscopic ventral mesh rectopexy using biological mesh for internal rectal prolapse is a safe and effective procedure for improving symptoms of obstructed defecation and faecal incontinence.

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Session EMERGENCY SURGERY AND TRAUMA;

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Authors - Obondo CA, Moussa O, Muthukumarasamy G, White RD, McBride K, Bhat R, Beverage E, Brennan JC, Holdsworth R.; Afiliation - Forth Valley Royal Hospital. Department of Vascular Surgery;

CLINICAL OUTCOMES OF ENDOVASCULAR TREATMENT IN CHRONIC SYMPTOMATIC MESENTERIC ISCHAEMIA;

Endovascular therapy is emerging as a primary treatment for chronic mesenteric ischaemia (CMI). Due to the low incidence of the condition, published studies have involved small patient numbers. The aim of this study is to examine and document the clinical outcome of percutaneous angioplasty and stenting (PTAS) in patients with symptomatic CMI. During the period June 2002–June 2013, all patients who underwent PTAS for CMI in three hospitals were re-trospectively included into this study. Patient demographics, lesion characteristics (stenosis/occlusion), major morbidity, recurrence and mortality were recorded. Twenty eight mesenteric vessels (13 superior mesenteric, 13 celiac and 2 inferior mesenteric) were treated in 25 patients (12 female and 13 male). Seven (25%) arteries were completely occluded and 21 (75%) had >60% stenosis. The mean age was 69 years and the most common symptom was postprandial angina (n=24, 96%). The average duration of symptoms was 9.6 months. Single vessel and two vessel PTAS was achieved in 84% (n=21) and 16% (n=4) respectively. There was no periprocedural mortality and major morbidity occurred in 2% (n=5). The median follow-up was 27.5 months. During this period, 18 patients (72%) reported symptom resolution, 5 (20%) recurrence and 2 were lost to follow-up. Re-intervention with clinical success was performed in 3 patients (12%) at a mean of 20 months from initial treatment. Seven patients (28%) died during the study period. Two (8%) of these were CMI-related deaths. This study supports published data advocating primary PTAS for symptomatic CMI. It is feasible, safe and clini-cally effective.

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Authors O. Sadieh, Asem Ghasoup,MD MRCS-Mahmoud Khashashneh,MD MRCS-Isamil Marey,MD-Adala Al Anzi,Abeer Al Anzi Afiliation - Saad Specialty Hospital,Khobar-KSA , Prince Abdul Mohsin General Hospital,Madinah-KSA

THE OUTCOME OF PATIENTS WITH BLUNT CHEST TRAUMA AND PULMONARY CONTUSION.

Introduction: Lung contusion is an entity involving injury to the alveolar capillaries, without any tear or cut in the lung tissue. This results in accumulation of blood and other fluids within the lung tissue. The excess fluid interferes with gas exchange leading to hypoxia pulmonary contusions following trauma may result in significant hypoxemia and decreased compliance which may progress over several days. Extensive contusions may result in respiratory difficulty or progress to adult respiratory distress syndrome, which increases mortality. Material and Method: A retrospective Study of all cases of trauma with pulmonary contusions admitted to our hospital from October 2011 to February 2012 Diagnosed on X-ray or CT scan. The cases were examined for age, type of injuries, admission APACHE II, SAPS II and SOFA scores, PaO2/FiO2 ratio, presence or absence of rib frac-tures, average positive fluid balance, average sedation dose, pulmonary hemorrhage, ventilator days, ICU days and hospital outcome. Result: There were 92 cases with multiple traumas admitted to ICU of them 35 cases with pulmonary contusions. 32male and 3 female, age 19-60 years. The mechanisms of injury were Head-on collision with heavy vehicles at high velocity, Hit and run accidents and fall from height or blunt injury to the chest due to fall of heavy machinery on the chest. Associated injuries included multiple rib fractures in 22 cases and the others 13 cases were with long bone fractures, abdominal injuries including splenic rupture, liver lacerations, pelvic fractures and head injury. 8 patients died 6 of them died in the ICU with refractory hypoxia and 2 patients died 1 week after trans-fer to a high dependency unit, one due to sepsis and the other due to massive haemothorax. In some patients the admission chest X-ray was normal, and worsened during the subsequent days others had infiltrates on the admission X-ray, diagnosis confirmed by Chest CT-SCAN in all cases. 6 cases of non survivors were classified as having ARDS and were severely hypoxic at the time of death. There was a significant difference in PaO2/FiO2 ratio at admission and throughout the ICU course, Non survivors had lower mean PaO2/FiO2 ratio throughout the ICU stay than survivors, (158 vs. 245), fluid balance and sedation dose, but not in ventilator days and ICU days. The incidence, frequency and amount of pulmonary hemorrhage were higher in the non survivors. Non survivors were more severely injured with higher admission mean APACHE II (14 vs. 7) and SAPS II (40 vs. 26) scores. However, the mean SOFA scores were not significantly different (non survivors 5.83 and survivors 3.83). Conclusion: Blunt trauma and pulmonary contusions can have a considerable mortality especially in the face of severe hypoxemia; attention to limit hypoxia and improve gas exchange should be undertaken early. Manage-ment of hemoptysis might improve outcome in pulmonary contusions.

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Authors –Mrktich Mrktichyan, Hovhannes Sarkavagyan, Tigran Khachatryan, Armen Khanoyan, Artak Manuky-an, Artur Sardaryan, Hayk Kikoyan; Afiliation - Yerevan State Medical University after Mkhitar Heratsi,”SURB GRIGOR LUSAVORICH” MEDICAL CEN-TER, Yerevan, Armenia;

TRAUMATIC RUPTURE OF THE DIAPHRAGM;

Background: Diaphragmal raptures due to chest blunt traumas are often associated with polytraumas and ac-companied by injures to other organs which leads to difficulty of proper and in-time diagnosis of such cases. The aim of this retrospective study was to analyze our experience with diagnostic methods and operative approach of traumatic rapture of diaphragm (TRD). Methods: 38 patients with TRD were treated in our hospital between 1993 and 2013. They were 34 men (89%) and 4 women (11%) ranging from 13 to 70 years. 29 patients (76%) showed a left TRD and 9 patients (24%) - ri-ght TRD. Multiple-associated injures were observed in 31 patients (82%), and isolated TRD - in 7 patients (18%). Causes of trauma included road traffic accidents for 33 patients (87%) and fall from height for 5 (13%). Results: TRD was diagnosed preoperatively in 32 patients (84%) by contrast X-Ray of gastrointestinal tract, ab-dominal ultrasound, and CT scan of the chest and abdomen. In 6 (16%) patients TRD was diagnosed during surgeries. We did not use pleural tapping to avoid iatrogenic injuries of abdominal organs. 27 patients (71%) underwent surgery upon 1 month of trauma episode, and the remaining 13 (34%) - after 1 month to 13 years. For surgical treatment, right lateral thoracotomy on the 6th interspace was performed in 9 (24%) patients with right TRD. The part of the diaphragm ruptured from the chest wall was repaired by simple interrupted suture to that wall on 1-2 interspaces above anatomical juncture-line which allowed restoring the diaphragm out of risky tension. 11 patients (29%) with old left TRD underwent left lateral thoracotomy on the 6th interspace by organs` pulling to abdomen and restoring the diaphragm. In both left and right TRDs the large diaphragmatic defects were repaired by polypropylene mesh. 18 (47%) patients with acute left TRD were treated by left lateral thora-cotomy on the 6th interspace accompanied by upper-medial laparotomy (11 cases) and laparoscopy (7 cases) for comprehensive examination of abdomen and restoring lesions. We observed 3 deaths (8 %) - 2 from severe craniocerebral trauma and 1 from pulmonary thromboemboli. Conclusions: In right TRD, we recommend to repair diaphragm on 1-2 interspaces above anatomical juncture--line and in left TRD, to accompany thoracotomy with laparoscopy.

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Authors - Kryshen V.,Kudriavtchev A.; Afiliation - General Surgery Department, Medical Academy, Dnipropetrovsk,Ukraine;

TAPP MODIFYING TECHNIQUE FOR STRANGULATED INGUINAL HERNIA;

Introduction: Differences in surgical technique believed to be necessary at laparoscopic strangulated hernia repairing. Aim of study: to develop special laparoscopic method applicable for strangulated inguinal hernia emergency treatment. Materials and methods: Indications for laparoscopy: absence of contraindications for laparoscopy, absence of full intestinal obstruction symptoms. 46 patients undrerwent surgery. Authors proposed laparoscopic method due to one-sided strangulated hernia. At 38 cases object of incarceration was bowels. Modified TAPP and soft meches sized 10x15 cm on the average were used for hernioplasty. Results: There were following modifications in TAPP method: presence of strangulation ring caused necessity in hernial gates dissection for bowels release. Unlike open operations firstly dissection of hernial gate was perfor-med , then inspected. Hernia gate dissection basing on our experience is better to perform remoted from large vessels and nervous tissue. These are fields at 2-3 and 10-11 clocks of conventional dial. Traction of strangulated ring was provided with surgical hook into abdominal cavity and outside of strangulated organ. There is massive tissue edema at affected zone, so to prevent bleeding and organ trauma we used to dissector or special hook instead of scissors. To estimate bowels life-ability - peristaltic grade, local glint and temperature measured with electronic thermometer at strangulated and healthy areas were used. We assume the programmed re-laparo-scopy can also be conducted with such purpose and under circumstances. Conclusion: Laparoscopic hernioplasty could be free implemented at patients with strangulated inguinal hernia. The post-operation complications rate is acceptable. Although some surgery features needs standard technique modification in particular.

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Authors - Baras R. Karakas, M.D.1 , Aslinur Sircan-KuĂ§uksayan, M. S.2, Gulsum Ă–zlem Elpek, M.D. Prof.3, Mu-rat Canpolat, PhD. Prof. Dr.2; Afiliation - 1Antalya Training and Research Hospital, Department of General Surgery, 2Biomedical Optics Re-search Unit, Department of Biophysics, Faculty of Medicine, Akdeniz University and 3Department of Pathology, Faculty of Medicine, Akdeniz University, Antalya, Turkey;

ASSESSMENT OF THE INTESTINAL VIABILITY BY DIFFUSE REFLECTANCE SPECTROSCOPY ON ISCHEMIA-REPER-FUSION INJURY IN THE RAT;

Background: Intestinal tissue viability prediction in the treatment of acute mesenteric ischemia remains a chal-lenge. We have utilized diffuse reflectance spectroscopy (DRS) to investigate the viability of bowel tissue after ischemia and reperfusion on an animal model in-vivo and in real-time. Methods: In this study, a total of 25 Spraque-Dawley rats were used. There were five study groups of rats bowel ischemia time. Superior mesenteric artery was occluded by a vascular clamp for different time periods (sham,30 min, 45 min, 60 min, and 90 min; n=5). Intestinal reperfusion was provided by releasing the clamps after each time period following the occlusion. Spectra were acquired by gently touching the optical fiber probe to the bowel tissue before ischemia, at the end of ischemia and after the reperfusion. Subsequently, the same bowel segments were removed for histopathologic examination. Results: Based on the correlation between the spectra acquired on the bowel segments and the results of histo-pathology, it is found that DRS is able to differentiate histopathological changing on intestinal ischemia-reperfu-sion injury in real time and in-vivo. Conclusion: DRS has potential to be used for the assessment of bowel viability in real time and in-vivo.

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Authors - Marvan J., Bačová J., Antoš F., Fanta J.; Afiliation - Surgical Department, 1st Medical Faculty, Charles Univerity, Hopital Na Bulovce, Prague;

SPECIFIC ISSUES IN THE MANAGEMENT OF AN ACUTE ABDOMEN IN PSYCHIATRIC PATIENTS;

Introduction: Our department is a neighbourhood medical facility for surgical patients from the largest psychiatric facility in the Czech republic. Therefore we come in contact with psychiatric patients almost every day. This subject of in-struction will discuss specific care for those patients. Material: Presentation of patients admitted with diagnosis of an acute abdomen from the psychiatric facility in course of the last three years including visual documentation – case reports. Discussion and conclusion:Summary of currect knowledge about specific issues during diagnostic procedures in case of psychiatric pa-tients pointing out the changes in pain perception, communication disorders, psychiatric medication which re-sult in worsened (delayed) diagnostics of an acute abdomen. Specific issues when treating psychiatric patients at the surgical department: Adverse events of the antipsychotic medication in relation to surgical therapy and risks resulting from discotinuation of such medication. Differential diagnostics and therapy of the delirant state.

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Authors - Dobbs T, Aveyard N, Bratby M, Hormbrey P; Afiliation - Oxford University/ Oxford University Hospitals;

DEEP VEIN THROMBOSIS - HAVE YOU CONSIDERED MAY-THURNER SYNDROME?

Introduction: MTS is a condition whereby the left common iliac vein is compressed against the lumbar vertebrae by the right common iliac artery. Chronic arterial pulsation causes intimal hyperplasia, increasing the risk of venous stasis and iliofemoral DVT. Believed to be present in around 22% of the population, it is only reported in 2%–3% of patients that present with a lower extremity DVT [1]. MTS is therefore likely to be chronically under-diagnosed and could partially explain the overall predominance of DVT in the left leg [2]. Patient: A 32-year-old woman presented to the emergency department with acute-onset left leg pain. Duplex ultrasound scan demonstrated an iliofemoral deep vein thrombosis (DVT). CT venogram confirmed the presence of a left-sided iliofemoral DVT and demonstrated May–Thurner syndrome. She underwent emergency thrombec-tomy and stenting and has made a good recovery with no further thrombotic episodes.Result: The diagnostic work-up is often halted once a diagnosis of DVT is made. This case reminds us that the mechanical causes of DVT, such as MTS, should be considered in the differential diagnosis along side other causes such as hypercoaguable states. MTS should be especially considered in younger patients with otherwise unexplained iliofemoral DVT, particularly if recurrent and ipsilateral. Conclusion: Interventional radiology with mechanical thrombectomy and stenting is the treatment of choice for MTS. Therefore, given the need for an invasive surgical approach to the management of MTS, a missed diagnosis could lead to significant morbidity and mortality in the Emergency setting.

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Session UPTODATE ON ENDOCRINE SURGERY

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Authors - Camenzuli C., Micallef A., Sammut Henwood K., Betts A.; Afiliation - Mater Dei Hospital, Malta;

DEMOGRAPHICS AND INCIDENCE OF THYROID CANCER: A POPULATION STUDY;

Thyroid cancer is not an uncommon pathology. Although mortality from this condition is low, the condition and its treatment lead to significant morbidity. The aim of this study was to evaluate the incidence and the demogra-phical characteristics of thyroid cancer in the Maltese population from 2008 to 2013. The mean yearly incidence of thyroid cancer was 39.2 with little inter-annual variations and a total of 195 documented cases. The most common subtype was papillary carcinoma followed by follicular carcinoma and then medullary carcinoma. Only one case of anaplastic carcinoma was recorded. Thyroid cancer was three times more common in females. Age demographics show a normal distribution curve with a wide range and mode at the 40 to 49 age group. There was no difference between the incidence of thyroid cancer in the different geographical areas of the country. In conclusion, thyroid cancer in Malta shows similar trends as published data. It is essentially a disease of young women. The research group proposes the development of a thyroid support group to help these patients assi-milate better their condition.

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Authors - Camenzuli C., Cassar N., Psaila J., Attard A.; Afiliation - Mater Dei Hospital, Malta;

USE OF CLOSED DRAINS UNDER SUCTION AFTER HEMITHYROIDECTOMY- A PRELIMINARY REPORT OF A RAN-DOMIZED CONTROLLED TRIAL.

Introduction: Wound drainage after thyroidectomy is fairly standard, but this practice has been challenged. Objectives: The primary aim was to investigate whether use of closed suction drains had any effect on re-ope-ration rates. The secondary aims included whether use of drains altered pain scores, patient satisfaction and complication rate. Method: Patients undergoing hemithyroidectomy under the care of one surgical firm were recruited. Patients were blindly randomised manually into two groups: drain or no drain. Standardised analgesic regimens were used. Patient demographics, co-morbidities, length of surgery, complications, pain scores and patient satisfac-tions scores were collected through a structured interview. Student T Test was used to statistically analyse results. Results: 21 participants have been recruited with the majority being females (86%). The mean age was 50.8 years (SD 14.5). The groups were homogeneous in terms of age, sex, BMI, co-morbidities, length of operation and thyroid status. There was no significant difference between pain scores (p values of 0.56 in the evening and 0.59 in the morning post operation) and patient satisfaction scores (p values of 0.14 in the evening and 0.15 in the morning post operation) between the groups. The only complication reported was hypocalcaemia in one patient of the drain group. No re-exploration or mortality was recorded. Conclusion: The preliminary result for this study shows a low complication rate with no significant differences in terms of patient satisfaction and pain scores between the groups. The research group will extend this RCT over the next year.

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Authors - Nicola PALESTINI, Enrico BRIGNARDELLO*, Milena FREDDI, Marco GALLO*, Alessandro PIOVESAN*, Guido GASPARRI; Afiliation - Departments of Surgery and *Oncology, University of Torino and A.O. Città della Salute e della Sci-enza di Torino, Italy;

IMPACT OF SURGERY ON SURVIVAL IN ANAPLASTIC THYROID CARCINOMA. A CASE SERIES OF PA-TIENTS REFERRED TO A SINGLE INSTITUTION BETWEEN 1999-2012;

Abstract content:Objective. We present our experience with surgical treatment followed by adjuvant therapy in selected patients with anaplastic thyroid carcinoma (ATC), including those with distant metastases (stage IVC). Patients and methods. Clinical and follow-up data for 55 patients (34 females; median age 73) referred to our Institutions from June 1999 and July 2012 were collected and analysed. Stage IVA patients were excluded. Thir-ty-one patients (56.4%) had distant metastases. Cases eligible for surgery were operated on with the intent to obtain a „maximal debulking” (i.e. total or near-total thyroidectomy and radical resection of the tumour with the involved regional lymph nodes, or minimal residual neck disease infiltrating vital structures); interventions that not achieved this goal were considered palliative operations. After surgery most cases received chemotherapy (paclitaxel or doxorubicin ± cis-platin) and/or radiotherapy, with adjuvant intent.Results. Surgery was possible in 41 patients (74.5%), and a „maximal debulking” was achieved in 29 cases (52.7%). Median overall survival was 5.5 months. Operated patients had a betted prognosis compared to those not eligible for surgical treatment (median survival: 6.5 vs. 1.5 months), with a 19.7% survival rate one year after surgery. Among the operated patients those who received a maximal debulking had a better survival, even in stage IVC, compared to the patients submitted to palliative operations (median survival: 6.6 vs. 3.2 months). The favourable effect of maximal debulking on survival was confirmed by multivariate analysis (HR = 5:36; 95% CI 2:34-12:27; p <0.001).Conclusions. In selected patients with ATC complete or near complete surgical resection of cervical disease can significantly ameliorate survival. This approach is also effective in cases with distant metastases at diagnosis, for which the surgical option should not be excluded.

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Authors - G.Gallo; G.Tomaino; N.Innaro; R.Sacco; Afiliation - Department of Surgery, Magna Graecia University, Catanzaro, Italy;

IONM: OUR EXPERIENCE;

Introduction : Injury to the recurrent laringea nerve(RLN) is a rare but very important complication of thyroid and parathyroid surgery. The aim of study : The aim of this study was to evaluate the ability of intraoperative recurrent laryngeal nerve monitoring to predict the postoperative functional outcome and the potential role of this technique in reducing the postoperative nerve palsy rate Material and Methods : Between December 2009 and August 2013 were undergoing surgery 383 patients (81M; 302 F), which 363 total thyroidectomy and 20 totalizations . The mean age was found to be 51.3 with a range between 12 and 82aa. In all interventions was used neurostimulation of the RLN according to a procedural al-gorithm (V1R1-V2R2) to evaluate their integrity. In patients with loss of signal, the control post-operative was carried out at the end of hospitalization and then at 2,4 and 6 months with visual assessment of the vocal cords.Results : Our results showed a loss of signal in V2 in 13 cases, 2 definitive paralysis, 6 unilateral transitional pare-sis, 1 unilateral definitive paresis and 1 bilateral definitive paresis. In 3 cases, that have not joined the follow-up, the loss of signal in V2 has occurred without any complications .Conclusion : In our experience the systematic use of neuromonitoring is efficient in predicting phoniatric com-plications, being the loss of signal in V2 strongly correlated with alterations in motility of the vocal cords evalu-ated post-operatively.

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Authors - Marcin Barczynski, Aleksander Konturek, Małgorzata Stopa, Wojciech Nowak; Afiliation - Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Krakow, Poland;

SCREENING FOR PRIMARY HYPERPARATHYROIDISM IN ELDERLY PATIENTS BEFORE THYROID SURGERY: RE-SULTS OF A RETROSPECTIVE COHORT STUDY WITH FIVE-YEAR FOLLOW-UP.;

Introduction: Primary hyperparathyroidism (pHPT) in the elderly occurs with a high prevalence. The aim of this study was to examine whether biochemical screening for pHPT before thyroidectomy may allow for synchronous parathyroid surgery and reduce the need for neck re-exploration. Material and methods: A retrospective cohort study. Elderly patients (over 65 years) who underwent biochemi-cal screening for pHPT before thyroid surgery and one-stage parathyroidectomy in case of positive preoperative workup for pHPT were compared to patients who underwent thyroidectomy without preoperative screening for pHPT. Primary outcome was need for re-exploration for pHPT in five-year follow-up. Secondary outcomes were absolute risk reduction and number needed to treat.Results: Of 2542 elderly patients, 1211 (treated in 1998-2002) underwent thyroidectomy without preoperative screening for pHPT and 1331 (treated in 2003-2007) underwent screening for pHPT before thyroidectomy. In the latter group, biochemical diagnosis of pHPT was made preoperatively in 23 (1.7%) patients who underwent thyroidectomy with synchronous parathyroidectomy and intraoperative iPTH assay (17 solitary parathyroid ade-nomas, 3 double parathyroid adenomas and 3 cases of parathyroid hyperplasia). None of the screened patients required surgical re-exploration during five-year follow-up while in patients not screened for pHPT before thy-roidectomy 18 (1.5%) individuals were diagnosed with pHPT and 15 (1.2%) underwent successful second-stage parathyroidectomy (p<0.001). Absolute risk reduction was 0.017 and number needed to treat was 59.Conclusions: Due to a high prevalence of pHPT in the elderly screening for this disease entity may be beneficial before thyroid surgery allowing for synchronous surgical removal of hyperfunctioning parathyroid tissue.

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Authors - Cherenko S., Larin O., Tovkay O.; Afiliation - Department of Endocrine Surgery; Ukrainian Scientific & Practical Center of Endocrine Surgery, Transplantation of Endocrine Organs and Tissues, Kyiv, Ukraine;

DIFFERENT OPTIONS OF ENDOSCOPIC ADRENALECTOMY FOR DIFFERENT ADRENAL LESIONS: LESSONS FROM EXTENSIVE PERSONAL EXPERIENCE;

Introduction: Laparoscopic adrenalectomy became “gold standard” for benign adrenal tumors, however some aspects of preferred surgical treatment regarding size, bilaterality, malignancy, catecholamine excess remains controversial. Aim of study: To analyze applicability of endoscopic adrenalectomy for different adrenal diseases, to compare results of endoscopic and conventional adrenalectomies.Material and Methods: 552 endoscopic (laparoscopic and retroperitoneal) adrenalectomies were performed in institute during 2003-2013 years for different clinical situation, including benign and malignant cortical and medullary adrenal tumors, cysts, bilateral pheochromocytomas and macronodular adrenal hyperplasia. Results were compared with 208 open adrenalectomy within 1995-2013 years. Results: Comparative studies have shown great advantages of the laparoscopic adrenalectomy against open ap-proaches (lumbotomy, laparotomy): reduction of blood loss (more than 5 times), diminishing of pain, decreasing rates of early and late complication (12% to 1.3 % and 23 % to 0.5 % correspondingly), perioperative mortality (from 3 % to 0.2 %), operation time (more than twice), term of hospital stay, time of recovery. Laparoscopic ap-proach is more preferable than retroperitoneal even in case of limited peritoneal adhesions.Conclusion: Extensive personal experience in adrenal surgery allows us to suggest laparoscopic adrenalectomy not only in case of benign moderate size tumors but also in patients with large (up to 16 cm) benign (including pheochromocytoma) and non-invasive malignant neoplasm.

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Session DECISION MAKING AND TRADE-OFFS IN SURGERY

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Authors - Arthur Felice, MD, MSc. FRCS Ed, FEBS.; Afiliation - University of Malta;

PROCESSES IN CLINICAL DECISION MAKING;

Introduction: Clinical decisions are mostly inherently uncertain and involve estimates of probabilities and balancing trade-offs. Objectives: To optimize the decision making process by elaborating on the various processes involved including currently available aids. Method: The processes employed by the clinician’s mind and the various aids e.g. multivariate analysis, decision analysis, clinical problem analysis, mechanistic case diagramming, clinical algorithms, guidelines, scoring systems, infor-mation technology and artificial intelligence, are individually analysed, highlighting their advantages and limita-tions. This involves a comparative quantitative assessment of some processes. The factors that may influence these processes are discussed. Results: The presentation proposes methods whereby the above limitations and constraints are dealt with in order to facilitate effective clinical decision making. The outcomes are compared. Conclusion: Decision making aids help, but do not replace clinical judgement.

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Authors - Kevin Cassar; Afiliation - Department of Surgery, University of Malta, Malta Mater Dei Hospital, Msida, Malta;

THE ROLE OF NON INVASIVE IMAGING IN CLINICAL DECISION MAKING AT A VASCULAR ONE STOP CLINIC;

Assessment of patients with primary varicose veins has traditionally been based solely on clinical assessment. The clinical decision to intervene and the type of procedure offered to patients are still frequently based exclu-sively on clinical judgement. Unfortunately clinical judgement alone often results in incorrect diagnosis of the source of incompetence and failure to identify atypical anatomy such as bifid venous sytems. This in turn leads to incorrect or inadequate interventions which not surprisingly contribute to the high recurrence rates observed after venous surgery and which vary between 20 and 60% at 5 years. 29% of all patients seen at a one-stop va-scular clinic for venous disease at Mater Dei Hospital Malta between 2007 and 2012 were referred for recurrent varicose veins, the majority of which were performed in the private sector. Even the most experienced surgeons are likely to misdiagnose or miss sources of incompetence in patients with varicose veins or fail to identify deep venous occlusive or reflux disease. Currently all patients referred to the one stop vascular clinic at Mater Dei undergo not only clinical assessment but also non-invasive testing such as ankle brachial pressure indices and dynamic venous duplex scanning. Assessment of spectral waveforms, ankle brachial pressure indices and/or toe brachial pressure indices in patients referred with venous disease provides the clinician with an objective assessment of the perfusion to the limbs. A venous duplex scan performed by the clinician examining the patient ensures that the deep veins are fully assessed to rule out occlusive or reflux disease. The duplex scan also identifies the presence and location of incompetence in the superficial vieins (saphenofemoral junction, saphenopopliteal junction, pelvic incompetence, perforator incompetence) as well as the duration and volume of reflux. In addition the duplex scan also provides anatomical information such as duplex saphenous trunks, depth of saphenous trunks, presence of Giacomini vein, level of the saphenopopliteal junction. This information is crucial not only in ensuring that the clinician reaches a correct diagnosis but also in aiding the clinician in advising patients about the best treatment options. The treatment options for venous disease have increased significantly over the last decade and these now include not only traditional open surge-ry but also foam sclerotherapy, endovenous laser ablation, radiofrequency ablation, combined mechanical and chemical treatment and other options. Detailed information of the source of reflux, the tortuosity, size and depth of the venous trunks affected is required to enable appropriate advice on treatment options. This information can only be obtained through detailed venous duplex scanning. Non-invasive imaging is now regarded not only as the gold standard in terms of assessment of lower limb venous disease but an essential part of clinical decision making. The routine inclusion of non invasive imaging as part of the initial clinical assessment of patients seen at the one stop vascular clinic at Mater Dei ensures that the patients are offered the appropriate treatment options and eliminates recurrence of varicose veins as a result of incorrect or inadequate surgery.

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Author - Jo Etienne Abela; Afiliation - Mater Dei and Gozo General Hospitals, Malta;

MANAGEMENT OF COMPLICATIONS OF ACUTE SEVERE PANCREATITIS - INVITED TALK;

The incidence of acute pancreatitis varies but is quoted at 5 to 80 per 100,000 population per year. Approxima-tely 20% of patients will have the severe form (SAP) which still carries a mortality in excess of 30%. This talk will describe the commonly encountered complications of SAP, touching upon the multi-organ dysfunc-tion syndrome, the limited role of ERCP, nutritional issues and concentrating (with images and videos) on the minimal access intervention for infected pancreatic necrosis. In addition to the established retroperitoneoscopic and laparoscopic techniques, novel gastroscopic techniques will be reviewed.

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Authors - Patrick Zammit; Afiliation - Urology Unit, Mater Dei hospital, Malta, Department of Surgery, faculty of Medicine and Surgery, University of Malta, University College London;

PREDICTION OF SUPERFICIAL BLADDER CANCER DISEASE PROGRESSION USING ARTIFICIAL NEURAL NE-TWORKS;

Published evidence suggests that early cystectomy offers better cure rates than the same after disease progres-sion. The literature is reviewed for prognostic factors and functional prognostic models. The cost terms of cystec-tomy are reviewed and compared with those of bladder conserving treatment. Artificial neural networks are introduced and the inherent difficulties in their application highlighted. The use of these models in urological and other fields of oncological survival reviewed. Details of pre-processing of the selected dataset are given and subsequently explored. Specific methods for the application of neural networks to survival data are discussed. Difficulties in their application and measure of discriminatory abilities are discussed and the handling of the issues detailed. The best performing network topology can achieve a receiver operating curve of 0.79 at ten years with the clini-cal data available at the first check cystoscopy. The literature review has highlighted that progression of superficial bladder cancer can generally be predicted no better now than 25 years ago. The application of artificial neural networks in this study pushes the accuracy of prediction by a few percent beyond linear techniques but not to a degree to be of consequence clinically.

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Authors - Miroslav Jirik 1, Miroslava Svobodova 2, Hynek Mirka 3, Vladislav Treska 2, Jan Bruha 2, Vaclav Liska 2; Afiliation - 1 Department of Cybernetics, Faculty of Applied Sciences, West Bohemia University in Pilsen, Czech Republic, 2 Department of Surgery, Medical School and Teaching Hospital Plzen, Charles University in Prague, 3 Department of Imaging Methods, Medical School and Teaching Hospital Plzen, Charles University in Prague,;

LIVER SEGMENTATION AND VOLUMETRY FROM PREOPERATIVE CT IMAGES, MANUAL AND SEMIAUTOMATIC ESTIMATION;

Objectives: The liver segmentation and volumetry estimation from preoperative CT images within pre-operative planning of liver surgery has become an essential task before any liver resection. Methods: Statistical analysis of the manual and semiautomatic liver segmentation and volumetry estimation has been evaluated in framework of our virtual liver surgery planning system development. Manual liver seg-mentation and volumetry estimation of 29 patients before any liver surgical intervention and after resection was compared to a virtual one estimated by the semiautomatic implicit combinatorial method based on 3D graph cut method. The manual and semiautomatic volumetry divergence and the liver segmentation time consumption are mandatory in the following virtual liver surgery planning system development. Results: Nonparametric statistical analysis shows a good correlation between both methods. Manual and se-miautomatic volumetry divergences were evaluated for 44 clinical events and both arterial and venous CT image phases. The median of obtained divergences errors lies between 4% to 5% with p=0,1; p=0,05 and p=0,01. The used semiautomatic method improves at least seven-times so time consuming manual segmentation. Conclusion: he developed virtual system promises an improvement of contemporary used manual method wi-thin the liver surgery planning. Acknowledgements: The project was supported by grants IGA MZ CR 13326 and 14329.

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Authors - Noel Cassar, Joseph Debono; Afiliation - Department of Surgery, Mater Dei Hospital, Malta;

PREDICTING AXILLARY LYMPH NODE METASTASIS PREOPERATIVELY TO AVOID UNNECESSARY AXILLARY SUR-GERY?

Introduction Sentinel lymph node biopsy (SLNB) has become the standard treatment for the axilla in early stage breast cancer (T1 and T2 tumours, and clinically impalpable nodes). However if a positive sentinel is found the patient may require a completion axillary clearance in a second operation, which has been associated with a complication rate of up to 70%. Aims The aim of the study is to determine whether axillary lymph node metastasis can be predicted pre-operatively in order to go directly to axillary clearance rather than sentinel lymph node biopsy, avoiding a second axillary operation. Methods/Design The medical records of those patients who had biopsy proven breast carcinoma and underwent axillary surgery (SLNB, sampling or clearance) in 2010 and 2011 were analysed. Potential risk factors for axillary lymph node me-tastases were identified. Univariable analysis was performed to determine whether there was any association between clincopathological factors and axillary lymph node metastases. Significant variables were entered into a multiple logistic regression model, and a metastasis risk score was (MRS) developed. Results Factors significantly associated with axillary lymph node metastasis included the presence of a palpable mass and the presence of skin tethering or nipple retraction. Each factor was given one point and the MRS was com-pared with the axillary lymph node status, accurately predicting the likelihood of lymph node metastasis. The area under the ROC curve was 0.726. Conclusion Use of the MRS helps in identifying those patients who would benefit from axillary clearance in the first instance, thus avoiding unnecessary axillary surgery.

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Authors - Rumyana Rumenova Smilevska, AndrĂ©s Garcia Marin, Asuncion Candela Gomis,Valentin NĂşĂ±ez Rodriguez, Maria Mingorance Alberola, Elena Martinez Guerrero, Miguel Morales Calderon, Salvador Garcia Garcia; Afiliation - San Juan de Alicante Universtity Hospital, Spain;

EARLY VS. DELAYED CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS EVIDENCE VS. EXPERIENCE;

Introduction. Nowadays the recommended treatment (and gold standard)for the acute cholecystitis is the early laparoscopic cholecystectomy in the first 72 hours of evolution of the symptoms, and after that period a delay-ed cholecystectomy or cholecystostomy is recommended depending on the severity of the local inflammation or general repercussion. (Tokyo Guidelines 13) Despite the scientific evidence of the superiority of early over delayed cholecystectomy, there is still controversy. The aim of this study is to analize the management of acute cholecystitis in terms of morbidity and hospital stay in the patients admitted in our center in the last 18 months. Material and methods. We realized a retrospective reviewed 173 patients that were admitted in our center from November 2011 till May 2013 with the diagnosis of acute cholecystitis. We evaluated their demographic factors, comorbidity, clinical manifestation and physical exploration, analytical and radiological findings, the treatment modality, the severity of the inflammation, and the hospital stay. The quantitative variables were defined by me-dian and percentiles (25, 75) and the qualitative Variables were defined by frequency and percentage. Results. We analized 173 patients, of which 61% (106 patients) were males and 39% (67) were females. The median age was 69 years (56; 80). The median time of symptoms was 48 hours (24, 96). Forty one percent (70) of the patients came to the emergency department with more than 72 hours of symptoms. Charlson comor-bidity index was 1(0; 1), and the age adjusted Charlson index was 3 (1; 4). According to the Tokyo Guidelines classification (TG13) 46% (80 patients) had mild cholecystitis, 43% (74) had moderate and 10% (18 patients) had severe one. Seventy six percent (132) of the patients has a medical treatment with delayed cholecystectomy, 128 patients with antibiotherapy and 4 patients had cholecystectomy, and 24% (41) had a surgical treatment early cholecystectomy. The morbidity in the surgical treatment group was 24% (10 patients). And the mortality was 1 patient in each group. In the group of medical treatment 18,9% (25 patients) presented a new episode of acute cholecystitis before the scheduled delayed cholecystectomy. The patients in the group with medical treatment were significantly older 71 years (64; 80) vs 61 years (46; 77) (p=0,02), and came with significantly more hours of evolution of the symptoms - 48 hours (24; 96) vs 24 hours (15; 48), (p=0,03). The median of hospital stay was significantly higher in the group with medical treatment 5 days (4;8) vs 4 days (3;6), (p=0,007).Conclusion. Despite the existence of evidence of the superiority of the early laparoscopic treatment of the acute cholecystitis, we continue having an important percentage of medical treatment, significantly for older patients with more time of evolution of the cholecystitis, that increases the hospital stay and has an elevated number of a new episode of acute cholecystitis before the scheduled surgery.

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Authors - Ms Elaine Borg, Dr Adrian Mifsud, Ms Josephine Psaila; Afiliation - Mater Dei Hospital;

FEEDING POLICY FOR ACUTE SURGICAL ADMISSIONS;

BACKGROUND Various feeding regimens have been established for peri-operative periods. In Malta, there is no set local protocol on feeding regimen for acute surgical admissions. The general impression is that patients are often left nil by mouth, awaiting further review. Prolonged fasting may be an unnecessary discomfort and cause for increased anxiety in our patients. The aim of this audit was to assess the level of diet restriction in acute sur-gical admissions in Malta, using the feeding policy established in Frenchay Hospital, North Bristol NHS Trust, UK. METHOD This was a retrospective review of data collected over a 4-week period (15th September till 20thOcto-ber 2012). All patients admitted in General Surgical through casualty in Mater Dei Hospital, Malta, were included in the study. Patients admitted in Urology, Paediatric Surgery, Vascular Surgery or Gynaecology, were excluded. The working diagnosis and the prescribed feeding regimen were documented. Statistical analysis was done using Sampling Distribution of the difference of two populations and Chi-square test, to note any statistical difference between the prescribed feeding regimen and that recommended by the Bristol`s protocol. RESULTS In total, 139 patients were included in this study. 45 patients (32.3% of 139 patients) received the cor-rect feeding regimen as per Bristol`s protocol. These patients were grouped according to diagnosis. 16 (11.5%) of these patients were being managed for cellulitis/peripheral vascular disease, 12 patients (8.6%) were admitted due gastro-intestinal/hepato-biliary (GI/HPB) problems, 14 patients (10%) were sent to theatre and 3 (2.2%) patients were admitted for surgical breast care management. The remaining 94 patients (67.7% of 139 patients) were not prescribed the appropriate feeding regimen as per Bristol`s protocol. 5 (3.6%) of these patients were admitted due to cellulitis/peripheral vascular disease, 80 patients (57.6%) had GI/HPB problems and 9 patients (6.5%) were operated but in view of the waiting period, were left nil by mouth for an inappropriate length of time. 64% of all patients were prescribed a nil by mouth regime awaiting further review. Chi-square test was used to assess any statistical difference between the feeding regimens that were prescribed in this audit, versus the regimen expected as recommended by the Bristol`s protocol. Chi-square test was highly statistically significant with a p-value of 0.0001. The Sampling Distribution of the difference of two proportions showed that the pro-portion of appropriate cases was significantly different from the proportion of inappropriate cases in cellulitis/peripheral vascular disease and GI/HPB groups. DISCUSSION As per Bristol`s protocol, 94 patients (67.7%) out of 139 patients did not receive the recommended regimen with 64% of these being on nil by mouth regime. This audit shows that a better feeding regimen can be prescribed to most patients being admitted for surgical care. CONCLUSION In order to reduce unnecessary discomfort and anxiety for our patients, a local protocol should be asserted to adequately guide the admitting doctor/surgeon to prescribe the appropriate feeding regimen in surgical admissions.

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Authors –Gyorgy Lazar, Zsolt Simonka, Attila Paszt, Szabolcs Abraham, Janos Tajti; Afiliation - University of Szeged, Department of Surgery, Szeged, Hungary;

LAPAROSCOPIC AND OPEN SURGICAL TREATMENT OF COLITIS ULCEROSA - A RETROSPECTIVE ANALYSIS;

Aims: Several reports from specialized centers have demonstrated the feasibility, safety, and good functional outcome of the minimally invasive procedures for ulcerative colitis (UC). This study was designed to evaluate the results of laparoscopic surgery and to compare to traditional open technique in the treatment for UC. Patient and method: Between 2005 and 2012 study period subjects consisted of 43 patients who had primary surgical treatment for CU, 20 through conventional laparotomy and 23 in whom surgery was via laparoscopic approach. 17 cases were emergency ones and 26 of them were planned surgical procedures. The short-term outcomes and cosmesis were evaluated in both groups. Mann-Whitney U test and Student’s t-test were used for statistical analysis. Results: There were no statistically significant differences between the two groups in the patient characteristics regarding BMI, age, gender, comorbidities, ASA classification. The average elapsed time from the appearance of CU to the operation was not significantly different in the two groups (lap vs open) (8.53Â± 5.72 vs. 7.94Â±9.92 years). There were 14 planned restorative proctocolectomies with ileal pouch-anal anastomosis (IPAA) via lapa-roscopy and 4 open traditional operations. The mean operative time was significantly longer in the laparoscopic group (243.85Â±49.42 vs 185Â±17.8 minutes; P < 0.001). There were 9 emergency subtotal colectomies with terminal ileostomy and mucus-fistula formation with LAP method, and 13 operations with traditional method. The mean operative time in LAP group was similarly longer (183.13Â±29.99 vs. 143.33Â±29.57 minutes). There was no significant difference between laparoscopic and open IPAA or subtotal colectomy with respect to estima-ted blood loss, blood transfusions, postoperative narcotic usage, return of bowel function, length of hospital/ICU stay, and hospital readmission rates. There was no death. Overall postoperative morbidity was similar between both groups [25% vs. 21.7 %, P = not significant (NS)], including major surgical postoperative complications in-dicated reoperation (20% vs. 13%). However, the minimal invasive technique associated less postoperative pain and resulted better cosmesis and patient satisfaction. Conclusion: A staged, minimally invasive approach for patients fulminant or not fulminant ulcerative colitis is technically feasible, safe, and reasonable operative strategy.

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Session POSTGRADUATE SURGICAL TRAINING

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Authors - Kevin Cassar; Afiliation - Department of Surgery, University of Malta , Mater Dei Hospital, Msida, Malta;

PROFESSIONALISM IN SURGICAL POSTGRADUATE TRAINING;

In a recent editorial in the Lancet, surgery was described as a specialty adrift which lacks professionalism and leadership. Professionalism and leadership are rather abstract concepts which are difficult to define. In-deed there is no universally agreed definition of either. However the qualities associated with professio-nalism are easily recognised and would include altruism, integrity, honesty, respect, accountability, compas-sion, excellence, lifelong learning and service. At the very core of professionalism should be the fundamental and universal principle of the medical profession which is compassion and sympathy for the sick. Virtue-ba-sed medical practice is threatened by delivery of a health service simply as a commodity which lacks the most essential ingredient care. Until recently the expectation was that surgical trainees would develop professio-nal attitudes and behaviour through observing their mentors and role models. As a result professionalism and leadership did not feature in any curriculum and were considered to form part of the hidden curriculum. Experience has shown that unfortunately relying on role modelling has often led to the perpetuation of inap-propriate and unprofessional behaviour patterns amongst surgical trainees, who in a short time become our surgical colleagues. Over the last few years professionalism has been recognised as one of the core compe-tences expected of surgical trainees and has been introduced into the surgical training curricula around the world, including the American College of Surgeons, the UK intercollegiate Surgical Curriculum Programme, the Royal Australasian College of Surgeons. Our own General Surgery Curriculum drawn up in 2007 includes a short section on Professional practices but this deals only with knowledge, clinical skills and communica-tion and fails to address attitudes and behaviours. In the digital age this should also cover use of social media. Inclusion of professionalism and leadership in the curriculum paves the way for formal teaching and tra-ining in this field. However teaching professionalism and leadership is in its infancy. Different training in-stitutions have developed innovative techniques for teaching including videos and film, video based vir-tual patient cases, anonymous patient stories, mentoring, coaching, and action learning. Professionalism and leadership need to be assessed in order to encourage trainees to give these areas the importance they deserve. It is recognised that if not formally assessed these are given low priority by trainees. Furthermore early identification of trainees who exhibit unprofessional behaviour allows remediation. 360 degree as-sessment (multi source feedback) has been used to assess professional behaviour and attitudes amongst trainees at various levels and this has been shown to be an effective tool at mediating changes in behavio-ur. Other tools used for assessment include the Conscientiousness index and the Professionalism index. A recognition of the importance of virtue based medicine in delivering high quality care has resulted in the in-troduction of professionalism and leadership in all the major surgical training curricula. This is being followed by developments in the teaching and assessment of trainees in these areas. Those training institutions that have not yet formally introduced professionalism and leadership into their curricula will need to address this deficien-cy to ensure that the product of their training programmes will be able to offer the quality of care expected of a modern surgical service.

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Authors - Stroman L, Johnston M, Arora S, King D, Darzi A; Afiliation - Imperial College, London, United Kingdom;

CHANGES IN THE SURGICAL TEAM MODEL TO IMPROVE JUNIOR DOCTOR SUPERVISION: AN INTERVENTION STUDY;

Introduction: Adequate junior doctor supervision when managing post-operative complications is vital for pa-tient safety.Objectives: This study aims to evaluate junior doctor supervision and make recommendations for improvement of the surgical team model and escalation of care.Material and Methods: A closed-loop study exploring perceptions of Attendings and Interns. An intervention bundle consisting of a ‘chief resident of the week’ on ward duty, twice-daily Attending ward rounds, escalation of care protocol and team contact cards was developed using feedback and literature. Validated questionnaires were completed before and following intervention. Semi-structured interviews allowed qualitative exploration of perceptions regarding escalation of care and were analyzed using emergent theme coding and grounded the-ory methodology. Quantitative data was analyzed using SPSS v.20. Results: 27 (16 Attendings, 11 interns) participants completed the study. Significant improvements in intern su-pervision following intervention (median pre 4.0 v post 6.0, p=0.039) and senior approachability (pre 5.0 v post 6.0, p=0.047) were seen. Both groups would feel safer as a patient in their hospital following intervention (pre 3.0 v post 4.5, p=0.021 & pre 3.0 v post 4.0, p=0.034). Participants stated improvements in knowledge of the escalation policy and improved junior supervision and safety for surgical patients: ‘‘I think that has made things better for the juniors because they have a single point of contact who is not going to be offsite or in theatre’’ (Attending 1). Conclusion: Changes in the surgical team model and improvements in the escalation protocol can improve pa-tient safety, doctor’s attitudes and prevent avoidable mortality.

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Authors - N. Pavia, S. Grixti, M. Brincat, O. Tsar, I. Knyazev, J. Mamo; Afiliation - Department of Obstetrics and Gynaecology, Mater Dei Hospital, Malta;

EFFECT OF LAPAROSCOPIC SIMULATION TRAINING ON GYNAECOLOGICAL SURGERY;

In January 2012 laparoscopic simulation training was introduced in the Gynaecology Department at Mater Dei Hospital. Its aim was to increase the proficiency of gynaecological surgeons in this approach and improve the management of gynaecological conditions. Aim: To assess whether there has been an increase in the number of laparoscopic operations following the intro-duction of laparoscopic simulation training. Method: Assessment of the number of laparoscopic surgeries performed in the Gynaecology department in the twelve months prior to the start of laparoscopic simulation training. This was compared with the number of laparoscopic surgeries performed from January 2012 to May 2013. Results: There has been an increase in laparoscopic procedures. The number of laparoscopic hysterectomies performed from January to May 2013 was 36; in 2012, 19 were performed and none were done in 2011. Me-anwhile, laparotomies for hysterectomy decreased from 693 in 2011, to 634 in 2012, to 152 from January to May 2013. Laparoscopic ovarian cystectomies increased from 11 in 2011, to 54 in 2012, and 35 in the 5 months of 2013. Open cystectomies decreased from 57, to 44, to 5 respectively. Laparoscopic Burch colposuspension started being performed since June 2013. 5 have been performed so far, with good results, while open Burch procedures have decreased to 5 since the start of 2013, with 55 in 2012 and 42 in 2011. There has also been a decrease in the number of conversions from laparoscopies to laparotomies with 21 in 2011, 16 in 2012 and 4 in the first 5 months of 2013. There was a reduction in the operation time, length of hospital stay, post-operative complications and pain, and better patient satisfaction. Since the start of training, there has also been a wider variety of surgical therapies performed laparoscopically. Conclusion: The introduction of laparoscopic simulation training in Mater Dei Hospital has influenced the mode of surgical management of gynaecological conditions. Laparoscopic Simulation Training has empowered the Gy-naecological Surgeons to perform more laparoscopic hysterectomies, myomectomies, laparoscopic Burch Colpo-suspension, Laparoscopic sacrocolpopexy apart from ovarian operations and adhesiolysis.

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Authors - Angeliki Lintzeri,Xanthi Agrogianni, Ioannis Lintzeris; Afiliation - Surgery Department,General Hospital of Tripolis, Greece;

THE ROLE OF RADIOFREQUENCY ABLATION IN SURGERY TREATMENT;

Introduction: Radiofrequency ablation- RFA is a minimal invasive therapeutic technique that is being applied in several cases of malignancies causing thermal tissue destruction. Objectives: To provide an overview of the current literature addressing the role of radiofrequency ablation (RFA) for the management of tumours or lesions in parts and organs of human organism. Material and Method: Current literature data was searched thoroughly in order to identify the benefit acquired by the use of RFA in surgical treatment as well as the feasibility, safety, therapeutic effects or complications of the method as these are derived from investigators conclusions worldwide. Results: According to data, RFA is accepted as the best therapeutic choice for patients with early-stage hepato-cellular carcinoma when liver transplantation or surgical resection are not the suitable options and for patients with hepatic metastatic disease especially from colorectal cancer. In addition to this RFA technique is being applied experimentally and evaluated in kidneys, adrenal glands, spleen, breast, pancreas, bone tissue, lung tissue, upper gastrointestinal tract for gastroesophageal reflux disease, colon and rectum, varicose veins either as a method of tissue destruction or as a method of tissue dissection . As the RFA experience also continues to mature, long term data supports on surgical efficacy of the ablative modality . Conclusions: RFA promises a safe, feasible treatment option for patients who cannot undergo a surgical resec-tion for various reasons. However, larger series are required in order to secure the encouraging results and defi-ne the terms for long term survival and quality of life.

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Session MISCELLANEUS SURGICAL TOPICS

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Authors - Darmanin M, Umana E, Debono J; Afiliation - Department of Surgery, Mater Dei Hospital, Malta;

MRI RESULT AND TREATMENT OUTCOME IN BREAST CANCER PATIENTS;

Introduction MRI is being increasingly used in management of patients with breast Cancer. Due to limitations imposed by availability, MRI is used selectively locally in tumours that are not easily visible on conventional radiology, such as lobular carcinoma, to assess the extent or presence of multifocal disease in the involved breast and to screen the contralateral breast. Aim To assess the effect of the MRI finding on the management plan of patients with breast cancer. Methods From 2010-2012 there were 42 cases of breast cancer which required an MRI as part of their assessment or ma-nagement. Prior to MRI a provisional plan for surgery was decided at the Multidisciplinary meeting. This decision was reassessed after MRI. Results 43% of the procedures were upstaged, 48% remained the same and 9% of the procedures were downstaged. Conclusion In patients with uncertain conventional radiology for breast cancer, MRI is an important adjunct to the armamen-tarium used to plan further management.

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Authors - Alexander Manchea; Afiliation - Cardiothoracic surgery, Department of Cardiac Services, Mater Dei Hospital;

CORONARY SURGERY IN THE OVER 70’S: SHORT AND LONG-TERM OUTCOMES. IS IT WORTHWHILE?

Introduction Life expectancy and the demand for a satisfying quality of life are increasing yearly. The treatment of cardiova-scular disease plays a role in achieving this goal. Patients and methods A retrospective analysis of our coronary surgical patient population from the start of the local cardiac surgical se-rvice in Malta in April 1995 until January 2012 (n=3557). Data and outcomes of patients over 70 years old (group A, n=785) were compared with those of patients under the age of 70 (group B, n=2772). Results The mean intervention rate was 3.2 times higher in group A (1502 versus 467 per million per year in group B). Repeat operations were performed in 0.51% in group A and in 0.47% in group B (p=ns). The mean Parsonnet risk stratification score was 12.8 for group A and 4.4 for group B. The mean EuroSCORE risk stratification score was 4.8 for group A and 1.9 for group B. Triple coronary artery bypass grafting was the commonest procedure (group A average 3.1 grafts per case, group B average 3.2). There were significantly fewer single (p<0.001) and quintuple (p=0.001) grafts, and significantly more double (p=0.03) grafts in group A. The use of an internal thoracic artery (ITA) was lower in group A (748/785, 95.3%) than in group B (2695/2772, 97.2%, p=0.006). The overall mortality was 2.7% in group A and 0.8% in group B (p<0.0001). Freedom from any post-operative complication occurred in 57.7% in group A and in 75.6% in group B (p<0.0001). Cardiac complications (except for perioperative MI and atrial flutter) were significantly higher in group A (p<0.0001), as were major neurological (p=0.001), renal (p<0.0001) and respiratory (p=0.02) complications as well as minor wound (p=0.03) complications. The average length of stay on intensive care was similar (1.19Â±1.84 days for group A and 1.13Â±1.48 days for group B, p=NS). The average HDU stay was longer in group A (1.43Â±2.70 vs 0.95Â±3.68 days, p=0.006) as was the average CSW stay (4.00Â±3.33 vs 3.25Â±2.23 days, p<0.0001). Kaplan Meier curves for group A demonstrate that life expec-tancy was preserved at 5 years. Conclusion The demand for cardiac surgical intervention in the elderly is high and likely to increase if we are to follow the trend in more developed nations. Although mortality and morbidity remain significantly higher, taken in the context of the overall clinical problem, cardiac surgery has much to offer to this select and growing population.

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Authors - Ms E. Borg, Prof K. Cassar; Afiliation - Mater Dei Hospital, Malta;

PROSPECTIVE STUDY OF MANAGEMENT AND OUTCOME OF INPATIENT DIABETIC FOOT ULCERS AND GAN-GRENE ACCORDING TO WAGNER›S CLASSIFICATION IN A TERTIARY HOSPITAL IN MALTA;

INTRODUCTION Diabetic patients have a 15% lifetime risk of developing foot ulceration. As ulcers often precede amputation, prompt management could prevent major amputation. With about 10% prevalence, Malta has the highest pre-valence of diabetes mellitus in the European Union. This study aims to investigate the aetiology, inpatient mana-gement and outcome of diabetic foot ulcers and gangrene and compare it to international data. METHODS Diabetic inpatients with foot ulcers or gangrene under the care of one vascular surgeon in Mater Dei Hospi-tal were recruited. Patients` demographics, comorbidities, management and outcomes were noted. Wagner`s classification was used to stratify the severity of the foot lesions. Patients with open surgical wounds had their wounds re-measured to assess healing rate. RESULTS 62 patients were recruited between November 2012 and January 2013. They were predominantly Type 2 DM (98.4%), male (69.4%) with a median age of 71 years (range 40-92). 67.7% of the foot lesions were ulcers, pre-dominantly in the toes (63.8%). According to the Wagner Classification the number of patients per stage were: Stage 1, 3 (4.8%); Stage 2, 12 (19.3%); Stage 3, 26 (41.9%) and Stage 4, 21 (34%). Aetiology was neuroischaemic in 33 patients (52.5%), ischaemic in 16 (25.4%), neuropathic in 12 (19%) and venous in 2 (3.2%). The median in-hospital stay was 12 days (range 2-59). 34 debridements, 44 minor amputations and 8 major amputations were performed during the study period. 41 patients (66.1%) underwent endovascular (29; 46.8%) or open (12; 19.3%) revascularization. 27 patients (43.5%) developed complications, with 24 (38.7%) requiring re-admission. 48.1% of these 27 patients were admitted due progression of disease whilst the remaining had complications included seroma formation (7.4%), infection (29.7%), wound dehiscence (11.1%) and new lesion (3.7%). 36 pa-tients (58%) had skin closure within 2 months. Average healing rate was of 3.11cm2 per month. 4 patients (6.5%) passed away. Out of the remaining 22 patients (35.5%) whose lesions had not healed: 15 (24.2%) had clear signs of healing. CONCLUSIONS Neuroischaemia was the commonest cause of diabetic foot ulceration or gangrene. Inpatient management and outcomes (major amputation and healing rates) are comparable to those reported in the literature.

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Authors - Hannah King, Amanda Rea, Nick Kalson, Georgios Akritidis, Bimbi Fernando, Fiona Mint, Seraphim Patel; Afiliation - Royal Free Hospital, Hampstead, UK;

QUALITY OF CONSENT DOCUMENTATION FOR MAJOR SURGICAL PROCEDURES REFLECTS THE OUTCOME OF THE CONSENT PROCESS;

Background:In the UK informed consent is required for all invasive procedures and in its written format is a legal document. Consent documentation is part of the framework in assessing performance in British hospitals and therefore requires quality monitoring. Previous research has demonstrated that documentation of consent is often incom-plete, and that patient understanding of the procedure, its risks and benefits may be poor after consent has been given. The aim of this study was to test the hypothesis that good quality consent documentation is associated with improved patient understanding. Method:We retrospectively reviewed 150 consent forms during April 2013 (50 orthopaedic, 50 general surgery/colo-rectal, 20 vascular and 30 renal transplant cases) to test the completeness and accuracy of documentation. We interviewed the corresponding patients one day post-procedure. Patients were asked to recall their procedure, details of benefits and risks if they were explained, and whether they were offered written material.Results:Documentation practice varied between different specialities (Fig. 1), with transplant, vascular and elective orthopaedic surgery documenting consent more carefully than general surgery and emergency orthopaedics. Transplant, vascular and elective orthopaedic patients were better able to recall their procedure (98% versus 77%), and what the risks (74 %vs. 49%) and benefits (100% vs. 50%) were than general and emergency orthopa-edic patients (Fig. 2). Transplant, vascular and elective orthopaedic patients were routinely given written mate-rial during the consent process. Conclusions:These results show clear areas of good practice. However, consent form documentation remains inconsistent. Interestingly, patients under care of specialities that documented consent carefully and provided written infor-mation were more likely to accurately recall information about their procedure. Emergency patients are more likely to have poor documentation, and this is consistent with poorer recall. The use of multi-media and written information could improve consent in elective patients. However, the importance of providing patients with co-pies of their consent form should not be under-estimated especially in the emergency population.

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Authors - Gordon Caruana-Dingli; Afiliation - Breast Clinic, Mater dei Hospital;

IMPROVING THE AESTHETIC OUTCOME OF BREAST CANCER SURGERY;

Abstract content: Oncoplastic surgery is an approach to breast cancer surgery combining optimal tumour resec-tion with plastic surgery techniques to combine a high cure rate with the best possible cosmetic outcome.The author will describe oncoplastic techniques practised at the Breast Clinic in Malta.

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Authors - Joseph Galea, Alexander Manche; Afiliation - Cardiac Surgical Section, Department of Cardiac Services, Mater Dei Hospital, B’Kara, Malta;

GENERAL SURGICAL COMPLICATIONS FOLLOWING CABG;

General surgical complications after coronary artery bypass surgery (CABG) are rare but with a high mortality. Patients undergoing CABG usually suffer from comorbidities such as diabetes, hypertension, peripheral vascular disease and cerebrovascular disease. The study concerns a series of 3557 consecutive patients undergoing CABG at the Cardiothoracic Units of St Luke’s Hospital and subsequently Mater Dei Hospital in Malta from April 1995 until December 2012. Of these post-CABG patients, 8 suffered from abdominal catastrophy (0.22%) during the first 30 days following surgery. Five patients had ischaemic bowel with 100% mortality. Two patients had over-sewing of a perforated duodenal ulcer and survived and one patient had suturing of an intractable bleeding gastric ulcer and survived. Thirty-two patients of 3557 suffered from upper gastrointestinal haemorrhage (0.9%) during the first 30 days postoperative-ly and were managed conservatively with repeated upper GI endoscopy, injection sclerotherapy and aggressive medical therapy. There was no mortality recorded in this group.In conclusion, the occurrence of acute ischaemic bowel following CABG in this series was lethal. However ble-eding ulcer and perforated ulcer post-CABG patients were treated successfully.

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Authors - Ian Said, Kevin Cassar; Afiliation - Univeristy of edinburgh ESSQ;

IS DEEP TISSUE BIOPSY CULTURE SUPERIOR TO SUPERFICIAL SWAB CULTURE IN THE EVALUATION AND TREAT-MENT OF DIABETIC FOOT INFECTION?

Diabetes mellitus is a growing problem being described as a global epidemic by the World Health Organisation. With rising prevalence rates and increasing longevity of the diabetic population, complications of diabetes will become an increasing healthcare burden over the coming years.Diabetic foot infection (DFI) is one of the commoner complications of type 2 diabetes and is the commonest reasons for hospitalisation of such patients. Management of diabetic foot infection is complex and there exists a longstanding debate as to which microbiological investigation provides more accurate results in the initial assessment of the diabetic foot. Most international guidelines favour deep tissue biopsy (DTB) culture as the investigation of choice.Our primary aim was to ascertain whether DTB is superior to superficial wound swab (SWS) and culture in the assessment of DFI. Secondary aims included comparing the microbiological yield of the two sampling techniques as well as investigation of the local prevalence of pathogens causing DFI.We have prospectively assessed 26 consecutive patients presenting with acute DFI. All of the patients were inve-stigated using both SWS and DTB and culture prior to starting antibiotic therapy as per local protocol. Concordance between DTB and SWS culture was only observed in 57.7% of our patients. 31% of patients would have been mistreated if they were only investigated by SWS culture. Our data suggests that DTB culture is supe-rior to SWS culture in guiding targeted antimicrobial therapy.

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Authors - Aaron Casha,Alexander Manche, Ruben Gatt, Marilyn Gauci, Pierre Schembri Wismayer, Marie-Therese Camilleri-Podesta, Joseph N Grima; Afiliation - Mater Dei Hospital, Malta;

IS THERE A BIOMECHANICAL CAUSE FOR SPONTANEOUS PNEUMOTHORAX?

Introduction Primary spontaneous pneumothorax has been explained as being without apparent cause. This paper deals with the effect of chest wall shape on pleural stress and explains the association with primary spontaneous pneumo-thorax. Methodology Rib cage measurements were taken from CXRs in 12 male patients and 12 age matched controls. Apical lung shape was investigated using paramedian coronal and sagittal CT reconstructions. A finite element analysis (FEA) model of lung was constructed including indentations for the first rib guided by CT scan data to assess pleural stress. This model was tested using different chest wall shapes. Results The pneumothorax patients had a taller chest (p=0.03), wider transversely (p=0.009) and flatter (p=0.03) as compared to controls. Prominent rib indentations were found on the lung surface on CT. FEA of the lung apex revealed significantly higher stress (x5-x10) in the apex as compared to the rest of the lung, accentuated (x4) in tall thin flattened chests. Conclusion The FEA model demonstrates high pleural stress in the apex of a flattened rib cage shape typical of spontaneous pneumothorax patients. High pleural stress is associated with spontaneous pneumothorax with the highest pleu-ral stress occurring in tall, flat chested young males.

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Authors - Lara Sammut, Annalisa Montebello, Gianluca Bezzina, Ali Virk, Gerald Busuttil; Afiliation - Department of Urology, Mater Dei Hospital, Malta;

AN AUDIT OF URINARY TRACT INFECTIONS AT THE UROLOGY UNIT AT MATER DEI HOSPITAL, MALTA;

Introduction Urinary Tract Infections are common and range from simple cystitis to urosepsis with shock that needs urgent treatment with extremely potent antibiotics. Aim The aim of this audit was to assess the management of all patient that developed a UTI as compared to the Eu-ropean Association of Urology Guidelines 2013. Method A retrospective audit which included all patient admitted to the urological wards at MDH who developed a UTI between the period of 15th October 2012 and 14th January 2013. Data included the patient`s risk factors, origin and nature of infection, management and outcome. Results There were a total of 67 infective episodes; 58 community acquired and 9 post operative infections. Post ope-rative infection rates : Endourology - 1.5%; Genital-Groin Surgery - 2.9%; Oncological Surgery - No infections. Infections included - simple UIT; UTI with sepsis; pyelonephritis; epididymitis/orchitis; pyonephrosis; wound in-fection; prostatitis; UTI with septic shock. Treatment included “ management with IV antibiotics, oral antibiotics, urosepsis treated on ward, emergency mephrostomy and urosepsis needing ITU. The most common organism cultured was E.Coli. Cefuroxime was the commonest empirical antibiotic used. The most common secondary antibiotic used was Ertapenem followed by Meropenem and Piperacillin/Tazobactam. Conclusion Urinary Tract Infections anre managed adequately and with good outcomes. Iatrogenic infection rates are within acceptable limits. Most broad spectrum antibiotics are suitable as prophylaxis. Fluoroquinolones and second line agents should be avoided as prophylaxis.

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Authors - Max Mifsud, Kevin Cassar; Afiliation - Department of Vascular Surgery, Mater Dei Hospital, Malta;

RANDOMISED CONTROLLED TRIAL OF ELECTRICAL CALF MUSCLE STIMULATION IN INFRAINGUINAL BYPASS SURGERY;

Introduction: Infrainguinal bypass surgery is frequently associated with postoperative lower limb swelling which often contributes to the development of wound complications, delayed healing and patient discomfort. Elec-trical calf muscle stimulation has been shown to reduce lower limb swelling in other settings. It has also been shown to improve venous flow rates in the lower limbs in healthy controls. The aim of this study was to evaluate whether the application of electrical calf muscle stimulation in the early postoperative period after infraingu-inal bypass surgery is of benefit in reducing lower limb swelling and improving lower limb venous flow rates. Design: Randomised controlled trial. Methods: Forty consecutive patients between May 2012 and May 2013 who were due to undergo infra-inguinal bypass for critical lower limb ischaemia (confirmed clinically and radio-logically on duplex ultrasound scan and/or with computed tomography angiography) in a tertiary referral centre were invited to participate in the trial. Subjects were randomly allocated to the control group (standard care) or the study group (standard care and application of electrical calf muscle stimulation for two 1 hour sessions daily from Day2 to Day 7 post operatively). Data was collected on patient demographics, surgical intervention, and major risk factors. The primary outcome measure was change in limb girth from the preoperative stage to Day 7 after surgery. The limb was measured using a tape measure at 3 predetermined sites (2cm and 10cm above the medial malleolus and 2cm below the tibial tuberosity) on the day before surgery and 7 days after surgery. Secondary outcome measures were the change in venous flow rates at rest and on calf compression in the po-pliteal vein between the preoperative stage and Day 7 after surgery. This was measured using duplex scanning using the same equipment (Philips HD11) by the same experienced sonographer in all patients. The area under the curve and the diameter of the popliteal vein were used to measure flow rates. The presence or absence of pitting oedema was also noted at both stages. (add what statistics were used). Results: The two groups were well matched with regards to patient demographics, legs operated and technical details of surgical procedure carried out. The age range was 50 to 93 (mean 72.75) in the control group and 41 to 91 (mean 70.95) in the study group. The male to female distribution was 11 to 9 in both groups. In both groups, the predominant surgical procedure was a femoral to below knee popliteal bypass (50% in both groups) using ipsilateral long saphenous vein (65% in control group, 40% in study group).The prevalence of risk factors was also similar between the two groups. More than 60% of patients in both groups never smoked or had stopped smoking more than one year prior to the surgery. Less than 25% of patients in both groups did not suffer from hypertension. 75% of patients in both groups had diabetes requiring oral hypoglycaemic agents or insulin. With regards to atherosclerotic disease, only one patient in each group had unstable angina and up to 25%a comple-ted cerebrovascular accident. 25% of patients had an estimated glomerular filtration rate below 50 mls/min. The distribution of both groups was normal. At one week post-operatively, the average change in leg girth in the control group was +8.85% (ankle), +2.02% (calf) and +11.04% (below knee). In the study group, the changes in leg girth were +6.10% (ankle), -4.88% (calf) and +4.24% (below knee. The changes in venous flow rates in the control group were +67.27% at rest and +41.14% on calf stimulation. In the study group, the changes in venous flow ratewere +193.88% at rest (p=0.01) and +71.98% (p=0.03) during stimulation. In both the control and study group, there was an increase in pitting oedema postoperatively but to a lesser extent in the study group. (what proportion had pitting oedema in total and what proportion in each group).Conclusions: Application of transcutaneous electrical calf muscle stimulation in the early postoperative period after infrainguinal bypass surgery results in significant reduction in postoperative lower limb swellingand signifi-cant increase in venous flow rates.

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Poster Session

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Authors- Asem Ghasoup,MD MRCS, Omar Sadieh,MD MRCS- Mahmoud Khashashneh MD,MRCS-Ismai Marey,MD-Nedal Shawagfeh,MD,Adala Al Enzi,Abeer Al Enzi Afiliation - Prince Abdul Mohsin General Hospital,Madinah-KSA Saad Specialty Hospital,Al Khobar, KSA

EARLY MARKERS OF ACUTE RESPIRATORY DISTRESS SYNDROME IN SEVERE TRAUMA PATIENTS.

Introduction: ARDS is a syndrome of acute lung injury that can be initiated due to a wide variety of insults to ei-ther direct (toxic gas inhalation, aspiration of abdominal contents) or indirect (multiple trauma, sepsis) factors. It occurs in an unpredictable fashion often after several hours or days after the insult. Majority of patients develop ARDS within first 24 hours of well-defined injuries or clinical conditions. Material and Methods: A prospective study of 76 severe trauma patients all patients older than 18 years with severe trauma admitted to our hospital from October 2011 to October 2012. The following variables were re-corded: age; sex; trauma type; injury mechanism; accident-admission delay; type of transport; fluids and blood administered in first 24 hours; injury severity by the Revised Trauma Score (RTS); Injury Severity Score (ISS); APACHE II; injury Diagnosis by International Classification of Diseases; presence and number of bone fractures and development of ARDS during ICU stay. Patients were admitted to ICU enrolled in the Trauma Registry 80.4% were males, and mean age was 32.2.Cause of injury was blunt trauma in 95.4% of cases. The most frequent injury mechanisms were road traffic accidents (72.3% [motorcycles 3.9%; automobiles 57.3%]) and falls from heights (11.1%). The remainder (13.7%) included work- and sports-related injuries, among others the mean se-verity scores were as follows: ISS, 22.3 and APACHE II, 14.4 points. Results: Acute respiratory distress syndrome developed in 5.3% of patients who were more severely ill with higher APACHE II and Injury Severity Score scores vs. patients not developing ARDS. Acute respiratory distress syndrome development was associated with fractures of femur, tibia, humerus and pelvis, with a number of long bone fractures, and with chest injuries (rib/sternal fracture and hemo/pneumothorax). Patients with ARDS required more colloids and red blood cell units than patients without ARDS during the first 24 hours. Analysis showed that ARDS was related to chest trauma, femoral fracture, APACHE II score, and blood transfusion during resuscitation. Conclusions: Risk of ARDS development is related to the first 24-hour admission variables it is remain a frequent and dreaded problem in modern intensive care units. Early identification of the case and its proper management may significantly decrease its mortality.

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Authors - Borasi Andrea, Bossotti Maurizio, Bona Alberto, Bellomo Maria Paola, Manfredi Silvio, De Paolis Paolo.; Afiliation - Presidio Sanitario Gradenigo, Torino, Italy;

LAPAROSCOPIC APPROACH TO ACUTE APPENDICITIS: OUR 8 YEARS EXPERIENCE AND COST ANALYSIS.

Introduction: Laparoscopic appendicectomy has only partly gained acceptance in the early years, because the advantages were not as obvious as for laparoscopic cholecistectomy. A quicker and less painfull recovery, less postoperative complications and better cosmesis seem to be in favour of endoscopic approach. Material and Methods: From 1/1/2006 to 31/5/2013 321 patients suspected to have an acute appendicitis were operated on. Patients were selected for open or laparoscopic approach on the basis of the experience in laparoscopic surgery of the team on call in the emergency room. 188 were approached by open surgery and 133 (41,4%) by laparoscopy. Considering our interim results of hospital stay (-1,8 days for laparoscopic cases), start-ing from 2011 the percentage of laparoscopic approach increased up to 70% (84/120). Mean operative time was 46,6 min for open cases (15-150) and 64,2 min (30-120) for laparoscopic cases, without differences between the 2 periods (2006-2010 vs 2011-2013). Results: Analyzing the clinical outcome of laparoscopic group, 15 patients (11,3%) required a conversion. 1 pa-tients was re-operated for bleeding. Minor complications were encountered in 9% of patients (13,9% for open cases). There was no mortality. Mean post operative stay was 4,3 and 3,1 days for open and laparoscopic groups, respectively. In the last years we noticed a constant increase of laparoscopic appendicectomies in emergency setting up to 77,3% in 2011. Despite approaching laparoscopically more complicated cases, conversion rate re-main still low and complications rate was in favour of laparoscopic group. Operative time 18 min longer and hospital stay 1,2 days shorter should be balanced for cost analysis. These good results could be attributed to the laparoscopic skill of the surgeons involved in most of the cases treated. Conclusions: Where surgical expertise and equipment are available, we recommend laparoscopy for diagnostic and therapeutic purposes for young female, obese patients and uncertain diagnosis.

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Authors - Butyrsky Olexandr, Dubovenko Viktor, Govorunov Igor, Butyrska Iryna, Makeieva Nadiia; Afiliation - Crimean Medical University, PE Clinical Hospital, 7th municipal hospital, University Clinic, Simfero-pol, Ukraine;

ABOUT OBLIGATORY NECK LYMPH NODE DISSECTION IN PAPILLARY THYROID CANCER.

Introduction: In treating papillary thyroid cancer (PTC), prophylactic central neck lymph node (NLN) dissection with extrafascial total thyroidectomy (ETTE) is controversial. This is because of a possibility of increased mor-bidity with uncertain benefits. This study is aimed to determine whether prophylactic central NLN dissection is always indicated. Material and Methods: This was a retrospective cohort study. It included patients with PTC without preoperative evidence of lymph node involvement. 45 patients who had clinically node-negative PTC were undergone for ETTE with central NLN dissection (4 - modified lateral dissection with final ETTE) within 2008-2011. Before we did not do it prophylacticly. Results: The indication for NLN dissection was positive result of fine-needle aspiration biopsy and urgent his-tological assessment of thyroid and LN within surgery. Among 45 patients the final histological investigation confirmed presence of metastases in NLN in 14 patients only (31%), others - reactive proliferation. As for postop-erative complications they are of usual rate (2% of recurrent laryngeal nerve damage, 2% - hypoparathyroidism, 2% - disease prolongation/relapsing (in group without preventive central NLN dissection). Rate of 3 and 5 years survival is same. Conclusions: central lymph node dissection should not be routine for PTC surgical management. It should be performed only after intra-operative histological confirmation of NLN metastases. If not confirmed no benefits of routine NLN dissection are observed.

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Authors - KRYSHEN V., LYASHENKO P.; Afiliation - General Surgery Chair, Medical Academy, Dnipropetrovsk ,Ukraine;

DYNAMICS OF CD -4 LYMPHOCYTES AT PERITONITIS DURING SORPTION DIALYSIS APPLICATION.

Introduction: Impair of cell-mediated immunity and multiple organ dysfunction (MOD) are the main factors of mortality in generalised peritonitis. The aim of the study was to check for the restoration of CD-4 lymphocytes in the postoperative period in patients with generalized peritonitis who underwent intra-abdominal sorption -transmembrane dialysis (ISTD). Material and Methods: The analysis of the tests result and surgical treatment of 94 patients with generalized peritonitis were conducted. To perform ISTD we use tubular membrane of viscose pulp and nanosilica sorbent. To assess the effectiveness of restoration of cellular immunity, marker CD-4 lymphocyte is calculated during the treatment period. Results: Results of marker CD-4 lymphocytes showed to whom ISTD was applied are very justifiable and rapidly restoration of CD-4 lymphocytes conditions which is clinically reflected by lower cases of MOD and remarkable subsided of systemic inflammation signs. Conclusions: Our data showed the effective impact of ISTD on restoration of CD-4 lymphocytes and cellular immunity on the whole which accompanied with reduce peritoneal cavity inflammations in feature and rate of surgery complications at generalised peritonitis.

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Authors - KRYSHEN V., LYASCHENKO P.; Afiliation - General Surgery Chair, Medical Academy,Dnipropetrovsk, Ukraine;

DYNAMICS OF ENDOGENOUS INTOXICATION DUE TO TRANSMEMBRANE DIALYSIS FOR PERITONITIS.

Introduction: One of the most complex problems of modern abdominal surgery is the treatment of peritonitis.The aim of the study was to evaluate the effectiveness of intra-abdominal sorption-transmembrane dialysis (ISTD) as a method of treatment of endogenous toxemia in patients with widespread peritonitis. Material and Methods: The analysis of the survey results and surgical treatment of 64 patients with widespread peritonitis was conducted. For the ISTD had been using tubular viscose cellulose membrane and silica sorbent. To assess the effectiveness of proposed method it was calculated basic parameters of endogenous intoxication markers . Results: Calculating markers intoxication in dynamics revealed such a trend: those patients to whom ISTD were used it has been showed more and faster reduction persistent MOF incidence and marked regression of systemic inflammations by earlier elimination of severe abdominal sepsis symptoms. Conclusions: The Intraabdominal sorption-transmembrane dialysis at generalised peritonitis promotes acceler-ated vivid regression of local inflammatory process and manifestation of endotoxemia which reduces rate of postoperative complications consequently.

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Authors - Trofimov M.V.; Afiliation - General Surgery Department,Medical academy, Dnepropetrovsk, Ukraine;

DYNAMICS OF BLOOD SEROTONIN AT PATIENTS WITH BLEEDING GASTRO-DUODENAL ULCER.

Introduction: Treatment of bleeding gastroduodenal ulcer remains one of the actual problems of modern public health services. Material and Methods: Complex observation of 40 patients with bleeding gastroduodenal ulcer which were on treatment in city clinical emergency hospital was conducted. All patients were under endoscopic monitoring to whom local endoscopic hemostasis was provided . As a rule, on the third day stomach mucous membrane biopsy was taken, which was followed by microbiological and specific immunohistochemical research with expose of the inducible NO-synthesis activity (i-NOS). The blood serotonin level was carried out at admission and on the third day of hospitalize. Results: The greatest increase of serotonin was observed on the third day. The most significant increase of se-rotonin has been at patients with bleeding gastric ulcer which revealed of considerable hemorrhage degrees such as 0,031ď‚±0,01 mkmol/l to 45,3ď‚±3,8 mkmol/l (p<0,01) and an unstable hemostasis with high risk re-current hemorrhage - with a thrombosis vessel presents in a defect zone- 0,04ď‚±0,02 mkmol/l to 8,6ď‚±1,5 mkmol/l (p<0,01) and a clot in defect zone- 0,02ď‚±0,01 mkmol/l to 1,7ď‚±0,02 mkmol/l (p<0,01). In both group the greatest increase of serotonin level in blood was revealed at continuation in cases of acute bleeding - from 0,04ď‚±0,004 mkmol/l to 0,3ď‚±0,002 mkmol/l (p<0,01) as well as the mostly activity i-NOS periulcerosis mucous membrane and microorganisms seminations by Streptococcus beta˛-haemoliticus predominance. Conclusions: So blood serotonin dynamics at patients with bleeding gastroduodenal ulcer indicated clear mul-tiple clinical parallels and could manage to ulcer bleeding.

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Authors - Kryshen V.P, Trofimov M.V.; Afiliation - Medical academy, Dnepropetrovsk, Ukraine;

DYNAMICS OF BLOOD CATECHOLAMINE AT PATIENTS WITH BLEEDING GASTRODUODENAL ULCER.

Introduction: Treatment of bleeding gastroduodenal ulcer remains one of the actual problems of modern public health services. Material and Methods: Complex observation of 40 patients with bleeding gastroduodenal ulcer which were on treatment in city clinical emergency hospital was conducted. All patients were under endoscopic monitoring to whom local endoscopic hemostasis was provided. As a rule, on the third day stomach mucous membrane biopsy was taken, which was followed by microbiological and specific immunohistochemical data with expose of the inducible NO-synthesis activity (i-NOS). The epinephrine and norepinephrine level in blood was carried out at admission and on the third day . Results: The greatest increase in the level of epinephrine and norepinephrine in blood was observed on the third day. The most significant increase of epinephrine level in blood in group of bleeding duodenal ulcer was observe- 7,8ď‚±1,3 nmol/l to 39,2ď‚±12,3 nmol/l (p<0,01).At high degree hemorrhage observed epinephrin in-crease -10,1ď‚±5,2 nmol/l to 58,1ď‚±13,2 nmol/l (p<0,05) and decrease in cases with massive degree hemor-rhage to 1,5+0,2 nmol/l (p<0,01). In both groups of patients the greatest increase of epinephrine was revealed at continuation in cases of acute bleeding - from 71,5ď‚±13,9 nmol/l to 105,1ď‚±20,1 nmol/l (p<0,01) and nor-epinephrine from 1,9ď‚±0,8 nmol/l to 4,2ď‚±0,9 nmol/l (p<0,01).At unstable hemostasis with high risk recurrent hemorrhage - clot in defect zone in group with duodenal bleeding ulcer we observed increase of epinephrine from 71,4ď‚±7,01 nmol/l to 105,1ď‚±13,02 nmol/l (p<0,05).The greatest increase of catecholamines went along with mostly activity i-NOS periulcerosis mucous membrane and Streptococcus beta-haemoliticus seminations with epinephrine -31,3ď‚±4,2 to 37,1ď‚±7,5 nmol/l; norepinephrine-6,5ď‚±1,2 nmol/l to 13,3ď‚±4,3 nmol/l. Conclusions: Thus blood catecholamine dynamics at patients with bleeding gastroduodenal ulcer connected with lot of clinical parameters and could be use for ulcer bleeding managing.

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Authors - Iarynko D.,Trofimov M., Kryshen V.,Iarynko A.; Afiliation - Medical academy, Dnepropetrovsk, Ukraine;

DYNAMICS OF BLOOD TYROSINE AT PATIENTS WITH BLEEDING GASTRODUODENAL ULCER.

Introduction: Treatment of bleeding gastroduodenal ulcer remains one of the actual problems of modern public health services. Material and Methods: Complex observation of 40 patients with bleeding gastro duodenal ulcer which were on treatment in the centre of gastroduodenal bleedings of city clinical emergency hospital was conducted. All pa-tients were under endoscopic monitoring to whom local endoscopic hemostasis was provided. As a rule, on the third stomach mucous membrane biopsy was taken, which was followed by microbiological and specific immu-nohistochemical investigation with expose of the inducible NO-synthesis activity (i-NOS). The check of tyrosine in blood was carried out at admission and on the third day of patients treatment.Results: The increase of tyrosine in blood was observed on the third day. The most significant growth of tyrosine level in blood in group of patients with bleeding gastric ulcer was revealed at considerable degrees hemorrhage from 0,4ď‚±0,3 mmol/l to 5,6ď‚±3,2 mmol/l (p<0,01) and an unstable hemostasis with high risk recurrent hem-orrhage - presence clot in defect zone- from 0,5ď‚±0,2 mmol/l to 8,7ď‚±1,6 mmol/l (p<0,01). In both groups of patients with bleeding ulcer the greatest increase of tyrosine level was revealed in cases of the most expressed activity i- NOS periulcerosis mucous membrane and severe gastroduodenal influence -atrophic changes from 0,2ď‚±0,06 to 4,3ď‚±1,9 mmol/ml (p<0,05). Conclusions: So data of blood tyrosine dynamics at patients with bleeding gastroduodenal ulcer indicated some clinical parallels and could be use to predict the development of ulcer bleeding.

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Authors - Manafov S.S.,Gerayzade R.B.; Afiliation - Department of Radiology, Scientific center of surgery named after M. A. Topchubashov, Baku, Azer-baijan.;

COMPARISON OF OPPORTUNITIES OF RADIOLOGICAL METHODS IN ACUTE INTESTINAL OBSTRUCTION CAU-SED BY A COMPLICATED EXTERNAL ABDOMINAL HERNIA.

Introduction: Acute bowel obstruction caused by abdominal hernia is the emergency pathology. Determination the viability of incarcerated bowel is important for surgeon strategy. The aim of the study was comparison and selection of the optimal radiological method in acute bowel obstruction causing by complicated abdominal her-nia. Material and Methods: 70 patients with acute bowel obstruction caused by abdominal hernias were examined using plain radiography, ultrasound (gray-scale and color Doppler mode) and Computed Tomography(CT). Re-sults were verified in subsequent surgical interventions. Results: Acute bowel obstruction was identified with all 3 methods. Ultrasound and CT in all cases equally cor-rectly identified the cause of bowel obstruction, the contents of the hernia sac , assess blood flow of herniated bowel and differentiate strangulated from incarcerated hernia. Results are statistically significant (p<0.05).Conclusions: Ultrasound is the most simple and highly informative diagnostic method in the case of acute bowel obstruction, caused by external abdominal hernia.

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Authors - Manafov S.S.,Gerayzade R.B.; Afiliation - Department of Radiology, Scientific center of surgery named after M. A. Topchubashov, Baku, Azer-baijan.;

ROLE OF ULTRASOUND IN THE SELECTION OF TREATMENT STRATEGY FOR MALIGNANT LARGE-BOWEL OB-STRUCTION (LBO).

Introduction: The aim of the study was to assess the role of abdominal ultrasonography in the selection of treat-ment strategy for LBO in patients with colon cancer . Material and Methods: 65 patients with LBO due to a colon cancer were undergone an abdominal ultrasound. Results: According to the results of ultrasonography 2 groups of patients are distinguished: for the 1st group - ul-trasound signs of LBO in the form of expanded bowel loops filled with liquid were found, but there is no free liq-uid in abdominal cavity and liver metastases; single tumour in the projection of colon in two sonographic options were revealed in these patients - polypoid roundish appearance (the minimum size in disclosed appearances 2 cm) and concentric irregular thickening of bowel wall (the minimum disclosed thickening of a wall consisted 1 cm); for the 2nd group - the loops of bowel filled with liquid, free liquid in lateral canals of abdominal cavity and liver metastases were found. The patients of 1st group were applied conservative treatment with strict US monitoring. Reduction of diameter and quantity of the loops expanded and filled with liquid suggested about positive dynamics and successful conservative treatment (40 patients); following the release of obstruction they were subject to elective surgery. The increase in diameter and quantity of the bowel loops filled with liquid, appearance of free liquid in abdominal cavity suggested about negative dynamics and need for urgent surgery, with the best prognosis of patients, than in case of delay of surgery (20 patients). So, if positive dynamics was not observed within 48 hours, the subsequent delay of surgery led to increase in post-surgical complications. The second group of patients (5 patients) were determined to be inoperable and pharmacological treatment was applied. Conclusions: Ultrasonography is a choice method at case follow-up of patients with LBO due to colon cancer, allowing to define the need for urgent surgery or possibility of conservative treatment with the subsequent elec-tive surgery and also to define how successful is conservative treatment carried out.

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Authors - Baris R. Karakas, M.D., S. Halide Akbas, M.D. Prof., Gulsum Ozlem Elpek, M.D. Prof., Fatih CELIK, M.D., Kemal Hakan Gulkesen, M.D., PhD. Assist. Prof., Nurullah Bulbuller, M.D., Assoc. Prof.; Afiliation - Department of General Surgery, Antalya Training and Research Hospital, 07100, Antalya, Turkey.;

THE EFFECTS OF LUTEOLIN ON THE INTESTINAL ISCHEMIA/REPERFUSION INJURY IN MICE.

Introduction: The purpose of this study was to investigate the potential protective effect of flavonoid Luteolin on ischemia-reperfusion (IR) injury in the mice intestines, which has not been investigated previously. Material and Methods: Twenty-four female C57BL/6 mice were randomly assigned into four groups, each con-sisting of 6 mice: sham group (no IR injury), the laparotomy + Luteolin group (no IR and Luteolin was intra-peritoneally administrated at 30 minutes after laparotomy), IR group (30 min of the superior mesenteric artery (SMA) and then 2 hours reperfusion), IR + Luteolin (30 min of the superior mesenteric artery (SMA) and then 2 hours reperfusion; Luteolin was intraperitoneally administrated before reperfusion). Mice intestine tissues were harvested for histopathologic and biochemical analysis. Total oxidant status (TOS) and total antioxidant capac-ity (TAC) levels of the intestinal tissues were measured by using Erel`s method. Oxidative stress index (OSI) was calculated by using TOS/TAC ratio. Results: Intestinal histologic changing significantly decreased in IR + Luteolin group when compared the IR group (p<0.05). Moreover, TOS tissue levels also significantly decreased in IR + Luteolin group when compared the IR group (p<0.05). TAC levels didn`t increase significantly in treatment group and also Luteolin treatment does not change TAC levels (p>0.05) Conclusions: The results of this study showed that Luteolin considerably protected the mice intestine against IR injury.

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Authors - Kirien Kjossev, Georgi Gurbev, Evgeni Belokonski, Ivan Teodosiev, Tihomir Atanasov.; Afiliation - Department of Surgery, Military Medical Academy, Sofia, Bulgaria;

IMPACT OF INTRAOPERATIVE COMPLICATIONS IN SURGERY FOR LIVER ECHINOCOCCOSIS.

Introduction: Despite advances in medical treatment and interventional radiology, the surgical approach re-mains the gold standard in management of cystic echinococcosis. The aim of this study was to evaluate the impact of intraoperative complications in surgery for liver echinococcosis. Material and Methods: The design was an observational retrospective study of a 25-years period (1988-2013). The intraoperative protocols of 254 patients that had undergone surgery for liver echinococcosis were analyzed. Since 2008 intraoperative assessment of severity and stage of the disease was performed by applying TN(R)C classification system. Results: In open surgery the radical technique was used in 58 patients, and the conservative technique was used in 181 patients. Laparoscopic surgery was performed in 15 patients where no conversion to open surgery were required. Intraoperative complications as a result of iatrogenic lesion or to complicated form of the cyst devel-oped in 16,1 %, including intraoperative hemorrhage (n=14), hollow viscus injury (n=13), lesion of parenchymal organs (n=13), and other (n=30). The total number of intraoperative complications is higher than the number of patients, in fact, 24 patients of them had more than one complication. Complications at the postoperative periods were occurred in 24,4 % of patients. Clear correlation was noted between the grade of cyst and rate of complications. Conclusions: The present study suggests that the rate of postoperative complications is higher in group of pa-tients with intraoperative complications in comparison to those with uneventful operative procedure. Morbidity rates can be significantly reduced with the use of modern operative techniques and well-planned surgical proce-dures based on correct assessment of cyst`s severity using TN(R)C classification system.

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Authors - Mr. Matthew T. Fenech, Dr. James G Diamond; Afiliation - University of Malta Department of Ophthalmology, Tulane University Department of Ophthalmol-ogy;

SILICONE OIL COMPLICATIONS IN RETINAL DETACHMENT REPAIR.

Introduction: Several silicone oils of different viscosities are used in the treatment of retinal detachments of varying pathology. The aim of the study was establishing a correlation between the use of various silicone oils and their final outcome. Material and Methods: Seventy-two cases of retinal detachments managed with silicone oil were reviewed in a retrospective chart analyses. Eighty nine patients were reviewed from which data on primary pathology, type of silicone oil, duration of oil in situ, and complications (including emulsification, increased intraocular pressure (IOP), re-detachment, cataract and presence of CME) were compiled. Of this number, 72 patients with post-oper-ative follow-up of two years or more were included. The data was analysed in an effort to determine the primary factor or factors of the varying silicone oil substitutes utilized responsible for the successful or non-successful re-attachment of the retina. Results: Retinal re-detachment rate is greater when Silicone Oil (SO) is removed before 12 months. Complex vs non-complex retinal re-detachments in sub-group analysis indicates superiority of retention of SO for greater than 12 months. Emulsification greater in low viscosity SO (1300cts). Conclusions: The results of this study regarding the similarity of various silicone oil (SO) viscosities in retinal re-attachment rates are comparable to the findings of published studies present in the ophthalmic literature on an international scale. The findings of this limited retrospective study support the hypothesis that it is the duration of the SO in situ as opposed to the viscosity or other SO attributes which influences the re-detachment rate.

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Authors - Mr Noel Cassar,Dr Alistair Bezzina, Mr Ernest Ellul; Afiliation - Department of Surgery, Mater Dei Hospital, Msida, Malta;

FEMORAL HERNIA AUDIT AT MATER DEI HOSPITAL 2009-2011.

Introduction: Femoral hernia is an uncommon condition, comprising between 2 and 5% of all groin hernias, but frequently gives rise to complications needing emergency surgery. The aim of the study was to analyse the situ-ation at Mater Dei Hospital with regards to femoral hernia repairs. Material and Methods: A retrospective analysis of patients undergoing femoral hernia repair between 1st Janu-ary 2009 and 31st December 2011 was carried out. Patient demographics, mode of admission, sac contents, resections performed during the repair, antibiotic use, duration of hospital stay, and complications arising post-operatively were noted for each patient. Results: 73 patients were included, of whom 18 (25%) were male and 55 (75%) were female, with the mean age being 61.3 years ( range 25 - 93 years). 38 patients (52%) underwent elective surgery while the remaining 35 patients (48%) were operated as an emergency. Small bowel resection was required in 11 patients (31.4%) undergoing emergency repair. Mesh repair was the most common method employed in 49 (76%) patients. Mean hospital stay was 3.2 days overall, with elective patients spending a mean of 1.5 days (range 1-5 days) in hospital, while emergency cases were hospitalised for a mean of 5.1 days (range 1 to 17 days) (p < 0.0005) Post operative complications developed in 6 patients following emergency surgery (p = 0.01) , with one death. Conclusions: Femoral hernia is predominantly found in the middle-aged and elderly, and emergency surgical correction is still needed in a high proportion of patients, with greater morbidity and mortality than those un-dergoing elective repair.

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Authors - Richard Apap Bologna, John Camilleri-Brennan MD, FRCS; Afiliation - University of Malta, Malta; NHS Forth Valley, Scotland;

PERIPHERAL VENOUS CANNULAS IN GENERAL SURGICAL WARDS: ARE WE FOLLOWING THE GUIDELINES?

Introduction: A peripheral venous cannula (PVC) is a commonly used medical device that may lead to complica-tions. Proper documentation ensures that complications are minimised. Objectives were to assess the quality of documentation on the insertion and care of PVCs in two general surgical wards of a Teaching General Hospital and to determine whether the documentation is following the local guidelines. Material and Methods: Data were collected prospectively. Patients from two general surgical wards who had a peripheral venous cannula in situ were identified and included in the study. The PVCs were inspected daily. Case notes were perused for the presence of documentation related to the insertion or care of the PVC. The care of the PVC was compared to the local guidelines in the document:˜Peripheral Venous Cannulation, NHS Education for Scotland. Results: One hundred and nine consecutive records were studied. Full documentation on the care, insertion and removal of PVCs was only present in 62 (57%) of cases. In the other cases, the relevant records were either incomplete or absent. In these cases it is therefore not known whether adequate care and attention was given to PVCs or not. Conclusion: The local guidelines state all PVC insertions and inspections should be documented. In view of the high percentage of PVCs in the surgical wards with either inadequate or absent documentation, we recommend that clinicians inserting these medical devices are educated on the importance of proper documentation in order to detect complications early and minimize risk.

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Authors - Liska Vaclav 1, Treska Vladislav 1, Daum Ondrej 2, Novak Petr1, Vycital Ondrej 1, Bruha Jan 1, Pitule Pavel 1; Afiliation - 1 Department of Surgery, Medical School and Teaching Hospital Plzen, Charles University in Prague, 2 Sikl Department of Pathology, Medical School and Teaching Hospital Plzen, Charles University in Prague; e-mail - [email protected];

TUMOR INFILTRATING LYMPHOCYTES AS PROGNOSTIC FACTOR OF EARLY RECURRENCE AND POOR PROGNO-SIS OF COLORECTAL CANCER AFTER RADICAL SURGICAL TREATMENT.

Introduction: Tumor infiltrating lymphocytes (TIL) were described as a good prognostic factor for patients with a high risk of relapse. The aim of this study was to analyse the relationship of contemporary clinical and histo-pathological factors and TIL to determine patients with a high risk of poor overall survival and tendency to early. Material and Methods: We analysed 150 patients who underwent radical surgical procedure for CRC between the years 2004-2007. The following clinical parameters were statistically analysed in relation to the disease free interval (DFI) and the overall survival (OS): staging, grading, preoperative leukocytosis, type of surgical procedure (radical vs. palliative), postoperative complications and postoperative oncological treatment. We evaluated en-dovascular (VI), endolymphatic (LI) and perineural infiltration (PI) by cancer cells. Lymphocytic infiltration was detected as intratumoral (ITL), intrastromal (ISL), peritumoral (PTL) and Crohn-like reaction (Crohn-like PTL). Re-active histological changes in lymph nodes (LN reactions) were detected as follicular hyperplasia (LN-FH), sinus histiocytosis (LN-SH) and the presence of granulomas (LN-GR). We examined also immunohistochemical positiv-ity of lymphocytes for CD4 and CD8. Results: The Spearman rank correlation coefficient did not prove any stronger correlation than a moderate cor-relation at LI and lymph node infiltration by metastatic process (Spearman rank correlation coeffiecient 0.56, p<0.05). Lymph node infiltration, CD4+ lymphocytic infiltration and VI were proved as negative prognostic factors of shorter overall survival. The presence of PTL, Crohn-like PTL, LN-FH, CD8+ was proved as a positive prognostic factor of OS. PI and lymph node infiltration were proved as a negative prognostic factor of an earlier recurrence. CD8+ lymphocytic infiltration was proved as a positive prognostic factor enlarging DFI. The Multivariate Cox Regression Hazard Model proved the combination of the severity of the lymph node infiltration by a metastatic process and the severity of CD8 positivity of infiltrating lymphocytes as the best prognostic factors for the predic-tion of risk of early recurrence and combination of the severity of lymph node infiltration by metastatic process and LN-FH as the best prognostic factors for the prediction of the risk of shorter overall survival.Conclusions: Tumor infiltrating lymphocytes seem to be promising prognostic factors that could find their use in colorectal surgery and consecutive oncological treatment as an indicator of the type or combinations of thera-pies reflecting the risk of patients to early recurrence or poor overall survival. The project was supported by grants IGA MZ CR 12025 and 14329.

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Authors - Mark Portelli, John Camilleri-Brennan MD FRCS; Afiliation - University of Malta, Malta; NHS Forth Valley, Scotland;

ANALGESIA IN POST-OPERATIVE DAY SURGERY PATIENTS: STANDARDISED REGIME OR INDIVIDUAL VARIA-TION?

Introduction: Despite advances in the management of post-operative pain there are variations in the methods used for pain relief. Guidelines have been developed in order to ensure uniformity in the administration of such crucial medication. Objectives were to analyze the analgesia given to ambulatory surgical patients and to deter-mine whether it complies with national guidelines. Material and Methods: Data were collected prospectively on 78 consecutive patients who had day-case surgery in a teaching hospital in Scotland. Data recorded included post-operative and discharge analgesia. A comparison was made with recommendations made by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) using the SPSS statistical package. Results: In the immediate post-operative setting, we noted a variation in the type and administration of analge-sia. Forty seven patients (60%) were given Fentanyl; 42 patients (54%) were given Dihydrocodeine; 60 patients (77%) were given Paracetamol; 39 patients (50%) were given Ibuprofen; 16 patients (21%) were given Morphine and 7 (9%) were given Tramadol. In patients who received general anaesthesia, 61% were given analgesia ac-cording to guidelines. On the other hand, only 37% of patients who had surgery under local anesthesia received analgesia that complied with the guidelines. Conclusions: There is a significant variability in the administration of post-operative analgesia, depending on the anaesthetist`s preference. We believe that adherence to published guidelines is important to ensure patient safety as well as avoiding complications.

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Authors - Ethan Caruana, John Camilleri-Brennan MD FRCS; Afiliation - University of Malta, Malta; NHS Forth Valley, Scotland;

GENERAL PRACTITIONER REFERRALS TO THE COLORECTAL SERVICE: DO THEY CONFORM TO THE PUBLISHED GUIDELINES?

Introduction: Guidelines have been devised to help General Practitioners (GP) in writing a fully informative refer-ral letter to secondary care, given that there had been a lack of uniformity in the referral process in the past. One such document has been devised by the Scottish Intercollegiate Guideline Network (SIGN) group. The aim of the study was to determine if GP referrals to the colorectal surgical service in a teaching general hospital in Scotland contain the requisite clinical and patient information that would enable the surgeon to prepare an appropriate management plan for the individual patient. Material and Methods: One hundred consecutive referrals to the colorectal surgical service in a teaching hospi-tal in Scotland were reviewed by the Authors. All referrals were compared to the criteria set by the SIGN guide-lines. Data were collected prospectively and analysed using the SPSS statistical package. Results: Out of 100 referrals, 28 were listed as urgent. Twenty two referrals lacked documentation of symptoms and signs, no examination was mentioned in 42, and only 37 patients had a digital rectal examination performed. There was no significant difference in content and quality between urgent and routine referral letters. Conclusions: A significant proportion of referrals letters, both urgent and routine, to the colorectal surgical ser-vice lacked proper documentation. We believe that it is essential that adequate clinical information is given in order to allow the surgeon to assess the clinical need and urgency for further treatment.

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Authors - K. Zarkov, Chr. Petkov, N. Nickolov, M. Nickolov; Afiliation - First Surgical Department, Fifth General Hospital, Sofia, Bulgaria;

ASPECTS OF THE TECHNICAL POSSIBILITIES FOR SPHINCTER PRESERVATION IN ULTRA LOW ANTERIOR RECTAL RESECTIONS.

Introduction: For rectal cancers localized 5cm or less above anal verge the options for radical operations are two: abdomino-perineal resection versus ultra low anterior resection that makes sphincter preservation possible. In this study we assess the feasibility of the performed ultra low anterior resections and simultaneous colo-anal anastomosis for rectal cancers localized 5cm or less above anal verge; complications and mortality rates. We present one option to perform the colo-anal anastomosis. Material and Methods: In all ultra low anterior resection cases we performed radical rectal resections with total mesorectal excision. The distal resection line is laid 3 or 2cm distally from the tumor. Frozen sections of the distal resection margin verifies no tumor invasion. In selected cases we perform pelvic lymphadenectomy of internal iliac and obturatory nodes. We present the technique of the perineal part of the operation after the radical mesorectal excision is done and rectum is resected proximally the sample is everted outside through the anus Then the distal resection line is formed. Utilizing this technique we have performed 9 operations for 2011-2012 period. All colo-anal anastomoses were done with a hand suture. Proximal stoma was brought out together with anastomosis in 2 cases. Results: Out of 52 rectal cancer patients operated through 2011-2012, in 9 patients we made ultra low anterior resection, all anastomoses were done with hand suture technique. Postoperative complications: Anastomotic leakage and fistula formation in 4 patients; necrosis and abscess - in 2. Mortality in hospital and within 30 days - 1 patient. Local relapse, leading to abdomino-perineal amputation - 1 patient. The main reason for complications with this technique is the insufficient blood supply to the bowel segments, taking part in the anastomosis, and the most devastating result is the anastomotic necrosis. That`s the reason for the crash of conservative attempt to solve these complications. The fact, that in one case despite the protective stoma we had anastomotic leak-age, leading to abdomino-perineal amputation, also proves that the proximal stoma does not contribute for low rectal anastomosis healing. Concusions: Despite the presence of complications, It is feasible to perform ultra low anterior resection with simultaneous colo-anal anastomosis with radical intent for the management of low rectal cancers, aiming at sphincter preservation.

95

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Authors - Rumyana Rumenova Smilevska, Andres Garcia Marin, Asuncion Candela Gomis, Valentin N. Rodri-guez, Maria Mingorance Alberola, Elena Martinez Guerrero, Miguel Morales Calderon, Salvador Garcia Garcia; Afiliation - San Juan de Alicante University Hospital, Spain;

INFLAMMATORY MARKERS AND ACUTE CHOLECYSTITIS.

Introduction: The systemic response in the acute abdomen is traduced in the rise of white blood cell (WBC) count, neutrophils and the C-reactive protein, as other inflammatory proteins, which are used for the diagnosis and to assess the severity of inflammation. The objective of this study was to evaluate the possibility of these markers to predict the severity of inflammation in acute cholecystitis. Material and Methods: We realized a retrospective analytical study of 173 patients that were admitted in our center from November 2011 till May 2013 with the diagnosis of acute cholecystitis. We evaluated their demo-graphic factors, comorbidity, clinical manifestation and physical exploration, analytical and radiological findings, the treatment modality, the severity of the inflammation, and the hospital stay. We evaluated the inflammatory markers for assessment of the severity of the acute cholecystitis. The quantitative variables were defined by me-dian and percentiles (25, 75) and the qualitative variables were defined by frequency and percentage. Results: Sixty one percent (106 patients) were males and 39% (67) were females. The median age was 69 years (56;80) and the age distribution was as follows: 12,1% of the patients were in the group below 45 years old (21), 23,7% (41 patients) were aged between 45 and 64, 53% (92 patients) were 65 to 84 years old, and 11% (19 pa-tients) were 85 years old and older. The median time of symptoms was 48 hours (24, 96). Forty one percent (70) of the patients came to the emergency department with more than 72 hours of symptoms. Charlson comorbidity index was 1(0; 1), and the age adjusted Charlson index was 3 (1; 4). 47% (82) had hypertension, 25% (43) had diabetes, 23% (40) had cardiovascular pathology, 8% (13) had respiratory pathology (BPCO), 6% (11) had renal insufficiency, 4% (6) had cirrhosis and 4% (7) had immunodeficiency. The median WBC count was 13.500 (9.800; 16.675), neutrophils 82,1% (74,2; 87,6%), bilirubin 0,9 mg/dl (0,6; 1,85), amylase 40 (26; 55) and the CRP 6 mg/dl (1,3; 16,3). According to the Tokyo Guidelines classification (TG13) 46% (80 patients) had mild cholecystitis, 43% (74) had moderate and 10% (18 patients) had severe one. Due to the little number of severe cholecystitis we combined them with the moderate one, in order to compare the results with the group of the mild cholecystitis The risk of having a moderate-severe cholecystitis was significantly higher in patients with CRP > 3,0 mg/dl , OR = 4,2 IC 95% (2,1; 8,3), p<0,01. Conclusions: The time of evolution of the symptoms, the white blood cell count and the C-reactive protein were significantly higher in the moderate-severe cholecystitis. The C-reactive protein was the unique inflammatory marker related with higher risk of having a moderate-severe cholecystitis. The results of the study suggest that the utilization of the C-reactive protein can assist in the severity of the acute cholecystitis, allowing an optimal management.

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Authors - Daniel Vella Fondacaro, Richard Apap Bologna, John Camilleri-Brennan MD FRCS; Afiliation - University of Malta, Malta; NHS Forth Valley, Scotland; A PROSPECTIVE EVALUATION OF COMPLICATIONS ASSOCIATED WITH PERIPHERAL VENOUS CANNULATION IN SURGICAL PATIENTS.Introduction: Peripheral venous cannulation (PVC) carries with it a number of complications. These compli-cations may contribute to morbidity in surgical patients. The aim was to analyse prospectively the incidence, causes and aetiology of PVC complications in surgical patients. Material and Methods: Ninety consecutive patients from two surgical wards in a teaching general hospital in Scotland were studied. The following data were collected: Sociodemographic data, date and reason for admis-sion, co-morbidities, primary indication for PVC, cannula size, insertion site and complications (phlebitis, ery-thema, swelling, tenderness, haematoma, extravasation and blockage). Results: 23.3% of cannulas exhibited complications (21/90 cannulas). 4.4% of cannulas were associated with phlebitis (4/90) while 6.7% were associated with pain (6/90), 5.5% haematoma (5/90), 2.2% extravasation (2/90), 1.1% blockage (1/90) and 13.3% erythema (12/90). Wider bore cannulas exhibited the least complications. PVC complications were associated with a delayed discharge home. Conclusions: The incidence of PVC complications in the surgical wards is high and has an impact on the patient`s stay in hospital. As clinicians we recommend that the local guidelines are followed (e.g. cannula changed every 72 hours, aseptic technique used etc) and that regular audit is carried out.

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Authors - Eleanor Borg, Dr. Mark Brincat, Dr. Sarah Grixti, Dr. Norma Pavia, Mr. John Mamo; Afiliation - Eleanor Borg: 4th year MD student at University of Malta, Dr. Mark Brincat, Dr. Norma Pavia: Foundation Year 1 doctors at Mater Dei Hospital Dr. Sarah Grixti: Basic specialist trainee in Obstetrics & Gynaecology at Mater Dei Hospital Mr. John Mamo: Consultant Obstetrician and Gynaecologist at Mater Dei Hospital;

BLOOD LOSS AND TRANSFUSION REQUIREMENTS IN MYOMECTOMY PATIENTS AT MATER DEI HOSPITAL.

Introduction: Myomectomy is the surgical removal of uterine leiomyomas, benign tumors of the myometrium. The leading indications for abdominal myomectomies are a palpable abdominal mass (63.7%), menorrhagia (57.7%), and subfertility (55.2%).[1] This procedure can also be done laparoscopically, with studies suggesting lower postoperative pain and shorter recovery time in comparison with laparotomy.[2][3] Blood loss is one of the main intraoperative complications of myomectomies. The aim was the assessment of blood loss and length of hospital stay post-operatively. Material and Methods: This retrospective clinical audit sets out to compare pre- and post-operative haemoglo-bin and haematocrit levels and record any post-operative transfusion requirements in patients undergoing elec-tive myomectomy in Mater Dei Hospital between October 2010 and May 2013. Analysis of mean length of stay with abdominal myomectomies and comparison with established studies was also done. Results: Out of 56 patients (mean age: 35), 50 patients underwent elective myomectomy via laparotomy, 4 pa-tients underwent laparoscopic myomectomy and 2 patients underwent laparoscopic myomectomy which had to be converted to open myomectomy. The mean reduction in haemoglobin levels in all the patients was 1.87g/dL (SD 1.32g/dL) which was also associated with a mean 5.37% (SD 3.82) reduction in haematocrit from the pre-op to the post-op period. The mean length of stay was 4.61 days. In patients with a recorded hospital stay longer than the mean length of stay, the reduction in haemoglobin and haematocrit was slightly higher but was not statistically significant unless a red cell concentrate transfusion was required (2 patients). Conclusions: The higher the blood loss the longer the hospital stay, especially if transfusion is required. The mean reduction in haemoglobin level during myomectomy operations is less than 2g/dL, with only two (3.57%) needing a blood transfusion. Length of stay (4.61 days) was higher than that cited in University of Michigan Medi-cal Center (3.62days) by Advincula et.al (2007).

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Authors - Hasan Altun, Aziz Bora Karip, Ahmet Yalin Iscan, Kafkas Celik, Umit Akyuz, Birol Agca, Kemal Memiso-glu; Afiliation - Fatih Sultan Mehmet Training and Research Hospital, Atasehir/Istanbul;

EARLY AND LATE EFFECTS OF NISSEN FUNDUPLICATION SURGERY ON BODY WEIGHT.

Introduction: Laparoscopic Nissen Funduplication is the most frequent surgical procedure for gastroesophageal reflux disease. Besides the effect to prevent reflux, the procedure also have an impact on eating habits and body weight. This study aimed to determine this effect and its causes. Material and Methods: Patients who underwent laparoscopic nissen funduplication between March 2008-April 2013 were enrolled to this study. Preoperative, first and sixth months after surgery, patients’ body mass index (BMI), gastrointestinal quality of life index scores (GIQLI) and dysphagia scores were recorded and analyzed. Results: Mean age was 40,29 +/- 11,85 years. For women, preoperative mean BMI was 27,945 +/- 5,16 kg/m2 while it was 25,924 +/- 4,11 kg/m2 for men. Mean preoperative dysphagia scores were 1,76 +/- 1,57 for women and 2,13 +/- 1,4 for men. Mean preoperative GIQLI score of all patients was 67,78 +/- 20,67. One month after surgery mean BMI results were 24,783 +/- 4 kg/m2 for men and 23,85 +/- 3,75 kg/m2 for women. Mean dysphagia score was 1,89 +/- 1,28 for women and 2 +/- 1,2 for men. Mean GIQLI score at the first postoperative month was 86,82 +/- 20,16 respectively. Mean BMI measurements at the sixth month were 26,81 +/- 4,93 kg/m2 for women and 27,17+/- 10,9 kg/m2 for men. The average GIQLI scores of patients was 98,3 +/- 20,81 at the sixth postoperative month. Conclusions: At the end of the first month patients showed weight loss. This may be due to early postoperative dysphagia and recommended diet. In the late period after six months of surgery weight gain was observed and it was thought to be due to the increased quality of life for the gastrointestinal tract.

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Authors - Ioannis Lintzeris,Xanthi Agrogianni, Angeliki Lintzeri; Afiliation - Surgery Department,General Hospital of Tripolis,Greece;

FLUID ADMINISTRATION IN PATIENTS WITH SEPTIC SHOCK.

Introduction: Fluid administration as part of the treatment beyond initial resuscitation and appropriate medica-tion in patients with septic shock is extremely essential. However, little is known regarding the type and quantity of fluids that should be administered to produce the best outcome. Objectives were to estimate the best selec-tion of type and amount of intravenous fluids that are required in the treatment of septic patient in shock. Material and Methods: A review of current literature was conducted through data bases such as Pub Med, Em-base, in order to define the current options of researchers related to fluid administration in patients with septic shock. Results: Several worth-noticing studies such as PRECISE, VASST, EGDT, meta-analyses and reviews were selected and studied. It is seems that there is a controversy among reports for the type of fluids associated with the bet-ter outcome. It is not clarified what is the best option, whether the colloids or crystalloids should be preferred. Conclusions: The only safe conclusion that can be made is that every patient should be treated in time, individu-ally, according needs, by careful fluid administration, aiming a Mean Arterial Pressure > 65mm Hg and Central Venous Pressure > 8mm Hg in order to acquire vital signs stability.

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Authors - N. Pavia, S. Grixti, O. Tsar, I. Knyazev, J. Mamo; Afiliation - Department of Obstetrics and Gynaecology, Mater Dei Hospital, Malta;

THE CHANGE FROM TRADITIONAL BURCH COLPOSUSPENSION TO LAPAROSCOPIC BURCH PROCEDURE.

Introduction: Since the introduction of laparoscopy and laparoscopic simulation training in the Gynaecology department at Mater Dei Hospital, the management of stress incontinence has been drastically changed and improved. Laparoscopic Burch procedure started being performed in June 2013 and has become the preferred option in most patients. The aim was to assess whether Laparoscopic Burch procedure has brought about an improvement in the management of patients with stress incontinence compared with those undergoing the traditional Burch colposuspension. Material and Methods: Assessment of the number of open Burch colposuspension and Laparoscopic Burch colposuspension procedures respectively and comparison of length of surgery, number of complications, post-operative pain, length of hospital stay, and overall patient satisfaction. Results: Since the introduction of the Laparoscopic Burch procedure, it has been increasingly performed in pref-erence to the open procedure. 42 open Burch colposuspensions were performed in 2011, 55 in 2012 and 5 in the first 8 months of 2013; whilst 5 laparoscopic Burch colposuspensions have been performed since June 2013 to August 2013. There has also been a corresponding decrease in length of surgery with increasing experience. Patient satisfaction is overall greater, with less post-operative pain and quicker return to daily routine. Complica-tions have been kept to a minimum and length of hospital stay has been decreased from an average of 4-5 days to 1-2 days. Conclusions: Laparoscopic Burch procedure has improved outcomes for the patient and may be less expensive for the hospital. Operating time is similar for either surgery and laparoscopic variant is by far preferred by both patients and surgeons.

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Authors - N. Pavia, S. Grixti, M. Brincat, O. Tsar, I. Knyazev, J. Mamo; Afiliation - Department of Obstetrics and Gynaecology, Mater Dei Hospital, Malta;

EFFECT OF LAPAROSCOPIC SIMULATION TRAINING ON GYNAECOLOGICAL SURGERY.

Introduction: In January 2012 laparoscopic simulation training was introduced in the Gynaecology Department at Mater Dei Hospital. The aim was to increase the proficiency of gynaecological surgeons in this approach and improve the management of gynaecological conditions. The aim was to assess whether there has been an in-crease in the number of laparoscopic operations following the introduction of laparoscopic simulation training. Material and Methods: Assessment of the number of laparoscopic surgeries performed in the Gynaecology de-partment in the twelve months prior to the start of laparoscopic simulation training. This was compared with the number of laparoscopic surgeries performed from January 2012 to May 2013. Results: There has been an increase in laparoscopic procedures. The number of laparoscopic hysterectomies performed from January to May 2013 was 36; in 2012, 19 were performed and none were done in 2011. Mean-while, laparotomies for hysterectomy decreased from 693 in 2011, to 634 in 2012, to 152 from January to May 2013. Laparoscopic ovarian cystectomies increased from 11 in 2011, to 54 in 2012, and 35 in the 5 months of 2013. Open cystectomies decreased from 57, to 44, to 5 respectively. Laparoscopic Burch colposuspension started being performed since June 2013. 5 have been performed so far, with good results, while open Burch procedures have decreased to 5 since the start of 2013, with 55 in 2012 and 42 in 2011. There has also been a decrease in the number of conversions from laparoscopies to laparotomies with 21 in 2011, 16 in 2012 and 4 in the first 5 months of 2013. There was a reduction in the operation time, length of hospital stay, post-operative complications and pain, and better patient satisfaction. Since the start of training, there has also been a wider variety of surgical therapies performed laparoscopically. Conclusions: The introduction of laparoscopic simulation training in Mater Dei Hospital has influenced the mode of surgical management of gynaecological conditions. Laparoscopic Simulation Training has empowered the Gyn-aecological Surgeons to perform more laparoscopic hysterectomies, myomectomies, laparoscopic Burch Colpo-suspension, Laparoscopic sacrocolpopexy apart from ovarian operations and adhesiolysis.

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Presenting Author - Ioannis Lintzeris, MD,MSc, PhD; Authors - Ioannis Lintzeris,Angeliki Lintzeri,Xanthi Agrogianni,Georgios Chatzoulis,Venetsanos Ponirakos; Afiliation - Surgery Department,General Hospital of Tripolis,Greece;

SURGICAL WOUND INFECTIONS BY GRAM NEGATIVE BACTERIA AND ANTIMICROBIAL RESISTANCE.

Introduction: Surgical site infections impact on morbidity and mortality rates. They represent an inherent risk factor after surgical procedures and contribute to prolonged hospital stays and adverse outcomes. Objectives were to analyze the etiological agents of infection among hospitalized surgical patients undertaking an abdomi-nal surgery and register the incidence of infection among them because of gram negative strains as well as the antimicrobial resistance. Material and Methods: A descriptive cross sectional study was conducted in a second level hospital from 2008 till 2013 involving 66 patients with infection by gram negative bacteria after undertaken an abdominal surgery. Wound swabs were taken from surgical site and processed using standard microbiological methods. Culture re-sults were registered. Antibiograms were obtained and evaluated for antimicrobial resistance. Results: Out of the 66 enrolled patients with positive cultures from the surgical site because of gram negative strains the most frequent pathogens were Escherichia Coli, Klebsiella Pneumonia, Pseudomonas Aeruginosa, Proteus. The predominant pathogen was Escherichia Coli in a percentage of 59%- 39 individuals. In 23 cases, there was sensitivity to cephalosporins, in 8 cases there was medium resistance to them and in the last 8 cases high resistance was registered. It is interesting that in 10 cases there was high resistance to cinolones. Conclusions: The isolates showed high resistance to common antibiotics in a percentage of 41% and to stronger antibiotics in a percentage of 25,6%. The high index of antimicrobial resistance among surgically infected pa-tients raises issues and is a matter of major importance.

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Authors - Farrugia A, Cassar K, Attard A, Abela J, Saliba K, Grech R, Mizzi A; Afiliation - Medical Imaging Department, Mater Dei Hospital, Tal-Qroqq, Malta Department of Surgery, Mater Dei Hospital, Tal-Qroqq, Malta;

ENDOVASCULAR COILING OF SPLENIC ARTERY ANEURYSMS - A SAFE AND EFFECTIVE ALTERNATIVE TO SURGI-CAL REPAIR.

Introduction: Splenic artery aneurysms (SAAs) are the commonest visceral artery aneurysms. They may present incidentally on cross-sectional imaging or in patients with pancreatitis or portal hypertension; or acutely with hy-povolaemic shock following rupture and intra-abdominal bleeding. Optimal treatment of SAAs is unknown. Open surgery has been the traditional treatment of choice. With increasing expertise in interventional radiology, there are now endovascular options for treatment of SAAs. It is hoped that such techniques will diminish morbidity and mortality that are associated with traditional surgery. Material and Methods: We present three cases of SAA; all treated with endovascular coiling. The first patient was a 68 year old male who presented with a 5.3cm diameter SAA detected on CT scan performed after an epi-sode of gallstone pancreatitis. The second patient was a 51 year old female who presented with a 4cm diameter SAA diagnosed incidentally on CT of the abdomen that was performed for non-specific abdominal pain. The third patient was a 50 year old male who presented with acute onset of upper abdominal pain and was found to have a 5cm diameter SAA, and no signs of rupture, on CT scan performed emergently. All three patients were treated endovascularly in the Radiology Department angiosuite; using a femoral artery approach. The coeliac trunk was selectively catheterized and a micro-catheter was introduced into the splenic artery. Coils were deployed in the afferent and efferent arteries and in the aneurysm itself. Results: The aneurysm was secluded from arterial circulation in all three patients. All three patients complained of left upper quadrant pain during and after the intervention and required opiate analgesia. The spleen was salvaged in all three cases. There were no major complications in either case. Patients were followed up with ultrasound and CT at regular intervals post-intervention to ensure complete thrombosis of the SAA. Conclusions: Endovascular embolization is a safe and effective treatment for SAAs and offers a realistic alterna-tive to traditional surgical techniques. The main side effect of this treatment in our series was pain. No major complications and no treatment-related mortality were recorded.

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Authors -Rumyana Rumenova Smilevska, Andres Garcia Marin, Asuncion Candela Gomis, Valentin N. Rodriguez, Maria Mingorance Alberola, Elena Martinez Guerrero, Miguel Morales Calderon, Salvador Garcia Garcia; Afiliation - San Juan de Alicante Universtity Hospital, Spain;

EARLY VS. DELAYED CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS - EVIDENCE VS. EXPERIENCE.

Introduction: Nowadays the recommended treatment (and gold standard)for the acute cholecystitis is the early laparoscopic cholecystectomy in the first 72 hours of evolution of the symptoms, and after that period a delayed cholecystectomy or cholecystostomy is recommended depending on the severity of the local inflammation or general repercussion. (Tokyo Guidelines 13) Despite the scientific evidence of the superiority of early over de-layed cholecystectomy, there is still controversy. The aim of this study is to analize the management of acute cholecystitis in terms of morbidity and hospital stay in the patients admitted in our center in the last 18 months. Material and Methods: We realized a retrospective reviewed 173 patients that were admitted in our center from November 2011 till May 2013 with the diagnosis of acute cholecystitis. We evaluated their demographic factors, comorbidity, clinical manifestation and physical exploration, analytical and radiological findings, the treatment modality, the severity of the inflammation, and the hospital stay. The quantitative variables were defined by me-dian and percentiles (25, 75) and the qualitative variables were defined by frequency and percentage. Results: We analized 173 patients, of which 61% (106 patients) were males and 39% (67) were females. The me-dian age was 69 years (56; 80). The median time of symptoms was 48 hours (24, 96). Forty one percent (70) of the patients came to the emergency department with more than 72 hours of symptoms. Charlson comorbidity index was 1(0; 1), and the age adjusted Charlson index was 3 (1; 4). According to the Tokyo Guidelines classifica-tion (TG13) 46% (80 patients) had mild cholecystitis, 43% (74) had moderate and 10% (18 patients) had severe one. Seventy six percent (132) of the patients has a medical treatment with delayed cholecystectomy, 128 pa-tients with antibiotherapy and 4 patients had cholecystectomy, and 24% (41) had a surgical treatment an early cholecystectomy. The morbidity in the surgical treatment group was 24% (10 patients). And the mortality was 1 patient in each group. In the group of medical treatment 18,9% (25 patients) presented a new episode of acute cholecystitis before the scheduled delayed cholecystectomy. The patients in the group with medical treatment were significantly older 71 years (64; 80) vs 61 years (46; 77) (p=0,02), and came with significantly more hours of evolution of the symptoms - 48 hours (24; 96) vs 24 hours (15; 48), (p=0,03). The median of hospital stay was significantly higher in the group with medical treatment 5 days (4; 8 ) vs 4 days (3; 6), (p=0,007). Conclusions: Despite the existence of evidence of the superiority of the early laparoscopic treatment of the acute cholecystitis, we continue having an important percentage of medical treatment, significantly for older patients with more time of evolution of the cholecystitis, that increases the hospital stay and has an elevated number of a new episode of acute cholecystitis before the scheduled surgery.

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Authors - Lara Sammut, Annalisa Montebello, Juanita Parnis, Gerald Busuttil; Afiliation - Department of Urology; Mater Dei Hospital, Malta;

CASE REPORT - SACRAL HERPES ZOSTER: A RARE CAUSE OF ACUTE URINARY RETENTION.

Introduction: A 77-year-old healthy lady presented with acute onset of lower abdominal pain, inability to pass urine, constipation, a palpable bladder, and a papulo-vesicular rash typical of herpes zoster on the right buttock. Catheterization showed a residual of 1000 ml. We report an uncommon case of acute urinary retention second-ary to herpes zoster infection of the sacral nerve roots S2-S4. This cause was first reported in the literature in 1890. Since then less than 150 cases have been reported worldwide. Material and Methods: A 77-year-old healthy lady presented to the Emergency Department with acute onset of lower abdominal pain, abdominal distension, inability to pass urine and constipation. This was not associated with hematuria, LUTS, chills or rigors. On physical examination patient was afebrile, vital signs were normal and a palpable distended urinary bladder was felt. A papulo-vesicular rash typical of herpes zoster was noted on the right buttock. Patient was immediately relieved by catheterization, with 1000 ml of clear urine obtained on blad-der drainage. Blood biochemistry was normal, urinalysis was not suggestive of a UTI and there was no bacterial growth on urine cultures. The patient started on oral Acyclovir for ten days and local barrier cream applied. Results: She was discharged the following day and a trial without catheter was performed two weeks later which subsequently failed with 423 ml residual urine on bladder US and 800 ml residual urine obtained when a catheter was reinserted. The second TWOC, two weeks later was successful with 83 ml residual urine on bladder US. Conclusions: The patient was diagnosed with acute urinary retention secondary to Herpes Zoster infection of the sacral nerves.

106


Authors - Xanthi Agrogianni,Angeliki Lintzeri,Georgios Vourliotakis, Venetsanos Ponirakos, Ioannis Lintzeris; Afiliation - Surgery Department, General Hospital of Tripolis, Greece;

CHRONIC PANCREATITIS AND PERSISTENT PLEURAL EFFUSION- AN UNCOMMON CLINICAL ENTITY.

Introduction: Pleural effusion is uncommon in chronic pancreatitis and can occur subsequently to a pancreatico-pleural fistula. It accounts to 0.4-4.5 % of cases with chronic pancreatitis. Objectives were to report an unusual case of persistent pleural effusion due to chronic alcoholic pancreatitis. Material and Methods: A 67 year old, male patient with a history of chronic alcoholic pancreatitis and smoking habit presented with thoracic symptoms, chest pain and mild abdominal pain. Chest X-ray and computed to-mography demonstrated a left-sided pleural effusion. Further analysis of pleural fluid showed elevated amylase concentrations. This finding was indicative of pancreaticopleural fistula which was then confirmed by performing magnetic resonance cholangiopancreatography. Results: The patient was treated with tube chest drainage followed by pleurodesis because of the persistent pleural effusion. He also received medication consisted of antibiotics and octreotide. After a two month period time, he is now clinically improved and released from symptoms. Conclusions: Pancreaticopleural fistulas are a rare clinical entity. A strong suspicion should be raised in every patient with signs of chronic alcoholic pancreatitis and pleural effusion even with predominant respiratory symp-toms.

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Authors - Dr Michelle Bugeja, Ms Josephine Psaila; Afiliation - none;

A CASE OF STERNOCLAVICULAR SEPTIC ARTHRITIS IN A PATIENT WITH NO PREDISPOSING FACTORS.

Introduction: Sternoclavicular septic arthritis accounts for 1% of septic arthritis in the general population. Com-mon risk factors include intravenous drug use (21%), distant site of infection (15%), diabetes mellitus (13%), trauma (12%) and infected central venous line (9%). No risk factor is found in 23% of cases. Material and Methods: In this report we describe a case of a 63 year old male with septic arthritis of the ster-noclavicular joint. The patient presented with a two week history of severe pain over the right clavicle, radiating down to his chest centrally and with a fever of 38.50C. On examination there was a tender, erythematous swell-ing over the right SCJ. The patient had full range of movement of the right shoulder joint but extension of the shoulder joint produced severe pain. Results: No predisposing risk factors were found. Infection was caused by Staph aureus which was diagnosed after CT-guided aspiration of a right retrosternal collection and blood cultures. Patient was managed successfully with antibiotic therapy and local aspiration and had a complete recovery without any complications.

108


Authors - Omari Gibradze, Mamuka Mikadze, David Tevtoradze, Paata Meshveliani; Afiliation - General Hospital /Beau Monde Ltd., Regional Hospital, Kutaisi, Georgia;

RADICAL DUODENOPLASTY IN THE TREATMENT OF ELDERLY PATIENTS WITH DUODENAL ULCER COMPLICA-TED BY BLEEDING.

Introduction: Based on an assessment of clinical and endoscopic risk elderly patients with acute bleeding duo-denal ulcer etiology characterized by a high risk of rebleeding. There is a need to optimize the surgical approach to the definition of the indications for emergency or urgent surgery, the choice of the volume and type of radical duodenoplasty.Material and Methods: From 2008 to 2013 206 elderly patients with acute bleeding of duodenal ulcer were admited to the surgical departments of Regional Hospital and General Hospital „ Beau Monde „ Ltd Kutaisi. In all patients the diagnosis was confirmed on the basis of clinical , laboratory, and endoscopic techniques. In order to prevent the loss factor of time and the evaluation of the risk of bleeding and continued conservative therapy in the elderly , leading to multiple organ dysfunction , is designed to identify the frequency of ‚critical’ clinical and endoscopic risk factors for rebleeding . Was performed medical -diagnostic program .Results: 62 patients were used endohemostasis isolated in 8 (13 %) cases there was bleeding out of 26 patients after combined endohemostasis 1 (1.8 %) cases - the bleeding . On the basis of medical diagnostic programs 44 patients underwent surgery, urgent surgery - 10 patients , 34 patients - delayed intervention. In 33 cases, made bridges duodenoplasty , 9 patients - segmental duodenoplasty . Postoperative complications were noted in 32 % of cases, mortality was 4.5 %.Conclusions: The use of radical duodenoplasty elderly patients with acute bleeding duodenal ulcer etiology re-duces the incidence of postoperative complications with 56.1 % to 32 % and the mortality rate from 12% to 4.5 %. Preserved structure and function pilorobulbarnoy zone , which affects the quality of life of elderly patients .

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Authors - Supreet Kaur,Gaurav Maheshwari, Iqbal Singh, R P Doley, Atul Joshi, Rajeev Kapoor, JD Wig; Afiliation - fortis hospital , Mohali, India;

EMERGENCY OR ELECTIVE ABDOMINAL SURGERY IN ELDERLY PATEINTS: IS THERE A DIFFERENCE IN OUTCO-ME?

Introduction: Objectives were to evaluate the outcome of patients aged 65 years and older after emergency and elective abdominal surgery in terms of morbidity and mortality. Material and Methods: Design: Prospective, population-based cohort study. Setting: Department of general Surgery, Fortis Hospital, Mohali. Participants: A total of 199 adults 65 years or older who underwent common abdominal procedures (emergency and elective) from February 2009 to February 2011 in a tertiary care hospital in North India. Main Outcome Measures: Differences in postsurgical morbidity and mortality and factors predict-ing it in setting of emergency and elective abdominal surgeries. Results: Emergency procedures (Group B) were necessary in 92 (46.2%) cases with a mortality rate of 19.6 % (n = 18). Elective surgery (Group A) was undertaken in 107 patients (53.8%) with a mortality rate of 8.4% (n =9). Mean age of group B (71.61± 6.319%) was significantly higher than group A(69.7 ± 3.509%). Group B had significantly higher number of patients (19.6%) aged more than 80 years. Coexisting medical problems were noted in 143 (71.8 %) patients. Patients in group B had significantly higher pulse rate, respiratory rate (p < 0.0001), body tem-perature (p =0.0003), indicating the presence of systemic inflammatory response syndrome. Group B patients had poorer nutritional status, as reflected by significantly lower values of total serum proteins (p <0.0001) and serum albumin (p = 0.002). These patients also had deranged renal function tests (p= 0.002) and coagulogram (p <0.0001. Morbidity was 72.8 %( n = 67) in emergency group and 53.3 % ( n = 57) in elective group. Local surgical complications in both the groups were comparable but systemic complications were more frequent in group B. Cardiac failure, respiratory failure, arrythmias and acute renal failure being the complications most commonly associated with a prolonged hospital stay and mortality. The overall mortality rate was 13.6% (n = 27), with higher incidence in emergency subgroup (19.6 % vs. 8.4%). Factors found stastically significant with mortality were; emergency surgery, and comorbid respiratory disease in form of COPD.Conclusions: The findings of the present study indicate that emergent etiology and coexisting medical problems were the factors for unfavorable outcome. Our study also shows that it is safe to operate on the elderly electively.

110


Authors - Karakaş BR, Aslaner A, Gündüz UR, Çalış H, Karakoyun Demirci R, Öngen AN, Öner OZ, Bülbüller N.; Afiliation - Department of General Surgery, Antalya Training and Research Hospital, 07100, Antalya, Turkey.;

IS THE DISTANCE OF LATERALIZATION IMPORTANT IN THE ASYMMETRIC MODIFIED LIMBERG FLAP PROCEDU-RE FOR THE SACROCOCCYGEAL PILONIDAL SINUS TREATMENT?

Introduction: This study analyses whether the distance of lateralization causes the early complication and recur-rence rates in sacrococcygeal pilonidal sinus disease patients who underwent lateralized asymmetric modified Limberg flap. This has not been investigated previously.Material and Methods: In this clinical study conducted between March 2012 and April 2013, a total of 40 pa-tients with sacrococcygeal pilonidal sinus were divided into two groups according to the lateralization distance of the lower part of the Limberg flap incision as group I (1 cm lateralized) (n=20) and group II (2 cm lateralized) (n=20). Early wound complications and recurrence rates were evaluated.Results: A total of 40 patients were included in the study (mean age: 25.6 ± 7.3 years). When the duration of operation, drain removal time, and length of hospital stay were compared, our data show no statistically signifi-cant difference between the two groups (p > 0.05). The mean follow-up was 10.4±4.2 months. Recurrences were observed in only one patient of group II. There were no significantly difference between the two groups in terms of overall wound complication and recurrence rates (p>0.05).Conclusions: The comparison of the two different distance of the lateralization for asymmetric modified Limberg flap procedure shows no significant differences regarding early complications and recurrences. Therefore, we conclude that a minimum 1 cm lateralization lower part of incision is sufficient for asymmetric modified Limberg flap procedure.

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Authors - Sammut M; Afiliation - Mater Dei Hospital;

THE USE OF PROPHYLACTIC ANTIBIOTICS IN SEVERE ACUTE PANCREATITIS.

Introduction: With an increasing incidence per year, acute pancreatitis remains a growing health problem. De-spite the literature available there is still controversy about the use of prophylactic antibiotics in severe acute pancreatitis (SAP). The aim of the literature review was to assess whether prophylactic antibiotics are of benefit in SAP. Material and Methods: A structured and systematic literature search was performed in PubMed, Ovid, Science Direct, EBSCO Host and Cochrane databases. 20 studies were included for critical analysis.Results: Although conflicting data and results were encountered, the use of prophylactic antibiotics in SAP was found to decrease the incidence of pancreatic infections, non-pancreatic infections, patients’ hospital length of stay and patient mortality rates. Although there was heterogeneity in the studies, these results were mostly en-countered with the use of prophylactic carbapenems. It was also noted that in SAP, close follow up is needed to monitor patient’s progress and monitor for the emergence of resistant microorganisms/fungal infections.Conclusions: Although the data is still controversial, the use of prophylactic antibiotics, in particularly carbapen-ems, should be considered in SAP. The duration for the use of prophylactic antibiotics was suggested to be between 7 to 21 days. The studies, which showed patient benefits and/or no changes, had levels 1 and 2 of evidence. The review showed that there is still no consensus about the “best” policy for prophylactic antibiot-ics in SAP and thus larger standardised studies are needed to assess the use of prophylactic antibiotics in SAP.

112


Authors - Nathania Bonanno, Simon Aquilina; Afiliation - Department of Surgery, Mater Dei Hospital, Malta;

THE ROLE OF C-REACTIVE PROTEIN AND WHITE CELL COUNT IN THE DIAGNOSIS OF ACUTE APPENDICITIS.

Introduction: Improving the diagnosis of acute appendicitis in order to prevent unnecessary surgery is crucial. The aim of this study was to identify the role of C-reactive protein (CRP) and white cell count (WCC) in patients with a preliminary diagnosis of acute appendicitis.Material and Methods: 98 patients (44 males; 44.9%) who were operated on for a clinical diagnosis of acute appendicitis between 1 July and 8 September 2013 at Mater Dei Hospital (MDH) were recruited in this retro-spective study. The average age was 31 years (range, 6-85). Preoperative serum samples were obtained from the patients to measure CRP and WCC. The patients were divided into two groups according to the histo-pathological features of the removed appendix: Group A (n=94), patients with acute appendicitis, and Group B (n=4), patients without acute appendicitis. Results were then correlated with WCC and CRP values by working out sensitivity, specificity and positive and negative predictive values (PPV and NPV, respectively) for each laboratory test, indi-vidually and in combination with one another. Results: 3 patients with WCC and CRP both in the normal range had acute appendicitis. This study showed a PPV of 100% for a raised CRP and 96.7% for a raised WCC in acute appendicitis, and a value of 100% when both pa-rameters were raised. CRP alone had a NPV of 40%, WCC alone had a NPV of 20%. The NPV improved to a value of 50% when both parameters were raised. Specificity of CRP was 100%, whilst that of WCC, 75%.Conclusions: CRP alone is a more helpful marker in the management of patients with suspected acute appendi-citis; its predictive value improves when combined with WCC. A patient with normal CRP has a low probability of appendicitis and may have a role in preventing unnecessary surgery..

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Authors - Kibil W, Hodorowicz-Zaniewska D, Kulig J; Afiliation - 1st Department of General, Oncological and Gastrointestinal Surgery, Jagiellonian University, Kra-kow, Poland;

MAMMOTOME BIOPSY IN DIAGNOSING AND TREATMENT OF INTRADUCTAL PAPILLOMA OF THE BREAST.

Introduction: Intraductal papilloma is a benign breast tumor which needs istopathological verification because of the risk of cancer coincidence. The aim of the study was to assess the value of the mammography-guided and ultrasound-guided vacuum-assisted core biopsy in the diagnosis and treatment of intraductal papillomas of breast and to answer the question if mammotome biopsy allows to avoid surgery in these patients. Material and Methods: In the period 2000-2011, a total of 2246 vacuum-assisted core biopsies were performed, of which 1495 were ultrasound-guided and 751 were mammography-guided (stereotaxic). In 76/2246 patients (3.4%), aged 19-88 years (mean age was 51,5) histopathological examination confirmed intraductal papilloma. Results: Atypical lesions were accompanying intraductal papilloma in 16/76 cases (21%). Open surgical biopsy performed in these group revealed invasive cancer in 3 women. In all 60 cases (79%) with benign papilloma in biopsy specimens, further clinical observation did not show recurrence or malignant transformation of lesions. Conclusions: Vacuum-assisted core biopsy is a minimally invasive and efficient method used for diagnosing in-traductal papilloma of the breast. If histopathological examination confirms a benign character of the lesion, surgery may be avoided but regular follow-up is recommended. However, in all cases histopathological diagnosis of papilloma with atypical hyperplasia, should always be indication for surgical excision.

114


Authors - Mr Karl Spiteri, Mr Joseph Debono; Afiliation - Association of Surgeons of Malta. Royal College of Surgeons of Edinburgh.;

COMPARISON OF RADIO-GUIDED OCCULT LESION LOCALISATION (ROLL) VERSUS WIRE-GUIDED LOCALISA-TION (WGL) FOR BREAST CONSERVING SURGERY FOR IMPALPABLE BREAST CANCER.

Introduction: There are an increasing number of impalpable breast lesions being diagnosed with the introduc-tion of breast screening services. With breast conserving surgery the accepted standard of treatment, new meth-ods have emerged for the localisation of impalpable lesions. The aim of treatment is to remove all tumour tissue whilst removing the least amount of normal breast tissue. Our aim is to compare the margin clearance rate, amount of breast tissue excised, and length of procedure for ROLL, which has been recently introduced in our local practice, with WGL.Material and Methods: Following injection of impalpable breast tumours with Technetium labelled colloid under US or stereotactic guidance, the lesions were localised and excised in theatre under the guidance of a gamma probe. The results of our first ROLL wide local excisions were compared our latest WGL wide local excisions. The data gathered included weight of excised tissue, tumour volume, clearance margins, and time for procedure. The Mann Whitney U test was used to test for statistical differences between the two groups, except for margin positivity rate where Fisher’s exact test was used.Results: All patients had successful localisation of the lesion using either technique. The operating time was shortened with the use of ROLL. Whilst there was a statistically significant reduction in the rate of positive mar-gins, this came at the expense of slightly larger excision specimens.Conclusions: Our initial experience with ROLL is a positive one. It is comparable to WGL and whilst resulting in slightly larger amount of normal breast tissue removed, it does improve negative margin rates.

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Authors - Khalid Akbari, Ragai Makar, Vivien NG, Simon Middleton, Daniel McGrath; Afiliation - Royal Berkshire Hospital Reading UK;

THE INFLUENCE OF RESECTED SPECIMEN LENGTH AND TUMOUR DIAMETER ON LYMPH NODE HARVEST IN COLORECTAL CANCER.

Introduction: In colorectal cancer surgery, lymph node status is an important predictor of prognosis in patients with non metastatic disease. Current guidelines suggest sampling a minimum of 12 or more lymph nodes for accurate staging. We aimed to study the impact of tumour diameter and specimen length on the number of harvested lymph nodes.Material and Methods: Retrospective data was collected on a series of consecutive patients with colorectal cancer who underwent laparoscopic resection over a 12 month period. Data relevant to tumour site, resection type, conversion to open procedure, number of lymph nodes sampled, tumour diameter, specimen length and neo-adjuvant therapy were collated. Results: A total of 130 resections were performed during study period. Two segmental resections for benign polyps were excluded. 128 colorectal cancer or dysplastic adenoma cases not suitable for endoscopic resection (6 patients) were included in the analysis. Laparoscopic resection was performed in 117 cases. 80 patients were male (64.5%). Mean age was 71 years. In 90.6% of laparoscopic cases the number of lymph node sampled was 12 or more. There is a correlation between specimen length and the number of total lymph nodes sampled (Pearson correlation r = 0.40, P value 0.000) and maximum tumour diameter (Pearson correlation r = 0.48, P value = 0.000). Conclusions: Our data suggest >90% compliance with current guidelines in laparoscopic surgery. Factors such as tumour diameter and specimen length have an impact on the number of lymph nodes harvested. Therefore, these two factors should be considered in interpretation of lymph node status.

116


Authors - Lintzeris Ioannis, Alexiou Ioannis, Dimitriou Maria, Agrogianni Xanthi, Datsis Konstantinos, Perrakis Nikos, Nomikos Iakovos, Papaemmanouil Virginia; Afiliation - 2nd Surgical Oncology Department Anticancer Hospital of Piraeus Metaxa ,Piraeus Attika GreeceMicrobiological Laboratory, Anticancer Hospital of Piraeus Metaxa, Piraeus Attika Greece;

ISOLATION AND CHARACTERIZATION PREVALENCE AND ANTIFUNGAL SENSITIVITY OF CANDIDA SPP IN GREEK CANCER PATIENTS OF A SURGICAL UNIT.

Introduction: The frequency of severe systemic fungal diseases has increased in the last few decades. Candida is an opportunistic pathogen that affects high–risk patients who are either immunocompromised or critically ill and is associated with almost 80% of all nosocomial fungal infections, representing the major cause of fungemia with high mortality rates (40%). Opportunistic pathogens from the genera Candida can invade human organism and may lead to mucosal and skin infections or to deep-seated mycoses of almost all inner organs, especially in immunocompromised patients. Nowadays, there are some effective antifungal agents, but, unfortunately, some of the pathogenic species show increasing resistance. This study wants to evaluate the distribution of Candida species and to determinate the antifungal susceptibility test of isolated Candida spp. in the surgical clinic of an anticancer hospital.Material and Methods: The material of this study a total of 40 isolates strains of Candida spp , was clinical sam-ples from different sources blood, wounds, sputum, urine, which collected over a period of 3 years from cancer patients of a surgical unit . All blastomyces that isolated were identified by classical methods using the following tests formation of germinative tubs , study of micromorphology, assimilation of carbon and nitrogens sourc-es, fermentation and urea hydrolysis. Also the isolated blastomyces, were identified by API20C AUX and ID32C (BIOMERIEUX). In vitro antifungal susceptibility to Candida species was determined with E-test (Ab-biodisk) ac-cording the NCCLS reference .One reference strain (C. Parapsilosis ATCC 22019 ) was included in each run for quality control. Minimum inhibitory concentrations (MIC) were performed to 6 antifungal agents: Fluconazole, itraconazole, posaconazole, amphotericin B, voriconazole and caspofungin.Results: Yeasts were recovered during the 3year period of the study and were diagnosed as fungal infections of C.albicans in 8 patients ,C. parapsilosis in 17 patiets and C. tropicallis in 15 patients. The isolated strains were all sensitive to caspofungin, voriconazole and Amphotericin B but were resistant 5 strains of C. parapsilosis (1 posaconazole ,2 fluconazole , 2 itraconazole) 2 strains of C .tropicallis (1 fluconazole, 1 itraconazole).Conclusions: This study demonstrates new patterns of breakthrough Candida in surgical patients. Candida albi-cans is not the dominant etiologic agent in mycoses in surgical cancer patients. Clearly demonstrates that there is indeed a higher prevalence of C. parapsilosis and C. tropicallis. Possibly the presence of C parapsilosis is associ-ated with vascular catheters.

117

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Authors - Kate Huntingford, Miriam Sterkel, Jo Etienne Abela; Afiliation - Mater Dei Hospital, Malta;

LAPAROSCOPIC INGUINAL HERNIA SURGERY - A SINGLE SURGEON’S EXPERIENCE.

Introduction: Laparoscopic inguinal hernia surgery has gained in popularity over the past two decades to be-come the procedure of choice for recurrent and bilateral inguinal herniation.Material and Methods: Fifty-six patients receiving this type of surgery from January 2011 to September 2013, were prospectively audited. The median age was 43 years (19 to 77). Three patients were female and had bilat-eral inguinal herniae. Thirty-nine male patients had bilateral inguinal herniae. Fourteen patients had unilateral herniae - 2 were primary, 12 were recurrent (1 femoral and 3 irreducible inguinal). The TEP extraperitoneal ap-proach was employed in all cases apart from the 3 irreducible cases which were treated via a transabdominal TAP approach. The TEP approach was achieved either by the dissection balloon (38 cases) or a balloon-less technique (15 cases). Preformed anatomical mesh was employed in 36 patients. Results: Three open conversions were effected (all three due to obesity and inability to assess landmarks prop-erly). The median operating time for all laparoscopic procedures was 75 minutes (50 to 135) with no significant difference in between TEP techniques, even allowing for anatomical mesh placement (p=0.07). Bilateral cases took on average 18 minutes longer. TAP, possibly, due to it being used less frequently was an average 25 minutes longer than a unilateral TEP. One patient had a delayed discharge of 3 days due to groin pain. All other patients (including open conversions)were discharged within 23 hours. One patient developed a Klebsiella wound infec-tion which was successfully treated with antibiotics. No recurrence was noted at the post-operative visit at 3 months. Three patients developed small ultrasound-proven but asymptomatic encysted hydrocoeles of the cord. Return to normal activities occurred at median of 2 weeks.Conclusions: Laparoscopic inguinal hernia surgery can be performed safely and expeditiously with a satisfactory outcome. The benefits of balloon dissection and anatomical mesh prostheses are not immediately apparent.

118


Authors - Lintzeris Ioannis,Alexiou Ioannis,Dimitriou Maria, Agrogianni Xanthi,Datsis Konstantinos, Perrakis Nikos, Nomikos Iakovos, Papaemmanouil Virginia; Afiliation - 2nd Surgical Oncology Department Anticancer Hospital of Piraeus Metaxa ,Piraeus Attika Greece Microbiological Laboratory Anticancer Hospital of Piraeus Metaxa, Piraeus Attika Greece

ISOLATION AND CHARACTERIZATION PREVALENCE AND ANTIFUNGAL SENSITIVITY OF CANDIDA SPP IN GREEK CANCER PATIENTS OF A SURGICAL UNIT.

Introduction: The frequency of severe systemic fungal diseases has increased in the last few decades. Candida is an opportunistic pathogen that affects high–risk patients who are either immunocompromised or critically ill and is associated with almost 80% of all nosocomial fungal infections, representing the major cause of fungemia with high mortality rates (40%). Opportunistic pathogens from the genera Candidacan invade human organism and may lead to mucosal and skin infections or to deep-seated mycoses of almost all inner organs, especially in immunocompromised patients. Nowadays, there are some effective antifungal agents, but, unfortunately, some of the pathogenic species show increasing resistance. This study wants to evaluate the distribution of Candida species and to determinate the antifungal susceptibility test of isolated Candida spp. in the surgical clinic of an anticancer hospital. Material and Methods: The material of this study a total of 40 isolates strains of Candida spp , was clinical samples from different sources blood, wounds, sputum, urine, which collected over a period of 3 years from cancer patients of a surgical unit. All blastomyces that isolated were identified by classical methods using the following tests formation of germinative tubs , study of micromorphology, assimilation of carbon and nitro-gens sources, fermentation and urea hydrolysis. Also the blastomyces that isolated, were identified by API20C AUX and ID32C (BIOMERIEUX). In vitro antifungal susceptibility to Candida species was determined with E-test (Ab-biodisk) according th NCCLS reference. One reference strain (C. Parapsilosis ATCC 22019 ) was included in each run for quality control. Minimum inhibitory concentrations (MIC) were performed to 6 antifungal agents : Fluconazole,itraconazole, posaconazole, amphotericin B, voriconazole and caspofungin.Results: Yeasts were recovered during the 3year period of the study and were diagnosed as fungal infections of C.albicans in 8 patients, C. parapsilosis in 17 patients and C. tropicallis in 15 patients. The isolated strains were all sensitive to caspofungin ,voriconazole and Amphotericin B but were resistant 5 strains of C. parapsilosis (1 posaconazole, 2 fluconazole, 2 itraconazole) and 2 strains of C. tropicallis (1 fluconazole, 1 itraconazole).Conclusions: This study demonstrates new patterns of breakthrough Candida in surgical patients. Candida al-bicans is not the dominant etiologic agent in mycoses in surgical cancer patients. It clearly demonstrates that there is indeed a higher prevalence of C. parapsilosis and C. tropicallis. Possibly the presence of C parapsilosis is associated with vascular catheters.

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