Objective: The effectiveness of teaching operative notes in surgical resident training program at King Abdulaziz University Hospital, Jeddah was studied. Materials and Methods: This was a prospective study done at Department of Surgery, King Abdulaziz University Hospital to evaluate the effect of teaching the surgical residents how to write operative notes. Twenty-one residents were asked to write operative notes of appendicectomy. Their operative notes were evaluated for medical record number (MRN), date and time of the operation, preoperative and postoperative diagnosis, names of surgeon, assistant, and anesthetist, name of the operation, incision, findings, closure, hemostasis, estimated blood loss, whether histopathology specimen was sent to the pathology department or not, postoperative orders, whether the patient went to the recovery room in a satisfactory condition or not, and signature of the operating surgeon. Two months of effective teaching of operative notes was given to them. They were again asked to write operative notes of appendicectomy. Notes were collected and studied and comparison was made with previous notes. Legibility of the operative notes was also studied. Results: In our study, we found that there was improvement of 29-39.9% in recording MRN and the date of operation by our residents after they were taught the art of writing operation notes. There was marginal improvement (4.7%) in stating whether it was elective or emergency operation. Documentation of surgeon's name, assistant's name, and anesthetist's name improved to 12.4-32.8%. Writing the name of the procedure and pre- and postoperative diagnosis improved to 31%. Details of the procedure such as position of patient and incision improved marginally to 5.9%. Mentioning the findings and description of the procedure showed no improvement, as it was 100% before teaching. Documenting hemostasis, estimated blood loss, and transfer to recovery room improved to 58.4%; however, there was no improvement in writing post-op orders and histopathology sent to the pathology department.Improvement of signature was only 9%. Conclusion: Effective teaching of how to write operative notes helps in the training of surgical residents.

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Glomus tumors (GT) are cutaneous and soft tissue mesenchymal neoplasms. The malignant variant that is, glomangiosarcomas (GS) are rare and account for <1% of all GT. GS are usually seen in adults with a wide age range of 20-89 years. GS usually have an indolent course with local aggressiveness. The treatment is complete surgical excision with excellent prognosis though metastasis workup is advised. Herein, we report an unusually large GS de novo in a 6-year-old girl. Complete surgical excision was performed. There was no evidence of recurrence or metastasis over the last 15 months of follow-up postoperatively. GS should be considered as one of the differential diagnosis of cutaneous and soft tissue neoplasms.

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Background: Most major hepatocellular carcinoma (HCC) staging systems recommend hepatic resection only for patients with early-stage of HCC. Still there is controversial about resection of patients with large HCC (defined as >5 cm). The aim of this retrospective study is to investigate the clinicopathological features that impacted the long-term outcomes of 1 year after hepatectomy of large HCC >5 cm in cirrhotic patients. Materials and Methods: From February 2012 to December 2015, a total of 92 patients with resection of large HCC on liver cirrhosis were reviewed retrospectively and considered for clinicopathological features that impacted the long-term outcomes. Time to recurrence (recurrence-free survival) and overall survival (OS) were determined by Kaplan-Meier analysis. Results: Twenty-nine (31.5%) patients developed tumor recurrence. The mean time until tumor recurrence was 12.4 ± 6.6 months. The cumulative 1-, 2-, and 3-year disease-free survival rates were 73%, 28%, and 18%, respectively. On multivariate analysis, male gender, α-fetoprotein >400, bilobed tumors, patients with portal hypertension, plasma transfusion, and absence of tumor capsule remained independent predictors for recurrence of HCC. The OS rates at 1, 2, and 3 years were 73%, 31%, and 16%, respectively. On multivariate analysis, α-fetoprotein >400 and plasma transfusion remained independent predictors for death. Conclusions: Liver resection is suggested in patients with large HCC and can be performed with acceptable overall and disease-free survival and morbidity rates. Identification of risk factors and close postresection follow-up with early detection are mandatory measures for prompt treatment of tumor recurrence which is reflected by a beneficial survival rate for this group of patients.

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Background: Oral cancer is one of the common cancers in India with dismal survival in advanced stages. Most of the patients present in advanced stages with borderline operability and such patients may be helped by chemotherapy to render them operable. It is well known that tumor growth is angiogenesis-dependent and thus vascular endothelial growth factor (VEGF) may be a surrogate marker of growth and angiogenesis. At present, there is a scarcity of predictive markers for oral cancer. In this prospective study, we studied VEGF expression and its role as a predictive marker in oral cancer. Materials and Methods: Patients with locally advanced oral cancer having borderline operability or unfit to undergo surgery in the primary setting were included in the study. VEGF expression of the cancerous tissue was studied in all patients. Three cycles of neoadjuvant chemotherapy (NACT) was administered before definitive treatment in locally advanced cases and response is assessed. VEGF levels were analyzed in cancer tissue and compared with normal surrounding mucosa. The response to chemotherapy was then correlated with VEGF score in patients receiving NACT to evaluate it as a predictive marker. Results: All forty patients were VEGF-positive and had a mean score of 1023 with 63% patients having Grade 3 expressions, whereas the normal surrounding mucosa had a VEGF score of 30. It was seen that in patients showing no response to treatment, the mean total VEGF score was significantly higher as compared to those showing complete or partial response. VEGF score correlated inversely with chemotherapy response, but no significant association was seen between VEGF grade and chemotherapy response. Conclusion: We can conclude from this study that VEGF is significantly overexpressed in cancer mucosa as compared to normal mucosa and overexpression of VEGF was found to be associated with chemoresistance and thus may serve as a negative predictive marker.

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Objective: The aim was to study the prophylactic effect of tamsulosin on postoperative urinary retention in benign anorectal surgeries. Background: Acute urinary retention (AUR) after anorectal surgeries is essentially a type of postoperative urinary retention (POUR). It is the most common complication of the procedure. Use of tamsulosin, a super selective alpha 1a adrenergic blocker has been found to reduce the risk of POUR. Patients and Methods: Patients who underwent anorectal surgeries for benign anorectal conditions were included in this study. Patients were randomly assigned into two groups. In one, group (cases), patients were given 0.4 mg of oral tamsulosin only 6 h preoperative and 6-8 h postoperatively. Inability/difficulty to pass urine, which necessitated catheterization after following patient for 24 h was labeled as POUR. Results: A total of 626 patients who underwent surgery for benign anorectal condition were included in the study and grouped into two groups with 313 patients in each group, control and case group. In the control group, 56 patients (17.9%) had inability to pass urine and required catheterization and in the case group, only eight patients (2.5%) needed catheterization following POUR. The difference in the requirement of catheterization following POUR was statistically significant (P = 0.04). Hemorrhoidectomy was the most common anorectal surgery associated with POUR. Conclusion: The use of tamsulosin in preoperative and postoperative period has been found effective to reduce the incidence of POUR following surgeries for benign anorectal pathologies.

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Introduction: The established success of damage control surgery (DCS) in trauma of torso motivates surgeon to apply similar concept in managing complicated intra-abdominal sepsis. The main objective of this study is to audit our new practice of such in nontrauma emergency abdominal surgery. Materials and Methods: We retrospectively reviewed all emergency abdominal surgeries (nontrauma) done from February 2013 to February 2014. All patients who had damage control procedures done for complicated intra-abdominal sepsis were analyzed. Results: A total of 60 patients were operated within that period. Six patients (10%) had undergone DCS with or without laparostomy. All were male with mean age of 48.5-year-old (26-61-years-old). Most were in ASA 3 (83%, 5 patients) with only one in ASA 4. Primary indications were ischemic bowel with mesenteric vein thrombosis (3 patients, 50%), abdominal compartment syndrome (ACS), bleeding post near total splenectomy for splenic abscess and gangrenous proctitis with purulent peritonitis. Nearly, all patients (5 patients, 83.3%) were severely acidotic with pH <7.2 intra-operatively, which triggered the DCS. Nevertheless, only 3 patients (50%) benefited from laparostomy and all of them achieved complete fascial closure within 2.6 days (mean). Their mean total Intensive Care Unit (ICU) stay was 15 days (9-32 days). Overall predicted mean Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity mortality rate was 51%. However, the observed (actual) mortality rate was only 33% (2 patients). Conclusion: The result of the practice of DCS in the septic abdomen is very encouraging. It appears able to reduce the mortality by 35%. A comparative analysis with larger series is therefore warranted to further confirm the findings.

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Context and Aims: Pneumatic reduction has a higher success rate and lower incidence of complications compared to barium enema and hydrostatic reductions. What is deterrent to its common use is the cumbersome technique. Our technique is simple that can be used in any hospital with locally available facilities. Settings and Design: This was a prospective study. Subjects and Methods: A total of 25 children were enrolled in the study between September 2015 and June 2016 at our institute. Patients were given air enema under US guidance using locally assembled equipment. The intraluminal pressure was monitored with a pressure gauge and was not permitted to go above 100 mmHg. A total of three attempts of 3 min each were allowed. Statistical Analysis Used: We just used simple statistic to calculate average. Results: There were 17 males and 8 females. The average age of the patients was 8.5 months. Twenty-two (88%) of the cases were reduced successfully while 3 (12%) failed to reduce. A majority of those that did not reduced had symptoms for at least 4 days. No bowel perforation occurred in our study. All cases of the intussusception have length <5 cm were reduced with pneumatic reduction in our study. Conclusions: The technique described is easy to assemble, safe, and effective. We recommend it for regular use in pneumatic reduction of intussusception, especially in the center have limited resources.

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H-type rectourethral fistula in males is a rare congenital anorectal malformation. It is associated with anal stenosis at normal site which generally delays diagnosis. We describe a case of a 6-month-old male child who presented with intermittent passage of fecal matter in urine along with ribbon-shaped stools through anal orifice, on straining. Investigations revealed an H-shaped rectourethral fistula with anal stenosis. Minimal sagittal anorectoplasty with fistula ligation was done.

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Duodenal duplication cysts are rare congenital abnormalities that are most commonly diagnosed in infancy and childhood. However, in rare cases, the lesion can remain asymptomatic until adulthood. An extremely rare case of a previously healthy young adult patient with recurrent acute pancreatitis, who was diagnosed with a duodenal duplication cyst, is presented. At laparotomy, a duplication cyst measuring 3.8 cm × 2.8 cm was found posteromedial to the 2 ^nd part of duodenum impinging over the head of pancreas. Cyst was excised. The patient is healthy and asymptomatic 1 year after surgery. The present case illustrates the necessity of considering a duodenal duplication cyst in the differential diagnosis of recurrent acute pancreatitis.

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Crossed fused ectopia is an asymptomatic fusion anomaly usually diagnosed incidentally or due to symptoms of associated urinary abnormalities. They are rarely associated with an ectopic opening of the ureter. We present a case of 6-year-old female with constant dribbling diagnosed to have left to right inferior crossed fused kidney with ipsilateral ureteral ectopy.

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Neurofibromatosis (NF) is a term that has been applied to a variety of related syndromes, characterized by neuroectodermal tumors arising within multiple organs and autosomal-dominant inheritance. NF-1, known as well as Recklinghausen's disease, is the most common type of the disease accounting 90% of the cases. A case of 50-year-old patient with NF is presented with a mass in the left side of the neck since 1-year and progressive dysphagia since 6 months worse for solids than liquids. Intraoperatively a large solid mass was found occupying the left side of the neck pushing the trachea and esophagus to the right side, infiltrating a portion of the wall of esophagus. The mass was resected en bloc along with a portion of the wall of esophagus, and primary esophageal repair was done. Histology revealed plexiform neurofibroma.

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Metastases in medullary carcinoma thyroid are not an uncommon phenomenon; however, metastases to the breast are extremely rare. Authors are reporting a rare case of medullary carcinoma thyroid metastases to breast in a 42-year-old female. Biopsy was performed to distinguish between primary duct carcinoma and metastatic medullary carcinoma thyroid. Further investigations revealed multiple involvements of cervical as well as axillary lymph nodes, bones, lungs, and dermis. Though survival of isolated metastases of medullary carcinoma thyroid to the breast may be better compared to other solid tumors of the breast, with wide spread dissemination survival is poor. Breast metastases on presentation seem to be a manifestation of wide spread disease.

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Cecal volvulus as an uncommon cause of acute intestinal obstruction is due to axial twist of the cecum and terminal ileum around their mesentery. Cecal volvulus is a surgical emergency requiring urgent laparotomy. Resection and anastomosis is the proposed choice of the operation depending on the general condition of the patient. In addition, to its rarity, lack of familiarity causes diagnostic doubt and consequently delays in treatment. In this paper, we report a case of cecal volvulus seen in a 31-year-old Saudi male presented with vomiting, abdominal pain, and distension.

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Although thyroglossal (TG) cysts are very common in children and young adults, their presentation in the elderly is very rare and often goes unnoticed unless we get the pathology report. This may lead to incomplete excision and recurrence of the cyst, together with the fact that there may be an increased risk of malignancy associated with the cysts in this subset of population. The early identification and complete removal of the cysts is prudent. Here, we endeavor to highlight a series of three cases in the elderly, who presented to us with midline cystic neck mass, which on further evaluation turned out to be a TG cyst.

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It is very rare that squamous cell carcinoma (SCC) arises from colorectal epithelium. A 34-year-old Filipino man was treated with chief complaints of anorexia, abdominal pain, and vomiting. The histological diagnosis as SCC was determined by biopsy during a colonoscopy. We diagnosed primary SCC of the colon after exclusion of any malignant lesions found by systemic computed tomography. Surgical complete resection was performed. The prognosis of this disease seems to be worse than that of adenocarcinoma.

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Gastric volvulus, wandering spleen and eventration of diaphragm share a common pathologic cause of absence or laxity of intraperitoneal ligaments. We hereby present a rare case of a 15-year-old male child with cerebral palsy presenting with organo-axial type of acute gastric volvulus resulting in gangrene of whole of stomach, associated with an infarcted wandering spleen, eventration of the diaphragm and cholelithiasis.

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Multiple intestinal atresia (MIA) associated with colonic atresia is very rare, especially with almost normal bowel length. This report deals with a case of multiple jejunoileal atresia associated with descending colon atresia, which was managed by multiple resection and primary anastomoses without use of stents and with total parenteral nutrition. Literature on the genesis, management and survival of MIA is reviewed.

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Objective: The aim was to determine the role of laparoscopy in the management of nonspecific abdominal pain (NSAP). Background: NSAP constitutes a good proportion of surgical admissions, both in emergency and elective settings with considerable diagnostic dilemma. Patients and Methods: All patients who presented with pain abdomen with no immediate cause and were labeled as NSAP after clinical assessment and investigations and following that underwent laparoscopy to make a definitive diagnosis were included in the study. Results: A total of 88 patients were included in the study. There were 59 (67%) females and 29 (33%) males. The mean age was 26 years (range 18-58 year). The common mode of admission was out-patient department 69 (78.4%) patients. Twenty-five (28.4%) patients presented with NSAP in lower abdomen, followed by 21 (23.8%) with right lower abdominal pain and 19 (21.5%) with central pain radiating to right lower abdomen. Diagnosis was established in 75 (85.2%) patients. In 13 (14.7%) no pathology was found. The most common diagnosis was pathology of appendix in 29 (32.9%) patients followed by pelvic pathology in 18 (20.4%) and abdominal tuberculosis in 14 (15.9%) patients. Most 37 (42%) of the patients stayed in the hospital for 24 h. There was no readmission and no major postoperative complications. Conclusions: Laparoscopy has a definitive role in diagnostic dilemma associated with NSAP. It has at the same time role in treatment of the condition; hence laparoscopy has a diagnostic and a therapeutic implication in management of NSAP.

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Introduction: The surgical transversus abdominis plane (TAP) block is a novel approach for postoperative analgesia after abdominal surgeries. The block was given intraperitoneally during the intraoperative period. We evaluated its analgesic efficacy in patients during the first 48 h of the postoperative period after abdominal surgery, in a randomized, controlled, double-blind clinical trial. Materials and Methods: Thirty adult patients undergoing surgery requiring midline abdominal incision were randomized and divided into two groups. Group-T received TAP block with 20 ml of 0.5% bupivacaine intraperitoneally, and Group-P received TAP block with normal saline (placebo). Each patient was evaluated by a blinded investigator in the postanesthesia care unit and at 1, 2, 4, 6, 12, 24, 36, and 48 h. Results: Diclofenac consumption was almost reduced by 50% in TAP group in comparison to placebo group (mean diclofenac requirement of the TAP group vs. placebo group was 110 ± 25 mg and 225 ± 28 mg, respectively; P < 0.0001). Mean time to first request of analgesic was significantly prolonged in TAP block (210 min) as compared to placebo (90 min). Postoperative verbal analog scores at rest and at movement were significantly reduced in TAP block group from 4 to 24 h postoperatively as compared to placebo group. All TAP block patients were quite satisfied with the postoperative analgesic regimen. Conclusion: Postoperative analgesic consumption of diclofenac was almost reduced to half in TAP block group as compared to placebo group, and also, time to first request of analgesic was significantly prolonged in TAP block group. The surgical TAP block is a novel approach for providing postoperative analgesia which is easy to perform, safe and has no adverse effects.

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Background: Iatrogenic bile duct injuries (IBDIs) remain an important problem in gastrointestinal surgery and represent a big challenge for surgeons. Aim: To review the management of IBDI and describe short- and long-term postoperative complications of surgical repair at our tertiary referral institute. Patients and Methods: This was a retrospective review of the medical record of all patients referred for the management of IBDIs between January 2005 and January 2015. One hundred patients formed the study cohort. Preoperative data including patient demographics, mechanism of injury, operative details, and postoperative outcomes were extracted. Research Ethics Board approval was obtained. Results: There were 36 men and 64 women, with a mean age 45.4 ΁ 11.5 years. Open cholecystectomy was the most common procedure in 61 patients, whereas laparoscopic surgery was the primary treatment in 39 patients. Twenty-nine patients treated by nonsurgical management in the form of endoscopic retrograde cholangiopancreatography (ERCP) and stenting and percutaneous abdominal drainage. Seventy patients underwent operative surgery in the form of Roux-en-Y H.J, and T-tube insertion in the common bile duct in two cases. Short-term complications encountered in 15 (20.8%) cases, with a significant correlation with a previous ERCP intervention (P = 0.047). Long-term complications encountered in 12 (16.6%) patients, with a significant relation with the intermediate timing (within 2 weeks) of repair (P = 0.037). Conclusions: Prompt diagnosis of the type and grade of injury is mandatory before deciding management. Intermediate time for surgical intervention was significantly related to stricture complications. ERCP should be done only in cases that can benefit from conservative management (Strasberg from A-D) as the incidence of postoperative complication is high after surgical repair.

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Background: Haemorrhoids is a common condition seen in general surgery practice. Treatment includes many methods ranging from rubber band ligation, infrared photocoagulation, sclerotherapy to stapler hemorrhoidectomy. Our study is done to evaluate the efficacy of both the procedures in a rural setting. Objectives of the study was to study the efficacy of two surgical methods of treatment of hemorrhoids, in terms of (1) operation time; (2) post-operative pain; (3) hospital stay; (4) return to normal activity and return to work. Methods: A comparative study was done between open and stapling methods for the treatment of symptomatic hemorrhoids in Al Azhar Medical College, Thodupuzha, India. Results: There was major statistically significant difference seen among different parameters between the two procedures of haemorrhoidectomy, open versus stapler procedure for prolapsing hemorrhoids (PPH) as evident from the p value. Conclusions: In our study there is a definite difference noted between two surgical methods in terms of hospital stay and return to work. As far as satisfaction of patient is considered in both the groups satisfaction is similar except for the cost of surgery which was the only cause of dissatisfaction.

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Aims and Objectives: This study is aimed at determining the frequency and histopathological patterns including grading and staging of bladder tumors as seen in University of Benin Teaching Hospital, Benin City, Nigeria and to compare with similar research works elsewhere. Materials and Methods: A retrospective study of all data of surgical excision and cystoscopic bladder biopsies received over a 10-year period (2003-2012) at the Department of Histopathology, University of Benin Teaching Hospital, Benin City, Nigeria. Histological criteria published by the World Health Organization/International Society of Urological Pathology were used for the diagnosis and grading of these tumors. Results: A total of 75 bladder lesions were received in the Pathology Department. Of these, 64% were males and 36% were females giving a male to female ratio of 1.7:1.0. The peak and mean age incidence of urothelial bladder lesions was 60-69 years and 54.9 years ± 8.6 standard deviation, respectively. Bladder tumors accounted for 74.7% of all bladder lesions. Fifty-one (68%) cases out of 75 lesions were malignant tumors. Transitional cell carcinoma (TCC) was the most commonly encountered histological pattern accounting for 64.7% of bladder cancer. High grade papillary urothelial carcinoma was the most common tumor grade accounting for 51.4%. Only 40.6% cases were urothelial confined carcinoma (PTa) while 29.7% each accounted for lamina propria (PT1) and muscle (PT2) invasive carcinoma. Conclusion: Bladder tumors are more commonly encountered in males with the majority of cases occurring in the 7 ^th decade. Both high-grade TCC in stage (PT2) and low-grade carcinomas stage (PTa) were relatively common patterns seen in this study.

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Context: Gastric carcinoma often present with nonspecific gastrointestinal symptoms like dyspepsia making its diagnosis difficult and its later detection in an advance stage. To reduce the mortality and morbidity early diagnosis of gastric carcinoma is of utmost importance. Aims: The aim was to detect gastric carcinoma in patients presenting with dyspepsia symptoms for upper gastrointestinal (UGI) endoscopy and to study the incidence of carcinoma stomach related to factors like age, alcohol and smoking. Design: Surveillance cross section study. Subjects and Methods: Data were collected in all clinically diagnosed cases of dyspepsia undergoing UGI endoscopy at Father Muller Medical College Hospital, with sample size of 119 patients. Multiple (6-8) biopsies from suspected lesions were taken and sent for histopathological examination. Statistical Analysis Used: Frequency, percentage, Chi-square test and Fischer's exact test. Results: Of the 119 patients subjected to UGI endoscopy, 13 (10.9%) of them had gastric carcinoma. Mean age of the patient in the study was 49.76. Majority of the patients were males 58.82% (n - 70) and females were 41.17% (n - 49). Gastric carcinoma was predominantly seen in males - 76% and females - 24%. Alarm symptoms were found present in 53.84% with gastric carcinoma. Gastric carcinoma had strong association with smoking 38.46%, but not significant with alcohol consumption and showed peaking in incidence in the fifth and sixth decade. Conclusions: A high index of suspicion by clinicians and availability of endoscopic facilities may help detect early lesions, especially in elderly patients with alarm symptoms.

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Background: Hepatocellular carcinoma (HCC) has endemic proportions in some regions of the world, including the Sub-Saharan Africa, China, and the Far East. One of its known complications is tumor rupture, with a bleak prognosis. Aim: This study aims to report on our experience with the management of ruptured HCC. Materials and Methods: We reviewed our records to retrieve cases of ruptured HCC, from September 2013 to December 2015. Results: We were able to identify five patients, all of them were males with a median age of 70 years (range 26). One patient had hepatitis B, three had Schistosoma, and the status of the fifth was undetermined. In one patient, who eventually died, an emergency laparotomy deemed necessary to control the bleeding. In the other four, who were stabilized to undergo computerized axial tomography scan, angioembolization of the tumor feeding vessels succeeded to arrest the bleeding. Unfortunately, two patients died shortly after the procedure, while the other two survived and were discharged for follow-up. Conclusion: Spontaneous rupture of HCC is a grave event with a dismal prognosis. The optimal management should be individualized, based on the condition of the patient, the tumor characteristics, the facilities, and expertise available. Close collaboration between the interventional radiologist, gastroenterologist, oncologist, and surgeon is fundamental for success. The emergency laparotomy may be the appropriate action for the unstable patients. For those who could be stabilized, angioembolization with or without chemotherapy is an attractive option. Conservative treatment may be reserved for those with the worst prognosis.

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Solid pseudopapillary tumors of the pancreas are rare tumors commonly found in females. Surgery is the primary treatment and the role of adjuvant chemotherapy or radiation is not well defined. Although they are mostly benign, they have the potential for late metastasis, thereby defining the need for long-term surveillance for such patients. This review article describes these tumors in detail and in addition, focuses on the management of the resected tumors and the need and indications for adjuvant treatment in selective cases.

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