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We report a case of a neonate, delivered by C-section, that rapidly developed respiratory compromise and hemodynamic instability prompting admission to critical care. Urgent cardiology assessment with echocardiography revealed severe systolic dysfunction from localized myocardial ischemia and pulmonary hypertension. Their management progressively escalated, eventually requiring inotropic support. Despite intensive treatment and meticulous nursing with demonstrable improvement of cardiac function, they deteriorated suddenly and died on Day 2 post-partum. This case emphasizes the challenge in early recognition of neonatal shock due to often nonspecific presentations, with hemodynamic compromise arising later. We recommend close vigilance for deterioration, awareness of indolent etiology including viral myocarditis, titration of appropriate inotropes and synergistic adjunctive vasodilators, and consideration of immune modulators such as corticosteroids that addresses biochemical deficiencies and support cardiac function. Ultimately, aggressive, targeted, and multi-focal treatment, especially in resource-limited environments, maximizes the chances of survival in challenging clinical situations such as progressive neonatal shock.

The emergence of the SARS-CoV-2 Omicron variant has raised concerns due to its increased transmissibility and potential implications on clinical characteristics and outcomes in infected individuals. The aims of this report were to study the profile of SARS-CoV-2 infection with omicron variant, investigate the infection outcome, reinfection rates with associated factors, antibody levels, and explore the associations between biochemical markers and disease severity. This prospective cohort study was conducted in Duhok city in the Northern of Iraq. All volunteers with confirmed SARS-CoV-2 RT–PCR and confirmed Omicron infection who were older than 18 years old and agreed to participate were recruited for this study. The study was carried out from January to April 2022. There were 234 cases of confirmed SARS-CoV-2 RT–PCR Omicron infection. The mean age was 48.12±17.3 years, 43.2% were vaccinated, and 40.2% were male. Among the recruited patients, 99.1% recovered and did not need hospitalization. In this study, (38.9%) had a history of previously confirmed COVID-19 infection. Reinfection was significantly higher in females than males (p=0.04; OR= 0.56). It was found that the IgG antibody levels were higher in patients who received Pfizer-BioNTech than in those who received other vaccines (p=0.001). The levels of IgG were also significantly higher in patients with mild infection (p=0.046), whereas the levels of D-dimer were significantly higher in patients with severe cases of the infection compared to those with mild or moderate cases (p=0.001). Additionally, the levels of C-reactive protein (CRP) were observed to be higher in individuals with moderate cases of infection than in mild and severe cases (0.001). Individuals who contracted the Omicron strain generally had positive outcomes. Reinfection with the Omicron variant was relatively high. IgG levels were higher in patients with mild disease, implying that they were associated with decreased disease severity. We found significant associations between D-dimer levels and the severity of the disease. Additional research is required to investigate the long-term effects of Omicron infection.

Sanjad-Sakati syndrome is a rare autosomal recessive genetic disorder that presents solely in Arabian people. Our case was reported from the Fallujah Teaching Hospital for Women and Children in Fallujah, Iraq. This syndrome is associated with hypoparathyroidism, growth retardation, atypical facial appearance, and a variable degree of mental retardation. It is usually caused by genetic mutations of the tubulin-folding cofactor E (TBCE; 604934), which is located on the 1q42.3 chromosome. This case was confirmed by a genetic study which revealed a pathogenic variant in the homozygous state in the TBCE gene. Typically, the physical features of this case involve microcephaly, long and narrow face, beaked nose, deep-set eyes, large ears, thin lips, long philtrum, micrognathia, and small hands and feet. Although Sanjad-Sakati syndrome is an incurable disease, early diagnosis helps with appropriate palliative treatment of the patient, reducing other associated metabolic and electrolyte disturbances, and allows for a genetic study and counseling of the family, especially in our society due to the high rate of consanguinity.

This is the third article in the series ‘Fundamentals of good medical practice’1,2. In this paper I will discuss the definitions of ‘Competence’ and ‘Performance’, the distinction and relationship between the two areas, and the possible/suggested different aspects of their assessment for the purpose of assuring the competence of current and future doctors, in particularly surgeons in practice.

MANAGEMENT OF COLORECTAL CANCER DURING PREGNANCY Majeed H Alwan MBChB, FRCSEd, FRACS, FACS, Gastrointestinal and General Surgeon, Tauranga Hospital, Tauranga, New Zealand. E-mail: majeedalwan@xtra.co.nz Abstract Although cancer in pregnancy is uncommon, several types of cancer were encountered. These include malignant melanoma, breast cancer, carcinoma of the cervix, bladder cancer, renal cancer, lymphomas, thyroid cancer, brain tumours, ovarian cancer, gastric and pancreatic cancer and colorectal cancer. Due to the uncommon incidence of the disease and therefore the limited experience coupled with the complexity of the situation which could affect the wellbeing of the foetus and mother, then the management of the pregnant woman with cancer might result in achieving less than the expected optimum. However, from the experience of single case reports and short reviews a reasonable management approach could be reached through multidisciplinary speciality collaboration. The author had encountered two pregnant women with colon cancer, both of them were symptomatic, and one of them had bowel obstruction. Their clinical presentation, diagnosis and management are described followed by a concise review of the literature.

Delirium is a common complication after surgery, especially among critically ill patients. The etiology is multifactorial and the condition is frequently identified after major complicated surgery. It is associated with prolonged hospital stay and increased morbidity and mortality. This paper present a complex case which required intensive treatment and support as a result of several complications including delirium. The case also serves a good example in discussing the different aspects of the condition.

Despite important advances in surgical care and minimized surgical trauma, postoperative complications are still of great concern. Nutritional depletion has been demonstrated to be a major determinant in the development of postoperative complications. Nutritional status of gastrointestinal surgical patients is an important issue, which need to be attended in particularly during the perioperative period. Fears of postoperative ileus and the integrity of the newly constructed anastomosis have led to the adoption of starvation with administration of intravenous fluids until the return of normal bowel sounds and passage of flatus. However, it has been shown that early postoperative enteral feeding is both beneficial and well-tolerated. Meta-analysis has shown that enteral feeding compared with parenteral nutrition is associated with fewer complications, reduced costs and a shorter hospital stay. Therefore it should be the preferred option whenever possible. Evidence to support preoperative nutrition is limited, but malnourished individuals fed for 7-10 days preoperatively may have improved surgical outcome. Prolong preoperative starvation is not essential, and the administration of preoperative carbohydrates is safe without the fear of increasing the risk of aspiration. Initially nutritional support was aimed at meeting the energy needs and providing proteins and other essential micronutrients, while now it is more directed at modulation of the immune functions, the so called immunonutrition. Multimodal strategies including minimal invasive surgery, adequate postoperative analgesia, nutritional care, and enforced mobilization resulted in reduction in postoperative complications and length of hospital stay.

Majeed H Alwan FRCS, FRACS, FACS, Gastrointestinal and General Surgeon, New Zealand 5 Tamworth Place, Gate Pa, TAURANGA, NEW ZEALAND. malwan@paradise.net.nz Abstract The traditional treatment of patients with adenocarcinoma of the rectum involved some form of radical surgery in fit patients followed by radiotherapy, or chemotherapy, or both depending on the stage of the disease and the general condition of the patient. More recently the emergence of neoadjuvant chemoradiotherapy (CRT) has fundamentally changed the management of these patients. Although initially it was recommended for locally advanced disease in an attempt of downstaging the tumour to make it resectable, the indication in using this modality had been widened. In clinical trials, up to 30% complete pathological response (pCR) of tumours have raised the question as to whether surgery, especially radical could be avoided in certain group of patients. A trial of omission of surgery in this group of patients has shown favourable long-term results. This article is an outline of the emerging factors for achieving complete pathological response; the non-operative or the minimal surgery strategies, methods of predicting response to chemoradiotherapy, and means of judging the complete pathological response.

The field of minimally invasive surgery has seen tremendous development and refinement since the first laparoscopic cholecystectomy was performed in 1987. Laparoscopic surgery has several advantages over traditional surgery. The next logical step in the evolution of minimally invasive surgery may be to eliminate all abdominal incisions. The terms being used in the literature include �incisionless�, �endoluminal�, �transluminal�, and �Natural Orifice Transluminal Endoscopic Surgery� (NOTES). This article aims to summarize the background and current status of NOTES.

Postoperative ileus (POI) is an inevitable adverse consequence of abdominal and other surgical procedures. Prolonged POI can lead to slow postoperative recovery, add to the patients discomfort and ultimately prolonged hospitalization and increased costs. It is believed that POI occurs as a result of inhibitory neural reflexes and inflammatory processes. The potential influence of endogenous opioids, in addition to exogenous opioids on the pathogenesis of POI has become more evident. The traditional routine use of nasogastric suction and the effects of prokinetic agents has been studied more and either challenged or refuted. Current treatment modalities, which are well studied includes the use of epidural long-acting local anaesthetics, early enteral feeding, multimodal postoperative care pathway, and less invasive surgical procedures. Recent research showed the usefulness of the newly introduced medications among the most promising is the peripherally acting �-opioid antagonist.

Background: Laparoscopic cholecystectomy is the standard treatment for symptomatic gallbladder disease. Preoperative prediction of a difficult laparoscopic cholecystectomy can help the surgeon to prepare better for intraoperative risk and the risk of conversion to open cholecystectomy. Objectives: Evaluation of the influence of gallbladder wall thickness, assessed by sonography preoperatively, on the outcome of laparoscopic cholecystectomy and to evaluate any intra- or postoperative complications in relation to them. Patients and Methods: This prospective clinical trial conducted in Department of Surgery, Al-yarmouk Teaching Hospital, between October 2010 and October 2012.Abdominal sonography performed in 122 consecutive patients before laparoscopic cholecystectomy. The surgeon re-verified sonographic findings in the operating room. Difficulty of laparoscopy was evaluated with multiple parameters related to the gall bladder wall thickness, so classified as easy or difficult laparoscopy or conversion. Results: Out of 122 patients with cholecystolithiasis on sonography, we encountered straight forward laparoscopic cholecystectomy in 87 patients (71.31%), difficult laparoscopic cholecystectomy in 27 (22.13%) and the procedure was converted to open cholecystectomy in 8 patients (6.55%). 47 patients(38.5%) had sonography revealing gallbladder wall thickness (>3 mm), and 75 patients (61.47%) had wall thickness < 3mm . Conclusions: Gallbladder wall thickening is the most sensitive indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to Laparotomy.

PATIENTS WITH METASTATIC CANCER OF UNKNOWN PRIMARY SITE: DIAGNOSTIC WORKUP AND THERAPEUTIC MANAGEMENT Majeed H Alwan FRCS, FACS, Gastrointestinal and General Surgeon, Wellington Hospital, Wellington, New Zealand Abstract Metastatic Cancer of Unknown Primary site (CUP) accounts for about 4% of all cancer patients and is therefore one of the 10 most frequent cancer diagnoses in man. It is defined as biopsy-confirmed malignancy for which the site of origin is not identified by routine workup. It is believed that CUP represents a heterogeneous group of malignancies that have a presumably, specific biology with clinical characteristics of rapid progression and random atypical metastases. The diagnostic work-up could be variable. Certain clinicopathological CUP entities are considered as favorable subsets responding to systemic platinum-based chemotherapy or managed by locoregional treatment. These subsets have a better prognosis than the average median survival time of four months in patients who belong to the non-favorable subsets.

The spleen is not considered any more to be dispensable1. By the end of the last century, virtually ‎none of the dogma believed to be unequivocally true 25 years earlier in the management of the ‎injured spleen was practiced. In this review several changes in the management of injuries to the ‎spleen, in particularly blunt injuries are presented. These includes: diagnosis, attempts of operative ‎splenic salvage, nonoperative management, and emphasis of preventing postsplenectomy ‎infection versus controlling bleeding.‎ ‎ Recently and during a period of less than two months, six patients with injury to the spleen (five ‎with blunt trauma and one atraumatic spontaneous rupture) were admitted under the care of the ‎present author. They are briefly presented before the rest of the review. As these cases have had ‎different presentation and management, it was thought that the discussion will give a further ‎account of the diversity of the management of injuries to this solid abdominal organ.‎

Pregnancy is the only physiologic condition that is treated in the hospital environment. All other medical conditions that are treated in such a setting are pathologic. When a pregnant patient develops a pathologic condition that requires surgical intervention, it is imperative to remember that the lives of two individuals are involved, the mother and the foetus. In such settings it is essential that the treating surgeon understand the physiologic states of these two individuals as an interdependent symbiotic relationship. Not only must appropriate maternal care be rendered, prevention of foetal complications is also desirable. Changing physiology and anatomical landmarks frequently cause confusion and delay in dealing with surgical problems in the pregnant patient. Both symptoms and signs could be modified, contributing to delay in seeking medical attention, timely referral for surgical evaluation, or the initiation of appropriate diagnostic procedures. Surgery during pregnancy is an uncommon event, but one that creates a great deal of anxiety for both patients and medical practitioners. Delays in diagnosis and definitive treatment represent the most significant risk for untoward outcome in both the mother and the foetus. Laparoscopic surgery has rapidly and widely spread in the management of wide abdominal conditions, which resulted in several significant benefits to the non-gravid patients. Pregnant patients and their foetuses could drive the same benefits from minimally invasive surgery, which are received by the non-gravidas. However, due to the several physiological and anatomical factors encountered during pregnancy many issues need to be thought about and dealt with. Optimal surgical treatment of the pregnant patient will be realized when there is collaboration between the various subspecialties involved in her care.

Surgical operations have developed in the method which the surgeon’s hands and eyes are used to gain ‎experience and advance the skills. However, to realize a new surgical therapy in the 21st century, it is ‎necessary to use various advanced technologies. These include among many, three dimensional medical ‎images, computer simulation and virtual reality technology, and robots in surgery. This is an outline of ‎the various aspects of these technologies with some more details about robotics in surgery as it is the ‎most recent advancement in that technology arena.‎

Review Article RETROPERITONEAL SARCOMA Majeed H Alwan MBChB, FRCSEd, FRACS, FACS, Gastrointestinal and General Surgeon, Tauranga Hospital, Tauranga, New Zealand. E-mail: majeedalwan@xtra.co.nz Abstract Retroperitoneal sarcoma (RPS) is a rare tumour. Its management is challenging because of often late presentation when the tumour attain a significant size, and its close relationship to several vital organs and structures in the retroperitoneum. Although surgery remains the main hope in controlling the disease, the use of neoadjuvant or adjuvant radiotherapy and/or chemotherapy remains controversial. Local recurrence is high and there are reports of successful second and third resections after recurrence. In this report the author reports two cases recently he had managed and presents the unique CT scan findings of the first case. This is followed by a brief review of the important matters related to this tumour.

This is an overview of the various factors related to the substernal (retrosternal) goitre. The presentation and discussion include the terminology of the condition, its definition, type, the mechanism and way the goitre descends in the thorax, its incidence, clinical features, investigations, and possible challenges in anaesthesia and surgical exposures.

Quality assurance and performance evaluations, have become central issues in medicine. There are several studies which indicates that general patients care is suboptimal in many different medical conditions and clinical settings1,2. Delivering high-quality care is important to all clinicians, but this issue may be more relevant to certain subgroups, such as those with less specialised training and those who deal with smaller number of patients3. There is also a general believe that the longer clinicians are in practice the more experienced they will be, and therefore it is assumed that this group of medical doctors are able to provide a high quality of care. But there are some studies that found a consistently or partially negative association. The aim of this report is to discuss this subject further and reach some conclusions.

Fast track surgery is a novel concept in perioperative care of patients undergoing elective surgical procedures that combines recent advances in anesthesia, new approaches to pain control, techniques that reduce the perioperative stress response and organ dysfunction, and the use of minimally invasive techniques. These measures aimed to rapid mobilization, early feeding, rapid recovery, minimize complications, and shorter in-hospital stay

Several studies have reported that different factors play an important role in the production of IgG after VOVID-19 vaccination. This study aimed at studying COVID-19 infection rates and severity in renal transplant recipients and vaccine responsiveness. comorbidity hemodialysis requirements, and immune suppression treatment regimens. In this cross-sectional study, IgG levels was measured in renal transplant recipients using automated benchtop immunoanalyzer Vidas at the Duhok Center for Kidney Disease and Transplantation. In this study group, only 30 individuals experienced the SARS-COVID-2 infection, with only three cases being severe. The most frequently reported symptoms of SARS-COVID-2 virus infection were fatigue (18/30) 60%, high temperature (17/30) 56%, headache (12/30) 40%, and poor endurance (11/30) 36.6%. The IgG titers were significantly different between the vaccinated 33.067 ± 2.5 versus unvaccinated individuals 23.916 ± 3.31with p value = 0.025. On the other hand, demographic characteristics of the cohort including: comorbidities, hemodialysis, different age groups, gender, infection/no-infection differences had no statistically significant impact on the IgG titers. Vaccination significantly increased the levels of protective IgG level in kidney transplant recipients. It is crucial to focus on increasing the acceptance of vaccination among kidney transplant recipients to prevent infections from other COVID-19 variants or pathogen outbreaks.