Introduction In actual pharmacological therapy we can see that some drugs can be added to other medical instruments to improve their activity: in example we can see medicated stent for some coronary disease, or hormonal medical devices used in pregnancy prevention, but other example are known today. In example Carmustine wafer is delivered by delivery systems in some brain cancer and radioactive seed implants in prostatic cancer. Ocular intra vitreal implants for some macular degenerations (MABS or cortisones) other implants delivery systems drugs, naltrexone implant for opiate dependence. Other strategies imply carrier use to deliver the drugs in the site of action: In example MABS linked to radioactive isotopes in some relapse of severe Hodgkin disease but many other example we can see in therapy used today. So we can think that other chronic conditions can be treated using a combination of drugs with other instrument to improve the clinical outcomes. This to make possible that the ERLICH MUGIC BULLETS can act in the right site reducing the side effect. In example today we can see various medical interventional radiological strategy to treat in coronary and hearth disease with medicate stents positioning or to local use of contrast agents or other valvle surgery procedures with global good clinical results.

Chronic Hepatic deficiency due to the ingestion of alcohol remains as one of the main causes of morbidity and mortality in our country. From it a variety of complications arise, one of them is the Hepatopulmonary Syndrome, which usually goes unnoticed and undiagnosed; this syndrome is distinguished by the presence of hypoxemia and pulmonary vasodilation. The gold standard to establish a diagnostic is contrast-enhanced Echocardiogram. No pathognomonic sign is known for this syndrome, which leads the present elaboration to evaluate the use of orthodeoxia by pulse oximetry as a screening test in the detection of Hepatopulmonary Syndrome cases. 

Acute pancreatitis forms a major bulk of our inpatient admission due to gall stone disease. Diagnosis of acute pancreatitis remains a challenge even now. Serum amylase remains the most commonly used biochemical marker for its diagnosis but its sensitivity can be reduced by late presentation, hyper-triglyceridemia and chronic alcoholism. We conducted a study to determine the levels of serum and urinary amylase in patients with acute pancreatitis and compared their sensitivity and correlation with CT findings vis-à-vis the severity of the disease. The study was taken as a post graduate research model in the Post graduate Department of General and Minimal Access Surgery, Govt. Medical College Srinagar, J&K, India 2014-2016 and submitted for the award of masters in General Surgery. A total number of 150 patients were enrolled in the studies which were admitted in our unit as acute pancreatitis. 73 (48.7%) belonged to the age group of 30-44 years, 15(10%) patients aged >60 years with 86 (57.3%) males and 64 (42.7%) females. We had 81 (54%) patients with biliary tract diseases, followed by 21 (14%) patients with worm induced, 20 (13.3%) had hyperlipidaemia and only 4 (2.7%) patients had post ERCP etiology. Tenderness in epigastrium was the presenting sign in 111 (74%), followed by chest signs in 25 (16.7%) patients, diffuse tenderness in 19 (12.7%), icterus in 11 (7.3%), low grade fever in 9 (6%) patients, shock in 5 (3.3%). Diabetes mellitus as a comorbidity was observed in 48 (32%) patients followed by hypothyroidism 37 (24.7%) patients. Hypertension was seen in 31 (20.7%) patients, COPD in 19 (12.7%) patients and obesity in 13 (8.7%) patients. Twenty two (14.7%) needed ICU admission; while as 128 (85.3%) were managed in the general ward. All the enrolled patients in our study were managed conservatively. Out of a total of 150 patients, 148 (98.7%) survived while as only 2 (1.3%) of our patients expired. At the time of admission in the hospital, 120 (80%) patients had serum amylase level of >450 U/L, 19 (12.7%) patients had 150-450 U/L levels while as 11 (7.3%) patients had <150 U/L serum amylase levels. CT has been shown to yield an early overall detection rate of 90% with close to 100% sensitivity after 4 days for pancreatic gland necrosis. The correlation of urinary amylase with the CECT Severity Scoring in a patient of acute pancreatitis is still ambiguous.

Morgagni hernia represents 2-4% of congenital diaphragmatic hernias. Only one-third of them are symptomatic, due to the hernia of abdominal viscera in the thoracic cavity, causing respiratory and digestive problems, some of them serious ones, such as intestinal obstruction. Acute presentation with incarceration of the contents is rare; there are only 7 cases described in the literature. We are presenting a case of diaphragmatic hernia that began with obstruction of the colon and secondary ischemia, requiring emergency surgery in two phases: first surgery to control the damage, with an open right hemicolectomy, and then later surgery to repair the hernia and perform bowel transit reconstruction, with proper postoperative evolution and no evidence of relapse. The treatment of Morgagni diaphragmatic hernia is surgical. Also in asymptomatic cases, due to the risk of incarceration, the most appropriate way to enter is abdominally, whether by way of laparotomy or laparoscopy, for the reduction of the contents of the hernia sac, the repair of the defect, as well as the performing of associated techniques on herniated viscera, as occurred in our case. A complicated congenital hernia is an infrequent pathology, and there is little experience in handling it. Acute presentation requires a combined treatment of the abdominal symptoms and repair of the hernia defect. The carrying over of surgical techniques for damage control into non-traumatic surgery in the face of serious hemodynamic instability is a widespread, accepted practice with the benefits of reducing mortality in critical patients and at times allowing the avoidance of ostomies.

Introduction: A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Herein we present a case of an elderly woman with an impacted gallstone in duodenum and discuss its’ management. Patient description: A 96-year-old woman was admitted to our department due to a gastric outlet obstruction. Initial gastroscopy revealed a gastric bezoar. An attempt for its extraction failed. She underwent a laparotomy in which a cholecystoduodenal fistula and a large impacted stone were found. Separation of the fistula, including closure of the duodenum side, cholecystectomy and removal of the obstructing gallstone were performed. Additional stones were found and retrieved during common bile duct (CBD) exploration. Surgery was finalized by duodenoplasty, closure and T-tube drainage of the CBD. Post-operative course was prolonged and uneventful. Discussion and Conclusions: Bouveret syndrome is a rare cause of gastric outlet obstructions. In this case, unsuccessful endoscopic treatment necessitated surgery for removal of impacted gallstone in the duodenum.

We present a review article on adrenal glands, with a special reference to their anatomy, physiology, evaluation, laparoscopic operative techniques with a short summary of review of literature.

Introduction - evolution of SARS-CoV-2 variants: With the unrestrained pandemic for over last one-and-half year, SARS-CoV-2 seems to have adapted to its habitat, the human host, through mutations that facilitate its replication and transmission. The G variant incorporating D614G mutation, potently more transmissible than the ancestral virus arose during January 2020 and spread widely. Since then, various SARS-CoV-2 variants of concern (VOCs) and variants of interest (VOIs) with higher infectivity or virulence or both, have evolved on the background of G variant, and spread widely. SARS-CoV-2 infection and the immunodynamics: As the virus becomes more transmissible, its lethality may drop. Apart from the humoral immunity, T-cell recognition from a previous SARS-CoV-2 infection or vaccination may modify the disease transmission correlates and its clinical manifestations. On the other hand, the immunity generated may reduce probability of re-infection as well as limit evolution of adaptive mutations, and emergence of highly infectious and immune-escape variants. There are complex issues related to the SARS-CoV-2 evolutionary dynamics and host’s immunodynamics. Trending etiopathoimmunological correlates: The evolution potential of SARS-CoV-2 is limited because of proofreading function of nsp14. The S protein mutations affect transmissibility, virulence, and vaccine efficacy. The D614G mutation in G variant with higher infectivity has turned the Chinese epidemic into a pandemic. Other SARS-CoV-2 variants, such as Alpha, Beta, Gamma, and Delta seem to have evolved as result of adaptation to selective pressures during periods of prolonged infections and subsequent transmission. Further, there is issue of convergent association of mutations. Basics of immunity and immune system failure: The nature of the immune response after natural SARS-CoV-2 infection is variable and diverse. There are pre-existing neutralizing antibodies and sensitized T cells elicited during previous infection with seasonal CoVs influencing the disease susceptibility and course. The virus has evolved adaptive mechanisms to reduce its exposure to IFN-I and there are issues related to erratic and overactive immune response. The altered neutralizing epitopes in the S protein in SARS-CoV-2 variants modify the immune landscapes and clinical manifestations. Conclusion: current scenarios and prospects: Presently, the SARS-CoV-2 infection is widespread with multiple evolving infectious variants. There is probability of its transition from epidemic to endemic phase in due course manifesting as a mild disease especially in the younger population. Conversely, the pandemic may continue with enhanced disease severity due to evolving variants, expanded infection pool, and changing immunity landscape. There is need to plan for the transition and continued circulation of the virus during the endemic phase or continuing pandemic for indefinite period.

Pulmonary Alveolar Proteinosis (PAP) is a rare lung disease characterized by excessive accumulation of surfactant lipids and proteins in alveoli and terminal airways. It is caused by impaired GM-CSF signaling [1]. Surfactant is synthesized and secreted by alveolar type II epithelial cells, and removed by uptake and catabolism by these cells, and the alveolar macrophages. Patients with PAP usually describe gradual onset of progressive exertional dyspnea and non-productive cough. However, an asymptomatic presentation is observed in up to 25% of cases, even in the presence of diffuse radiographic changes. Three recognized subtypes exist. Autoimmune PAP is associated with neutralizing GM-CSF autoantibodies and accounts about 90% of cases. Secondary PAP may occur in the context of any disease that reduces the abundance or functionality of alveolar macrophages, resulting in impaired surfactant clearance. Congenital PAP is the result of genetic mutations that disrupt GM-CSF signaling, including mutations in the α- or β-chains of the GM-CSF receptor [1-3].

This case shown here represents a rare situation where the breast implant is spontaneously and inadvertently migrated from its submammary position via the thoracic wall into the ipsilateral pleural cavity after performing an ipsilateral thoracotomy due to atypical wedge resection of the right upper lobe four months ago. Intraoperatively, the implant has been neither dislodged nor manipulated in any way. In the literature, there are some sparse case descriptions where such breast implant migrations are encountered after VATS procedure (video-assisted thoracoscopy) [2] and open thoracotomy surgery [3]. Interestingly, our case report is quite similar to those which was published by Dutch colleagues in 2014 [4]. Considering the etiology and pathomechanism of such an implant migration as shown here, there is a common agreement that both a leakage of the implant´s fibrous capsule and an operative transection of the intercostal thoracic wall are prerequisite to create a potential migrating pathway to allow implants moving towards the pleural cavity [5]. Additionally, it is believed that the negative pressure within the pleural cavity also alleviates the unidirectional herniation by “sucking in the implant” into the interpleural space [6]. Sometimes, external repetitive pressures such as stretching massages may cause or trigger such an implant dislocation. Furthermore, there are cases described in which, seemingly, implant migration does occur without known preceding thoracic surgery [7]. Eventually, there are cases published in the literature with intrapleural spreading of disrupted breast implant debris [8]. With our patient, thanks to the absence of any discomfort or pain, it was concluded after agreed statement of an interdisciplinary round table discussion not to remove the dislocated implant surgically because of potential intercostal tissue damage and subsequent pain to await. More astonishing, the clinicians involved in this case wondered the fact that the missed implant of her right breast remained either unnoticed or has been completely neglected by the female patient. In this short communication, we present a rare and unusual case of an obviously vanishing breast implant which is found to be inadvertently migrated into the adjacent pleural space after undergoing thoracic surgery. According to common legal policy at our institution, an approval for case reports is generally provided as it was obtained in this particular case.

Despite the fact, that lung cancer is more common among older smoking men, however it may also develop among young women without a smoking anamnesis. We report here a history of a non-smoking woman, 40 years old, with a diagnosis of lung adenocarcinoma at IV stage. Despite the fact, the woman received three lines of palliative chemotherapy, the disease progressed. After the sample of the tumor was tested by genetic approach, ROS1 mutation was detected, and the patient was treated with a ROS1 inhibitor, Crizotinib. Sharp improvement was observed already after the first week of treatment. After one-month adenocarcinoma shrink, and specific supraclavicular lymph nodes disappeared. Unfortunately, due to problems with financing the treatment was stopped, after what the disease began to progress rapidly, and the patient died after a month due to brain metastasis. This case is noteworthy also because the patient was first diagnosed a thrombophilia with thrombi present in deep calf veins, left heart ventricle and lungs Adenocarcinoma was discovered occasionally when during video-assisted thoracoscopic surgery biopsy specimen was taken from suspicious mass in the lower lobe of the right lung. This story reminds us that lung carcinoma may start with a paraneoplastic syndrome, like thrombophilia as in this case and finding of adenocarcinoma of the lung in young, non-smoking persons is indicative for possible ROS1 gene mutation. In such cases early treatment with ROS1 protein-tyrosine kinase inhibitors should be started as soon as possible.