Background: Noncirrhotic portal hypertension (NCPH) is a condition when a high hepatic venous pressure gradient with preserved liver functions and the absence of parenchymal dysfunction. NCPH with portal vein thrombosis (PVT) is a rare condition. Surgery aims to reduce portal vein flow and alter portal vein circulation. Case: A male, 59 years old, complained of blackish stool in the last 2 weeks and enlarged abdomen. Physical examination revealed anemia and melena with splenomegaly and ascites. Laboratory findings were anemia, normal hepatobiliary function, and no liver infection. Abdominal Doppler ultrasonography and contrast-enhanced abdominal computed tomography scan revealed ascites, splenomegaly, noncirrhotic liver, dilatation of portal vein, low portal vein peak velocity, and PVT. Esophagogastroduodenoscopy revealed esophageal varices grade 3 with a positive red color sign and cardia stomach varices. We performed a modified Sugiura technique through the left subcostal incision and proximal splenorenal shunt. The procedures of the modified Sugiura technique are splenectomy, devascularization, transection, and end-to-end anastomosis of the lower esophagus above the gastroesophageal junction, devascularization of the upper 2/3 of the lesser and greater curvatures of the stomach, and pyloroplasty. Portal circulation alteration used the proximal splenorenal shunt with end-to-side anastomosis of the splenic vein to left renal vein. At the one-year follow-up after surgery, his physical condition was better and there was no sign of complications. Conclusion: Devascularization procedure using a modified Sugiura technique is useful to treat and avoid rupture of esophageal varices. Portal circulation alteration using the proximal splenorenal shunt is a good choice. The treatment in NCPH utilizing the combination of modified Sugiura technique and the proximal splenorenal shunt is proper without complication.

Colorectal cancer has become one of the most frequent malignancy and the leading cause of death from cancer globally. Global Burden Cancer in 2013 had placed colorectal cancer in third place morbidity level and forth most lethal cancer globally. Understanding prognostic marker is essential to increase prognosis prediction in patients with colorectal cancer, especially in patient with the later stages. Several studies have reported the prognostic value of Ki67 expression in patient with colorectal cancer. Ki67 protein expression is associated with proliferative activation from intrinsic cell population in malignant tumor cells, where Ki67 can be used as a marker for tumor aggressivity. Expressions from protein Ki67 are associated with proliferative activities from intrinsic cell population in malignant tumor cells, where Ki67 can be used as marker from tumor cell’s aggressivity. Several diagnostic applications for pKi67 has already been explained, where Ki67 is significantly higher in malignancy compared to normal tissue. pKi67 is also increased along with the decrease of tissue differentiation, and it correlates with the presence of metastasis that can not be seen and tumor clinical phase. Prognostic value from Ki67 had been investigated in many studies with their potential as reliable marker in breasts, soft tissue, lungs, prostate, cervix, and central nervous system. Positive expression from Ki67 in colorectal cancer shows a better prognosis in patient who received surgical treatment and adjuvant radiochemotherapy, but not in a patient who received only a surgical treatment.

The majority of colorectal cancer (CRC) are sporadic CRC that can be caused by genetic variations such as Single Nucleotide Polymorphisms (SNPs). The CCND1 gene polymorphism rs9344 could involve at the beginning and the development of CRC. This study aimed to analyze the association between CCND1 gene polymorphism rs9344 with the grade and invasion degree of colorectal cancer in at Prof. Dr. I.G.N.G. Ngoerah Central General Hospital, Denpasar, Bali. This cross-sectional study was carried out at the Integrated Biomedical Laboratory Unit, Faculty of Medicine, Udayana University. Data analysis of 32 samples showed majority age was above 50 years old as many as 28 (87.5%), with men as 21 samples (65.6%). Histopathology description was adenocarcinoma in 32 samples (100%). Grading histopathology low grade was 31 samples (96.6%). The degree of tumor invasion was high as 25 samples (78.1%). From the aspect of pathological stage pNx as much as 27 (84.4%). The majority location of tumors was on the left side as 21 samples (65.6%). The polymorphisms of CCND1 rs9344 genotype sequentially AA as 20 samples (62.5%), AG as 9 samples (28.1%), while GG as 3 samples (9.4%). The statistical analysis found that CCND1 gene polymorphism rs9344 was not associated with colorectal cancer grade (p>0.05), and not associated with invasion degrees of colorectal cancer (p>0.05). Taken together, we conclude that no significant association between the CCND1 gene polymorphism rs9344 with grade and invasion degree of colorectal cancer at Prof. Dr. I.G.N.G. Ngoerah Central General Hospital, Denpasar, Bali.

Background: Colorectal cancer (CRC) is the most common type of cancer found in people over 50 years of age and is a disease associated with aging. CRC is the most preventable and curable cancer due to the pre-clinical phase until it becomes cancer between 10 -20 years. The B-RAF mutation plays an important role in the prognosis and treatment of CRC patients. The B-RAF V600E mutation is the most common B-RAF mutation. This study aims to analyze the relationship between mutations in the B-RAF V600E gene with age, grading, and clinical response in CRC patients in Bali. Method: We used FFPE samples that were confirmed as CRC tissues by the pathologist. Identification of BRAF V600E mutation was identified using polymerase chain reaction (PCR) and direct sequencing. Data on age, grade, and clinical response were recorded from the patient's medical record. Data was analized using Fisher-exact test. Results: The B-RAF V600E mutation samples were identified in 3 out of 74 samples (4.1%). The B-RAF V600E mutation was found in 3/3 of the samples (100%), which aged over 50 years old. All those mutated cases (100%) were low grade. Positive vs. negative clinical response was shown at 2/3 (66.7%) samples vs. 1/3 (33.3%) sample. No significant correlation was found between B-RAF V600E gene mutation and age (p=0.643), grading (p=0.808), and clinical response (p=0.358). Conclusion:We have identified the prevalence and type of BRAF mutation in our cases, however, there is no significant correlation between mutation B-RAF V600E gene and age, grade and clinical response of CRC patients at the center general hospital (RSUP) Prof. Dr. IGNG Ngoerah, Bali.

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Objective: To conduct a network meta-analysis (NMA) in comparing biliary stents types' outcomes and complications in unresectable MBO. Methods: The study was conducted in accordance with the PRISMA and NMA extension . Comprehensive searches of the Cochrane Library, MEDLINE, and Scopus were done analyzing randomized controlled trials that included subjects with unresectable malignant biliary obstructions that underwent biliary stents placement from any approaches. The types of stents that included were full-covered metal (FMS), partially-covered metal (PMS), uncovered metal (UMS), plastic (PLS), Iodine-125 seeds strands (IRS), antireflux (ARS), and paclitaxel-coated (PXS) stents. The outcome parameters were clinical success, median patency duration, medial survival, and early 30-day mortality. The complications included were stent occlusion, stent migration, cholangitis, cholecystitis, pancreatitis, hemorrhage, and hemobilia. The NMA will be done based on Bayesian method, Markov Chain Monte Carlo algorithm, using BUGSnet package in R studio. Transivity was controlled by methods and consistency of the NMA will be fitted by deviance information criterion. Data analysis in NMA were presented in Sucra plot, league table, and forest plot. Result: Thirty-six RCTs were included with 3502 subjects. ARS had the best clinical success and longest median patency. However, it was associated with higher rate of complications. IRS had a good clinical success (RR 1.63; 95%CI 0.67-6.25), long median patency (MD 21.14;, and high significant survival rate (MD 69.89; 95%CI 22 to 117.57) compared to others stents. It was associated unsignificant complications of cholecystitis, hemobilia, and hemorrhage. Conclusion: Iodine-125 seeds strands had the promising good outcome and tolerated complications among others and should be considered as a standard stent to be used in unresectable malignant biliary obstructions.

Colorectal cancer is reported as the third most common case worldwide in men and accounts for 10% of all cancers. Matrix metalloproteinases (MMPs) comprise a family of zinc-dependent endopeptidases that affect the degradation and remodeling of extracellular components and contribute to the three Hallmarks of cancer. TIMP-1 is an endogenous MMP inhibitor with multiple functions related to the tumor microenvironment and colorectal cancer development. This study used a prospective cohort study design to prove that colorectal mucosa with high TIMP-1 expression is a prognostic factor in the incidence of colorectal cancer compared to normal/low TIMP values. This study involved 53 samples consisting of 27 polyp patients and 26 colorectal cancer patients. The bivariate analysis results showed a significant difference between TIMP-1 levels in cancer patients and colorectal polyps (p<0.001; 95%CI: 33.65-67.31). The cut-off value of 66.50 obtained a sensitivity value of 80.8% and a specificity value of 77.8% (p<0.001). Spearman rho correlation test found a significant positive correlation between TIMP-1 levels and cases of colorectal cancer (p<0.001) of 0.680. This study shows a significant relationship between TIMP-1 levels and colorectal cancer, where TIMP-1 is a good predictor of colorectal cancer incidence.

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