BMC Surgery

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A, B Enhanced CT revealed a cystic ovarian mass with an irregularly shaped solid component measuring 34 × 29 cm and single-nodule liver tumor measuring 3.8 cm in segment 2. C Colonoscopy showed type 2 cancer in the lower rectum. D A histopathological evaluation of the ovarian tumor showed mucinous adenocarcinoma forming a cystic lesion containing mucin (Hematoxylin and eosin (HE) 100×). Immunohistochemistry staining showed that the ovarian tumor was CK7-positive (E), CK20-negative (F), and CDX2-negative. (H) Histopathological findings of the liver tumor showed adenocarcinoma consisting of atypical columnar epithelium with necrosis (HE 200×). (G) Immunohistochemistry staining showed that the liver tumor was CK7-negative (I) and CK20-positive (J)
Background Patients with giant ovarian tumor often have severe symptoms, such as abdominal distention, and the tumor tends to grow rapidly; therefore, sufficient preoperative assessments are difficult to perform. It is not always easy to differentiate between primary and metastatic ovarian cancer, especially when the ovarian tumor is huge, since a precise diagnosis of ovarian tumor depends on the histopathological findings of the excised specimen. Although metastatic ovarian tumors account for over 20% of all malignant ovarian tumors, preoperative colonoscopy is not considered a routine examination before surgery for giant ovarian tumor. Case presentation We herein report 3 cases of giant (> 25 cm) ovarian tumor with colorectal cancer. All three patients visited the clinic with progressing abdominal distention, and were referred with primary ovarian malignancy. Case 1: Rectal tumor was suspected by a digital examination at the outpatient clinic, and rectal cancer was diagnosed preoperatively by colonoscopy. Computed tomography revealed a single-nodule liver tumor. Ovariectomy, rectal resection, and partial hepatectomy were performed. A histological examination revealed both primary mucinous ovarian carcinoma and rectal carcinoma with liver metastasis. Case 2: Initially, the ovarian tumor was diagnosed as primary carcinoma based on the histological findings of an incision biopsy at the previous hospital. Chemotherapy for ovarian cancer was administered without remission, and subsequently, the patient was referred to our hospital. Since the CEA level was high (142 ng/ml), colonoscopy was performed and cecal cancer was diagnosed. Ovariectomy and right colectomy were performed, and the ovarian tumor was histologically diagnosed as metastatic adenocarcinoma. Case 3: Initial ovariectomy was performed, and rectal cancer was suspected at intra-operative surveillance. Colonoscopy was performed after surgery, and rectal cancer was diagnosed. The ovarian tumor was diagnosed as metastatic adenocarcinoma. After six cycles of FOLFOX, rectal resection was performed. Conclusion Regrettably, two of three cases in the current series were not diagnosed with colorectal cancer at the start of treatment. This experience suggests that screening colonoscopy should be considered before treatment for every case of giant ovarian tumor.
a The area of tenderness above the lateral side of the right tibia. b A well-defined abnormal lesion on the femoral lateral supracondylar confluent with the periosteum of the femur. c A purple mass located on the anterolateral aspect of the femur periosteum. d H&E staining, original magnification × 100.
Previously reported glomus tumors in the knee area: side, cases, sex, history of trauma, location, size, age, duration of illness, and pathological category
Background Glomus tumors commonly affect the extremities, especially subungual. And glomus tumors rarely occur around knee, which are often misdiagnosed. A lack of experience with glomus tumors is likely the cause. Case presentation A 42-year-old female presented with continuous dull pain of right knee for the past 7 years. Severe pain was experienced after walking a few hundred meters or climbing up or down stairs. The patient had a slight limp, and the lateral superior aspect of her right knee was tender to palpation. The range of motion and skin around her right knee were normal. Magnetic resonance imaging revealed a well-defined abnormal lesion confluent with the periosteum on the femoral lateral supracondylar. She was finally diagnosed with glomus tumor according to pathological results. After surgery, the pain disappeared, and the patient was discharged three days postoperatively. At the 18-month follow-up visit, the patient reported sustained pain relief, and regular follow-ups were continued. Additionally, 30 published reports documenting 36 cases of glomus tumors around the knee were reviewed, which showed that 20% of all reported cases of glomus tumor around the knee had a history of trauma. The median age for male with glomus tumor was greater than that of female; however, the median duration of illness between the two groups was equivalent. The mean diameters of glomus tumors ranged from 4 to 65 mm, and locations around the knee included the knee joint cavity, soft tissue (e.g. popliteal fossa, patellar tendon, iliotibial band, and Hoffa’s fat pad), distal femur, and proximal tibia. Conclusion Literature review demonstrated that no significant differences were found between male and female with glomus tumor in regard to location (left or right side) and illness duration. It was noting that a history of trauma may be a cause of glomus tumor and approximate 94.4% of glomus tumors was benign. The most effective therapy accepted for glomus tumors is complete surgical excision, and recurrence was rare after complete surgical excision.
Population flowchart
Subgroup analyses of TIR on re-amputation regarding HbA1c, LEAD, and smoking. CI confidence interval, OR odds ratio, TIR time in range, LEAD lower extremity arterial disease
  • Su LiSu Li
  • Ze-Xin HuangZe-Xin Huang
  • Dong-hao LouDong-hao Lou
  • [...]
  • Sheng ZhaoSheng Zhao
Purpose In recent years, time in range (TIR), defined as a percentage within a target time range, has attracted much attention. This study was aimed to investigate the short-term effects of Time in Rang on diabetic patients undergoing toe amputation in a more specific and complete manner. Methods A retrospective analysis on patients with diabetic foot ulcer (DFU) treated by toe amputation or foot amputation at the First Affiliated Hospital of Wenzhou Medical University between January 2015 and December 2019 were evaluated. A 1:1 match was conducted between the TIR < 70% group and the TIR ≥ 70% group using the nearest neighbor matching algorithm. Data were analyzed using Chi-squared, Fisher’s exact, and Mann–Whitney U tests. Results Compared with patients in the TIR ≥ 70% group, patients in the TIR < 70% had a higher rate of re-amputation, and a higher rate of postoperative infection. Multivariate analysis revealed that smoking, lower extremity arterial disease and TIR < 70% were risk factors for surgery of re-amputation. The results of subgroup analysis found that the TIR < 70% was associated with a greater risk of re-amputation in patients with HbA1c < 7.5%, lower extremity arterial disease, and non-smokers. Conclusions TIR can be used as a short-term glycemic control indicator in patients with DFUs and should be widely accepted in clinical practice. However, a future multicenter prospective study is needed to determine the relationship between TIR and toe re-amputation in diabetic foot patients.
Discriminatory accuracy for predicting calcaneal fracture patients with SSI by receiver operator characteristics (ROC) analysis calculating area under the curve (AUC)
A nomogram to predict the incidence of SSI in calcaneal fracture patients
Example of using nomogram to predict SSI
Calibration curve for nomogram prediction of SSI in calcaneal fracture patients
  • Jia-sen HuJia-sen Hu
  • Cheng-bin HuangCheng-bin Huang
  • Shu-ming MaoShu-ming Mao
  • [...]
  • You-ming ZhaoYou-ming Zhao
Background Compared with open comminuted calcaneal fractures, less emphasis is placed on postoperative surgical site infection (SSI) of closed comminuted calcaneal fractures. This study aimed to identify the risk factors associated with SSI and build a nomogram model to visualize the risk factors for postoperative SSI. Methods We retrospectively collected patients with closed comminuted calcaneal fractures from the Second Affiliated Hospital of Wenzhou Medical University database from 2017 to 2020. Risk factors were identified by logistics regression analysis, and the predictive value of risk factors was evaluated by ROC (receiver operating characteristic curve). Besides, the final risk factors were incorporated into R4.1.2 software to establish a visual nomogram prediction model. Results The high-fall injury, operative time, prealbumin, aspartate aminotransferase (AST), and cystatin-C were independent predictors of SSI in calcaneal fracture patients, with OR values of 5.565 (95%CI 2.220–13.951), 1.044 (95%CI 1.023–1.064), 0.988 (95%CI 0.980–0.995), 1.035 (95%CI 1.004–1.067) and 0.010 (95%CI 0.001–0.185) (Ps < 0.05). Furthermore, ROC curve analysis showed that the AUC values of high-fall injury, operation time, prealbumin, AST, cystatin-C, and their composite indicator for predicting SSI were 0.680 (95%CI 0.593–0.766), 0.756 (95%CI 0.672–939), 0.331 (95%CI 0.243–0.419), 0.605 (95%CI 0.512–0.698), 0.319 (95%CI 0.226–0.413) and 0.860 (95%CI 0.794–0.926), respectively (Ps < 0.05). Moreover, the accuracy of the nomogram to predict SSI risk was 0.860. Conclusions Our study findings suggest that clinicians should pay more attention to the preoperative prealbumin, AST, cystatin C, high-fall injury, and operative time for patients with closed comminuting calcaneal fractures to avoid the occurrence of postoperative SSI. Furthermore, our established nomogram to assess the risk of SSI in calcaneal fracture patients yielded good accuracy and can assist clinicians in taking appropriate measures to prevent SSI.
PRISMA flow diagram of study selection
Closure rate
A Number of endoscopic stent/sponge changes, B endoscopic treatment duration, C duration of hospitalization, D duration of intensive care unit stay
A Treatment related complications, B major complications, C esophago-tracheal fistula, D esophageal stenosis/stricture
A Re-operation, B in-hospital mortality
  • Pasquale ScognamiglioPasquale Scognamiglio
  • Matthias ReehMatthias Reeh
  • Nathaniel MellingNathaniel Melling
  • [...]
  • Michael TachezyMichael Tachezy
Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference − 11.57 days; 95% CI [− 17.45 to − 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.
Diagram for the BMI distribution of the patients preoperatively
  • Foolad EghbaliFoolad Eghbali
  • Mansour BahardoustMansour Bahardoust
  • Abdolreza PazoukiAbdolreza Pazouki
  • [...]
  • Fatemeh Sadat Hosseini-BaharanchiFatemeh Sadat Hosseini-Baharanchi
Background Historically, Roux-en-Y gastric bypass (RYGB) has been considered the gold standard of bariatric surgery (BS). This procedure acts as a mixed restrictive and malabsorptive operation. Methods This retrospective cohort study included 410 morbidly obese patients (BMI > 40 kg/m ² or BMI > 35 kg/m ² along with at least one major comorbidity) who underwent primary laparoscopic RYGB surgery from 2009 to 2015 by a single surgery team. The patients were 18 years and older with at least 12 months of follow-up. Total weight loss (%TWL) and comorbidity resolution were compared in short-term (12 months) and mid-term (12–60 months) follow-ups. The primary and secondary outcomes were evaluating the effect of Roux-en-Y on weight loss and control of comorbidities, respectively. Results The mean ± SD age, weight, and BMI at surgery were 40.1 ± 10.58 years, 123.32 ± 19.88 kg, and 45.78 ± 5.54 kg/m ² , respectively, and 329 (80%) were female, and 62 (15%) had T2DM. %TWL was significantly higher in T2DM patients 9 months postoperatively and after that. Patients with lower BMI (< 50 kg/m ² ) at surgery and non-diabetic patients had a significantly lower %TWL over a short- and long-term follow-up (P < 0.001). Conclusions BS remains the most efficacious and durable weight loss treatment. However, a proportion of patients will experience insufficient weight loss following BS.
Etiology of hyperlactatemia
Distribution of measured peak lactate concentration (mmol/L) by subgroups
Kaplan-Maier 90 days overall survival depending on blood lactate concentration at ICU admission
Kaplan-Maier 90 days overall survival in patients with severe hyperlactatemia depending on different etiologic factors (log rank analysis)
Association between 12 h lactate clearance and mortality. The black lines show 12 h lactate clearance of 0% and the cutoff having highest specificity to predict ICU mortality regarding sensitivity and specificity (12 h lactate clearance of 29.4%)
  • Julia SpiegelbergJulia Spiegelberg
  • Ann-Kathrin LedererAnn-Kathrin Lederer
  • Sibylla ClausSibylla Claus
  • [...]
  • Lampros KousoulasLampros Kousoulas
Background Etiology of hyperlactatemia in ICU patients is heterogeneous—septic, cardiogenic or hemorrhagic shock seem to be predominant reasons. Multiple studies show hyperlactatemia as an independent predictor for ICU mortality. Only limited data exists about the etiology of hyperlactatemia and lactate clearance and their influence on mortality. The goal of this single-center retrospective study, was to evaluate the effect of severe hyperlactatemia and reduced lactate clearance rate on the outcome of unselected ICU surgical patients. Methods Overall, 239 surgical patients with severe hyperlactatemia (> 10 mmol/L) who were treated in the surgical ICU at the University Medical Center Freiburg between June 2011 and August 2017, were included in this study. The cause of the hyperlactatemia as well as the postoperative course and the patient morbidity and mortality were retrospectively analyzed. Lactate clearance was calculated by comparing lactate level 12 h after first measurement of > 10 mmol/L. Results The overall mortality rate in our cohort was 82.4%. Severe hyperlactatemia was associated with death in the ICU (p < 0.001). The main etiologic factor was sepsis (51.9%), followed by mesenteric ischemia (15.1%), hemorrhagic shock (13.8%) and liver failure (9.6%). Higher lactate levels at ICU admission were associated with increased mortality (p < 0.001). Lactate clearance after 12 h was found to predict ICU mortality (ANOVA p < 0.001) with an overall clearance of under 50% within 12 h. The median percentage of clearance was 60.3% within 12 h for the survivor and 29.1% for the non-survivor group (p < 0.001). Conclusion Lactate levels appropriately reflect disease severity and are associated with short-term mortality in critically ill patients. The main etiologic factor for surgical patients is sepsis. When elevated lactate levels persist more than 12 h, survival chances are low and the benefit of continued maximum therapy should be evaluated.
The IV segment portal vein reconstruction. A The extended right grafts. The ‘a stands for the left portal vein, and ‘b’ and ‘c’ mean the IV segment portal vein. B Iliac vein of dornor. C The reconstruction of IV-segment and left portal vein by the iliac vein. ‘d’ stand for the reconstruction vein. D The reconstruction vein by the color doppler ultrasound
The ischemic of extended right grafts in SLT before and after IV-segment portal vein reconstruction. A The ischemic region in the ERG and ‘a’ mean the ischemic area. B The IV segment was reconstructed and we can find that the ischemic region was decreased. ‘b’ stands for the ischemic region. C The reconstruction vein in the extended right graft, ‘d’ means the reconstruction vein. E The reconstruction vein was tested by ultrasound, we can see the blood vessel patency (d)
  • Dong WangDong Wang
  • Ning FanNing Fan
  • Xin WangXin Wang
  • [...]
  • Yuan GuoYuan Guo
Background Liver transplantation is one of the most effective treatments for end-stage liver disease. Split liver transplantation (SLT) can effectively improve the utilization efficiency of grafts. However, split liver transplantation still faces shortcomings and is not widely used in surgery. How to improve the effective transplantation volume of split liver transplantation and promote the postoperative recovery of patients has important clinical significance. Methods In our study, the donor’s liver was split into the extended right graft and left lateral sector, and the IV segment occur ischemia. To guarantee the functional graft size, and avoid complications, we reconstructed the IV segment portal vein and left portal vein. And we analyzed the operation time, intraoperative bleeding, liver function, and postoperative complications. Results In our research, 14 patients underwent IV segment portal vein reconstruction, and 8 patients did not undergo vascular reconstruction. We found that the ischemic area of the IV segment decreased significantly after IV segment portal vein reconstruction. We found that there was no significant difference in operation time and postoperative complications between the patients of the groups. There were significant differences in ALT on the 1st day and albumin on the 6th day after the operation. Conclusion It indicates that IV segment reconstruction in SLT surgery can alleviate the graft ischemic and promote the recovery of liver function after the operation. And, IV segment reconstruction as a novel operating procedure may be widely used in SLT.
A D3 lymph node dissection at the root of the inferior mesenteric artery, B preservation of the left colonic artery; LCA left colonic artery; IMA inferior mesenteric artery; SHP superior hypogastric plexus
A Everted rectum with toothed ring forceps; B Rectal specimens pulled out of the body; C rectum and tumour were cut off under direct observation; D specimen after resection, check the cutting edge
A Opening the distal rectum; B expansion of distal bowel with TEM instrument; C insert protective sleeve; D pulling out the specimen through the protective sleeve
A Proximal purse string suture, iodophor gauze protection, proximal clipping; B complete reconstruction, pelvic floor reconstruction)
Background Natural orifice specimen extraction surgery (NOSES) has the advantages of less postoperative pain, fast bowel function recovery, reduced hospital stay and better cosmetic effects. In our centre, anterior resection of rectal cancer with preservation of the left colonic artery (LCA) was performed using NOSES. The feasibility, safety and short-term clinical efficacy of the technique were discussed. Methods A retrospective analysis was performed on 19 patients who underwent laparoscopic anterior resection of rectal cancer with left colonic artery preservation and natural orifice specimen extraction in the Gastrointestinal Surgery Center of Sichuan Cancer Hospital from September 2018 to December 2019. General information about the patients, perioperative data and short-term postoperative results were analysed. Results All operations were completed smoothly, with an average operation duration of 304.36 ± 45.04 min, intraoperative bleeding of 76.31 ± 61.12 ml, first time off bed of 14.42 ± 3.56 h, first time to anus exhaust of 15.26 ± 8.92 h, first time to liquid diet of 2.94 ± 1.12 days, and average postoperative stay of 10.21 ± 3.13 days. Two patients developed temporary intestinal obstruction, and one patient developed pulmonary infection. All of them recovered well after active supportive treatment and were successfully discharged. Conclusion Laparoscopic NOSES for rectal cancer with left colon artery preservation is safe and feasible, with satisfactory short-term results, and is worthy of further clinical investigation.
Determination of the optimal cut-off value of AAR. A Correlation analysis of AST and ALB (R² = -0.22); B–D X-tile analysis of recurrence-free survival data for AAR, which divided AAR into the low-risk (AAR < 0.7), intermediate-risk (AAR 0.7–1.6), and high-risk (AAR > 1.6) groups. AAR aminotransferase to albumin ratio, AST aspartate aminotransferase, ALB albumin
Correlation between AAR and hepatic inflammation and fibrosis score. A correlation analysis of AAR and the G score; B–D correlation analysis of AAR and the fibrosis score (ALBI, APRI, and FIB-4)
Kaplan–Meier estimates of survival by AAR in the primary and validation cohorts. A and B In the primary cohort, HCC patients in the high-risk group had worst prognosis in terms of RFS, whereas those in the low-risk group had best prognosis. A higher risk score was correlated with worse prognosis. C and D In the validation cohort, AAR (> 1.6, 0.7–1.6, and < 0.7) performed well in stratifying patients with distinguished prognosis. RFS recurrence-free survival, OS overall survival
Multivariate Cox proportional hazards analyses of the clinicopathological factors associated with RFS and OS. A Factors associated with RFS in the multivariate analysis model. B Factors associated with OS. RFS recurrence-free survival, OS overall survival
Aims This study aimed to evaluate the clinical significance of the preoperative aminotransferase to albumin ratio (AAR) in patients with hepatocellular carcinoma (HCC) after hepatectomy. Methods From five hospitals, a total of 991 patients with HCC admitted between December 2014 and December 2019 were included as the primary cohort and 883 patients with HCC admitted between December 2010 and December 2014 were included as the validation cohort. The X-tile software was conducted to identify the optimal cut-off value of AAR. Results In the primary cohort, the optimal cut-off value of the AAR was defined as 0.7 and 1.6, respectively. Compared to patients with AAR 0.7–1.6, those with AAR > 1.6 showed significantly worse overall survival (OS) and RFS, whereas those with AAR < 0.7 showed significantly better OS and RFS (all p < 0.001). Pathologically, patients with AAR > 1.6 had more aggressive tumour characteristics, such as larger tumour size, higher incidence of microvascular invasion, and severe histologic activity, and higher AFP level than patients with AAR < 0.7. Consistently, the abovementioned clinical significance of AAR was confirmed in the validation cohort. Conclusions A high AAR was significantly correlated with advanced tumours and severe hepatic inflammation, and a worse prognosis of HCC.
Illustration of the perfused cadaveric model. (RA right atrium; IVC inferior vena cava; RCCA right common carotid artery; Rt right; CFA common femoral artery; PA pulmonary artery; REBOA resuscitative endovascular balloon occlusion of the aorta) (Figure provided courtesy of Dr.Tongporn Wannatoop, Bangkok, Thailand)
A Demonstration of cardiac repair with felt strip reinforcement during manually simulated beating heart. B Exposure of arch branches via sternotomy. C Simulated vascular injury with pulsatile bleeding at brachial artery. D1, D2 Practicing resuscitative endovascular balloon occlusion of the aorta (REBOA) with pressure monitor
Background To develop a perfused cadaveric model for trauma surgery simulation, and to evaluate its efficacy in trauma resuscitation advanced surgical skills training. Methods Fourteen fourth-year general surgery residents attended this workshop at Siriraj Hospital (Bangkok, Thailand). Inflow and outflow cannulae and a cardiopulmonary bypass pump were used to create the perfusion circuit. Inflow was achieved by cannulating the right common carotid artery, and outflow by cannulation of both the right common femoral artery and the internal jugular vein. Arterial line monitoring was used to monitor resuscitation response and to control perfusion pressure. The perfusion solution comprised saline solution mixed 1:1 with glycerol (50%) and water with red food dye added. Advanced surgical skills during life-threatening injuries and damage control resuscitation operations were practiced starting from the airway to the neck, chest, peripheral vessels, abdomen, and pelvis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was also practiced. Post-workshop survey questions were grouped into three categories, including comparison with previous training methods; the realism of anatomical correlation and procedures; and, satisfaction, safety, and confidence. All questions and tasks were discussed among all members of the development team, and were agreed upon by at least 90% of experts from each participating medical specialty/subspecialty. Results The results of the three main groups of post-workshop survey questions are, as follows: (1) How the training compared with previous surgical training methods—mean score: 4.26/5.00, high score: 4.73/5.00; (2) Realism of anatomical correlation and procedures—mean score: 4.03/5.00, high score: 4.60/5.00; and, (3) Satisfaction, safety, and confidence—mean score: 4.24/5.00, high score: 4.47/5.00. Conclusion The developed perfused cadaveric model demonstrated potential advantages over previously employed conventional surgical training techniques for teaching vascular surgery at our center as evidenced by the improvement in the satisfaction scores from students attending perfused cadaveric training compared to the scores reported by students who attended earlier training sessions that employed other training techniques. Areas of improvement included ‘a more realistic training experience’ and ‘improved facilitation of decision-making and damage control practice during trauma surgery’.
Background Post-partum abdominal wall insufficiency (PPAWI) with rectus diastasis is present in over 30% of women after pregnancy. Little is known about how PPAWI affects the social, sexual life and self-esteem of patients. This study was designed to evaluate the safety of onlay mesh combined with abdominoplasty and its impact on the well-being of the patients. Method Two hundred patients with PPAWI underwent surgery with onlay mesh and abdominoplasty. The safety of the procedure was assessed by postoperative complications, time of hospitalization and time of drainage. Before the operation and 6 months later, a questionnaire asking about the patient’s sexual and social life and the presence of back pain was completed. The final cosmetic effect was assessed separately. Results The onlay procedure with abdominoplasty was found to be safe and fast. The mean operation time was 82 min, and the drainage time was 2.1 days. In this group < 2% postoperative complications were noted. There were no recurrences within the 6 month. Significant improvements in social and sexual life and the level of self-esteem were noted. Back pain was relieved or minimalized in all patients. The final cosmetic effect was insufficient for 2 patients (1%). Conclusion PPAWI can be treated safely with onlay mesh and abdominoplasty. The patients’ symptoms were strongly correlated with the morphological status of the front abdominal wall and improved after the procedure. Describing the psychological and social consequences of PPAWI should lead the surgical societies to propose a definition of a new disease called PPAWIS (post-partum abdominal wall insufficiency syndrome).
a Pelvic floor defect after pelvic exenteration and design of gracilis flaps on the inner side of both thighs. b The flap is freed with the proximal end of the muscle as a pedicle. c The skin was removed, and the muscle and subcutaneous tissues of the fascia were retained to prepare the gracilis adipofascial flap. The flap was rotated at 180° into the pelvic floor defect through the subcutaneous tunnel. d The pelvic floor defect was repaired with the gracilis adipofascial flap. e The recipient and donor sites were sutured. f 8 months postoperatively. g Gynecological MRI indicated good survival of the muscle flap, as marked by the white arrow (preoperative on the left side and postoperative 4 months on the right side)
Background Pelvic exenteration is a radical surgery performed in selected patients with locally advanced or recurrent pelvic malignancy. It involves radical en bloc resection of the adjacent anatomical structures affected by the tumor. The authors sought to evaluate the clinical application of a depithelized gracilis adipofascial flap for pelvic floor reconstruction after pelvic exenteration. Methods A total of 31 patients who underwent pelvic floor reconstruction with a gracilis adipofascial flap after pelvic exenterationat Peking University Third Hospital from 2014 to 2022 were enrolled in the study. The postoperative follow-up durations varied from 4 to 12 months. Results The survival rate of the flap was 96.77% with partial flap necrosis in one case. The total incidence of postoperative complications associated with the flap was 25.81%, with an incidence of 6.45% in the donor site and 19.35% in the recipient site. All complications were early complications, including postoperative infection and flap necrosis. All patients recovered after treatments, including anti-infectives, dressing change, debridement, and local flap repair. Long-term follow-up showed good outcomes without flap-related complications. Conclusions A depithelized gracilis adipofascial flap can be applied for pelvic floor reconstruction after pelvic exenteration. The flap is an ideal and reliable choice for pelvic floor reconstruction with few complications, an elevated survival rate, sufficient volume, and mild effects on the function of the donor site.
Preoperative photograph of left thigh showing a giant mass on the anterolateral region of left thigh (A). Anteroposterior radiograph of the left thigh showing a giant soft-tissue mass located at the left thigh without periosteal reaction of femur shaft (B). Coronal and axial Magnetic resonance imaging (MRI) of the left thigh showing the large pseudotumor masses on the anterolateral region of left thigh (C, D). Axial computerized tomography of leg showed intramuscular hematoma in left thigh (E–H). Diffusion weighted MRI and T2 weighted MRI of the brain showed there were multiple acute cerebral infarctions in bilateral lateral ventricles (internal border zone) and multiple ischemic foci in the white matter areas and basal ganglia of the bilateral cerebral hemispheres (I–L)
Background Cerebral infarction (CI) is an unusual complication in patients with bleeding disorders. To our knowledge, this is the first case of postoperative internal border-zone infarction (I-BZI) from Hemophilia A. Case presentation We present a case of Hemophilia A developing I-BZI, after surgical treatment of giant hemophilic pseudotumor. A 36-year-old man was introduced from other hospital by Hemophilia with giant hemophilic pseudotumor in his left thigh. Patient and his relatives did not have a history of thrombophilia. After excluding the relevant surgical contraindications, we performed the operation of pseudotumor resection. Prior to surgery, blood tests revealed hemoglobin of 137 g/L. FVIII activity was 1.5%. Activated partial thromboplastin time (APTT) was 71.50 s and D-dimer was 3.33 mg/L FEU. Immediately before surgery, the patient received an intravenous infusion of FVIII products (Xyntha ® ) at a dose of 3500 IU for his body weight of 80 kg. Post-operative day two (POD2), patient developed vomiting, decreased response, and dysarthria. Hemoglobin was 54 g/L with blood pressure of 110/70 mmHg. Magnetic resonance imaging of the brain showed there were multiple acute cerebral infarctions in bilateral lateral ventricles (internal border zone) and multiple ischemic foci in the white matter areas and basal ganglia of the bilateral cerebral hemispheres. This case suggested that acute severe anemia can be one of the causes of I-BZI. Conclusions For the treatment of I-BZI caused by acute anemia from Hemophilia A, volume expansion, red blood cell supplement and continuous improvement of coagulation with suitable dose of factor VIII (FVIII) should be considered to improve prognosis.
Background Day of the week when elective gastrointestinal surgery is performed may be influenced by various background and tumor-related factors. Relationships between postoperative outcome and when in the week gastrectomy is performed remain controversial. We undertook this study to evaluate whether weekday of gastrectomy influenced outcomes of gastric cancer treatment (“weekday effect”). Methods Patients who underwent curative surgery for gastric cancer between 2004 and 2017 were included in this retrospective study. To obtain 2 cohorts well balanced for variables that might influence clinical outcomes, patients whose gastrectomy was performed early in the week (EW group) were matched 1:1 with others undergoing gastrectomy later in the week (LW group) by use of propensity scores. Results Among 554 patients, 216 were selected from each group by propensity score matching. Incidence of postoperative complications classified as Clavien-Dindo grade II or higher was similar between EW and LW groups (20.4% vs. 24.1%; P = 0.418). Five-year overall and recurrence-free survival were 86.0% and 81.9% in the EW group, and 86.2% and 81.1% in the LW group (P = 0.981 and P = 0.835, respectively). Conclusions Short- and long-term outcomes were comparable between gastric cancer patients who underwent gastrectomy early and late in the week.
Patient enrollment flowchart
Changes in the blood test values of (a) WBC, (b) ALP, and (c) γ-GTP at the onset of post-PD cholangitis and after starting the initial treatment. Blood test results showed changes in the (a) white blood cell (WBC) counts, (b) alkaline phosphatase (ALP) levels, and (c) gamma-glutamyl transpeptidase (γ-GTP) values at the onset of post-pancreaticoduodenectomy cholangitis (PPDC) and after starting the initial treatment. For WBC counts, the median at the onset of PPDC and first blood test after starting treatment were 10,385 (range: 4120‒21,690) and 6000 (range: 2570‒17,260), respectively (a). The Wilcoxon signed-rank sum test for the two corresponding groups showed a statistically significant difference with P = 1.2 × 10–6 (a). For ALP level, the median at the onset of PPDC and first blood test after starting treatment were 614 (range: 204‒2890) and 516 (range: 135‒2706), respectively (b). A statistically significant difference was noted among the two corresponding groups, with P = 3.2 × 10–3 (b). For γ-GTP values, the median at the onset of PPDC and first blood test after starting treatment were 160 (range: 9‒1693) and 184 (range: 9‒1042), respectively (c). A statistically significant difference was noted among the two corresponding groups, with P = 0.016 (c)
Background Postoperative cholangitis is a late complication of pancreaticoduodenectomy (PD). This study aimed to elucidate the pathogenesis of post-PD cholangitis (PPDC) and explore its optimal treatment. Methods We retrospectively analyzed 210 patients who underwent PD at our institute between 2009 and 2018. Patients who underwent follow-up for less than 1 year or had cholangitis caused by cancer recurrence were excluded from the analysis. Diagnostic criteria for cholangitis and its severity were determined based on the classification of acute cholangitis provided by the 2018 Tokyo Guidelines (TG18). Results PPDC occurred in 19 (11%) of the 176 included patients. Of these 19 patients, nine experienced more than one episode of cholangitis (total episodes, 36). For 14 patients (74%), the first episode of PPDC occurred within two years after surgery. Based on the TG18, 21 episodes were mild and 15 episodes were moderate; none were severe. Blood culture test results were positive for 16 of 24 episodes. Most patients were hospitalized and treated with intravenous antibiotics (median, seven days). The blood test values improved promptly after treatment was started. Four patients with recurrent cholangitis underwent endoscopic examination, and three of them had anastomotic stenosis of the hepaticojejunostomy. The univariate and multivariate analyses did not indicate any significant predictive factors for PPDC development. Conclusion Mild and moderate PPDC occurred and improved with short-term antimicrobial treatment. Temporary reflux into the intrahepatic bile ducts may have been the cause of PPDC while anastomotic stenosis may be involved in recurrent cases.
Cancellations of elective surgical procedure among departments of WSUCSH, Ethiopia, 2021
Background Cancellations of cases are common; most of those cancellations are due to avoidable causes. It is a major cause of psychological trauma for patients and their families. Although little is known in Ethiopia, the aim of this study is aimed to assess the prevalence and the cause of elective surgery cancellation. Methods A cross-sectional prospective study design was conducted on 326 patients scheduled for elective surgery from October 1 to December 1st. All consecutive elective surgical cases scheduled during the study period were included in the study. Data were collected using a prepared and pretested questionnaire and entered into SPSS version 23 for analysis. The result of the study was reported in the form of text, tables, and graphs. Result During the study, 326 patients were scheduled for elective surgery, among those, 83(25.6%) of surgery was canceled. Patient-related (31.32%) and administrative-related (26.5%) factors were the two most causes of cancellation. Conclusion Patient-related and administrative-related factors were the leading causes of cancellation of elective surgical operations in our hospital. Concerned bodies should bring a sustainable change and improvement to prevent unnecessary cancellations and enhance cost-effectiveness through communications, careful planning and efficient utilization of the available hospital resources.
MRI, colonoscopic and operative findings of the lateral pararectal mass in the same patient. A Sagittal image showing a large mucocele without sphincteric involvement (A). Image B confirms the mucocele locale and dimensions on axial MRI. B On flexible endoscopy the mucocele appears as a pararectal submucosal mass without any luminal connexion. C Clear mucoid material was evacuated from the mass. D The operative specimen included part of the rectal mucocele with visible rectal mucosa and retained staples. F Operative view in which the mucocele was formally opened and marsupialized with the rectal lumen
Proposed mechanisms of mucocele formation after SH—double purse string and single purse string approaches. A Open configuration of the stapler with a double purse string. B Configuration after stapler firing. When a double purse string is used widely placed sutures can lead to a small rectal mucocele that is excluded from the stapled cavity during the stapler firing. C A PSH (partial stapled hemorrhoidopexy) stapler prior to firing. D After firing unresected tissue forms a mucosal bridge. E With a single purse string a loose prolapsing fold of rectal mucosa can be excluded with separation after stapler firing (F)
Background Stapled haemorrhoidopexy (SH) has resulted in a unique collection of procedural complications with postoperative mucocele a particularly rare example. This study is designed to comprehensively describe the characteristics of rectal mucocele and discuss its pathogenesis following SH surgery. Methods A database of patients presenting with a rectal mucocele following an SH procedure was established and studied retrospectively. Results Seven patients (5 males; median age 32 years, range 20–75 years) were identified. All patients complained of variable anal discomfort with 5/7 presenting with inconstant anal pain, 2 with de novo evacuatory difficulty. These cases appeared at a median time of 6 months (range 2–84 months) after SH surgery. Conclusion Rectal Mucocele develops when mucosal fragments become embedded and isolated under the mucosa. It is a preventable complication of SH surgery by ensuring correct purse string placement prior to stapled haemorrhoid excision.
The ROC curve for POPF associated with DFV1 and drain fluid amylase on the first postoperative day
Background The purpose of this study was to determine how the drain fluid volume on the first day after surgery (DFV 1) can be used to predict clinically relevant post-operative pancreatic fistula following distal pancreatectomy (DP). Method A retrospective analysis of 175 patients who underwent distal pancreatectomy in hepatobiliary surgery at Chengdu 363 Hospital (China) from January 2015 to January 2021 has been performed. Depending on the presence of pancreatic fistula, all patients were divided into two groups: POPF and non-POPF. The clinical factors were analyzed using SPSS 17.0 and Medcalc software. In order to assess the effectiveness of DFV 1 in predicting POPF after surgery, ROC curves were used to calculate its cut-off point,, which yielded sensitivity and negative predictive value of 100% for excluding POPF. Result Of the 175 patients who underwent distal pancreatectomy, the incidence of overall pancreatic fistula was 36%, but the rate of clinically significant (grade B and C) fistula, as defined by the International Study Group on Pancreatic Fistula, 30 was only 17.1% (28 grade B and 2 grade C fistula). The results from univariate and multivariate logistic regression analysis showed that drain fluid volume on the first postoperative day (OR = 0.95, P = 0.03), drainage fluid amylase level on POD1 (OR = 0.99, P = 0.01) and the preoperative ALT level (OR = 0.73, P = 0.02) were independent risk factors associated with CR-POPF. Receiver operating characteristic (ROC) curve analysis revealed that a drainage volume of 156 mL within 24 h and an amylase greater than 3219.2 U/L on the first postoperative day were the optimal thresholds associated with complications. Conclusion After distal pancreatectomy, the drainage volume on the first postoperative day can predict the presence of a clinically relevant pancreatic fistula.
Background Perineal wound complications are common after abdominoperineal resection (APR) for rectal adenocarcinoma. Delayed wound healing may postpone postoperative adjuvant therapy and, therefore, lead to a worse survival rate. Negative-pressure wound therapy (NPWT) has been suggested to improve healing, but research on this subject is limited. Methods The aim of this study was to assess whether NPWT reduces surgical site infections (SSI) after APR for rectal adenocarcinoma when the closure is performed with a biological mesh and a local flap. A total of 21 consecutive patients had an NPWT device (Avelle, Convatec™) applied to the perineal wound. The study patients were compared to a historical cohort in a case–control setting in relation to age, body mass index, tumor stage, and length of neoadjuvant radiotherapy. The primary outcome was the surgical site infection rate. The secondary outcomes were the wound complication rate, the severity of wound complications measured by the Clavien–Dindo classification, length of hospital stay, and surgical revision rate. Results The SSI rate was 33% (7/21) in the NPWT group and 48% (10/21) in the control group, p = 0.55. The overall wound complication rate was 62% (13/21) in NPWT patients and 67% (14/21) in the control group, p > 0.90. The length of hospital stay was 15 days in the NPWT group and 13 in the control group, p = 0.34. The wound severity according to the Clavien–Dindo classification was 3b in 29% (6/21) of the NPWT group and in 38% (8/21) of the control group. A surgical revision had to be performed in 29% (6/21) of the cases in the NPWT group and 38% (8/21) in the control group, p = 0.73. Conclusion NPWT did not statistically decrease surgical site infections or reduce wound complication severity in perineal wounds after APR in this case–control study. The results may be explained by technical difficulties in applying NPWT in the perineum, especially in female patients. NPWT devices should be further developed to suit the perineal anatomy before their full effect can be assessed. Trial registration The study was registered as a prospective registry study (266/2018, registered 15th of November 2018)
Splenic CECs (“*” marks the cysts). A A recurrent cyst after unroofing (Case 21). B The cyst compressing left renal and renal artery (Case 26). C Stratified squamous epithelium (HE staining). D Simultaneous separate CEC and hemagioma (white arrow shows the enhanced hemangioma, Case 19). E Cytokeratin immunohistochemical staining labels the epithelium. F Simultaneous separate CEC and omentum mesothelial cyst (white triangle shows the omentum mesothelial cyst, Case 28)
Splenic vascular malformations. A CT of splenic diffused lymphangiohemangiomatosis (white arrow shows the accessory spleen involved, Case 25). B Intraoperative picture of Case 25. C MRI of splenic diffused lymphangiomatosis (Case 20). D Intraoperative picture of Case 20. E HE staining of Case 25 shows lymphatic malformation space filled with eosinophilic amorphous proteinaceous fluid (black arrow) and capillary malformation space filled with blood (hollow arrow). F D2-40 immunohistochemical staining of Case 20 labels lymphatic endothelium
Imaging pictures (contrast CT) with corresponding pathology pictures (HE staining) of splenic focal lymphatic malformation, SANT, and splenic hamartoma. A, B Splenic focal lymphatic malformation (Case 30, black arrow shows focal endothelial papillary projections). C, D: SANT (Case 3, CT shows a typical “spoke-wheel” sign). E, F: Splenic hamartoma (Case 2, CT shows a heterogeneously enhanced hypodense mass)
Background Benign splenic lesions are rarely encountered. This study aimed to review the clinical characteristics and surgical outcomes in a case series of 30 pediatric patients. Methods From January 1st, 2001 to December 31st, 2021, 30 pediatric patients from a single center were consecutively included. Electronic medical records were reviewed and patients were followed up. Clinical presentations, imaging features, surgical procedures, pathological diagnoses, and prognoses were summarized. The lesion locations and 7-day postoperative platelet levels were compared between total and partial splenectomy patients. Results Eighteen males and twelve females were included, with mean age at surgery 116.4 ± 43.6 months. The clinical presentations included abdominal pain (16/30), splenomegaly (6/30), skin petechia (2/30), hemolytic jaundice (1/30), and no symptoms (5/30). Pathological diagnoses included congenital epithelial cyst (CEC, 17/30), vascular malformation (8/30), sclerosing angiomatoid nodular transformation (SANT, 3/30), hamartoma (1/30), and leiomyoma (1/30). Patients undergone total splenectomy were more likely to have a lesion involving the hilum than those undergone partial splenectomy (68.4% vs 31.6%, P = 0.021). The 7-day postoperative platelet level was higher in total splenectomy patients than partial splenectomy patients (adjusted means 694.4 × 10 ⁹ /L vs 402.4 × 10 ⁹ /L, P = 0.002). Conclusions Various clinical characteristics of pediatric benign splenic lesions are summarized. The most common pathological diagnoses are congenital epithelial cyst and vascular malformation. Partial and total splenectomy result in good prognosis with a low recurrence rate, and the former is preferred to preserve splenic function if possible.
Background We conducted a prospective cohort study to evaluate effective techniques for breast reconstruction after partial mastectomy due to breast cancer. Determining the method of reconstruction is often difficult as it depends on the location of the cancer and the amount of tissue excised.. Here, we present a new technique, using the vertical latissimus dorsi (LD) flap, that can be used in all partial mastectomies and can almost conceal scarring. We also compared these results to those of the mini LD flap. Methods We analyzed the data of a total of 50 and 47 patients, who underwent breast reconstruction with the mini LD flap and the vertical LD flap, respectively. Immediately after tumor excision, breast reconstruction was initiated. The skin flap for vertical LD was designed in a planarian shape, such that it may be hidden as much as possible and minimize bulging during closure, and the LD muscle flap was designed with a sufficient distance in the inferior direction. Results Our finding showed that the vertical LD flap group required significantly less total operation time than the mini LD flap group. While the mini-LD flap resulted in a scar that was difficult to conceal, the donor site scar of the vertical LD flap could not be seen easily, and no scar was visible on the back. Conclusions The vertical LD flap is useful for partial breast reconstruction, in all breast regions requires a rather small volume of the flap. Moreover, recovery was relatively fast with high patient satisfaction.
Flow-chart showing recruitment of study participants into the study
Comparative ROC curves for the PIPAS severity score and the qSOFA score tool for predicting in-hospital mortality of peritonitis
Abbreviations A&E: Accident and Emergency; APACHE II: Acute physiological And Chronic Health Evaluation II; AUC : Area Under the Receiver Operating Characteristic curve; AVPU: Alert/ Verbal response/ response to Pain/Unresponsive scale; CI: Confidence interval; CKD: Chronic Kidney Disease; CVD: Cardiovascular Diseases; GCS: Glasgow Coma Scale; HDU: High dependence Unit; ICU: Intensive Care Unit; MNRH: Mulago National Referral Hospital; MPI: Mannheim Peritonitis Index; PIPAS: Physiological indicators for prognosis in Abdominal sepsis; PIRO-IAS: Predisposition Infection, Response Organ dysfunction score for Intra-Abdominal Sepsis; qSOFA: Quick Sequential (sepsis-related) Organ Function Assessment; ROC curve: Receiver Operating Characteristic curve; SpO 2 : Peripheral blood Oxygen saturation; SoM-REC: Makerere University School of Medicine's Research and Ethics Committee; UNCST: Uganda National Council of Science and Technology; WSES: World Society of Emergency Surgery; WSESSSS: World Society of Emergency Surgery's Sepsis Severity Score.
Sensitivity and specificity values for various PIPAS severity score cut-off values for predicting in-hospital mortality of peritonitis
Background: The majority of the prognostic scoring tools for peritonitis are impractical in low resource settings because they are complex while others are quite costly. The quick Sepsis-related Organ Failure Assessment (qSOFA) score and the Physiologic Indicators for Prognosis in Abdominal Sepsis (PIPAS) severity score are two strictly bedside prognostic tools but their predictive ability for mortality of peritonitis is yet to be compared. We compared the predictive ability of the qSOFA criteria and the PIPAS severity score for in-hospital mortality of peritonitis. Method: This was a prospective cohort study on consecutive peritonitis cases managed surgically in a tertiary hospital in Uganda between October 2020 to June 2021. PIPAS severity score and qSOFA score were assessed preoperatively for each case and all cases were then followed up intra- and postoperatively until discharge from the hospital, or up to 30 days if the in-hospital stay was prolonged; the outcome of interest was in-hospital mortality. We used Receiver Operating Characteristic curve analysis to assess and compare the predictive abilities of these two tools for peritonitis in-hospital mortality. All tests were 2 sided (p < 0.05) with 95% confidence intervals. Results: We evaluated 136 peritonitis cases. Their mean age was 34.4 years (standard deviation = 14.5). The male to female ratio was 3:1. The overall in-hospital mortality rate for peritonitis was 12.5%. The PIPAS severity score had a significantly better discriminative ability (AUC = 0.893, 95% CI 0.801-0.986) than the qSOFA score (AUC = 0.770, 95% CI 0.620-0.920) for peritonitis mortality (p = 0.0443). The best PIPAS severity cut-off score (a score of > = 2) had sensitivity and specificity of 76.5%, and 93.3% respectively, while the corresponding values for the qSOFA criteria (score > = 2), were 58.8% and 98.3% respectively. Conclusions: The in-hospital mortality in this cohort of peritonitis cases was high. The PIPAS severity score tool has a superior predictive ability and higher sensitivity for peritonitis in-hospital mortality than the qSOFA score tool although the latter tool is more specific. We recommend the use of the PIPAS severity score as the initial prognostic tool for peritonitis cases in the emergency department.
Contrast-enhanced axial MRI scans in a 59-year-old woman with MMNST. A A 4.7 cm cystic mass at the para-aortic region, abutting onto the 3rd and 4th portion of the duodenum, showed a hyperintense solid part and a hypointense cystic part on T1WI, and B a hypointense solid part and a hyperintense cystic part on T2WI. C T2WI with fat suppression also showed a hypointense solid part and a hyperintense cystic part. D Contrast-enhanced T1WI showed identical enhancement with T1WI
A Coronal FIESTA (Fast Imaging Employing Steady-state Acquisition) sequence revealed a 4.7 cm cystic mass with a hyperintense solid part and a hypointense cystic part at para-aortic region, abutting onto the 3rd and 4th portion of the duodenum. B Coronal T2WI showed a hypointense solid part and a hyperintense cystic part
A–D Representative gross picture of malignant melanocytic nerve sheath tumor (MMNST). The tumor was a well-encapsulated, black, and elastic fibrotic tumor that grossly mimicked melanoma
A Microscopy revealed a well-encapsulated tumor with lymphoid cuffing; the tumor was composed of pigmented tumor cells and showed cystic degeneration (H&E stain, objective lenses ×4, original magnification ×40, scale bar 1000 μm). B Higher magnification revealed that the tumor cells had an epithelioid to spindle shape, mild nuclear atypia, small nucleoli, and abundant intracytoplasmic melanin pigments (H&E stain, objective lenses ×40, original magnification ×400, scale bar 100 μm). C Immunohistochemically, the tumor cells were positive for SOX10 (Objective lenses ×10, original magnification ×100, scale bar 100 μm). D Immunohistochemically, the tumor cells were positive for HMB45 (Objective lenses ×10, original magnification ×100, scale bar 100 μm). E Immunohistochemically, the tumor cells were positive for collagen type IV with a peri-tumoral circumferential pattern (Objective lenses ×10, original magnification ×100, scale bar 100 μm). F Immunohistochemically, the tumor cells were negative for AE1/AE3 (Objective lenses ×10, original magnification ×100, scale bar 100 μm). To acquire microscopic images, Nikon Eclipse Ni microscope, Nikon Plan Fluor series lenses, Nikon DS-Ri2 camera, and the acquisition software of NIS-Elements. 5.11.0 were used
Background Malignant melanotic nerve sheath tumor (MMNST), formerly called melanotic schwannoma, is a rare tumor of neural crest derivation which most frequently arises from the region of spinal or autonomic nerves near the midline. Recent studies have reported malignant behavior of MMNST, and there still has no standard management guidelines. Intra-abdominal MMNST, which has never been reviewed as an entity, is even rarer. In this study, we present a rare case of a cystic MMNST arising from the para-aortic region and mimicking an intra-abdominal gastrointestinal stromal tumor (GIST), and review the literature regarding MMNSTs located in the abdominal cavity. Case presentation A 59-year-old female was incidentally found a tumor located in the left para-aortic area by non-contrast computed tomography. A Magnetic Resonance Imaging showed a cystic mass originated from the inferior mesenteric artery (IMA) territory. A GIST was initially diagnosed. The tumor was resected en bloc by laparoscopic surgery and was found between mesocolon and Gerota’s fascia with blood supply of IMA. Grossly, dark brown materials were noted at the inner surface of the cystic wall. Microscopically, the tumor cells were melanin-containing, and no psammomatous bodies were present. Immunohistochemically, the tumor showed positivity for MART1, HMB45, collagen IV, and SOX10, and negativity for AE1/AE3. MMNST was favored over malignant melanoma, since the tumor was located near ganglia and had cells with less atypical cytology and a low mitotic rate, and subsequent adjuvant radiotherapy was performed. The patient was alive with no evidence of recurrent or metastatic disease 11 months after radiotherapy. Conclusions Our review of abdominal MMNST cases showed a female predominance, with an average age of 54.8 years, and a trend toward being a larger tumor showing cystic or necrotic changes. Local recurrence and metastasis rate were reviewed, and both showed a low rate. Diagnosis of MMNST should combine all the available findings, and complete excision of the tumor should be performed, followed by long-term patient monitoring.
A After end-to-end anastomosis of the transected right gastroepiploic artery and vein. B In vitro view after gastric conduit pull up. RGEA right gastroepiploic artery, RGEV right gastroepiploic vein
Intraoperative ICG fluorescence imaging showed patency of the reconstructed right gastroepiploic artery and adequate perfusion of the gastric conduit after vascular reconstruction. RGEA right gastroepiploic artery
Postoperative contrast computed tomography scan at postoperative day 10 revealed a patent right gastroepiploic vessel (red arrow), which could be identified from the proximal (A, B) to the distal edge of the gastric conduit (C, D)
Background Esophagectomy remains the standard treatment for esophageal cancer or esophagogastric junction cancer. The stomach, or the gastric conduit, is currently the most commonly used substitute for reconstruction instead of the jejunum or the colon. Preservation of the right gastric and the right gastroepiploic vessels is a vital step to maintain an adequate perfusion of the gastric conduit. Compromise of these vessels, especially the right gastroepiploic artery, might result in ischemia or necrosis of the conduit. Replacement of the gastric conduit with jejunal or colonic interposition is reported when a devastating accident occurs; however, the latter procedure requires a more extensive dissection and multiple anastomosis. Case presentation A 61-year-old male with a lower third esophageal squamous cell carcinoma (cT3N1 M0) who received neoadjuvant chemoradiation with a partial response. He underwent esophagectomy with a gastric conduit reconstruction. However, the right gastroepiploic artery was accidentally transected during harvesting the gastric conduit, and the complication was identified during the pull-up phase. An end-to-end primary anastomosis was performed by the plastic surgeon under microscopy, and perfusion of the conduit was evaluated by the ICG scope, which revealed adequate vascularization of the whole conduit. We continued the reconstruction with the revascularized gastric conduit according to the perfusion test result. Although the patient developed minor postoperative leakage of the esophagogastrostomy, it was controlled with conservative drainage and antibiotic administration. Computed tomography also demonstrated fully enhanced gastric conduit. The patient resumed oral intake smoothly later without complications and was discharged at postoperative day 43. Conclusion Although the incidence of vascular compromise during harvesting of the gastric conduit is rare, the risk of conduit ischemia is worrisome whenever it happens. Regarding to our presented case, with the prompt identification of the injury, expertized vascular reconstruction, and a practical intraoperative evaluation of the perfusion, a restored gastric conduit could be applied for reconstruction instead of converting to more complicated procedures.
The participant selection process for the surgery and control groups
The incidence rates of new-onset comorbidities in the participants at the end of the follow‑up period (p-value < 0.001 for all comorbidities)
Background Obesity is a global health priority, particularly in developing countries. The preventive effect of bariatric surgery against obesity-related diseases in the developing countries of the Middle East and North Africa region, where type 2 diabetes mellitus (T2DM), hypertension (HTN), and dyslipidemia prevail, has not been examined. Method Severely obese participants who underwent bariatric surgery were compared with their counterparts who underwent no intervention. These patients had been followed up in two prospective cohort studies for three years. We here determined the incidence of new-onset T2DM, HTN, and dyslipidemia and reported absolute and relative risks for the incidence of these comorbidities in the two groups. Results In this study, 612 participants in the bariatric surgery group were compared with 593 participants in the control group. During the follow-up period, T2DM developed in eight (2.9%) people in the surgery group and 66 (15.0%) people in the control group ( P < 0.001). New-onset HTN and dyslipidemia showed significantly lower frequencies in the surgery group compared to the control group (4 (1.8%) vs. 70 (20.4%) and 33 (14.3%) vs. 93 (31.5%), respectively). Regarding a less favorable metabolic profile in the surgery group at the baseline, the relative risk reductions associated with bariatric surgery were 94, 93, and 55% for the development of T2DM, HTN, and dyslipidemia, respectively. Conclusion The risk reduction of obesity-related comorbidities after bariatric surgery should be considered in the decision-making process for public health in the region, which bariatric surgery could result in the prevention of comorbidities.
Swimming-plot shows the treatment process for each patient
Patient #3’s pre- and postoperative imaging of ICA balloon embolization. a, b he preoperative imaging, yellow arrow indicates the pseudoaneurysm. c The post-operative imaging
Preoperative and postoperative MRI images of the cranial base. a Patient #1. b Patient #2. c Patient #4. d Patient #6
Exposure and protection of ICA in endoscopic endonasal surgery. a Reveal the contents of the PF. b, c Removal of the ET and preservation of the EVP. d–g Removal of lesions around ICA, free ICA. h Fill in autologous fat. i Reconstruction of cranial base with LNF. SS, sphenoid sinus; PS: pterygoid process; IA: infraorbital artery; MA: maxillary artery; PF: pterygopalatine fossa; ET: eustachian tube; EVP: evator veli palatine; IPS: inferior petrosal sinus; ICA: internal carotid artery; PD: petrous drum; LNF: lateral nasal flap
a Shows the summarization of clinical symptoms of patients with cranial base HPC/SFT from currently available publications. b Shows the HE staining picture of the typical HPCs’ patient
Background Hemangiopericytomas (HPCs) are uncommon soft tissue tumors. HPCs that grow in the cranial base are rare. Therefore, skull-base surgeons tend to overlook this disease. This study aimed to increase the awareness of HPCs by summarizing case data from our institution and related publications. We also aimed to contribute to the number of reported cases for future systematic reviews of HPCs. Methods This study included all patients who underwent surgery for HPC/solitary fibrous tumor (SFT) between August 2015 and August 2019. All surgeries were performed at Xiangya Hospital Central South University. We analyzed clinical characteristics, surgical highlights, treatment modalities, and outcomes. Results We included six patients, aged 32–64 years. Lesions were located in the parapharyngeal space in three patients, pterygopalatine fossa in two, and saddle area in one. All patients underwent nasal endoscopic endonasal surgery. In five patients, tumors involved the internal carotid artery (ICA). The exposure and protection of the ICA during surgery are challenging but critical to complete tumor removal. The 3-year overall survival(OS) rate was 66.7%. Conclusions HPC/SFTs are rare tumors of the cranial base that are prone to recurrence. Cranial base HPC/SFTs are often closely associated with the ICA. To our knowledge, this case series reports the largest number of cases of HPCs associated with the ICA. We believe that there is a strong relationship between patient prognosis and whether the tumor encircles the ICA and whether the tumor is completely resected. To confirm this suggestion, more cases are needed for further analysis.
Representative intraoperative images of the CEFB procedures. a After removal of a giant pituitary adenoma breaching the diaphragma sellae, a grade III CSF leak is observed. b Absorbable ADM is placed to cover the margin of the residual diaphragma sellae as the first subdural inlay. c An optimal amount of autologous fat graft is placed inside the sellar space to sustain the ADM and generate appropriate tension to fit the following steps for the rigid buttress. d Partial dural suturing with 3 stitches was applied on the “Y”-shaped dural incision to reduce the dural defect and confine it under the centre of the rigid buttress. e An onlay of fascia lata is longitudinally placed to cover the dural defect with a redundancy of 10 mm on the front and rear ends. The lateral edges of the fascia slightly exceed the lateral bone defect margin. f A bone flap graft is transversely embedded under the lateral defect edges to buttress the longitudinally placed fascia underneath, forming a cruciate embedding complex. The fascia can stretch out through the frontal and rear gaps between the bone flap and defect edge. g Surplus grafts of fascia and fat are used to cover and strengthen the entirety of the CEFB constructs. h Surgicel and Nasopore are placed inside the sphenoid sinus to fix and support the fat and fascia. i The nasal mucosa is repositioned back to the septum without formation of the PNSF. ACA anterior cerebral artery, ADM acellular dermis matrix, OC optic chiasm, BF bone flap, FL fascia lata, DS diaphragma sellae, PS pituitary stalk, SC surgicel, NP nasopore, M mucosa, SE septum
Representative postoperative images of CEFB outcomes. a During debridement under endoscopy 3 weeks after surgery, the bone flap and fascia are found to be in place and firmly attached to the defect. b Preoperative coronal and c sagittal CT images of the skull base bone structure. d Immediate postoperative coronal and e sagittal CT images of CEFB reconstruction. f Three months after surgery, coronal and g sagittal CT images demonstrate no dislocation or detachment of the bone flap. BF bone flap, FL fascia lata, Arrowhead = bone flap graft
Representative intraoperative images of CEFB variants. a Two separated bone flap grafts are embedded at the planum sphenoidale and sellar floor respectively, buttressing the fascia in different directions on angled planes. b The bone graft is tailored into narrow strips and then wedged at intervals onto the defect for economical use of the limited bone graft harvest. BF bone flap, FL fascia lata
Background Cerebral spinal fluid (CSF) leak remains an important issue in endoscopic endonasal surgery (EES). A standard protocol for skull base closure has not yet been established, and the application of rigid buttress has not been given sufficient attention. To emphasize the functions of support and fixation from rigid buttress in reconstruction, we introduced the cruciate embedding fascia-bone flap (CEFB) technique using autologous bone graft to buttress the fascia lata attachment to the partially sutured skull base dural defect and evaluated its efficacy in a consecutive case series of grade II–III CSF leaks in EES. Methods Data from consecutive patients diagnosed with sellar region lesions with grade II–III CSF leaks during EES were collected from May 2015 to May 2020. Skull base reconstructions were performed with the CEFB or the conventional pedicle vascularized nasoseptal flap (PNSF). Related clinical data were analysed. The combined use of the CEFB and PNSF was applied to an additional supplemental case series of patients with grade III leak and multiple high-risk factors. Results There were 110 and 65 patients included in the CEFB and PNSF groups, respectively. The CEFB demonstrated similar effects on the incidence of postoperative CSF leak (2.7%), intracranial infection (4.5%), and lumbar drainage (LD) placement (5.5%) as PNSF (3.1%, 3.1%, and 6.2%), but with less epistaxis (CEFB: 0%, PNSF: 6.2%) and nasal discomforts (CEFB: 0%, PNSF: 7.7%). The LD duration (CEFB: 6.67 ± 2.16 days, PNSF: 10.50 ± 2.38 days), bed-stay time (CEFB: 5.74 ± 1.58 days, PNSF: 8.83 ± 3.78 days) and hospitalization time (CEFB: 10.49 ± 5.51 days, PNSF: 13.58 ± 5.50 days) were shortened in the CEFB group. The combined use of CEFB and PNSF resulted in 0 postoperative CSF leaks in the supplemental case series of 23 highly susceptible patients. Conclusion This study suggested that the new CEFB technique has the potential to prevent postoperative CSF leak in EES. The results indicated that it can be used effectively without PNSF in suitable cases or applied in addition to a PNSF with high compatibility when necessary. Its effectiveness should be further verified with a larger cohort and better design in the next step. Trial Registration Current Controlled Trials ChiCTR2100044764 (Chinese Clinical Trial Registry); date of registration: 27 March 2020. Retrospectively registered
Disconnection and removal of specimens of the NOSES group. A The rectal mesentery is adequately naked by the surgeon. B The surgeon makes a transverse rectal incision 2 cm below the tumor. C The rectal stump is disinfected again. D Establish a sterile tumor-free channel. E The tumor-bearing rectum is closed and a protective sleeve is placed. F The tumor-bearing bowel is pulled out of the body through the protective sleeve and the specimen is removed. G The specimen is removed and the anastomotic staple holder is placed. H The distal incision is closed. I Complete the intestinal anastomosis
Comparison of short-term curative effect between two groups of patients. A Postoperative VAS scores in two groups of patients after PSM. B, C EORCT Quality of Life questionnaire-Core 30 results of two groups after PSM. B, Functional Scales. C: Symptom Scales. D Scores of body image and cosmetic scales after PSM. (Higher scores indicate better body image and higher satisfaction with scars). (*p < 0.05, **p < 0.01, ***p < 0.001)
Comparison of long-term curative effect between two groups of patients. A Overall survival, B Disease-free survival
Background Natural orifice specimen extraction surgery (NOSES) has been increasingly applied in radical surgery of abdominal and pelvic organs, but it is still in the exploratory stage. There is insufficient evidence to prove its efficacy. Methods From January 2013 to June 2017, a total of 351 patients diagnosed with rectal cancer were eventually included in this study. Patients who underwent NOSES were assigned to the NOSES group, while patients undergoing conventional laparoscopic assisted resection were assigned as to the LAP group. Propensity score matching was used to align clinicopathological features between the two groups. Results From the perioperative data and postoperative follow-up results of both groups, patients in the NOSES group had less intraoperative bleeding (47.0 ± 60.4 ml vs 87.1 ± 101.2 ml, P = 0.011), shorter postoperative gastrointestinal recovery (50.7 ± 27.3 h vs 58.6 ± 28.5 h, P = 0.040), less postoperative analgesic use (36.8% vs 52.8%, P = 0.019), lower postoperative pain scores (P < 0.001), lower rate of postoperative complications (5.7% vs 15.5%, P = 0.020), more satisfaction with body image (P = 0.001) and cosmesis (P < 0.001) postoperatively. The NOSES group had a higher quality of life. Moreover, there was no significant difference in overall survival (OS) and disease-free survival (DFS) between the two groups. Conclusion NOSES could be a safe and reliable technique for radical resection of rectal cancer, with better short-term outcomes than conventional laparoscopy, while long-term survival is not significantly different from that of conventional laparoscopic surgery.
Combined approach was performed. Preoperative CT revealed FMS (A–C); fungus blocks were removed through MMA (D). No additional fungus block was revealed via MMA (E). IMA (F) revealed a residual fungus block in the alveolar recess (black arrows). The residual fungus block was found (G and H) and removed through IMA (I), but revealed another block in the anterior wall (red arrows) (J)
Objective The objective of this study was to compare the long-term results of extended middle meatal antrostomy (MMA) and MMA combined with inferior meatal antrostomy (IMA, combined approach) for the treatment of fungal maxillary sinusitis (FMS). Methods and materials A retrospective analysis including 90 patients with non-invasive FMS was treated with endoscopic extended MMA via antidromic extended medial wall (extended MMA group), or with both MMA and IMA (combined approach group). The recurrence rate, operation time, and complications were evaluated at postoperative 12 and 36 months. Results Of the 90 patients, 52 patients were in the extended MMA group and 38 patients in the combined approach group. CT revealed the thin medial wall or bone defect in 63.33% (57/90) patients. The mean operation time in the extended MMA group was significantly shorter than that of combined approach group (42.5 ± 6.5 vs 57.4 ± 4.9, P < 0.01). At postoperative 12 months postoperatively, the recurrence rate was 3.85% (2/52) in the extended MMA group and 0.0% (0/38) in the combined approach group, the difference wasn’t significant ( X 2 = 0.618, P > 0.05). The recurrence rate wasn’t increased during the follow-up period over time in both groups.13.5% (7/52) patients complained of cheek numbness in the extended MMA group, 60.5% (23/38) patients complained of cheek numbness and epiphora in 5.3% (2/38) patients in the combined approach group, the difference was significant ( X 2 test , P < 0.01). However, no major complications were observed in both groups. In addition, IMA closure was observed in 4 (10.5%) in the combined approach group at 12 months postoperatively and in 9 (23.6%) at 36 months postoperatively. Conclusions Extended MMA via antidromic extended medial wall may effectively prevent the recurrence and reduce the complications of FMS, IMA wasn’t necessary for the treatment of FMS in most cases.
Computed tomography images indicating the calculation of LAR. At the level where the brachiocephalic artery crosses the trachea, LAR is calculated by dividing the long axis length of the trachea by the short axis length. a Neonate without tracheal collapse. b Neonate with tracheal collapse complicated by esophageal atresia. BA brachiocephalic artery, LAL long axis length of the trachea, SAL short axis length of the trachea
Surgical image of posterior tracheopexy. The posterior tracheal membrane was fixed to the anterior longitudinal spinal ligament by placing two sutures after esophageal anastomosis. PTM posterior tracheal membrane, ALSL anterior longitudinal spinal ligament, EA esophageal anastomosis, SVC superior vena cava
Comparison of postoperative LAR between two groups with or without respiratory support at 30 days
Evaluation of LAR as diagnostic indicator for TM requiring prolonged respiratory support after EA repair using ROC curve
Background Esophageal atresia (EA) is often associated with tracheomalacia (TM). The severity of TM symptoms varies widely, with serious cases requiring prolonged respiratory support and surgical treatment. Although we performed thoracoscopic posterior tracheopexy (TPT) during primary EA repair to prevent or reduce the symptoms of TM, few studies have investigated the safety and effectiveness of TPT during primary EA repair. Therefore, this study aimed to evaluate the safety and efficacy of TPT in neonates. Methods We retrospectively reviewed the records of all patients diagnosed with TM who underwent primary thoracoscopic EA repair between 2013 and 2020 at the Nagoya University Hospital. Patients were divided into two groups: TPT (TPT group) and without TPT (control group). TPT has been performed in all patients with EA complicated by TM since 2020. We compared patient backgrounds, surgical outcomes, postoperative complications, and treatment efficacy. Results Of the 22 patients reviewed, eight were in the TPT group and 14 were in the control group. There were no statistically significant differences in the surgical outcomes between the groups (operation time: p = 0.31; blood loss: p = 0.83; time to extubation: p = 0.30; time to start enteral feeding: p = 0.19; time to start oral feeding: p = 0.43). Conversion to open thoracotomy was not performed in any case. The median operative time required for posterior tracheopexy was 10 (8–15) min. There were no statistically significant differences in postoperative complications between the groups (chylothorax: p = 0.36; leakage: p = 1.00; stricture: p = 0.53). The respiratory dependence rate 30 days postoperative (2 [25%] vs. 11 [79%], p = 0.03) and the ratio of the lateral and anterior–posterior diameter of the trachea (LAR) were significantly lower in the TPT group (1.83 [1.66–2.78] vs. 3.59 [1.80–7.70], p = 0.01). Conclusions TPT during primary EA repair for treatment of TM significantly lowered respiratory dependence rate at 30 days postoperative without increasing the risk of postoperative complications. This study suggested that TPT could improve TM associated with EA.
Grades of intrapedicular accuracy and facet joint violation: A grade A, B grade B, C grade C, D grade D, and E grade E; F Grade 0, G Grade 1, H Grade 2, and I Grade 3
Measurement of superior facet angle (A) and incision depth (B)
Abstract Background The superiorities in proximal facet joint protection of robot-assisted (RA) pedicle screw placement and screw implantation via the cortical bone trajectory (CBT) have rarely been compared. Moreover, findings on the screw accuracy of both techniques are inconsistent. Therefore, we analyzed the screw accuracy and incidence of facet joint violation (FJV) of RA and CBT screw insertion in the same study and compared them with those of conventional pedicle screw (PS) insertion. The possible factors affecting screw accuracy and FJV were also analyzed. Methods A total of 166 patients with lumbar degenerative diseases requiring posterior L4-5 fusion were retrospectively included and divided into the RA, PS, and CBT groups from March 2019 to December 2021. The grades of intrapedicular accuracy and superior FJV were evaluated according to the Gertzbin–Robbins scale and the Babu scale based on postoperative CT. Univariable and multivariable analyses were conducted to assess the possible risk factors associated with intrapedicular accuracy and superior FJV. Results The rates of optimal screw insertion in the RA, PS, and CBT groups were 87.3%, 81.3%, and 76.5%, respectively. The difference between the RA and CBT groups was statistically significant (P = 0.004). Superior FJVs occurred in 28.2% of screws in RA, 45.0% in PS, and 21.6% in CBT. The RA and CBT groups had fewer superior FJVs than the PS group (P = 0.008 and P
Flow diagram of patients selected for analysis
Receiver operating characteristic curve for the prediction model Area under the curve was 0.871 (95% confidence interval 0.814–0.904)
Calibration of the model for anastomotic leakage The x-axis shows the predicted probability of anastomotic leakage, and the y-axis shows the observed probability of anastomotic leakage
Decision curve analysis of the prediction model with and without LCR in internal A and temporal B cohort. The horizontal coordinate of the graph is the threshold probability, and the vertical coordinate is the net benefit
Nomogram predicting the probability of AL. To estimate the probability of AL, mark patient values at each axis, draw a straight line perpendicular to the point axis, and sum the points for all variables. Next, mark the sum on the total point axis and draw a straight line perpendicular to the probability axis
Background & Aims Lymphocyte-C-reactive Protein Ratio (LCR) has been demonstrated as a promising new marker for predicting surgical and oncological outcomes in colorectal carcinoma (CRC). However, anastomotic leakage (AL) is also likely related to this inflammatory marker. Herein, we aimed to identify preoperative predictors of AL and build and develop a novel model able to identify patients at risk of developing AL. Methods We collected 858 patients with CRC undergoing elective radical operation between 2007 and 2018 at a single center were retrospectively reviewed. We performed univariable and multivariable analyses and built a multivariable model that predicts AL based on preoperative factors. Propensity adjustment was used to correct the bias introduced by non-random matching of the LCR. The model's performance was evaluated by using the area under the receiver operator characteristic curves (AUROCs), decision curve analysis (DCA), Brier scores, D statistics, and R2 values. Results Age, nutrition risk screening 2002 (NRS2002) score, tumor location and LCR, together with hemoglobin < 90 g/l, were independent predictors of AL. The models built on these variables showed good performance (internal validation: c-statistic = 0.851 (95%CI 0.803–0.965), Brier score = 0.049; temporal validation: c-statistic = 0.777 (95%CI 0.823–0.979), Brier score = 0.096). A regression equation to predict the AL was also established by multiple linear regression analysis: [Age(≥ 60 year) × 1.281] + [NRS2002(≥ 3) × 1.341] + [Tumor location(pt.) × 1.348]-[LCR(≤ 6000) × 1.593]-[Hemoglobin(< 90 g/L) × 1.589]-6.12. Conclusion Preoperative LCR is an independent predictive factor for AL. A novel model combining LCR values, age, tumor location, and NRS2002 provided an excellent preoperative prediction of AL in patients with CRC. The nomogram can help clinical decision-making and support future research.
Flow chart depicting the inclusion and exclusion approached for the current study participants
Background Although obesity is a popular reason for choosing laparoscopic appendectomy (LA) versus open appendectomy (OA), however, the question of whether there is a difference remains. Our goal is to investigate if there is a difference between OA and LA in obese patients. Methods Fifty-eight obese patients diagnosed with acute appendicitis according to ALVARDO score at department of surgery at Suez Canal university hospitals from March 2020 till August 2021 were included. The study participants were assigned in two groups LA and OA. This study aimed to comparing between LA and OA regarding intraoperative complications, length of hospital stays, post -operative pain, and rate of post-operative complications. Meanwhile, using SF-36 scoring questionnaire, the quality of life was compared between both groups. Results A total of 58 patients were included in the present study (LG = 29 patients and OG = 29 patients). The early post-operative complications (within 30 days after surgery) were significantly lower in the LA group (5 patients out of 29) than the OA (11 patients out of 29). Additionally, lower incidence of complications was noticed in the LA group (2 out of 29 patients) compared to OA (6 patients out of 29) beyond 30 days after operation. Patients with laparoscopic surgery had statistically significant higher overall quality of life scores (SF-36) (72 ± 32) compared to open surgery patients (66 ± 35) 2 weeks after operation . Conclusion The laparoscopic procedure was associated with lower incidence of post operative complications. However , open appendectomy was superior for a shorter operative time. Laparoscopic approach is not only used for therapeutic purposes, but also it has a diagnostic role.
A The schema of heterotopic auxiliary rat liver transplantation with portal vein arterialization. B End-to-side anastomosis of the donor hepatic portal vein and the recipient left common iliac artery is made with a running 10–0 prolene suture. The free flap is embedded in the anastomosis to prevent an excessive blood flow speed or volume to reduce the chances of a high perfusion injury in the donor liver. C, D End-to-side anastomosis is made between the donor liver supra-hepatic and infra-hepatic caval vein and the recipient inferior vena cava. E End-to-end anastomosis is made between the right renal artery and the donor liver portal vein using the stent method
Temporal changes in the plasma concentrations of liver function parameters post-transplant. A ALT; B AST; C total bilirubin; D cholinesterase. Data are expressed as mean ± standard deviation. *P < 0.05 vs. the control group
Hematoxylin and eosin staining of normal rat liver (A), and donor liver 14 days post-transplant in the experimental group (B) and the control group (C). Magnification × 40
Immunohistochemical staining of liver tissue with specific antibodies. A Expression of TNF-α in liver tissue on post-transplant day 1, 3, 5, 7, and 14 in the experimental group and the control group (left panel). B Expression of IL-6 in liver tissue on post-transplant day 1, 3, 5, 7, and 14 in the experimental group and the control group (left panel). C Expression of HGF in liver tissue at post-transplant day 1, 3, 5, 7 and 14 in the experimental group and the control group (left panel). In A, B, and C expression is quantified and shown in bar graphs (right panels). Magnification × 200
Immunoblotting assays showing the expression of TNF-α, IL-6, and HGF in liver tissue on post-transplant day 1, 3, 5, 7, and 14 (left panels). A Experimental group. B Control group
Background and Aim The success of partial donor liver transplantation is affected by the implantation site of the donor liver and the vascular reconstruction approach. We investigated the effects of different donor liver implantation sites and vascular reconstruction approaches on liver regeneration using a rat kidney-sparing heterotopic auxiliary liver transplantation model, with portal vein arterialization (PVA). Methods Sixty male Sprague–Dawley rats underwent end-to-end anastomosis of the donor liver portal vein and the right renal artery stent (control group), or end-to-side anastomosis of the donor liver portal vein and the left common iliac artery (experimental group). Results The experimental group had significantly lower plasma levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, and cholinesterase than the control group (all, P < 0.05). The levels of tumor necrosis factor-α (TNF-α), interleukin 6 (IL-6), and hepatocyte growth factor (HGF) in the liver were significantly higher in the experimental group than that in the control group (all, P < 0.05). Hematoxylin and eosin (HE) staining of the liver tissue specimens indicated that the experimental group had greater hepatocyte regeneration compared to the control group. Conclusions The modified kidney-sparing PVA model of heterotopic auxiliary liver transplantation is more conducive to liver regeneration with quicker return of liver function.
Creating surgical access is a critical step in laparoscopic surgery. Surgeons have to insert a sharp instrument such as the Veress needle or a trocar into the patient’s abdomen until the peritoneal cavity is reached. They solely rely on their experience and distorted tactile feedback in that process, leading to a complication rate as high as 14% of all cases. Recent studies have shown the feasibility of surgical support systems that provide intraoperative feedback regarding the insertion process to improve laparoscopic access outcomes. However, to date, the surgeons’ requirements for such support systems remain unclear. This research article presents the results of an explorative study that aimed to acquire data about the information that helps surgeons improve laparoscopic access outcomes. The results indicate that feedback regarding the reaching of the peritoneal cavity is of significant importance and should be presented visually or acoustically. Finally, a solution should be straightforward and intuitive to use, should support or even improve the clinical workflow, but also cheap enough to facilitate its usage rate. While this study was tailored to laparoscopic access, its results also apply to other minimally invasive procedures.
Scatter fitted plot: a Intraoperative blood loss vs tumor volume and b operative time vs tumor volume. Pearson correlated test
Background Since Gagner performed the first laparoscopic adrenalectomy in 1992, laparoscopy has become the gold-standard procedure in the treatment of adrenal surgical diseases. A review of the literature indicates that the rate of intra- and postoperative complications are not negligible. This study aims to describe the single-center experience of adrenalectomies; and explore the associations between body mass index (BMI) and tumor volume in main postoperative outcomes. Methods Retrospective observational study with a prospective database in which we described patients who underwent adrenalectomy between January 2015 and December 2020. Operative time, intraoperative blood loss, conversion rate, complications, length of hospital stay, and comparison of the number of antihypertensive drugs used before and after surgery were analyzed. Analysis of BMI and tumor volume with postoperative outcomes such as anti-hypertensive change (AHC) in drug usage and pre-operative conditions were performed. Results Forty-five adrenalectomies were performed, and all of them were carried out laparoscopically. Four were performed as a robot-assisted laparoscopy approach. Nineteen were women and 26 were men. Mean age was 54.9 ± 13.8 years. Mean tumor volume was 95.698 mm ³ (3.75–1010.87). Mean operative time was shorter in right tumors (2.64 ± 0.75 h) than in left tumors (3.33 ± 2.73 h). Pearson correlation was performed to assess the relationship between BMI and AHC showing a direct relationship between increased BMI and higher change in anti-hypertensive drug usage at postoperative period r(45) = 0.92, p > 0.05 CI 95%. Higher tumor volume showed a longer operative time, r(45) = 0.6 (p = 0.000 CI 95%). Conclusions Obese patients could have an increased impact with surgery with an increased change in postoperative anti-hypertensive management. Tumor volume is associated with increased operative time and blood loss, our data suggest that it could be associated with increased rates of morbidity. However, further prospective studies with larger sample sizes are needed to validate our results.
Objective To evaluate the safety of performing surgery on cavernous haemangiomas in the liver larger than 10 cm and establish preoperative predictors of intraoperative blood transfusion and morbidity. Methods A total of 373 patients with haemangiomas larger than 10 cm who underwent surgery in our hospital were retrospectively analysed. According to tumour diameter, the patients were divided into a giant haemangioma (GH) group (241 cases) (10 cm ≤ diameter < 15 cm) and an enormous haemangioma (EH) group (132 cases) (diameter ≥ 15 cm). Clinical parameters were then compared between the two groups. Results Compared with the GH group, the EH group had higher rates of leukopenia (10.6% vs. 4.5%), anaemia (26.5% vs. 15.7%), and thrombocytopenia (13.6% vs. 6.2%). The occlusion time in the EH group was longer than that in the GH group (26.33 ± 14.10 min vs. 31.85 ± 20.09 min, P < 0.01). The blood loss and blood transfusion in the EH group were greater than those in the GH group (P < 0.05). Moreover, the morbidity in the EH group was higher than that in the GH group (17.4% vs. 9.13%, P < 0.05). According to the results of the multivariable analysis, the operation time and size of the haemangioma may be independent risk factors for blood transfusion (P < 0.05). Additionally, the size of the haemangioma may be an independent risk factor associated with complications (P < 0.05). Conclusion Enormous haemangioma is more likely to cause haematologic abnormalities than giant hepatic haemangioma. The risks of the operation and postoperative complications of enormous haemangioma are higher than those of giant hepatic haemangioma.
Case 1 of a 68 years old male patient with left FNF. A Classified as Garden I, i.e. incomplete FNF, only involving lateral cortex break, with medial cortex remaining intact, as shown on X-ray. B Classified as Garden II, i.e. complete FNF, involving medial cortex break, as shown on CT coronal plane. C Classified as Garden II, i.e. complete FNF, involving slight displacement, as shown on CT horizontal plane
Case 2 of a 70 years old female patient with left FNF. A Classified as Garden I, i.e. incomplete FNF, only involving medial cortex break, with lateral cortex remaining intact, as shown on X-ray. B and C Classified as Garden I, i.e. incomplete FNF, with lateral cortex remaining intact, as shown on CT coronal plane and horizontal plane. D Classified as Garden II, i.e. complete FNF, as found during operation
Results of classfication according CT images
Kappa values for the 4 types Garden classification of CT images
Background Accurate classification of femoral neck fracture (FNF) is crucial for treatment plan and therapeutic outcomes. Garden classification is commonly used in the clinic, but its stability and consistency remain controversial. The aim of this study was to evaluate the stability and consistency of Garden classification based on X and CT images, and to analyze whether it is valid for Garden I in the elderly. Methods X-ray and CT images from 886 elderly patients with FNF were collected, four orthopaedic surgeons and four radiologists evaluated these images independently, and determined the fracture type based on Garden classification. Three months later, The exercise was repeated and the results were compared based on 4 types Garden classification (I, II, III and IV) and 3 types Garden classification (I + II, III and IV). Kappa was used to measure inter- and intraobserver agreement. The patients with Garden I incomplete FNF confirmed by 8 observers together based on images combined with medical history were compared with the intraoperative results. Results Four types Garden classification, there was little consistency inter- and intraobservers (Kappa from 0.18 to 0.43) based on X-ray images, while professors consistency (0.56 to 0.76) was higher than residents (0.28 to 0.35) based on CT. 3 types Garden classification showed almost perfect agreement inter- and intraobservers, which ranged from 0.76 to 0.90. Totally 52 patients were diagnosed as Garden I, 38 of whom underwent arthroplasty. All surgical cases showed complete fracture during operation. Conclusions There was low consistency and repeatability in 4 types Garden classification (I, II, III and IV), while 3 types Garden classification (I + II, III and IV) had high consistency among observers. In the elderly, all undisplaced femoral neck fracture may be Garden II, no Garden I.
The second-generation TiRobot system
Robot-assisted pedicle screw placement
Screw deviation measurement
Pedicle screw placement accuracy
Perioperative and postoperative outcomes
Background Robot-assisted spine surgery aims to improve the accuracy of screw placement. We compared the accuracy and safety between a novel robot and free hand in thoracolumbar pedicle screw placement. Methods Eighty patients scheduled to undergo robot-assisted (40 patients) and free-hand (40 patients) pedicle screw placement were included. The patients’ demographic characteristics, radiographic accuracy, and perioperative outcomes were compared. The accuracy of screw placement was based on cortical violation and screw deviation. Safety outcomes mainly included operative time, blood loss, revision, and complications. Results A total of 178 and 172 screws were placed in the robot-assisted and free-hand groups, respectively. The rate of perfect screw position (grade A) was higher in the robot-assisted group than in the free-hand group (91.0% vs. 75.6%; P < 0.001). The rate of clinically acceptable screw position (grades A and B) was also higher in the robot-assisted group than in the free-hand group (99.4% vs. 90.1%; P < 0.001). The robot-assisted group had significantly lower screw deviation than the free-hand group [1.46 (0.94, 1.95) mm vs. 2.48 (1.09, 3.74) mm, P < 0.001]. There was no robot abandonment in the robot-assisted group. No revision was required in any of the groups. Conclusions Robot-assisted pedicle screw placement is more accurate than free-hand placement. The second-generation TiRobot–assisted thoracolumbar pedicle screw placement is an accurate and safe procedure. Trial registration retrospectively registered
Synovial cyst at L4–L5 level in MRI. A Axial level cut in T2 sequence. B Axial section in T1 sequence. C Sagittal section in T2 sequence
Synovial cyst at L4–L5 level in MR. In sagittal section (A) and axial section (b), both in T2 sequence, of one of the patients with a cauda equina syndrome
Zygapophyseal infiltration under fluoroscopic guidance with contrast medium, confirming CS rupture by observing contrast extravasation
Postoperative result according to McNab score
Background There is controversy regarding the treatment of symptomatic synovial cysts, specifically, the need for a concomitant fusion when surgical resection of the synovial cysts is required. We present a retrospective review of a series of patients treated for symptomatic synovial cysts of the lumbar region during the last 20 years by a single surgeon, analyzing the current available literature. Methods Retrospective review. The same surgical technique was applied to all patients. Demographic, clinical, surgical data and synovial cyst recurrence rate were recorded. Postoperative results reported by patients were documented according to the McNab score. Results Sixty nine subjects, with mean follow-up of 7.4 years. 62% (43) were female, with a mean 57.8 years at the time of surgery. In 91.3% (63), the primary management was conservative for a minimum period of 3 months. All subjects underwent surgery due to the failure of conservative treatment. The segment most operated on was L4–L5 (63.77%). 91.3% (63) of the sample reported excellent and good and 6 subjects (8.6%) fair or poor results. There was no evidence of synovial cysts recurrence at the operated level. Conclusion In symptomatic synovial cysts, it seems that conservative treatment is only effective in a limited number of patients and in the short term. Thus, the recommendation of a surgical indication should proceed as soon as the conservative management fails to result in significant symptom relief. Based on our results, we recommend, together with the resection of the cyst, the instrumentation of the segment to avoid its recurrence and the management of axial pain.
Preoperative and intraoperative findings. A MRCP showed cystic dilatation of the distal common bile duct (arrow). B ERCP showed cystic dilatation of the distal common bile duct (arrow). C ERCP showed an anomalous pancreaticobiliary duct junction. D Duodenoscopy showed that the duodenal papilla was flat and granular with no protrusions. E Choledochoscopy showed the opening of the cyst (arrow). F Laparoscopic hepaticojejunostomy was used to treat the type III cysts
Background Type III choledochal cysts (CCs) are the rarest and least well-characterized of the five variants of biliary cysts. Only a few relevant studies have been conducted and a gold standard treatment for type III CCs is still lacking because of their scarcity. An unusual case of type III CC with choledochocele at the end of the distal common bile duct (CBD) with no bulging of the duodenum is presented here. Case presentation A 61-year-old woman presented to our department with repeated upper abdominal pain for one year. Laboratory examination revealed abnormal liver function and a slight increase in the white blood cell (WBC) count and proportion of neutrophils. In an MRCP of the patient, the distal CBD was found to have a cystic structure indicative of a type III CC. Endoscopic retrograde cholangiopancreatograpy (ERCP) revealed cystic findings compatible with Todani type III CCs. However, duodenoscopy did not show a bulge in the duodenum so laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy were performed. In her 6-month follow-up, the patient reported that recovery from the operation was uneventful. Conclusions ERCP has become the gold standard for diagnosing type III CCs. Type III CCs can be treated minimally invasively with laparoscopic cholecystectomy and Roux-en-Y hepaticojejunostomy.
The placement of the inter-anastomosis drainage (IAD) tube. After completing the duct-to-mucosa anastomosis, the IAD tube was placed at the interspace between the jejunal wall and pancreatic parenchyma through the end of the jejunum (a). A 10 Fr silicone tube (BLAKE Silicone Drains-Hubless, Ethicon) was arranged in an “I” shape and was inserted into the inter-anastomosis space. The external drainage tube of the MPD stent was placed and fixed, and Blumgart mattress sutures (3-0 PDS-II, Ethicon) were ligated by wrapping the IAD tube inside (b). The IAD tube was completely enveloped by the jejunal wall and pancreatic parenchyma (c). Reinforcing 4-0 PDS-II sutures were occasionally added to both edges in order to ensure a water-tight seal. At the end of the surgery, the IAD suction tube was connected to a low-pressure continuous-suction device
Amylase value and the drainage volume of each patient in the IAD + B group. Bar-graph (left side) indicates the amylase value of IAD tube collection, and the right side indicates the volume of the IAD collection. Arrows revealed the existence of grade B or C pancreatic fistula
MPD location types and IAD tube placement in each cases. The inter-anastomosis drainage (IAD) in Blumgart-type pancreatojejunostomy works effectively when the pancreas resection surface is wide (not small) and the main pancreatic duct locates on the dorsal side because IAD tube placed fine in water-tight manner (a). IAD tube placement did not work well when the resection surface is thin or small (b) and the main pancreatic duct locate on the ventral side (c)
Background: Pancreatic fistula remains the biggest problem in pancreatic surgery. We have previously reported a new pancreatojejunostomy method using an inter-anastomosis drainage (IAD) suction tube with Blumgart anastomosis for drainage of the pancreatic juice leaking from the branched pancreatic ducts. This study aimed to evaluate the postoperative outcomes of our novel method, in pancreatojejunostomy and investigate the nature of the inter-anastomosis space between jejunal wall and pancreas parenchyma. Methods: This retrospectively study consist of 282 pancreatoduodenectomy cases, including 86 reconstructions via the Blumgart method plus IAD (B + IAD group) and 196 cases reconstructed using the Blumgart method alone (B group). Postoperative outcomes and the amylase value and the volume of the drainage fluids were compared between the two groups. The IAD tube was placed to collect amylase-rich fluid from the inter-anastomosis space during operative procedure between the jejunal wall and pancreatic stump. Results: The daily IAD drainage volume and the amylase level was significantly higher in patients with a soft pancreas (vs hard pancreas; 16.5 vs. 10.0 mL/day, p = 0.012; 90,900 vs. 1634 IU/L, p < 0.001, respectively). The mean amylase value of IAD collection in 86 cases of B + IAD group was 63,100 IU/L. The incidence of clinically relevant pancreatic fistula grade B and C (23.2% vs. 23.0%, p = 0.55) and the hospital stay was similar between the groups (median 17 vs. 18 days, p = 0.55). In 176 patients with soft pancreas, the incidence of pancreatic fistula grade B and C (33.3% vs. 35.3%, p = 0.67) and the hospital stay was also similar between the groups (median 22.5 vs. 21 days, p = 0.81). Conclusions: Positive effect of the IAD method observed in the pilot cases was not reproduced in the current study. IAD tube objectively demonstrated the existence of amylase-rich discharge at the anastomosis site, and countermeasures to eliminate this liquid are highly desired for preventing pancreatic fistula, especially in patients with soft pancreatic texture. Trial registration Retrospectively registered.
a Reflux esophagitis, no Barrett epithelium 09/2016. b Reflux esophagitis 05/2018
a Bile reflux in the esophagus 08/2019. b Barrett’s esophagus 12/2019
Background The number of mini gastric bypass / one anastomosis bypass (MGB-OAGB) procedures in bariatric patients that have been performed world-wide has drastically increased during the past decade. Nevertheless, due to the risk of subsequent biliary reflux and development of ulcer and neoplastic (pre)lesions caused by long-time bile exposure, the procedure is still controversially discussed. In here presented case report, we could endoscopically demonstrate a transformation from reflux oesophagitis to Barrett’s metaplasia most likely caused by bile reflux after mini-gastric bypass. To our knowledge, this is a first case study that shows development of Barrett’s metaplasia after MGB-OAGB. Case presentation We present the case of a 50-year-old female which received a mini-gastric bypass due to morbid obesity (body mass index (BMI) 42.4 kg/m ² ). Because of history gastroesophageal reflux disease (GERD), a fundoplication had been performed earlier. Preoperative gastroscopy showed reflux esophagitis (Los Angeles classification grade B) with no signs of Barrett’s metaplasia. Three months post mini-gastric bypass, the patient complained about severe bile reflux under 40 mg pantoprazole daily. Six months postoperative, Endoscopically Barrett’s epithelium was detected and histopathologically confirmed (C1M0 after Prague classification). A conversion into Roux-en-Y gastric bypass was performed. The postoperative course was without complications. In a follow up after 6 months the patient denied reflux and showed no signs of malnutrition. Conclusions The rapid progress from inflammatory changes of the distal esophagus towards Barrett’s metaplasia under bile reflux in our case is most likely a result of previous reflux disease. Nevertheless, bile reflux appears to be a potential decisive factor. Study results regarding presence of bile reflux or development of endoscopically de-novo findings after MGB-OAGB are widely non-conclusive. Long-term prospective studies with regular endoscopic surveillance independent of clinical symptoms are needed.
The treatment protocol for rib fracture patients in CGMH. a Standard treatment prior to SSRF. b The treatment algorithm for SSRF
Background Rib fractures are the most common thoracic injury in patients who sustained blunt trauma, and potentially life-threatening associated injuries are prevalent. Multi-disciplinary work-up is crucial to achieving a comprehensive understanding of these patients. The present study demonstrated the experience of an acute care surgery (ACS) model for rib fracture management from a single level I trauma center over 13 years. Methods Data from patients diagnosed with acute rib fractures from January 2008 to December 2020 were collected from the trauma registry of Chang Gung Memorial Hospital (CGMH). Information, including patient age, sex, injury mechanism, Abbreviated Injury Scale (AIS) in different anatomic regions, injury severity score (ISS), index admission department, intensive care unit (ICU) length of stay (LOS), total admission LOS, mortality, and other characteristics of multiple rib fracture, were analyzed. Patients who received surgical stabilization of rib fractures (SSRF) were analyzed separately, and basic demographics and clinical outcomes were compared between acute care and thoracic surgeons. Results A total of 5103 patients diagnosed with acute rib fracture were admitted via the emergency department (ED) of CGMH in the 13-year study period. The Department of Trauma and Emergency Surgery (TR) received the most patients (70.8%), and the Department of Cardiovascular and Thoracic Surgery (CTS) received only 3.1% of the total patients. SSRF was initiated in 2017, and TR performed fixation for 141 patients, while CTS operated for 16 patients. The basic demographics were similar between the two groups, and no significant differences were noted in the outcomes, including LOS, LCU LOS, length of indwelling chest tube, or complications. There was only one mortality in all SSRF patients, and the patient was from the CTS group. Conclusions Acute care surgeons provided good-quality care to rib fracture patients, whether SSRF or non-SSRF. Acute care surgeons also safely performed SSRF. Therefore, we propose that the ACS model may be an option for rib fracture management, depending on the deployment of staff in each institute.
Background This study aimed to evaluate the feasibility and safety of the trans-oral endoscopic thyroidectomy vestibular approach (TOETVA) with neuroprotection techniques for the surgical management of papillary thyroid carcinoma (PTC). Methods Patients with PTC who underwent TOETVA between December 2016 and July 2020 were included in this study, and their relevant clinical characteristics, operational details, and surgical outcomes were reviewed and extracted from their medical records for further analysis. Results A total of 75 patients successfully underwent TOETVA with zero conversions. Unilateral lobectomy with isthmectomy and total thyroidectomy were completed for 58 and 17 patients, respectively, all using our unique neuroprotective procedure and ipsilateral central neck dissection (CND). The mean number of retrieved lymph nodes versus positive lymph nodes was 6.8 ± 3.7 vs. 1.5 ± 2.3. Postoperative complications included three cases of transient superior laryngeal nerve (SLN) palsy (4.0%), five cases of transient recurrent laryngeal nerve (RLN) palsy (6.7%), 14 cases of transient hypoparathyroidism (18.7%), two cases of numb chin (2.7%) and two cases of flap perforation (2.7%). The follow-up period for patients with PTC lasted for 15.6 ± 10.9 months, during which no other complications or tumor recurrence were observed. Conclusion TOETVA can be safely performed for patients with PTC with satisfactory results during the short-term follow-up period. Our neuroprotection techniques can be integrated into TOETVA, which is worth recommending for PTC patients who desire better cosmetic surgical outcomes.
Diagram of the data collection process
The primary (A, C) and secondary (B, D) stent patency rates within the 12-month and 24-month follow-up examination in two subgroups respectively. The tabular data present the number of patients
Patient characteristics, postoperative PTS symptoms, perioperative conditions, deep vein anatomic conditions, surgery procedures and postoperative patency rates in 22 PTS patients
Objective Post-thrombotic syndrome (PTS), an important complication of deep venous thrombosis (DVT), adversely affects patients’ quality of life. Endovascular intervention in PTS can relieve symptoms rapidly with high therapeutic value. This study mainly focuses on how to improve postoperative stent patency rates and aims to find prognostic factors impacting patency. Methods According to the specific inclusion and exclusion criteria, PTS patients who underwent endovascular intervention at the First Affiliated Hospital of Sun Yat-sen University from December 1, 2014, to December 31, 2019, were included in this single-center prospective study. Follow-up data were collected and analyzed regularly over 2 years. Results Overall, 31 PTS patients were enrolled in the study. The mean age of these patients was 55.39 ± 11.81, including 19 male patients. Stent implantation was successful in 22 PTS patients, with a technical success rate of 70.97%. The average Villalta scores of the stent-implanted group and the non-stent-implanted group were 5.95 ± 2.57 and 5.78 ± 2.95, respectively, with no significant difference observed. In the stent-implanted group, the perioperative patency rate was 81.81% (18/22), and the follow-up patency rates were 68.18% (15/22) within 3 months, 59.09% (13/22) within 6 months, 45.45% (10/22) within 1 year, and 36.36% (8/22) within 2 years. Based on the stent placement segments, the 22 PTS patients were divided into two subgroups: the iliofemoral vein balloon dilation + iliofemoral vein stent implantation (FV-S) subgroup and the iliofemoral vein balloon dilation + iliac vein stent implantation (FV-B) subgroup. In the FV-S subgroup, the perioperative patency rate was 100.00% (14/14), and the follow-up patency rates were 85.71% (12/14), 71.43% (10/14), 57.14% (8/14) and 50.00% (7/14), which were higher than those for overall stent patency of all patients. The postoperative patency rates in the FV-B subgroup were 50.00% (4/8), 37.50% (3/8), 37.50% (3/8), 25.00% (2/8), and 12.50% (1/8). The secondary postoperative patency rates in the FV-B subgroup were 100.00% (8/8), 87.50% (7/8), 75.00% (6/8), 62.50% (5/8) and 50.00% (4/8). Conclusions For PTS patients with iliofemoral vein occlusion but patent inflow, iliofemoral vein stent implantation is a more efficient therapeutic option than iliofemoral vein balloon dilation with iliac vein stent implantation for PTS patients.
Plain upright PA-CXR. Image shows a large volume of sub-diaphragmatic free air
Gross appearance of affected loops. Image shows wide-spread, cystic lesions in the sub-serosa of small intestines
Microscopic image of incisional biopsy. Image shows chronic inflammatory reaction characterized by histiocytes and giant cells lining multiple cysts
(This image was taken by Olympus OM 35 mm SLR microscope, original magnification, × 40; scale bar, 100 µm)
Microscopic image of incisional biopsy. Image shows chronic inflammatory reaction characterized by histiocytes and giant cells lining multiple cysts
(This image was taken by Olympus OM 35 mm SLR microscope, original magnification, × 100; scale bar, 100 µm)
Background Pneumatosis intestinalis is an abnormal presence of free air outside the lumen of the intestines in many shapes. It is classified based on its etiology to primary or secondary, it affects adults as well as infants and can involve any part of the GI tract. Case presentation We report a case of a 55-year-old man with a past medical history of a surgically repaired perforated duodenal ulcer who presented with an acute abdominal pain, Flatulence and constipation. On examination of the abdomen; severe distension, tenderness and tympanicity on percussion were noted. An erect CXR was performed and showed bilateral sub-diaphragmatic air levels. We performed an abdominal Paracentesis under the right subcostal margin which led to evacuation of large amounts of air. Next, an investigational laparotomy showed that the reason was a gastric volvulus associated with an anterior and posterior gastric wall lacerations. The suitable surgical repair approach was taken, but another lesion was detected incidentally. A pneumatosis cystoides intestinalis (PCI) was extended along large length of the intestines in many shapes and without any symptoms or signs. Conclusions Pneumatosis cystoides intestinalis has been reported continuously in relation to peptic ulcer disease (PUD). We aim to report a new association of a gastric volvulus and PCI secondary to pyloric stenosis caused by a duodenal ulcer; which we believe can aid in the diagnosing of dangerous complications, of a rare disease.
Sagittal and axial CT scans of the thoracic spine demonstrating thoracic spinal stenosis caused by multi-level ossification of ligamentum flavum and posterior osteophytes (T9/10, T10/11, T11/12)
Sagittal and axial MRI of the thoracic spine showed multi-level severe thoracic spinal stenosis (T9/10, T10/11, T11/12) and spinal cord compression
Sagittal and axial MRI of the lumbar spine showed multi-level severe upper lumbar spinal stenosis (L1/2,L2/3,L3/4) caused by posterior osteophytes and short pedicle
A 26-year-old female patient with thoracolumbar spinal stenosis, kyphoscoliosis and pectus excavatum. She underwent extensive laminectomy, ponte osteotomy and posterior fusion surgery (T9-L4). The kpphoscoliosis was improved significantly in preoperative and postoperative radiographs (A,B). At 6 months follow-up, the curve correction and spinal alignment were maintained very well(C)
Sagittal CT scan showed the depressed sternum into thoracic cavity. The Louis angle (the angle between the manubrium and the body of the sternum) is 120 degree (A). The coronal CT scan demonstrated central depression of sternum with Haller Index of 3.4 and sternal rotation angle of 7 degree (B)
Background Pectus excavatum is the most common congenital chest wall defect. Thoracolumbar spinal stenosis and kyphoscoliosis was seen in patients with pectus excavatum. It can be caused by ossification of the ligamentum flavum, which is rare in patients with pectus excavatum. Case presentation We reported a 26-year-old woman presented bilateral lower extremities weakness and numbness for two months, progressive worsening. She was diagnosed as thoracolumbar spinal stenosis with ossification of the ligamentum flavum, thoracolumbar kyphoscoliosis associated with pectus excavatum. The posterior instrumentation, decompression with laminectomy, and de-kyposis procedure with multilevel ponte osteotomy were performed. Her postoperative course was uneventful and followed up regularly. Good neurologic symptoms improvement and spinal alignment were achieved. Conclusions Pectus excavatum, kyphoscoliosis associated with thoracolumbar spinal stenosis is rare, and thus her treatment options are very challengeable. Extensive laminectomy decompression and de-kyphosis procedures can achieve good improvement of neurologic impingement and spinal alignment.
Top-cited authors
Bruno Amato
  • University of Naples Federico II
Antonio Biondi
  • University of Catania
Francesco Basile
  • University of Catania
Esther Consten
  • Meander Medisch Centrum
Willem A Bemelman
  • University of Amsterdam