A giant trichobezoar in a child with attention deficit hyperactivity disorder: A case report

INTRODUCTION AND IMPORTANCE

Trichobezoars are uncommon gastrointestinal concretions that develop due to the accumulation of ingested hair, predominantly affecting young females with concurrent psychiatric conditions like trichotillomania and Trichophagia. These masses typically form in the stomach but may also protrude into the intestines, potentially leading to severe complications if not promptly identified and treated. The present case study outlines the clinical manifestation, diagnostic complexities, surgical intervention, and postoperative care of a 10-year-old female patient with a substantial gastric trichobezoar, underscoring the significance of considering this disorder in pediatric individuals with gastrointestinal manifestations and a psychiatric history.

CASE PRESENTATION

The research article details the case of a 10-year-old female patient with a multifaceted medical history, which includes attention-deficit/hyperactivity disorder (ADHD), chronic constipation, growth retardation, and a background of neonatal seizures. She was admitted to the emergency department presenting with epigastric pain, nausea, and vomiting. Notably, the patient displayed pica-like behaviors, specifically the ingestion of hair, which ultimately led to the diagnosis of a trichobezoar, a form of gastric obstruction resulting from the accumulation of ingested hair. Diagnostic imaging techniques, including abdominal X-ray and computed tomography (CT) scan, confirmed the presence of a substantial trichobezoar within the stomach, necessitating surgical intervention via exploratory laparotomy for removal. The pathological examination of the excised mass revealed a considerable quantity of hair intermingled with fecal matter. Following the surgical procedure, the patient exhibited a positive recovery trajectory and was subsequently referred for psychiatric assessment and behavioral therapy to address the underlying issues associated with trichotillomania, with the objective of preventing future occurrences. This case underscores the critical need for the identification and management of behavioral concerns in pediatric patients exhibiting similar clinical presentations.

DISCUSSION

The patient exhibited symptoms such as epigastric pain, nausea, and vomiting, in addition to a medical history of Attention Deficit Hyperactivity Disorder (ADHD) and pica-like behaviors. Diagnostic imaging confirmed the presence of a large trichobezoar, leading to the necessity of an exploratory laparotomy for its surgical removal. This case highlights the crucial role of comprehensive clinical assessment and imaging in the diagnosis of trichobezoars, especially in children with behavioral concerns. Managing such cases typically involves a multidisciplinary approach that combines surgical procedures with psychiatric assessment and behavioral therapy to reduce the likelihood of recurrence.

CONCLUSION

This case underscores the importance of considering trichobezoars in the list of potential diagnoses for pediatric patients exhibiting gastrointestinal symptoms, particularly in individuals with psychiatric or neurodevelopmental histories. Timely identification and management are crucial in averting serious complications linked to trichobezoars. The favorable surgical result in this particular patient underscores the significance of holistic care that attends to both the physical and psychological dimensions of the condition, ultimately enhancing the long-term outlook. Additional research is required to explore the relationship between underlying psychiatric conditions, particularly ADHD, and the formation of trichobezoars. Furthermore, novel therapeutic strategies need to be developed.

SAME day amBulatory c (SAMBA): a multicenter, prospective, randomized clinical trial protocol

BACKGROUND

A recent meta-analysis concluded that outpatient appendectomy appears feasible and safe, but there is a lack of high-quality evidence and a randomized trial is needed. The aim of this trial is to demonstrate that outpatient appendectomy is non-inferior to conventional inpatient appendectomy in terms of overall morbi-mortality on the 30th postoperative day (D30).

METHODS

SAMBA is a prospective, randomized, controlled, multicenter non-inferiority trial. We will include 1400 patients admitted to 15 French hospitals between January 2023 and June 2025. Inclusion criteria are patients aged between 15 and 74 years presenting acute uncomplicated appendicitis suitable to be operated by laparoscopy. Patients will be randomized to receive outpatient care (day-surgery) or conventional inpatient care with overnight hospitalization in the surgery department. The primary outcome is postoperative morbi-mortality at D30. Secondary outcomes include time from diagnosis to appendectomy, length of total hospital stay, re-hospitalization, interventional radiology, re-interventions until D30, conversion from outpatient to inpatient, and quality of life and patient satisfaction using validated questionnaires.

DISCUSSION

The SAMBA trial tests the hypothesis that outpatient surgery (i.e., without an overnight hospital stay) of uncomplicated acute appendicitis is a feasible and reliable procedure in establishments with a technical platform able to support this management strategy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05691348. Registered on 20 January 2023.

Well-differentiated neuroendocrine tumors of the appendix: Diagnosis, differentials, and disease progression

Well-differentiated neuroendocrine tumors are the most common neoplasm of the appendix. They are graded and staged using World Health Organization and American Joint Committee on Cancer criteria, respectively. They may be invisible grossly or form rounded yellow nodules, sometimes in the appendiceal tip. They show classic neuroendocrine tumor features microscopically, forming nests and cords of monotonous cells with salt-and-pepper chromatin and amphophilic cytoplasm. They are positive for neuroendocrine markers by immunohistochemistry, but their molecular characteristics are not well defined. pT-category staging relies primarily on tumor size, though higher-stage cases may involve the subserosa or mesoappendix. Few entities enter the differential diagnosis, but lesions such as goblet cell adenocarcinoma, poorly differentiated neuroendocrine carcinoma, and mixed neuroendocrine-non-neuroendocrine neoplasm may be considered. Appendiceal neuroendocrine tumors may metastasize to regional lymph nodes, but farther spread is rare. The most consistently proven risk factor for such spread is tumor size, though different studies have proposed different cutoffs. Other potential risk factors include lymphovascular invasion and margin positivity. Tumors smaller than 1 cm can be treated by appendectomy, while hemicolectomy is recommended for tumors larger than 2 cm. Proper treatment for cases measuring 1-2 cm remains a matter of debate.

Trends and levels of the global, regional, and national burden of appendicitis between 1990 and 2021: findings from the Global Burden of Disease Study 2021

BACKGROUND

Appendicitis is a common surgical emergency that poses a large clinical and economic burden. Understanding the global burden of appendicitis is crucial for evaluating unmet needs and implementing and scaling up intervention services to reduce adverse health outcomes. This study aims to provide a comprehensive assessment of the global, regional, and national burden of appendicitis, by age and sex, from 1990 to 2021.

METHODS

Vital registration and verbal autopsy data, the Cause of Death Ensemble model (CODEm), and demographic estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) were used to estimate cause-specific mortality rates (CSMRs) for appendicitis. Incidence data were extracted from insurance claims and inpatient discharge sources and analysed with disease modelling meta-regression, version 2.1 (DisMod-MR 2.1). Years of life lost (YLLs) were estimated by combining death counts with standard life expectancy at the age of death. Years lived with disability (YLDs) were estimated by multiplying incidence estimates by an average disease duration of 2 weeks and a disability weight for abdominal pain. YLLs and YLDs were summed to estimate disability-adjusted life-years (DALYs).

FINDINGS

In 2021, the global age-standardised mortality rate of appendicitis was 0·358 (95% uncertainty interval [UI] 0·311-0·414) per 100 000. Mortality rates ranged from 1·01 (0·895-1·13) per 100 000 in central Latin America to 0·054 (0·0464-0·0617) per 100 000 in high-income Asia Pacific. The global age-standardised incidence rate of appendicitis in 2021 was 214 (174-274) per 100 000, corresponding to 17 million (13·8-21·6) new cases. The incidence rate was the highest in high-income Asia Pacific, at 364 (286-475) per 100 000 and the lowest in western sub-Saharan Africa, at 81·4 (63·9-109) per 100 000. The global age-standardised rates of mortality, incidence, YLLs, YLDs, and DALYs due to appendicitis decreased steadily between 1990 and 2021, with the largest reduction in mortality and YLL rates. The global annualised rate of decline in the DALY rate was greatest in children younger than the age of 10 years. Although mortality rates due to appendicitis decreased in all regions, there were large regional variations in the temporal trend in incidence. Although the global age-standardised incidence rate of appendicitis has steadily decreased between 1990 and 2021, almost half of GBD regions saw an increase of greater than 10% in their age-standardised incidence rates.

INTERPRETATION

Slow but promising progress has been observed in reducing the overall burden of appendicitis in all regions. However, there are important geographical variations in appendicitis incidence and mortality, and the relationship between these measures suggests that many people still do not have access to quality health care. As the incidence of appendicitis is rising in many parts of the world, countries should prepare their health-care infrastructure for timely, high-quality diagnosis and treatment. Given the risk that improved diagnosis may counterintuitively drive apparent rising trends in incidence, these efforts should be coupled with improved data collection, which will also be crucial for understanding trends and developing targeted interventions.

FUNDING

Bill and Melinda Gates Foundation.

Feasibility of a novel unassisted single-channel transcolonic endoscopic appendectomy for the treatment of appendiceal lesions (with video)

BACKGROUND

Transcolonic endoscopic appendectomy (TEA) is rapidly evolving and has been reported as a minimally invasive alternative to appendectomy. We aimed to characterize the feasibility and safety of a novel unassisted single-channel TEA.

METHOD

We retrospectively investigated 23 patients with appendicitis or appendiceal lesions who underwent TEA from February 2016 to December 2022. We collected clinicopathological characteristics, procedure‑related parameters, and follow‑up data and analyzed the impact of previous abdominal surgery and traction technique.

RESULTS

The mean age was 56.0 years. Of the 23 patients with appendiceal lesions, fourteen patients underwent TEA and nine underwent traction-assisted TEA (T-TEA). Eight patients (34.8%) had previous abdominal surgery. The En bloc resection rate was 95.7%. The mean procedure duration was 91.1 ± 45.5 min, and the mean wound closure time was 29.4 ± 18.6 min. The wounds after endoscopic appendectomy were closed with clips (21.7%) or a combination of clip closure and endoloop reinforcement (78.3%), and the median number of clips was 7 (range, 3-15). Three patients (13.0%) experienced major adverse events, including two delayed perforations (laparoscopic surgery) and one infection (salvage endoscopic suture). During a median follow-up of 23 months, no residual or recurrent lesions were observed, and no recurrence of abdominal pain occurred. There were no significant differences between TEA and T-TEA groups and between patients with and without abdominal surgery groups in each factor.

CONCLUSION

Unassisted single-channel TEA for patients with appendiceal lesions has favorable short- and long-term outcomes. TEA can safely and effectively treat appendiceal disease in appropriately selected cases.

A Rare Case of Breast Metastasis from a Primary Lung Tumor: Case Report

Breast metastasis originating from a primary lung tumor is exceedingly rare and can present challenges in distinguishing it from primary breast cancer. This case report discusses the management of a 64-year-old woman who initially presented with a nodule in her left breast. A biopsy revealed an infiltrating ductal carcinoma. Despite negative BRCA genetic testing, her significant family history of cancer and the presence of a newly detected right breast lesion led to a bilateral mastectomy. Post-operative imaging identified multiple hypodense nodules and a spiculated pulmonary nodule, necessitating further investigation. An endoscopic lung biopsy confirmed a primary pulmonary carcinoma with histological features similar to the breast carcinoma, suggesting the lung as the primary source. This case highlights the complexity of differentiating breast metastasis originating from a lung tumor and primary breast cancer. It underscores the importance of comprehensive diagnostic evaluations and the consideration of extramammary origins in metastatic cases. The findings emphasize the role of multidisciplinary teams in managing such rare and challenging cases and highlight the necessity for thorough and repeated assessments in atypical breast cancer presentations.

Is language a barrier in the management of acute appendicitis?

BACKGROUND

Language preference is a contributing factor for prolonged time from symptom onset to appendectomy within pediatrics, but is poorly characterized in adults. We aimed to investigate associations between language barriers and delays in assessment and treatment for adults with acute appendicitis.

METHODS

In a multiethnic community, patients aged ≥18 years old who underwent appendectomy were identified between January 2017 and August 2022 at a single institution. Negative binomial regression was used to compare interval wait times to imaging, medication administration, and surgical evaluation between patients with limited English proficiency and those who are English proficient.

RESULTS

Of the 1469 patients included, 48% (n = 699) were with limited English proficiency. Average age was higher for patients with limited English proficiency (45 vs 36, P < .001). Most of them were Asian (54%) and without private insurance (65%, P < .001). Symptom duration, incidence of septic shock, and date/time of presentation to the emergency department were similar. Patients with limited English proficiency presented more frequently with gangrenous appendicitis (20% vs 15%, P = .013) but not perforated (23% vs 20%, P = .065). They experienced longer wait times for surgical evaluation (376 vs 348 min, incidence rate ratio [IRR], 1.08; P = .002) but similar times for imaging, and medications administered. After controlling for demographics, triage acuity, and hospital factors, significantly longer wait times for surgical evaluation persisted (IRR adjusted, 1.07; P = .038). There was no significant difference in hospital length-of-stay, postoperative infection, or 30-day readmission rate.

CONCLUSION

Adult patients with limited English proficiency may experience longer wait times for surgical evaluation for acute appendicitis, but this may not result in clinically significant delays in the initiation of treatment.

Small-bowel trichobezoars with intestinal obstruction in children: three case reports and literature review

Trichobezoars are conglomerates of hair within the gastro-intestinal tract, commonly detected in the stomach, and they can present with the Rapunzel syndrome. Isolated small-bowel trichobezoars are extremely rare. Three female patients presented with abdominal pain and bilious vomiting, and underwent various imaging examinations. Two were diagnosed with small-bowel trichobezoars with intestinal obstruction and one with intestinal obstruction only. All three underwent surgery. Two underwent laparoscopic exploration and one underwent a laparotomy. One and two patients had isolated small-bowel trichobezoars in the ileum and jejunum, respectively. Two patients were followed up by a psychiatrist, and all recovered well without recurrence. These three cases emphasise the importance of a comprehensive medical history and imaging in patients with small-bowel obstruction to determine the possibility of bezoars.

Novel insights: crosstalk with non-puerperal mastitis and immunity

The two primary types of non-puerperal mastitis (NPM) are granulomatous lobular mastitis (GLM) and plasma cell mastitis (PCM). Existing research indicates that immune inflammatory response is considered to be the core of the pathogenesis of GLM and PCM, and both innate and adaptive immune responses play an important role in the pathophysiology of PCM and GLM. However, the regulatory balance between various immune cells in these diseases is still unclear. Consequently, we present a comprehensive summary of the immune-related variables and recent advances in GLM and PCM.

Acute Gastric Volvulus: A Rare Complication of Hiatal Hernia

Gastric volvulus, characterized by stomach rotation, is a rare condition arising from congenital or acquired factors. Predominantly affecting pediatric and elderly populations, it necessitates a high index of suspicion for timely diagnosis. Delayed recognition may precipitate severe complications such as ischemia, strangulation, and septic shock, often culminating in fatal outcomes. We present a case of a 71-year-old male initially admitted for suspected gastroenteritis, subsequently developing acute gastric volvulus during hospitalization, necessitating immediate surgical intervention. This case contributes to the scant literature on gastric volvulus in the elderly demographic.

Emergency Care for High-Altitude Trekking and Climbing

Introduction: High altitude regions are characterized by harsh conditions (environmental, rough terrain, natural hazards, and limited hygiene and health care), which all may contribute to the risk of accidents/emergencies when trekking or climbing. Exposure to hypoxia, cold, wind, and solar radiation are typical features of the high altitude environment. Emergencies in these remote areas place high demands on the diagnostic and treatment skills of doctors and first-aiders. The aim of this review is to give insights on providing the best possible care for victims of emergencies at high altitude. Methods: Authors provide clinical recommendations based on their real-world experience, complemented by appropriate recent studies and internationally reputable guidelines. Results and Discussion: This review covers most of the emergencies/health issues that can occur when trekking or during high altitude climbing, that is, high altitude illnesses and hypothermia, freezing cold injuries, accidents, for example, with severe injuries due to falling, cardiovascular and respiratory illnesses, abdominal, musculoskeletal, eye, dental, and skin issues. We give a summary of current recommendations for emergency care and pain relief in case of these various incidents.

Ultrasound-based deep learning radiomics nomogram for differentiating mass mastitis from invasive breast cancer

BACKGROUND

The purpose of this study is to develop and validate the potential value of the deep learning radiomics nomogram (DLRN) based on ultrasound to differentiate mass mastitis (MM) and invasive breast cancer (IBC).

METHODS

50 cases of MM and 180 cases of IBC with ultrasound Breast Imaging Reporting and Data System 4 category were recruited (training cohort, n = 161, validation cohort, n = 69). Based on PyRadiomics and ResNet50 extractors, radiomics and deep learning features were extracted, respectively. Based on supervised machine learning methods such as logistic regression, random forest, and support vector machine, as well as unsupervised machine learning methods using K-means clustering analysis, the differences in features between MM and IBC were analyzed to develop DLRN. The performance of DLRN had been evaluated by receiver operating characteristic curve, calibration, and clinical practicality.

RESULTS

Supervised machine learning results showed that compared with radiomics models, especially random forest models, deep learning models were better at recognizing MM and IBC. The area under the curve (AUC) of the validation cohort was 0.84, the accuracy was 0.83, the sensitivity was 0.73, and the specificity was 0.83. Compared to radiomics or deep learning models, DLRN even further improved discrimination ability (AUC of 0.90 and 0.90, accuracy of 0.83 and 0.88 for training and validation cohorts), which had better clinical benefits and good calibratability. In addition, the information heterogeneity of deep learning features in MM and IBC was validated again through unsupervised machine learning clustering analysis, indicating that MM had a unique features phenotype.

CONCLUSION

The DLRN developed based on radiomics and deep learning features of ultrasound images has potential clinical value in effectively distinguishing between MM and IBC. DLRN breaks through visual limitations and quantifies more image information related to MM based on computers, further utilizing machine learning to effectively utilize this information for clinical decision-making. As DLRN becomes an autonomous screening system, it will improve the recognition rate of MM in grassroots hospitals and reduce the possibility of incorrect treatment and overtreatment.

The Global Burden of Sepsis and Septic Shock

A dysregulated host response to infection causes organ dysfunction in sepsis and septic shock, two potentially fatal diseases. They continue to be major worldwide health burdens with high rates of morbidity and mortality despite advancements in medical care. The goal of this thorough review was to present a thorough summary of the current body of knowledge about the prevalence of sepsis and septic shock worldwide. Using widely used computerized databases, a comprehensive search of the literature was carried out, and relevant studies were chosen in accordance with predetermined inclusion and exclusion criteria. A narrative technique was used to synthesize the data that were retrieved. The review's conclusions show how widely different locations and nations differ in terms of sepsis and septic shock's incidence, prevalence, and fatality rates. Compared to high-income countries (HICs), low- and middle-income countries (LMICs) are disproportionately burdened more heavily. We talk about risk factors, comorbidities, and difficulties in clinical management and diagnosis in a range of healthcare settings. The review highlights the need for more research, enhanced awareness, and context-specific interventions in order to successfully address the global burden of sepsis and septic shock.

Presentation and Management of Granulomatous Mastitis in the United States: Results of an American Society of Breast Surgeons Registry Study

BACKGROUND

Granulomatous mastitis (GM) is a benign, chronic, inflammatory disease lacking clear treatment guidelines. The purpose of this American Society of Breast Surgeons (ASBrS) prospective, multisite registry was to characterize the presentation of GM and identify treatment strategies associated with symptom resolution and optimal cosmesis.

METHODS

ASBrS members entered data into a registry on patient demographics, treatment, symptoms, and cosmesis over a 1-year period. Initial symptoms were graded as mild, moderate, or severe. The Chi-square test and logistic regression were used to identify factors related to symptom improvement and cosmesis.

RESULTS

Overall, 112 patients with a mean age of 36 years were included. More patients were Hispanic (49.1%) and from the Southwest (41.1%), and management included observation (4.5%), medical (70.5%), surgical (5.4%), or combination treatment (19.6%). Immunosuppression was used in 83 patients (74.1%), including 43 patients who received intralesional steroid injections. Patients with severe symptoms were more likely to undergo surgical intervention compared with those with mild or moderate symptoms (21.4% vs. 0% and 7.5%, respectively; p = 0.004). Within 1 year, 85 patients (75.9%) experienced symptom improvement and/or resolution at a median of 3 months. Receipt of immunosuppressive therapy was predictive of improvement or resolution at 1 month (odds ratio 4.22; p = 0.045). One-year physician-assessed cosmesis was excellent or good for 20/35 patients (57.1%) and was not associated with type of treatment or symptom severity.

CONCLUSION

Although GM can have a protracted course, the majority of patients in this registry resolved within 1 year, with good cosmetic result. Treatment with immunosuppression appears to be most beneficial, and a symptom-based algorithm may be helpful to guide treatment.

Granulomatous Mastitis: An Initial Presentation of Undiagnosed Prolactinoma

Granulomatous lobular mastitis (GLM) is a rare, benign inflammatory disease of the breast that shares some physical diagnostic features with breast cancer. GLM has been rarely reported to be associated with prolactinoma. In this report, we present a case of undiagnosed prolactinoma in a 37-year-old woman with its initial presentation as GLM. We discuss the underlying pathophysiologic mechanisms for the development of GLM and the potential immunomodulatory role of prolactin in the development of GLM. We also highlight the need to assess for possible prolactinoma in GLM, which might go undiagnosed as in the case of our patient who did not seek medical attention for her amenorrhea, which is likely due to hyperprolactinemia that might also have other clinical implications on cardiovascular and bone health due to consequent estrogen deficiency.

Rare and Complicated Granulomatous Lobular Mastitis (2000-2023): A Bibliometrics Study and Visualization Analysis

Purpose

Granulomatous mastitis (GLM) is a rare and complex chronic inflammatory disease of the breast with an unknown cause and a tendency to recur. As medical science advances, the cause, treatment strategies, and comprehensive management of GLM have increasingly attracted widespread attention. The aim of this study is to assess the development trends and research focal points in the GLM field over the past 24 years using bibliometric analysis.

Methods

Using GLM, Granulomatous mastitis (GM), Idiopathic granulomatous lobular mastitis (IGLM), and Idiopathic granulomatous mastitis (IGM) as keywords, we retrieved publications related to GLM from 2000 to 2023 from the Web of Science, excluding articles irrelevant to this study. Citespace and VOSviewer were employed for data analysis and visualization.

Results

A total of 347 publications were included in this analysis. Over the past 24 years, the number of publications has steadily increased, with Turkey being the leading contributor in terms of publications and citations. The University of Health Sciences, Istanbul University, and Istanbul University Cerrahpasa were the most influential institutions. The Breast Journal, Breast Care, and Journal of Investigative Surgery were the journals that published the most on this topic. The research primarily focused on the cause, differential diagnosis, treatment, and comprehensive management of GLM. Issues related to recurrence, hyperprolactinemia, and Corynebacterium emerged as current research hotspots.

Conclusion

Our bibliometric study outlines the historical development of the GLM field and identifies recent research focuses and trends, which may aid researchers in identifying research hotspots and directions, thereby advancing the study of GLM.

Surgical and Pre-surgical Factors Affecting Appendectomy Outcomes in Jeddah, Saudi Arabia: A Retrospective Record Review

BACKGROUND

Appendectomy is the preferred treatment for acute uncomplicated appendicitis and the most common emergency abdominal surgery. While previous studies have investigated variables affecting post-appendectomy complications, local research is limited, and data on complication rates are scarce. Therefore, this study aimed to investigate appendectomy outcomes and the factors influencing them.

METHODS

This retrospective record review included all patients who underwent appendectomies at our center between 2013 and 2023, excluding those who underwent appendectomies as part of other procedures. Data were retrieved from the hospital database and recorded on predesigned Google Forms.

RESULTS

A total of 556 patients were included. Complications occurred in 60 patients (10.8%); the most common included intra-abdominal collections (n=19, 3.4%), postoperative fever (n=13, 2.3%), and surgical site infections (n=11, 2.0%). The most frequently documented histopathological diagnoses included acute appendicitis (n=402, 72.3%), perforated appendicitis (n=109, 19.6%), and gangrenous appendicitis (n=19, 4.4%). Surgical site infection rates were higher after open appendectomies (6.0% vs. 0.9%, P=0.006), while intra-abdominal collections were more frequent after laparoscopic appendectomies (4.1% vs. 0.0%, P=0.095). Additionally, histopathology results showing complicated or chronic appendicitis were associated with higher complication rates (P<0.001, odds ratio=3.793, 95% confidence interval=1.957-7.350).

CONCLUSION

To the best of our knowledge, this is the largest retrospective review of appendectomy cases in Saudi Arabia. However, this study was conducted in a tertiary care center, which may have caused the rates of complications to appear lower than those in primary centers. We recommend a multi-center study be conducted to establish more accurate results.

Refractory and Recurrent Idiopathic Granulomatous Mastitis Treatment: Adaptive, Randomized Clinical Trial

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is mostly described as an autoimmune disease with higher prevalence among Middle Eastern childbearing-age women. This study aimed to evaluate the best treatment of choice in patients with resistant or recurrent IGM.

STUDY DESIGN

Patients with established recurrent or resistant IGM who were referred to the Breast Cancer Research Center from 2017 to 2020 were randomly assigned to either one of the following treatment groups: A (best supportive care), B (corticosteroids: prednisolone), and C (methotrexate and low-dose corticosteroids). This adaptive clinical trial evaluated radiological and clinical responses, as well as the potential side effects, on a regular basis in each group, with patients followed up for a minimum of 2 years.

RESULTS

A total of 318 participants, with a mean age of 33.52 ± 6.77 years, were divided into groups A (10 patients), B (78 patients), and C (230 patients). In group A, no therapeutic response was observed; group B exhibited a mixed response, with 14.1% experiencing complete or partial responses, 7.7% maintaining stability, and 78.2% experiencing disease progression. Accordingly, groups A and B were terminated due to inadequate response. In group C, 94.3% achieved complete response, 3% showed partial remission, and 2.7% had no response to therapy. Among the entire patient cohort, 11.6% tested positive for antinuclear antibodies, 3.5% for angiotensin-converting enzyme, and 12.3% for erythema nodosum. Notably, hypothyroidism was a prevalent condition among the patients, affecting 7.2% of the cohort. The incidence of common side effects was consistent across all groups.

CONCLUSIONS

The most effective treatment option for patients with recurrent or resistant IGM is a combination therapy involving steroids and disease-modifying antirheumatic drugs such as methotrexate.

Imiquimod as a new treatment in refractory idiopathic granulomatous mastitis: report of two cases

INTRODUCTION

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory lesion of the breast that mimics breast cancer or infection. Immunological pathogenesis is strongly suggested for the disease.

REASON FOR THE REPORT

The treatment remains controversial, comprising a spectrum from observation or NSAIDs to immunosuppressive agents and surgery. Intractable cases are not uncommon and represent a major treatment challenge. Therefore in this study, we examine the effect of a topical immunomodulator agent, imiquimod, on refractory IGM. Patient 1 had IGM for 9 months and had not responded to the existing treatments. She responded to a 7-week course of imiquimod. In patient 2, the disease had begun 4 months sooner and had been resistant to all treatments; it responded to imiquimod after 4 weeks. Ulcers appeared on the skin of both patients but resolved safely.

OUTCOME

Both patients were very satisfied with the results. Imiquimod can be an appropriate local treatment with limited adverse effects in refractory IGM. We propose similar studies to assess the efficacy of imiquimod in IGM further, paying attention to the possibility of developing skin wounds.

A meta-analysis of idiopathic granulomatous mastitis treatments for remission and recurrence prevention

Purpose

The major aim of our meta-analysis was to review the effectiveness of various treatment modalities for achieving successful remission and preventing recurrence for women with idiopathic granulomatous mastitis (IGM). This knowledge is instrumental in developing evidence-based guidelines for clinicians to improve management strategies and outcomes for patients with IGM.

Methods

A systematic literature search was performed on MEDLINE (Ovid), Embase (Elsevier), PubMed, Cochrane Library, Web of Science, and Google Scholar; studies published to 19 January 2022 were included. A meta-analysis of 57 observational studies was performed. The results of two randomized controlled trials were also examined.

Results

There were 3,035 IGM patients across the observational and randomised studies. Overall recurrence and remission rates across all treatment strategies in 59 studies are 87.9% (2,667/3035) and 13.5% (359/2667), respectively. The studies reported 19 different treatment strategies, comprising observation, medical monotherapies, surgery, and combinations involving medical therapies, with and without surgery. Among monotherapy treatment, surgical management had the highest pooled remission rate (0.99 [95% confidence interval (CI) = 0.97-1.00]); among combination therapy, this was steroids and surgery (0.99 [0.94-1.00]). Antibiotic monotherapy had the lowest remission rate (0.72 [0.37-0.96]). The highest recurrence rates belonged to treatments that combined antibiotics and surgery (0.54 [0.02-1.00]), and antibiotics, steroids, and surgery (0.57 [0.00-1.00]). Most successful for preventing recurrence were observation (0.03 [0.00-0.10]), methotrexate (0.08 [0.00-0.24]), and steroids and surgery (0.05 [0.01-0.12]). There is a significant association between longer follow-up duration and recurrence rate reported, p = 0.002.

Conclusion

Combination therapies, especially those incorporating antibiotics, steroids, and surgery, have demonstrated higher remission rates, challenging the use of antibiotic monotherapy. There is an increased emphasis on the need for personalised, multi-pronged approach for preventing IGM recurrence, with longer follow-up care. More prospective future work in IGM research, with standardised diagnostic criteria, treatment protocols, and reporting guidelines will be important for developing treatment protocols and guidelines clinicians can adhere to in the clinical management of IGM patients.Systematic review registration: PROSPERO (CRD42022301386).

Controversies and Future Directions in Management of Acute Appendicitis: An Updated Comprehensive Review

Globally, acute appendicitis has an estimated lifetime risk of 7-8%. However, there are numerous controversies surrounding the management of acute appendicitis, and the best treatment approach depends on patient characteristics. Non-operative management (NOM), which involves the utilization of antibiotics and aggressive intravenous hydration, and surgical appendectomy are valid treatment options for healthy adults. NOM is also ideal for poor surgical candidates. Another important consideration is the timing of surgery, i.e., the role of interval appendectomy (IA) and the possibility of delaying surgery for a few hours on index admission. IA refers to surgical removal of the appendix 8-12 weeks after the initial diagnosis of appendicitis. It is ideal in patients with a contained appendiceal perforation on initial presentation, wherein an initial nonoperative approach is preferred. Furthermore, IA can help distinguish malignant and non-malignant causes of acute appendicitis, while reducing the risk of recurrence. On the contrary, a decision to delay appendectomy for a few hours on index admission should be made based on the patients' baseline health status and severity of appendicitis. Post-operatively, surgical drain placement may help reduce postoperative complications; however, it carries an increased risk of drain occlusion, fistula formation, and paralytic ileus. Furthermore, one of the most critical aspects of appendectomy is the closure of the appendiceal stump, which can be achieved with the help of endoclips, sutures, staples, and endoloops. In this review, we discuss different aspects of management of acute appendicitis, current controversies in management, and the potential role of endoscopic appendectomy as a future treatment option.

Bilateral Metastatic Gynecomastia from Small-Cell Lung Tumors in a Man: A Report of a Rare Case

A case of a man with the recent onset of painful bilateral firm gynecomastia is reported. Mammography confirmed increased breast density. Biopsy characterized both masses as metastases of a small-cell lung tumor. This case highlights the atypical presentation and complements the literature regarding the rarity of breast metastases from small-cell lung cancer in men. Teaching point: Bilateral gynecomastia in a man with a long history of cigarette smoking should be considered with caution.

Factors Affecting Survival Outcomes in Neuroendocrine Tumor of the Appendix over the Past Two Decades

BACKGROUND

Appendiceal neuroendocrine tumors (NETs) rank as the third most frequent neoplasm affecting the appendix, originating from enterochromaffin cells. This study aims to evaluate the influence of various prognostic factors on the mortality rates of patients diagnosed with NETs of the appendix.

METHODS

Conducted retrospectively, the study involved 3346 patients, utilizing data sourced from the Surveillance, Epidemiology, and End Results (SEER) database. Our analysis centered on investigating demographic characteristics, clinical features, overall mortality (OM), and cancer-specific mortality (CSM) among the cohort. Variables showing a p-value < 0.1 in the univariate Cox regression were incorporated into the multivariate Cox regression analysis. A Hazard Ratio (HR) > 1 indicated an unfavorable prognosis.

RESULTS

In the multivariate analysis, higher OM and CSM were observed in males, older age groups, tumors with distant metastasis, poorly differentiated tumors, and those who underwent chemotherapy. Non-Hispanic Black individuals showed elevated mortality rates.

CONCLUSION

Delayed diagnosis may contribute to the increased mortality in this community. Improved access to healthcare and treatment is crucial for addressing these disparities. Larger prospective studies are needed to pinpoint the underlying causes of elevated mortality in non-Hispanic Black populations, and randomized controlled trials (RCTs) are warranted to evaluate therapies for advanced-stage appendix NETs.

Two Days Versus Five Days of Postoperative Antibiotics for Complex Appendicitis: Cost Analysis of a Randomized, Noninferiority Trial

OBJECTIVE

To compare costs for 2 days versus 5 days of postoperative antibiotics within the antibiotics after an aPPendectomy In Complex appendicitis trial.Background:Recent studies suggest that restrictive antibiotic use leads to a significant reduction in hospital stays without compromising patient safety. Its potential effect on societal costs remains underexplored.

METHODS

This was a pragmatic, open-label, multicenter clinical trial powered for noninferiority. Patients with complex appendicitis (age ≥ 8 years) were randomly allocated to 2 days or 5 days of intravenous antibiotics after appendectomy. Patient inclusion lasted from June 2017 to June 2021 in 15 Dutch hospitals. The final follow-up was on September 1, 2021. The primary trial endpoint was a composite endpoint of infectious complications and mortality within 90 days. In the present study, the main outcome measures were overall societal costs (comprising direct health care costs and costs related to productivity loss) and cost-effectiveness. Direct health care costs were recorded based on data in the electronic patient files, complemented by a telephone follow-up at 90 days. In addition, data on loss of productivity were acquired through the validated Productivity Cost Questionnaire at 4 weeks after surgery. Cost estimates were based on prices for the year 2019.

RESULTS

In total, 1005 patients were evaluated in the "intention-to-treat" analysis: 502 patients were allocated to the 2-day group and 503 to the 5-day group. The mean difference in overall societal costs was - €625 (95% CI: -€ 958 to -€ 278) to the advantage of the 2-day group. This difference was largely explained by reduced hospital stay. Productivity losses were similar between the study groups. Restricting postoperative antibiotics to 2 days was cost-effective, with estimated cost savings of €31,117 per additional infectious complication.

CONCLUSIONS

Two days of postoperative antibiotics for complex appendicitis results in a statistically significant and relevant cost reduction, as compared with 5 days. Findings apply to laparoscopic appendectomy in a well-resourced health care setting.

Volvulus is Stressful: Stress-Induced Cardiomyopathy Secondary to Gastric Volvulus and Paraesophageal Hernia

Stress-induced cardiomyopathy (SCM) is a cardiac systolic dysfunction caused by various stressful triggers. It is often transient and reversible upon the reversal of the underlying stressor. We present the case of a 70-year-old female with SCM in the setting of gastric volvulus and incarcerated para-esophageal hernia.

Appendectomy versus antibiotic treatment for acute appendicitis

BACKGROUND

Acute appendicitis is one of the most common emergency general surgical conditions worldwide. Uncomplicated/simple appendicitis can be treated with appendectomy or antibiotics. Some studies have suggested possible benefits with antibiotics with reduced complications, length of hospital stay, and the number of days off work. However, surgery may improve success of treatment as antibiotic treatment is associated with recurrence and future need for surgery.

OBJECTIVES

To assess the effects of antibiotic treatment for uncomplicated/simple acute appendicitis compared with appendectomy for resolution of symptoms and complications.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and two trial registers (World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov) on 19 July 2022. We also searched for unpublished studies in conference proceedings together with reference checking and citation search. There were no restrictions on date, publication status, or language of publication.

SELECTION CRITERIA

We included parallel-group randomised controlled trials (RCTs) only. We included studies where most participants were adults with uncomplicated/simple appendicitis. Interventions included antibiotics (by any route) compared with appendectomy (open or laparoscopic).

DATA COLLECTION AND ANALYSIS

We used standard methodology expected by Cochrane. We used GRADE to assess the certainty of evidence for each outcome. Primary outcomes included mortality and success of treatment, and secondary outcomes included number of participants requiring appendectomy in the antibiotic group, complications, pain, length of hospital stay, sick leave, malignancy in the antibiotic group, negative appendectomy rate, and quality of life. Success of treatment definitions were heterogeneous although mainly based on resolution of symptoms rather than incorporation of long-term recurrence or need for surgery in the antibiotic group.

MAIN RESULTS

We included 13 studies in the review covering 1675 participants randomised to antibiotics and 1683 participants randomised to appendectomy. One study was unpublished. All were conducted in secondary care and two studies received pharmaceutical funding. All studies used broad-spectrum antibiotic regimens expected to cover gastrointestinal bacteria. Most studies used predominantly laparoscopic surgery, but some included mainly open procedures. Six studies included adults and children. Almost all studies aimed to exclude participants with complicated appendicitis prior to randomisation, although one study included 12% with perforation. The diagnostic technique was clinical assessment and imaging in most studies. Only one study limited inclusion by sex (male only). Follow-up ranged from hospital admission only to seven years. Certainty of evidence was mainly affected by risk of bias (due to lack of blinding and loss to follow-up) and imprecision. Primary outcomes It is uncertain whether there was any difference in mortality due to the very low-certainty evidence (Peto odds ratio (OR) 0.51, 95% confidence interval (CI) 0.05 to 4.95; 1 study, 492 participants). There may be 76 more people per 1000 having unsuccessful treatment in the antibiotic group compared with surgery, which did not reach our predefined level for clinical significance (risk ratio (RR) 0.91, 95% CI 0.87 to 0.96; I2 = 69%; 7 studies, 2471 participants; low-certainty evidence). Secondary outcomes At one year, 30.7% (95% CI 24.0 to 37.8; I2 = 80%; 9 studies, 1396 participants) of participants in the antibiotic group required appendectomy or, alternatively, more than two-thirds of antibiotic-treated participants avoided surgery in the first year, but the evidence is very uncertain. Regarding complications, it is uncertain whether there is any difference in episodes of Clostridium difficile diarrhoea due to very low-certainty evidence (Peto OR 0.97, 95% CI 0.24 to 3.89; 1 study, 1332 participants). There may be a clinically significant reduction in wound infections with antibiotics (RR 0.25, 95% CI 0.09 to 0.68; I2 = 16%; 9 studies, 2606 participants; low-certainty evidence). It is uncertain whether antibiotics affect the incidence of intra-abdominal abscess or collection (RR 1.58, 95% CI 0.61 to 4.07; I2 = 19%; 6 studies, 1831 participants), or reoperation (Peto OR 0.13, 95% CI 0.01 to 2.16; 1 study, 492 participants) due to very low-certainty evidence, mainly due to rare events causing imprecision and risk of bias. It is uncertain if antibiotics prolonged length of hospital stay by half a day due to the very low-certainty evidence (MD 0.54, 95% CI 0.06 to 1.01; I2 = 97%; 11 studies, 3192 participants). The incidence of malignancy was 0.3% (95% CI 0 to 1.5; 5 studies, 403 participants) in the antibiotic group although follow-up was variable. Antibiotics probably increased the number of negative appendectomies at surgery (RR 3.16, 95% CI 1.54 to 6.49; I2 = 17%; 5 studies, 707 participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

Antibiotics may be associated with higher rates of unsuccessful treatment for 76 per 1000 people, although differences may not be clinically significant. It is uncertain if antibiotics increase length of hospital stay by half a day. Antibiotics may reduce wound infections. A third of the participants initially treated with antibiotics required subsequent appendectomy or two-thirds avoided surgery within one year, but the evidence is very uncertain. There were too few data from the included studies to comment on major complications.

Ultrasound-guided microwave ablation for the treatment of idiopathic granulomatous mastitis: comparison with surgical excision

BACKGROUND

Idiopathic granulomatous mastitis (IGM) results in notable clinical symptoms and breast deformity. This study aimed to evaluate the clinical feasibility of microwave ablation (MWA) for the treatment of IGM through comparison with surgical excision.

METHODS

From June 2016 to December 2020, a total of 234 consecutive patients admitted to the hospital were retrospectively included in this study. IGM was pathologically confirmed via breast biopsy in all included patients. These patients were divided into the MWA group (n = 91) and surgical group (n = 143) based on the type of treatment. Patients in both groups received oral prednisone prior to intervention. The clinical remission rate, recurrence rate, operative pain, complications, and BREAST Q score were compared between the two groups.

RESULTS

There were 340 lesions in the MWA group, and 201 lesions in the surgical group were ultimately included. Significant differences in the complete remission rate (96.7% vs. 86.7%, p = 0.020), recurrence rate (3.3% vs. 13.3%, p = 0.020), operation time (48.7±14.6 min vs. 68.1±36.4 min, p < 0.001), postoperative pain (p < 0.001) and postoperative BREAST Q score (p < 0.001) were observed between the MWA and surgical groups.

CONCLUSIONS

Microwave ablation is feasible for the treatment of IGM, due to its high curative rate and low recurrence rate. Because of the minimal invasiveness of MWA and sufficient preservation of the gland and contour of the breast, patients are more satisfied with the appearance of the breast. Therefore, for patients with complex conditions requiring surgery, MWA is a good alternative treatment.

Is pelvic ultrasound useful in the clinical assessment and management of women with right iliac fossa pain? A single-centre retrospective study

INTRODUCTION

Acute right iliac fossa (RIF) pain is a common presenting symptom in surgical patients, with a wide range of differentials, particularly in premenopausal females. This study explores ultrasound usage in the management of women aged 16-55 years presenting with RIF pain.

METHODS

A total of 1,082 patients who presented to a tertiary hospital over 12 months were included. Data were collected from patients' electronic records, including initial clinical impression, imaging, management, operative findings, histology and subsequent hospital attendances within 6 weeks and within 6 months.

RESULTS

Following clinical assessment, 607 (56%) of patients underwent an ultrasound. Of these, 280 (25.9%) patients received no radiological imaging on initial presentation, and 252 (42%) had pathology identified on ultrasound. The most common finding was an ovarian cyst, closely followed by unexplained free pelvic fluid. Of the 607 patients scanned, 29 (4.8%) had an ultrasound diagnosis of appendicitis; 254 of 1,082 (23.5%) patients underwent operative management. Of the 254 patients who had surgery, 179 (70.5%) had preoperative imaging. Of the 29 (11.4%) cases where the intraoperative finding was gynaecological, 15 (51.7%) cases had not had any preoperative imaging. The negative appendicectomy rate was 21.3% (45/211). Of the 45 patients who had a histologically normal appendix, 22 (48.9%) had not had any previous imaging. Ultrasound had a specificity of 78% for diagnosing appendicitis.

CONCLUSIONS

In patients who underwent operative management, a negative finding or finding not requiring surgical management was associated with no preoperative imaging. This supports the use of ultrasound scans as an adjunct in a multimodal approach to the assessment of women presenting with RIF pain.

The Diagnostic Value of Biomarkers in Acute Mesenteric Ischaemia Is Insufficiently Substantiated: A Systematic Review

OBJECTIVE

There is an urgent need for accurate biomarkers to support timely diagnosis of acute mesenteric ischaemia (AMI) and thereby improve clinical outcomes. With this systematic review, the aim was to substantiate the potential diagnostic value of biomarkers for arterial occlusive AMI.

DATA SOURCES

The Pubmed, Embase, and the Cochrane Library electronic databases were searched.

REVIEW METHODS

A systematic review of the literature has been conducted to define the potential diagnostic value of biomarkers for arterial occlusive AMI. All studies including ≥ 10 patients describing biomarkers for macrovascular occlusive AMI between 1950 and 17 February 2023 were identified within the Pubmed, Embase, and the Cochrane Library electronic databases. There were no restrictions to any particular study design, but letters and editorials were excluded. The QUADAS-2 tool was used for the critical appraisal of quality. The study protocol was registered on Prospero (CRD42021254970).

RESULTS

Fifty of 4334 studies were eligible for inclusion in this review. Ninety per cent of studies were of low quality. A total of 60 biomarkers were identified, with 24 in two or more studies and 15 in five or more studies. There was variation in reported units, normal range, and cut off values. Meta-analysis was not possible due to study heterogeneity. Biomarkers currently recommended by the European Journal of Vascular and Endovascular Surgery, European Society for Trauma and Emergency Surgery 2016, and World Society of Emergency Surgery 2017 guidelines also had heterogeneous low quality data for use in the diagnosis of AMI.

CONCLUSION

This systematic review demonstrates high heterogeneity and low quality of the available evidence on biomarkers for arterial occlusive AMI. No clinical conclusions can be drawn on a biomarker or combination of biomarkers for patients suspected of arterial occlusive AMI. Restraint is advised when rejecting or determining AMI solely based on biomarkers.

CT of appendicoliths in adult appendicitis: clinical significance and characteristics of overlooked cases

OBJECTIVES

Accurate computed tomography (CT) identification of appendicoliths in adults with acute appendicitis is crucial as it may preclude nonoperative management due to high risk of failure and complications. This investigation aimed to identify the significance of appendicoliths in acute appendicitis and to evaluate the performance of portovenous-phase (PVP) CT and the consequences of overlooked appendicoliths.

METHODS

CT examinations of 324 consecutive patients (mean age 51.9 years, 112 men) with pathologically confirmed acute appendicitis were retrospectively included. Two radiologists independently reviewed the images, and disagreement was resolved by a consensus.

RESULTS

Appendicoliths were identified in 134/324 patients, of which 75 had complicated appendicitis. Among 190 patients without appendicoliths, 52 had complicated appendicitis. An appendicolith was independently associated with complicated appendicitis (adjusted odds ratio 2.289; 95% CI: 1.343-3.902; p = 0.002). The larger minimum diameter was significantly associated with complication. The 4.5-/6.0-mm cutoffs for minimum and maximum diameters of appendicoliths demonstrated 82.7%/85.3% sensitivity and 35.6%/33.9% specificity in predicting complications. The PVP alone had 82.1-88.1% sensitivity, respectively per patient and per appendicolith, and a 100% specificity in the detection of appendicoliths, as compared with combined noncontrast and PVP. PVP overlooked 28/237 appendicoliths (11.8%) corresponding to 24/134 patients (17.9%). Of the 24 patients with overlooked appendicoliths, 16 had complicated appendicitis but 14 were correctly categorized by findings other than appendicoliths. In total, 2/127 patients (1.6%) with complicated appendicitis were misdiagnosed as having uncomplicated appendicitis.

CONCLUSIONS

Appendicoliths in acute appendicitis were strongly associated with complications. While PVP overlooked some appendicoliths, only 1.6% of complicated appendicitis were misclassified when considering other CT findings.

CLINICAL RELEVANCE STATEMENT

This study found a strong association between appendicoliths and complications. Its presence may preclude conservative management. Although portovenous-phase CT overlooked some appendicoliths, the combination with other CT findings allowed correct classification in a vast majority of cases.

KEY POINTS

• Accurate identification of appendicoliths is crucial for nonoperative management decisions in adult acute appendicitis. • Appendicoliths are strongly associated with complications in adult acute appendicitis. • Portovenous-phase CT overlooked some appendicoliths, but only a small percentage of patients with complicated appendicitis were misclassified when considering other CT findings.

Treatment modalities for granulomatous mastitis, seeking the most appropriate treatment with the least recurrence rate: a systematic review and meta-analysis

BACKGROUND

Granulomatous mastitis (GM) is a rare, benign, inflammatory breast disease with an unknown etiology that predominantly affects women of reproductive age. The definitive treatment of GM is currently controversial; an appropriate therapeutic strategy has yet to be identified, and the disease's high recurrence rate remains. This study aims to determine the recurrence rate for each GM treatment strategy to identify the most appropriate treatment modality.

METHODS

The search for relevant articles was undertaken using three international databases, including Medline, Scopus, and Web of Science. Articles published in English until the end of 2021 evaluating the recurrence rate of GM were included. Using Stata 13.0, the pooled incidence and 95% confidence interval (CI) for the recurrence rate were determined.

RESULTS

Sixty-five eligible studies were included in our study. The recurrence rates of systemic steroid use, topical steroid use, antibiotic use, methotrexate use, observation, drainage, excision, antibiotic use and surgery, steroid use and surgery, antibiotic and steroid use, methotrexate and steroid use were 24% (95% CI: 21-27%), 11% (95% CI: 6-21%), 18% (95% CI: 14-22%), 13% (95% CI: 7-22%), 11% (95% CI: 7-17%), 65% (95% CI: 50-78%), 13% (95% CI: 10-16%), 23% (95% CI: 14-36%), 7% (95% CI: 5-11%), 11% (95% CI: 6-18%), and 4% (95% CI: 2-8%), respectively. Drainage had the highest recurrence rate, while combined methotrexate and steroid treatment had the lowest rate.

CONCLUSION

The optimal treatment strategy for GM depends on the disease's severity, consequences, and the patient's features. The study results indicate that combination therapy is preferable for minimizing the risk of relapse and reducing treatment complications.

Causative microbes and antibiotic susceptibility of acute appendicitis in adults and children

BACKGROUND

In recent years, some studies have found that acute uncomplicated appendicitis can be treated with antibiotics alone. Because of the lack of relevant research on treating acute appendicitis in Taiwan, this study investigated the microbiological characteristics of acute appendicitis to permit accurate empirical antibiotic use for uncomplicated appendicitis.

METHODS

In this single-center retrospective cohort study, patients listed in the Taiwan National Health Insurance Research Database with a discharge diagnosis of acute appendicitis were identified. Data for bacterial specimens and antibiotic susceptibility tests among patients treated at Tri-Service General Hospital between January 2016 and December 2021 were analyzed.

RESULTS

Among 2805 patients diagnosed with acute appendicitis, 167 (6%) were <18 years old. The culture positivity rates among children and adults were 33% and 18%, respectively. In total, 367 aerobes and 207 anaerobes were isolated. The predominant aerobic gram-positive coccus was viridans group streptococci (8.9%), the most common aerobic gram-negative bacillus was Escherichia coli (27.9%), and the most common anaerobic microorganism was Bacteroides spp. (27.7%). The results of antibiotic susceptibility testing of the predominant microorganisms revealed that 86.3% of gram-positive aerobes were susceptible to ampicillin, 76.3% of gram-negative aerobes were susceptible to gentamicin, and all anaerobic isolates were susceptible to metronidazole.

CONCLUSION

Triple first-line antibiotic combination therapy, including ampicillin, gentamicin, and metronidazole, remains highly effective against the pathogens that cause acute appendicitis.

Misdiagnosis of Acute Appendicitis Cases in the Emergency Room

Acute appendicitis (AA) is one of the most frequent surgical emergencies, especially in pediatric populations, with its misdiagnosis in emergency settings presenting significant health risks. This misdiagnosis leads to various complications, such as delayed treatment or unnecessary surgeries. Factors such as age, gender, and comorbidities contribute to diagnostic errors, leading to complications such as peritonitis and increased negative appendectomy rates. This underscores the importance of accurate clinical assessment and awareness of common pitfalls, such as cognitive biases and over-reliance on laboratory tests. This review delves into the prevalence of AA misdiagnosis, its health burden, and the challenges inherent in the diagnostic process. It scrutinizes the effectiveness of different diagnostic approaches, including clinical assessment and imaging techniques. The treatment paradigms for AA are also explored, focusing on surgical interventions and the potential of conservative treatments using antibiotics. The review underscores the criticality of precise diagnosis in preventing adverse outcomes and ensuring effective treatment.

Staged operation in the surgical treatment of granulomatous lobular mastitis

Background

Granulomatous lobular mastitis (GLM) is a chronic inflammatory breast condition characterized by an unclear etiology and an undefined therapeutic approach. Surgical intervention is considered an alternative modality for managing GLM. Staged operation is the predominant and characteristic surgical approach in the treatment of GLM in our center; therefore, we evaluated the efficacy of staged operative techniques in this cohort study.

Methods

We retrospectively reviewed 212 patients with GLM who underwent staged operation between August 2020 and July 2022 in the inpatient department of our institute. Their clinical history information, clinic complaints, treatment details, surgical outcomes, follow-up results, and scores on the satisfaction questionnaire were analyzed. The patients were called for follow-up and consultation with a deadline of August 2023.

Results

The median follow-up time was 27 months (range, 14-37 months). In total, 212 patients were treated with three different staged procedures according to the individual assessment and patient willingness, including 168 patients who underwent one-stage debridement operation and two-stage suture operation (DO + SO), 25 patients who underwent one-stage debridement operation without suture (DO), and 19 patients who underwent one-stage debridement and simultaneous suture operation (DSO). The median recovery time was 29 days (range, 14-60 days). A minority of patients developed postoperative complications, including effusion (1.89%), flap ischemia (0.94%), areola-nipple ischemia (0.94%) and sinus tract formation (2.36%). The scores of the satisfaction questionnaire were 43.10±3.09, and 186 patients (87.74%) gave high scores for postoperative breast appearance. Only 5 of 212 patients (2.36%) developed recurrence.

Conclusions

Staged operation performed in our institute is an effective and safe surgical therapy in patients with GLM, yielding a short recovery time, low recurrence and good cosmetic results.

Outcome of Laparoscopic Versus Open Appendectomy for Acute Appendicitis-Results of a Propensity Score Matching Analysis of 542 Patients and Consequences for the Military Surgeon

INTRODUCTION

Appendectomy is the treatment of choice for acute appendicitis. The procedure can be performed open or laparoscopically. However, laparoscopy is not available on military missions abroad. It is unclear whether treatment outcomes differ between the two surgical approaches.

MATERIALS AND METHODS

Treatment data of all patients undergoing open and laparoscopic appendectomies in the German Armed Forces Hospital of Ulm from 2013 to 2017 were collected retrospectively. A propensity score matching analysis was performed to minimize the influence of potential confounders and to assess the influence of surgical approach on outcome (reoperations, superficial and deep surgical infections, length of postoperative ileus, need for intravenous analgesics, and operative time).

RESULTS

A total of 542 patients with complete datasets were included in the propensity score matching analysis, among these 64 with open and 478 laparoscopic procedures. There were no statistically significant differences between open and laparoscopic surgeries with respect to all outcome variables, with the exception of a 25-minute prolonged operative time for the open approach.

CONCLUSIONS

Open appendectomy can be considered equivalent in outcome to the laparoscopic procedure and thus can be performed on military missions abroad without compromising outcome. Military surgeons must continue to be trained and confident in open appendectomy.

Gastrointestinal trichobezoars in the pediatric population: a retrospective study

BACKGROUND

Trichobezoar is an extremely rare condition characterized by a foreign body in the gastrointestinal tract (GIT) among children. The foreign body may exist in the digestive tract for several years, and it becomes evident if complications develop. The current study aimed to present 21 cases of GIT trichobezoars.

METHODS

Retrospective analysis of children who were diagnosed with trichobezoars between August 2012 and December 2022. Patient demographics, clinical presentation, diagnosis, and therapy were collected and analyzed.Twenty-one patients had GIT trichobezoars. Data were collected and analyzed retrospectively.

RESULTS

Twenty-one patients were identified. All patients were female. Their mean age at admission was 8.9 ± 1.9 years. Furthermore, 19 (90.5%) patients presented with abdominal pain, 16 (76.2%) with vomiting, and 13 (61.9%) with a palpable mass. Sixteen patients underwent gastroduodenoscopy. Among them, 15 had gastric trichobezoars. Moreover, 12 patients underwent computed tomography scan. Eight patients presented with gastric and small intestinal BZs, one presented with increased small intestinal contents with dilation, and one presented with abundant gastric contents. Then, 20 patients underwent surgery. Among them, five underwent laparoscopic-assisted minilaparotomy (LAML), and the rest underwent laparotomy. The results showed that 10 (50%) patients had gastric trichobezoars; 7 (35%), Rapunzel syndrome; and 3 (15%), small bowel trichobezoars. Two patients developed superficial wound infection postoperatively. One patient had a recurrent gastric trichobezoar.

CONCLUSION

Trichobezoar should be considered in young girls with a history of hair eating or those with hair in the vomit or feces. Timely diagnosis and aggressive treatment are the keys to reducing complications and improving prognosis. Laparoscopic-assisted minilaparotomy is a safe, feasible, and effective surgical method for treating trichobezoars.

"Bezoar Egg"-A Rare Cause of Small Bowel Obstruction

Small bowel obstruction is a frequent medical condition with various causes, the most common being postoperative adhesions, volvulus, intussusception, hernias, and tumors. A bezoar-induced blockage of the small intestine is a rare condition that accounts for approximately 4% of all small bowel obstruction cases. Herein, we present the case report of a 71-year-old patient with diffuse abdominal pain caused by a small bowel obstruction due to a calcified bezoar (bezoar egg) resulting from a post-radiation intestinal stricture. The patient underwent a small bowel excision with the extraction of the bezoar, after which a full recovery was made.

Small bowel obstruction caused by dehydrated apple ingestion: the challenges of preoperative radiological diagnosis and surgical management

A man in his 60s with a virgin abdomen presented with sudden-onset generalised abdominal pain and fevers. The night prior, he snacked on supermarket purchased dehydrated apples. CT abdomen and pelvis revealed small bowel obstruction (SBO) to the mid ileum and small amount of free fluid within the pelvis. The patient underwent emergency exploratory laparotomy. High-grade SBO was identified, caused by large obstructing phytobezoars, with three further proximal large phytobezoars identified. All four phytobezoars were extracted and found to be rehydrated pieces of dehydrated apple that had increased in size in the gastrointestinal tract. The patient was later found to have further phytobezoars in the stomach which passed conservatively. The patient recovered well. This case demonstrates the challenges of preoperative radiological diagnosis in phytobezoar-related SBO and the significance of enterotomy orientation and closure to ensure a safe repair to withstand the passage of any residual rehydrating phytobezoars.

Sesquiterpene from Artemisia argyi seed extracts: A new anti-acute peritonitis agent that suppresses the MAPK pathway and promotes autophagy

To find novel anti-inflammatory drugs, we screened anti-inflammatory compounds from 18 different types of Artemisia argyi seed extracts. The in vitro and in vivo anti-inflammatory activities of the screened compounds and their mechanisms were characterized. We first detected the cytotoxic effect of the compounds on RAW264.7 cells and the inhibitory effect on LPS-induced NO release. It was found that sesquiterpenoids CA-2 and CA-4 had low cytotoxic and strong NO inhibitory activity with an IC50 of 4.22 ± 0.61 μM and 2.98 ± 0.23 μM for NO inhibition, respectively. Therefore, compound CA-4 was studied in depth. We found that compound CA-4 inhibited LPS-induced pro-inflammatory factor production and M1 macrophage differentiation in RAW264.7 cells. Additionally, CA-4 inhibited the expression of p-ERK1/2, p-JNK, iNOS, and COX-2 by blocking the MAPK signaling pathway. CA-4 also promoted the expression of autophagy-related proteins such as LC3 II and Beclin-1 by inhibiting activation of the PI3K/AKT/mTOR signaling pathway, and promoted the generation of autophagosomes. Finally, CA-4 significantly inhibited the degree of inflammation in mice with acute peritonitis, showing good anti-inflammatory activity in vivo. Consequently, compound CA-4 may be a promising drug for the treatment of acute inflammatory diseases and provide new ideas for the synthesis of novel anti-inflammatory compounds.

Construction of a Multi-Indicator Model for Abscess Prediction in Granulomatous Lobular Mastitis Using Inflammatory Indicators

Background

Granulomatous lobular mastitis (GLM) is a chronic inflammatory breast disease, and abscess formation is a common complication of GLM. The process of abscess formation is accompanied by changes in multiple inflammatory markers. The present study aimed to construct a diagnosis model for the early of GLM abscess formation based on multiple inflammatory parameters.

Methods

Based on the presence or absence of abscess formation on breast magnetic resonance imaging (MRI), 126 patients with GLM were categorised into an abscess group (85 patients) and a non-abscess group (41 patients). Demographic characteristics and the related laboratory results for the 9 inflammatory markers were collected. Logistics univariate analysis and collinearity test were used for selecting independent variables. A regression model to predict abscess formation was constructed using Logistics multivariate analysis.

Results

The univariate and multivariate analysis showed that the N, ESR, IL-4, IL-10 and INF-α were independent diagnostic factors of abscess formation in GLM (P<0. 05). The nomogram was drawn on the basis of the logistics regression model. The area under the curve (AUC) of the model was 0.890, which was significantly better than that of a single indicator and the sensitivity and specificity of the model were high (81.2% and 85.40%, respectively). These results predicted by the model were highly consistent with the actual diagnostic results. The results of this calibration curve indicated that the model had a good value and stability in predicting abscess formation in GLM. The decision curve analysis (DCA) demonstrated a satisfactory positive net benefit of the model.

Conclusion

A predictive model for abscess formation in GLM based on inflammatory markers was constructed in our study, which may provide a new strategy for early diagnosis and treatment of the abscess stage of GLM.

Idiopathic Granulomatous Mastitis

Idiopathic granulomatous mastitis (IGM) is a rare, benign inflammatory disorder of the breast that is often underrecognized. The exact etiology and pathophysiology are unknown, but milk stasis is felt to play a role. Classically, this condition is noninfectious, but many cases are noted to be associated with Corynebacterium species. Most patients affected are parous women with a mean age of 35, and many have breastfed within five years of diagnosis. Patients typically present with a painful mass and symptoms of inflammation, and these features can sometimes mimic breast cancer. Biopsy is needed to make a definitive diagnosis, and noncaseating granulomas are found on core biopsy. Many patients have a waxing and waning course over a period of six months to two years. Goal of treatment is to avoid surgery given poor wound healing, high risk of recurrence, and poor cosmetic outcomes. Medical treatment is preferred and includes observation, antibiotics, steroids, and immune modulators such as methotrexate. In more recent years, topical and intralesional steroids have become the treatment of choice, with similar outcomes to oral steroids.

A Rare Case of Traumatic Colonic Intramural Hematoma in Saudi Arabia

Colonic intramural hematomas are rarely encountered clinically. They are most commonly caused by blunt trauma to the abdomen. Diagnosis is usually reached by a combination of a detailed history, physical examination, and radiological investigations. A 14-year-old female patient presented to the emergency department complaining of abdominal pain with a history of a go-karting accident. Upon physical examination, the patient was tachycardic and hypertensive, with right-side abdominal tenderness and fullness. After going through routine radiological investigations, a computed tomography scan showed a large intramural hematoma of the ascending colon measuring around 7.7 x 8.4 x 2 cm. The patient was admitted for conservative management. Throughout her admission, serial examinations were performed, which showed improvement in the patient's condition and the size of the hematoma. The patient was discharged in a stable condition after showing good recovery. Following up with the patient a month later, she was in good condition with no active complaints, and an ultrasound was done that revealed complete resolution. To our understanding, this report of colonic intramural hematoma caused by the unusual etiology of the go-karting accident, which was successfully managed conservatively, adds significantly to the literature.

The Impact of Biomarkers on the Early Detection of Acute Mesenteric Ischemia

BACKGROUND

acute mesenteric ischemia (AMI) is a life-threatening condition that is caused by inadequate blood flow through the mesenteric vessel and is related to high mortality rates due to systemic complications. This study aims to systematically review the available literature concerning the major findings of possible biomarkers for early detection of acute mesenteric ischemia in the human population.

METHODS

studies that measured the performance of biomarkers during acute mesenteric ischemia were identified with the search of PubMed, Embase, Medline, and Cochrane library.

RESULTS

from a total of 654 articles, 46 articles examining 14 different biomarkers were filtered, falling within our inclusion criteria. Intestinal fatty acid-binding protein (I-FABP) was the most commonly researched biomarker regarding AMI, with sensitivity ranging from 61.5% to 100% and specificity ranging from 40% to 100%. The second most commonly researched biomarker was D-dimer, with a sensitivity of 60-100% and a specificity of 18-85.71%. L-lactate had a sensitivity of 36.6-90.91% and a specificity of 64.29-96%. Several parameters within the blood count were examined as potential markers for AMI, including NLR, PLR, MPV, RDW, DNI, and IG. Citrulline, interleukin 6 (IL-6), and procalcitonin (PCT) were the least-researched biomarkers.

CONCLUSION

different biomarkers showed different accuracies in detecting AMI. I-FABP and D-dimer have been the most researched and shown to be valuable in the diagnosis of AMI, whereas L-lactate could be used as an additional tool. Ischemia-modified albumin (IMA), alpha glutathione S-transferase (αGST), interleukin 6 (IL-6), and citrulline showed potential use in their respective studies. However, further research needs to be done on larger sample sizes and with controls to reduce bias. Several studies showed that neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), red-cell distribution width (RDW), delta neutrophil index (DNI), and immature granulocytes (IGs) might be useful, as well at the same time be widely distributed and affordable in combination with other markers presenting higher specificity and sensitivity.

Prevalence of Neuroendocrine Tumours (NET) in Patients Undergoing Appendicectomy for Acute Appendicitis: A Tertiary Care Study

Introduction Acute appendicitis is one of the common causes of acute abdomen in adults, which is managed widely with appendicectomy. Neuroendocrine tumours are the most common appendiceal tumours diagnosed incidentally on appendicectomy specimens.  Methods  Demographic data, presenting complaints, indications for appendicectomy, and the histology findings based on histopathological reports of the patients who have undergone appendicectomy for appendicitis at surgical units of Teaching Hospital, Jaffna, from 1st of January 2019 to 31st of December 2022 were retrospectively analyzed.  Results Of the 1341 histopathology reports, 0.2% (n=3) were neuroendocrine tumours (NET). The mean age of the patients with NET was 48.6, and 66.6% of them were females. All three NETs identified in appendicectomy specimens were well differentiated and smaller than 2 cm. All three had negative resection margins and were managed only with appendicectomy.  Conclusion  NETs of the appendix are the commonest appendiceal neoplasms. The majority of them are diagnosed incidentally in appendicectomy specimens. Surgical management of the tumours is either by appendicectomy or hemicolectomy, which depends mainly on tumor size. Surgical decisions should be tailor-made to the patients based on multi-disciplinary team decisions.

Framework and guide for intralesional steroid injections in idiopathic granulomatous mastitis

PURPOSE

Literature on how to perform intralesional steroid injections, a valuable therapy for idiopathic granulomatous mastitis (IGM), is limited. This technical note offers a detailed technical guide on intralesional steroid injections for IGM and provides a framework for long-term follow-up.

METHODS

Ultrasound characterization of IGM severity considering breadth, depth, and ancillary findings was used to guide steroid dosing and injection frequency. Clinical and sonographic breast diagrams were designed for accurate longitudinal tracking of IGM. A step-by-step guide for ultrasound-guided IGM aspirations and intralesional steroid injections was developed.

RESULTS

A detailed approach for ultrasound-guided IGM interventions with clinical and sonographic breast diagrams for longitudinal follow-up is now in practice.

CONCLUSIONS

The treatment approach described provides a framework for multidisciplinary treatment of IGM and offers insights that may contribute to the ongoing development and improvement of management strategies for this challenging disease.

A rare presentation of gastric phytobezoar: Simultaneous bleeding and perforation. combined laparoscopic and endoscopic approach. Report of a case

INTRODUCTION

Bezoars are intraluminal conglomerates of indigestible foreign materials that accumulate in the gastrointestinal tract. We describe our experience with a patient with gastric perforation and concomitant gastric haemorrhage with severe anaemia, in whom we successfully extracted a giant gastric phytobezoar by cooperative laparoscopic and endoscopic surgery.

CASE PRESENTATION

A 68-year-old man was admitted with melena and septic shock. CT scan revealed a gastric perforation. We performed a combined laparoscopic and endoscopic approach with gastrotomy, removal of the phytobezoar and laparoscopic gastric suture. The suture was examined for leakage with the endoscopic hydropneumatic test to obtain direct vision of the suture and no evidence of leakage by insufflation of the area.

DISCUSSION

Gastric bezoars can be managed conservatively, endoscopically or surgically. Endoscopic removal, if effective, would be an attractive alternative for bezoar treatment. Usually endoscopic attempts are unsuccessful because of the large size of the bezoar and the difficulty in fragmentation. The laparoscopic approach for bezoar seems to have better postoperative outcomes. The main criticisms of the technique are abdominal spillage with risk of contamination as well as longer operative times.

CONCLUSION

In our case we simultaneously performed laparoscopic surgery and endoscopic operative procedure in accordance with the principles of laparoscopic and endoscopic cooperative surgery to treat the gastric bezoar in order to overcome the limits of a single technique.

Local steroid injection in severe idiopathic granulomatous mastitis as a new first-line treatment modality with promising therapeutic efficacy

Background

Intralesional steroid injection has recently evolved as a novel treatment modality for localized idiopathic granulomatous mastitis (= IGM). We aimed to explore the therapeutic efficacy of local steroid injections (LSI) in patients with severe IGM.

Methods

Fifty-one patients diagnosed with severe IGM were included in the study and treated with either local steroid injection (LSI) alone (n = 25) or combined LSI with systemic oral steroid treatment (OST) (n = 26). The local steroid injection protocol included an intralesional triamcinolone acetonide injection into the palpable granulomas every 4-week, and topical administration of steroid-containing pomades twice a day on the affected surface of the breast. Patients with a combined LSI and OST received low-dose oral methylprednisolone (<16 mg).

Results

Patients with LSI alone required more LSI applications than those in the combined LSI with OST group (LSI: 5 ± 2.9; vs. LSI/OST: 3.5 ± 2.5; p = 0.080) to obtain an effective optimum therapeutic response. At a median of 12 months (range, 4-42), no difference was found in complete response rates between patients in the LSI group and the combined LSI group with OST (52 vs. 53.9%, p = 0.999). However, steroid-related systemic side effects were lower in the LSI alone group (p < 0.008).

Conclusion

Local steroid injection could be considered as the first-line treatment in patients with severe IGM until a therapeutic response has been obtained either as the sole treatment modality or combined with oral steroids. Compared with systemic oral steroid therapy, local steroid administration can be considered a new treatment modality with fewer side effects.

Awareness of Appendectomy and Its Complications Among Saudis

BACKGROUND

Acute appendicitis is one of the most common surgical causes of acute abdominal pain in adults and children in the emergency department. It is treated by appendectomy by either an open or laparoscopic approach. Although laparoscopic appendectomy has been used for the last 35 years, there are still indications for an open approach in some cases.

OBJECTIVES

 The aim of this study was to explore the awareness of the general population in Saudi Arabia of appendectomy according to the surgical approach.

METHODS

A cross-sectional survey using a questionnaire constructed by an expert based on Google Forms (Google, Mountain View, CA) was used from February to March 2022. Variables were demographical data, general knowledge, history of appendectomy, its surgical approach, and postoperative complications, if any.

RESULTS

The study included 162 participants. The awareness level of acute appendicitis was high (72.2%). History of appendectomy was almost 30% and was significantly more common in males than females (p = 0.045). The rate of postoperative complications showed a significant difference between open (4.3%) vs. laparoscopic approaches (8%) (p = 0.001).

CONCLUSION

 Young, educated Saudis are aware of the importance of surgical intervention for acute appendicitis. However, further hospital-based studies are recommended concerning the role of the surgical approach and its various impacts on postoperative complications.

Typhoid Intestinal Perforation Prognostic Score in Poor-Resource Settings

Background

Mortality from peritonitis due to typhoid intestinal perforation (TIP) in sub-Saharan Africa is high.

Objectives

This study aimed to determine the predictive factors of mortality, propose a prognostic score, and determine the appropriate surgical treatment for TIP in low-resource settings.

Materials and Methods

This was a retrospective data collection of peritonitis due to TIP admitted at Zinder National Hospital from 2014 to 2021. To build a typhoid intestinal perforation prognostic score (TIPPS), patients were randomised into two groups: a score-building group and a validation group. Univariate and multivariate analyses were performed to identify risk factors of mortality. The value of P <0.05 was assigned significant for all analyses.

Results

TIP accounted for 52.4% (n = 1132) of all cases of peritonitis (n = 2159). The median age was 12 years. Rural provenance represented 72.2% (n = 817). Deaths accounted for 10.5% (n = 119). The factors influencing mortality were respiratory rate ≥24/min (odds ratio [OR] = 2.6, P = 0.000), systolic blood pressure <90 mmHg (OR = 0.31, P = 0.002), serum creatinine >20 mg/L (OR = 2.6, P ≤ 0.009), haemoglobin (OR = 2.1, P = 0.000), comorbidity (OR = 3.5, P = 0.001), the American Society of Anesthesiologists score IV&V (OR = 3.3, P = 0.000), admission and management delay > 72 h (OR = 3.2, P = 0.001), and a number of perforations (OR = 2.4, P = 0.0001). These factors were used to build a "TIPPS" score, which ranged from 8 to 20. The risk of mortality was associated with increased TIPPS. The performance of this score was good in the two groups (area under receiver operating characteristic > 0.83). According to the severity and mortality risk of TIP, we classified TIPS into four grades: grade I (low risk: 8-10), grade II (moderate risk: 11-13), grade III (high risk: 14-16) and grade IV (very high risk: 17-20).

Conclusion

The TIPPS is simple. It can describe the severity of the disease and can predict the risk of death. The study highlights the importance and impact of timely and adequate perioperative resuscitation in more complicated cases.