Less is more: The use of single biodegradable stenting to treat biliary anastomotic strictures in pediatric liver transplantation

This study reports our experience of using biodegradable biliary stents (BBSs) for anastomotic biliary strictures (ABSs) in pediatric patients undergoing liver transplants. It involves the analysis of a retrospective data collection from January 2014 to January 2023, including all pediatric recipients of liver transplants in our center treated for ABSs with BBSs. In phase 1 (2014-2019), there was an initial percutaneous transhepatic cholangiography with anastomotic dilatation followed 2 weeks after a second percutaneous transhepatic cholangiography with BBS insertion. In phase 2 (2019-2023), the BBS was placed shortly after ABS dilatation, requiring only 1 percutaneous transhepatic cholangiography. All patients were followed up with routine tests and ultrasound. Forty-six ABSs were diagnosed in 43 pediatric recipients of liver transplants with a median of 6.7 months after liver transplantation (0.1-246.8 mo). Eight out of 46 ABSs (17.4%) treated with BBSs relapsed (median recurrence time: 6.5 mo; 1.6-17.0 mo). Four resolved with further BBS placement; only 4 needed surgical revision (8.7%) after a median follow-up time of 43.9 months (0.3-106.3). There were no differences in ABS recurrence rate, time between stent placement and recurrence, or the presence of cholangitis based on whether the BBS was deployed in 1 or 2 steps. Patients with end-to-end anastomosis had a higher ABS recurrence (OR 10.8; 1.4-81.3, p = 0.008) than those with bilioenteric anastomosis. The use of biodegradable stents could be a good option for treating ABSs in pediatric patients undergoing liver transplants, with our series showing a success rate of over 90% and an average follow-up of 43.9 months.

The Bra Project: Preventing Wounds in Women After Sternotomy

BACKGROUND

Women with large breasts are at risk for wounds after sternotomy.

LOCAL PROBLEM

Over 12 months, 7 of 110 female patients who underwent sternotomy (6.4%) had 274 additional hospital days related to pressure injuries and sternal dehiscence after sternotomy. The financial burden for the longer stays was more than $751 000. The purpose of this quality improvement initiative was to implement a soft, comfortable bra to prevent wounds and sternal dehiscence in female patients after sternotomy.

METHODS

Nurses implemented a new bra that reduced wound tension, had stretchable material that could expand for swelling, did not absorb moisture, and was available in a range of sizes to accommodate all women. Staff members measured patients' chest circumference before surgery and dressed patients in the bra in the operating room immediately after surgery. Patients wore the bra for breast support 20 to 24 hours a day for 6 weeks after surgery.

RESULTS

The new bra was used for 82 patients. No patients who wore the bra developed sternal dehiscence or chest pressure wounds. The wound incidence rate decreased from 6.4% to 0%.

CONCLUSION

Female patients undergoing sternotomy should be dressed in a comfortable and appropriately sized bra immediately after surgery and should wear it for 6 weeks. Such a bra can help prevent sternal dehiscence and pressure injuries.

Retrospective comparison of laparoscopic and open surgery for obturator hernia: a single-center experience

PURPOSE

This retrospective cohort study aims to compare perioperative outcomes between laparoscopic and open surgical repair of obturator hernia, a rare but clinically significant abdominal wall hernia.

METHODS

We analyzed 13 consecutive patients with CT-confirmed obturator hernia causing small bowel obstruction (2017-2023). Six underwent open repair and seven received laparoscopic transabdominal preperitoneal (TAPP) repair with mesh. Outcomes included operative time, blood loss, hospitalization duration, and CRP levels.

RESULTS

Laparoscopic repair significantly reduced hospitalization duration (median 7 vs. 13 days; P = 0.049) and postoperative inflammation (CRP 10.66 vs. 79.07 mg/L; P = 0.003), with less blood loss (10 vs. 30 mL; P = 0.001). No recurrences occurred during 12-month follow-up.

CONCLUSIONS

Laparoscopic obturator hernia repair demonstrates advantages in reducing hospital stay, minimizing surgical trauma, and attenuating systemic inflammatory response as compared to open approach. However, larger multicenter studies are warranted to validate these findings given the limited sample size.

Clinical features and endoscopic management of sharp wooden object ingestions: a systematic review of 479 cases

Background and aims

Ingested sharp objects pose increased risks of adverse events compared with other foreign bodies. We conducted the largest systematic review to date of sharp wooden object ingestions to elucidate patterns in clinical presentation and guide management practices.

Methods

Cochrane Library, Google Scholar, Ovid MEDLINE, Ovid Embase, PubMed, Scopus, and Web of Science Core Collection databases were searched for cases of adults who ingested sharp wooden objects. Descriptive statistics were reported for risk factors, clinical presentations, laboratory and imaging findings, adverse events, and treatments.

Results

Analysis of 479 cases showed that most patients were unaware of ingestion (74.8%) and toothpicks were the most common ingested item (92.5%). Male sex (70.1%), substance use (9.4%), and edentulousness (6.1%) were risk factors. Common symptoms included abdominal pain (83.7%) and fever (36.7%). Imaging identified the object in 48.1% of cases, with computed tomography being the most sensitive (54.7%). Objects were commonly found in the gastrointestinal tract (79.3%). They were consistently found in the gastrointestinal tract when patients were aware of ingestion or imaging showed an intraluminal/transluminal location. Endoscopy visualized the objects 76.1% of the time, with successful removal in 88.8% of cases; 4.7% of patients required surgery following endoscopic removal. Adverse events included perforation (87.5%) and abscess (33.0%), with a mortality rate of 5.0%.

Conclusions

Ingestion of sharp wooden objects presents heterogeneously and can lead to serious complications. Endoscopic removal is safe and effective. We propose a clinical algorithm to guide physicians in diagnosing and managing suspected sharp wooden object ingestion.

Mesenteric lymphangioma in childhood: a case report and narrative literature review

Lymphangioma is an uncommon benign neoplasm of the lymphatic system, predominantly observed in children and infants and infrequently in adults. Mesenteric lymphangioma is very rare. This article reports on the case of a 4-year-old female who was admitted to the hospital due to abdominal pain. Ultrasonography identified a cystic mass in the abdominal cavity, diagnosed as mesenteric lymphangioma, for which surgical intervention was advised. The patient underwent laparoscopic lesion resection with small bowel resection and anastomosis under general anesthesia. Pathological examination confirmed the diagnosis of mesenteric lymphangioma. In children, it frequently presents as an acute abdomen. Our comprehensive literature analysis strongly suggests that treatment decisions for pediatric mesenteric lymphangioma need to be guided by a careful assessment of individual patient presentations. Although exploratory laparotomy with tumor resection and involved bowel segment removal remains the gold-standard treatment, the advent of laparoscopic techniques and sclerotherapy has facilitated the evolution of personalized therapeutic strategies, potentially reducing dependence on conventional surgical approaches in the future.

Inflammatory myofibroblastic tumors of the colon in pediatrics: clinical presentation, management, and outcomes-A case report and systematic review of literature

PURPOSE

Inflammatory myofibroblastic tumors (IMTs) of the colon represent an exceptionally rare entity in the pediatric population. This systematic review aims to comprehensively analyze the clinical presentation, diagnostic workup, management strategies, and outcomes of colorectal IMTs in children.

METHODS

A systematic literature review was conducted across multiple electronic databases (inception to January 2025), including MEDLINE (via PubMed), Embase, Cochrane, Web of Science, and Google Scholar. Two independent reviewers screened abstracts, reviewed studies, and extracted data on all reported cases of colorectal IMTs in the pediatric population, including one previously unreported case from our institution.

RESULTS

Including our case, 53 pediatric patients with colorectal IMTs were identified from 39 studies. The mean age at diagnosis was 7 years (range: 5 months-17 years) with a slight female preponderance. The IMTs comprised a wide range of anatomic locations with rectum (27%) and ascending colon (24%) being the most common. Abdominal pain (54%), gastrointestinal bleeding (29%), and fever (21%) were the predominant symptoms. Anemia was the most common laboratory abnormality (62%). Surgical resection was the primary treatment modality in 98% of cases. After a mean follow-up of 38 months ( range: 3-181 months), the local recurrence rate was 11%, with no distant metastases reported.

CONCLUSION

Colorectal IMTs in children present diagnostic and therapeutic challenges. While complete surgical resection remains the gold standard treatment, emerging therapies such as ALK inhibitors and NSAIDs warrant further investigation. The potential for late recurrence mandates long term follow-up.

Expanding pediatric liver transplants: the role of split grafts, allocation policies, and machine perfusion

PURPOSE OF REVIEW

Pediatric liver transplant waitlist mortality remains disproportionately high, particularly among infants under one year old. Despite the success of split liver transplantation (SLT) in improving pediatric access to transplants, its utilization remains limited. This review examines barriers to SLT adoption, explores the impact of pediatric-focused allocation policies, and evaluates the potential of machine perfusion technology in expanding the pediatric donor pool.

RECENT FINDINGS

Studies have demonstrated that SLT outcomes are comparable to whole graft transplants when performed at experienced centers. However, logistical challenges, technical expertise, and policy limitations hinder its widespread adoption. Countries with pediatric-prioritized allocation and mandatory SLT policies, such as Italy and the United Kingdom, have significantly reduced pediatric waitlist mortality. Additionally, machine perfusion technology has emerged as a promising solution, allowing for ex vivo graft splitting and reducing ischemic injury, which may enhance graft utilization.

SUMMARY

A multifaceted approach is necessary to improve pediatric liver transplant outcomes, including stronger pediatric-first allocation policies, SLT training expansion, and integration of machine perfusion technologies. Implementing these strategies in the United States could significantly reduce pediatric waitlist mortality without negatively impacting adult transplant candidates.

Idiopathic mesenteric phlebosclerosis: a rare but important disease in Asian populations

Idiopathic mesenteric phlebosclerosis (IMP) is a rare form of ischemic colitis that predominantly impacts Asian populations. Despite some recognizable signs, there is a significant lack of awareness about IMP. In this review, we explore the etiology, pathogenesis, imaging manifestations, endoscopic traits, and therapeutic modalities of IMP. In addition, we discuss the deficiencies in the current comprehension of IMP and the potential research orientations in future.

Laparoscopic surgery for impacted dentures in the descending colon: A case report

INTRODUCTION AND IMPORTANCE

Denture ingestion, commonly seen in older adults, can also occur in younger individuals. Most dentures require intervention as they cannot be excreted naturally. We report a case of a young male undergoing laparoscopic surgery to remove dentures impacted in the descending colon two months post-ingestion.

CASE PRESENTATION

A 30-year-old male presented with intermittent left lower quadrant abdominal pain for three days. He had accidentally swallowed his dentures two months earlier. Abdominal X-ray showed a radiopaque foreign body in the descending colon. Endoscopic retrieval attempts failed, necessitating urgent surgery. The dentures were removed successfully through laparoscopic surgery, and the perforation was closed using continuous horizontal PDS 4.0 sutures. The postoperative course was uneventful and the patient was discharged on postoperative day four.

CLINICAL DISCUSSION

Denture ingestion poses a significant risk due to the nature of the object, often requiring removal as it cannot pass through the gastrointestinal tract. Removable dentures are a known risk factor for such accidents. Diagnosis typically involves abdominal X-rays or CT scans. Endoscopic retrieval is often attempted first but carries a risk of perforation, which may require emergency surgical intervention.

CONCLUSION

Surgical approaches depend on the location and extent of perforation and the patient's abdominal condition. Early laparoscopic intervention should be considered in cases where surgery is indicated, as it offers a minimally invasive and effective solution.

Primary subcutaneous hydatid cyst in the left flank: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Hydatidosis, a major parasitic disease in Mediterranean countries, primarily affects the liver and lungs, but in rare cases, it may also affect the subcutaneous tissue. Subtle symptoms often delay diagnosis. This report presents a rare case of left flank hydatid cyst.

CASE PRESENTATION

We report a 40-year-old man who had been suffering from a painless mass in the left flank for three months, which was recently painful, and was diagnosed with a subcutaneous hydatid cyst. Imaging and serology tests were inconclusive. The intact cyst was surgically removed, and histology confirmed hydatid cysts. Postoperative albendazole therapy was given for three months and resulted in complete recovery.

CLINICAL DISCUSSION

Hydatid cysts caused by Echinococcus granulosus primarily affect the liver and lungs, with subcutaneous cases being rare. This is the first reported case of a primary subcutaneous hydatid cyst in the left flank.

CONCLUSION

Hydatid disease should be considered in the differential diagnosis of soft tissue tumors, particularly in endemic areas. Outside of typical liver or lung involvement, diagnosis can be challenging and often delayed.

Clinical assessment of computed tomography for detecting ingested blister packs: A single-center retrospective study

Objectives

Blister pack (BP) ingestion poses serious risks, such as gastrointestinal perforation, and accurate localization by computed tomography (CT) is a common practice. However, while it has been reported in vitro that CT visibility varies with the material type of BPs, there have been no reports on this variability in clinical settings. In this study, we investigated the CT detection rates of different BPs in clinical settings.

Methods

This single-center retrospective study from 2010 to 2022 included patients who underwent endoscopic foreign body removal for BP ingestion. The patients were categorized into two groups for BP components, the polypropylene (PP) and the polyvinyl chloride (PVC)/polyvinylidene chloride (PVDC) groups. The primary outcome was the comparison of CT detection rates between the groups. We also evaluated whether the BPs contained tablets and analyzed their locations.

Results

This study included 61 patients (15 in the PP group and 46 in the PVC/PVDC group). Detection rates were 97.8% for the PVC/PVDC group compared to 53.3% for the PP group, a significant difference (p < 0.01). No cases of BPs composed solely of PP were detected by CT. Blister packs were most commonly found in the upper thoracic esophagus.

Conclusions

Even in a clinical setting, the detection rates of PVC and PVDC were higher than that of PP alone. Identifying PP without tablets has proven challenging in clinical. Considering the risk of perforation, these findings suggest that esophagogastroduodenoscopy may be necessary, even if CT detection is negative.

Small bowel obstruction secondary to strangulated obturator hernia with transected ileal segment: A case report

INTRODUCTION AND IMPORTANCE

Obturator hernia is a rare abdominal wall hernia (<1 % incidence) that occurs through the obturator foramen, often in elderly, emaciated women. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis is the diagnostic modality of choice, with a high accuracy of 78 %-100 %.

CASE PRESENTATION

An 84-year-old frail woman with COPD presented with generalized abdominal pain, abdominal distention, vomiting, and right thigh pain. CECT revealed a right-sided obturator hernia causing small bowel obstruction. Emergency exploratory laparotomy revealed a right-sided strangulated obturator hernia. Postoperatively, the patient developed septic shock and multiorgan dysfunction syndrome (MODS) and succumbed to death on the 5th postoperative day.

CLINICAL DISCUSSION

Obturator hernia is a rare abdominal hernia with an incidence of 0.07-1 %, an often-overlooked condition, more common in elderly women (around 70-90 years) with risk factors like low BMI, multiparity, and chronic conditions such as COPD. It presents with nonspecific symptoms, including abdominal pain, distension, and vomiting, and is often difficult to diagnose. Early CECT has improved the preoperative diagnosis rate from 43 % to 90 %, thus playing a crucial role in preventing morbidity and mortality. Treatment is surgical, but the mortality rate is high due to delayed diagnosis, bowel strangulation, and underlying preexisting illness.

CONCLUSION

Obturator hernias are a rare but important cause of small bowel obstruction, especially in elderly, frail, malnourished women without prior abdominal surgeries. Medial thigh pain and mild abdominal distension warrant high suspicion and prompt diagnosis using CECT. Early surgical intervention is critical to prevent severe complications and reduce associated morbidity and mortality.

Anatomical Considerations for Biliary Interventions: Navigating Challenging Cases

A thorough understanding of normal biliary anatomy, common variants, and surgically altered anatomy is essential for the success of biliary interventions. Variations in biliary anatomy are seen in up to 40% of patients and frequently influence procedural planning and outcomes. This review highlights classical biliary anatomy, its common variations, and the challenges posed by surgical modifications, such as those encountered after cholecystectomy, liver resection, or biliary reconstructions. Case-based examples are used to explore the implications of these variations and modifications on interventional approaches, including the management of bile leaks, strictures, and complex obstructions. Strategies incorporating advanced imaging and procedural techniques, such as rendezvous interventions, are discussed to address complications and optimize outcomes. This article provides a practical framework for interventional radiologists to navigate challenging biliary cases with confidence and precision.

Amyand's hernia with appendicitis in a 64-year-old male: a case report

We present a medical case of a 64-year-old male patient who exhibited symptoms of a hernia in the right inguinoscrotal region, which could not be reduced, and was accompanied by a systemic inflammatory response, ultimately revealing a perforated appendicitis during surgery as the hernia's contents. The relatively rare occurrence and lower probability of an Amyand's hernia may prompt a question about the most effective surgical treatment for our patient. The main aim of this study is to expand the current body of research on this condition, which should allow for a more thorough understanding of it.

Surgical Strategy for Pediatric Liver Tumors Involving the Hepatic Venous Confluence and the Inferior Vena Cava

BACKGROUND

Pediatric liver tumors presenting as centrally located masses with contact to or even invasion of all three hepatic veins (HVs) and the inferior vena cava (IVC) present significant surgical challenges. While liver transplantation may be indicated in truly unresectable tumors, extended liver resection with vascular reconstruction can be an organ-preserving alternative.

OBJECTIVE

This study aimed to present a reference center's strategy for children with liver tumors involving the hepatic venous confluence or the retrohepatic IVC who underwent extended liver resection with vascular reconstruction.

METHODS

All pediatric patients undergoing major hepatectomy with reconstruction of an HV or the IVC over a 10-year study period were included. Preoperative imaging, surgical techniques, and short- and long-term postoperative data were analyzed.

RESULTS

From a total of 125 pediatric major hepatectomies, 17 children (15 hepatoblastoma, two undifferentiated embryonal sarcoma) underwent liver resection with vascular reconstruction of an HV or the IVC. In nine cases an HV was reconstructed, and in eight children, a partial resection of the IVC was performed. Total vascular exclusion of the liver was applied in 16/17 cases. No 90-day postoperative mortality, no major postoperative complication, and no local relapse occurred; 16/17 patients are alive without relapse at a median follow-up of 44 months (range 19-111).

CONCLUSION

This is the largest single-center series to report major hepatectomies with HV or IVC reconstruction in children. In specialized centers, these complex procedures are associated with excellent outcomes. Successful tumor resection can be achieved in selected cases even in locally advanced tumor stages.

A Case Report and Literature Review on the Management of Foreign Body-Related Duodenal Perforation: Can We Avoid the Scalpel?

Gastrointestinal perforation remains one of the most commonly encountered surgical emergencies. Despite the advancement in surgical techniques and treatment modalities, retroperitoneal duodenal perforation remains a lethal surgical emergency. While perforations of the gastrointestinal tract are typically managed with laparotomy for repair and decontamination, the advancement in endoscopic technique and equipment shed a light on non-operative management for intestinal perforation. We present here a case of duodenal perforation successfully treated by endoscopic approach.

Impact of Multiple Kidney Retransplants on Post-Transplant Outcomes in the United States

BACKGROUND

Kidney retransplantation offers a valuable treatment option for patients who experience graft failure after their initial transplant. There is an increasing number of patients undergoing multiple retransplants. However, the impact of multiple kidney retransplants on post-transplant outcomes remains unclear. This study aimed to assess the association between the number of kidney retransplants and post-transplant outcomes in kidney retransplant recipients.

METHODS

We used the Organ Procurement and Transplantation Network and United Network for Organ Sharing (OPTN/UNOS) database to identify kidney-only retransplant recipients in United States from 2010 through 2019. We categorized kidney retransplant recipients based on their number of kidney retransplant into one and two plus kidney retransplant groups. The association of one vs two plus kidney retransplants with death-censored graft failure and patient death was assessed using Cox proportional hazard analysis, and acute rejection using logistic regression analysis.

RESULTS

Of 17,433 kidney retransplant recipients included in this study, 15,821 (91%) and 1612 (9%) had one and two plus kidney retransplants, respectively. Patients with two plus kidney retransplants were younger, predominantly White, had higher panel reactive antibody (PRA), public insurance, and education, but had less history of diabetes mellitus and total HLA mismatch compared with patients with one kidney retransplant. After adjusting for potential confounders, having two plus kidney retransplants was significantly associated with increased risk of death-censored graft failure (hazard ratio [HR] = 1.20, 95% confidence interval [CI] = 1.02-1.42) and allograft rejection (odds ratio [OR] = 1.30, 95% CI = 1.09-1.54), but it was not significantly associated with patient death.

CONCLUSIONS

Patients undergoing multiple kidney retransplants face a higher risk of graft failure and rejection compared with those with a single retransplant. These findings underscore the need for tailored management and monitoring strategies to improve outcomes for patients receiving multiple kidney retransplants.

Clinical Outcomes of Percutaneous Transhepatic Biliary Drainage in Pediatric Patients following Liver Transplantation

Purpose

Cholestatic complications remain a primary cause of post-liver transplantation (LTX) morbidity in pediatric patients. Standard biliary access by endoscopic retrograde cholangioscopy may not be feasible due to modified biliary drainage. Percutaneous transhepatic biliary drainage (PTCD) may be performed alternatively. However, systematic data concerning safety and efficacy of PTCD in these patients are scarce.

Methods

In this retrospective study, procedural and safety characteristics of PTCD in pediatric patients following LTX were analyzed. We compared laboratory indicators of inflammation, cholestasis, and graft function before and at 6 and 12 months after the first PTCD insertion. Efficacy was analyzed by percentage of patients without cholangitis, need for surgical biliary re-intervention and re-transplantation during a follow-up period of 60 months.

Results

Over a decade, PTCD was attempted in a total of 15 patients, with technical success (93.3%) in 14 patients. Periprocedural complications, including bleeding (7.1%) and cholangitis (21.4%) were observed in patients. During follow-up, both MELD-score (baseline: 13 [8-15] vs. 12 months: 8 [7-8], p<0.001) and parameters of cholestasis (GGT: baseline: 286 [47-458] U/L vs. 12 months: 105 [26-147] U/L, p=0.024) decreased. Prior to PTCD, cholangitis (64.3%) and cholangiosepsis (21.4%) were common complications. In contrast, following PTCD, cholangitis occurred in only one patient (7.1%). Five patients (35.7%) needed surgical biliary re-intervention and two (14.3%) required re-transplantation.

Conclusion

PTCD in pediatric patients following LTX had an acceptable safety profile, demonstrating a biochemical improvement of both cholestasis and graft function and may prevent cholestatic complications, thus reducing the need for surgical re-intervention and re-transplantation.

Subxiphoid hernia, definition and repair: an international delphi consensus

PURPOSE

Subxiphoid incisional hernias (SIH) are rare and challenging to repair, often occurring post- cardiac surgery after sternotomy and pericardial drainage. The literature on SIH is limited, with small patient cohorts and no established consensus on optimal repair strategies published yet. This present study aimed at proposing the definition and the surgical management and decision-making processes for SIH repair through an international Delphi consensus among expert surgeons.

METHODS

Using a modified Delphi technique, 69 international abdominal wall surgeons were invited. Three rounds were conducted to reach consensus on the definition, characteristics, classification, preoperative imaging and surgical approaches for SIH. Consensus was defined as more than 70% of agreement on 32 statements across 12 topics.

RESULTS

Sixty-nine experts were enrolled from 5 continents. Concerning definition of SIH, consensus was reached: a defect where the M1 part represents the most challenging and representative part. According to the expert panel, a mesh should be used in an extraperitoneal position. Both open and minimal invasive surgical (MIS) approach (E-TEP and/or ventral TAPP) are viable for W1 (< 4 cm) SIH repair. Achieving sufficient mesh overlap (> 5 cm) and defect closure are the 2 primary goals during SIH repair, whatever the approach and the technique. Expert panel agreed that a solid understanding of the anatomy is crucial and difficult in this area, due to the proximity of bony structures. For cranial overlap, exposing the central tendon of the diaphragm after cutting the posterior rectus sheath horizontally reached consensus. Concerning lateral overlap, the panel agreed on a retro rectus repair with TAR for ≥W2 hernia, while total preperitoneal repair is not. Mesh fixation is deemed unnecessary if adequate overlap is achieved. In case of difficulties of closure, only TAR might be helpful, with bridging as a last resort. They agreed that SIH ≥W2 should be referred to an expert hernia center.

CONCLUSION

This Delphi consensus defined SIH and was an opportunity to emphasize the anatomy of the subxiphoid region. It opens the way for future strong studies on the subject, leading for recommendations.

Abdominal wall hematoma as a complication of drainage after laparoscopic cholecystectomy: a case report

Background

Abdominal wall hematoma represents a potential postoperative complication that requires prompt identification and appropriate management. This case report retrospectively analyzes a patient who developed an abdominal wall hematoma associated with a drainage tube and puncture site following laparoscopic cholecystectomy at our hospital. The clinical characteristics, treatment modalities, and relevant literature are reviewed to highlight strategies for the prevention and management of postoperative hematomas, with the aim of providing valuable insights for clinical practice. We managed a patient who had undergone laparoscopic cholecystectomy for gallstones complicated by cholecystitis. On the first postoperative day, a hematoma developed at the site of the abdominal drainage tube insertion. Despite initial attempts at hemostasis through abdominal wall compression, these measures proved ineffective, necessitating the use of a urinary catheter balloon for effective compression hemostasis.

Case presentation

We treated a patient who had undergone laparoscopic cholecystectomy for gallstones complicated by cholecystitis. On the first postoperative day, a hematoma developed at the site of the abdominal drainage tube insertion. Despite initial attempts at hemostasis using abdominal wall compression, these measures were ineffective, necessitating the use of a urinary catheter balloon for effective compression hemostasis.

Conclusion

The urinary catheter balloon tamponade was effectively employed postoperatively to achieve hemostasis for the hematoma at the abdominal wall drainage site. It provides a viable alternative for early intervention in hematoma management.

A case report of a mesenteric cystic lymphangioma in a young adult woman presenting to the emergency room

BACKGROUND

Mesenteric cystic lymphangiomas (MCLs) are rare benign tumours seen in adults. The clinical presentation may vary from asymptomatic to acute abdominal pain with inexplicable abdominal pain, nausea and vomiting.

CASE PRESENTATION

In the current case report, a 22-year old, healthy women presented to the emergency room with acute abdominal pain in need of urgent surgical exploration. Histopathological examination revealed an mesenteric cystic lymphangioma.

CONCLUSION

In patients with inexplicable abdominal pain, the suspicion of MCLs and proper diagnostic strategies are important. The primary treatment of MCLs consists of radical surgical resection to prevent invasion in surrounding tissue. Tertiary referral centres should be consulted to support in the diagnosis, treatment and follow-up of MCLs.

Strangulated Amyand's hernia with testicular necrosis in an adult: A case report

INTRODUCTION

Amyand's hernia is a rare condition defined by the presence of the vermiform appendix within an inguinal hernia sac. The occurrence of Amyand's hernia with testicular necrosis is particularly uncommon, further complicating its clinical presentation and management.

CASE PRESENTATION

A 50-year-old male presented with a two-year history of progressive right scrotal swelling, acutely worsened over four days with pain and fever. Examination revealed a firm, tender, irreducible right scrotal mass with overlying erythema. Laboratory tests showed leukocytosis. Imaging confirmed an inflamed appendix within the hernial sac, consistent with Amyand's hernia complicated by abscess formation. Emergency surgery revealed a gangrenous appendix, scrotal abscess, and necrotic right testicular tissue. The patient underwent appendectomy, orchiectomy, hernia repair, and abscess drainage. He recovered uneventfully, with symptom resolution and no recurrence at follow-up.

DISCUSSION

The progression of Amyand's hernia to appendicitis and subsequent perforation, as seen in our case, can result in severe complications, including abscess formation and testicular necrosis. The Losanoff and Basson classification categorizes Amyand's hernia based on the appendix's condition and associated complications, ranging from a normal appendix (Type 1) to severe extra-sac pathology such as gangrene or malignancy (Type 4). Our case aligns with Type 4, involving a perforated appendix with gangrene and a scrotal abscess, necessitating extensive surgical intervention.

CONCLUSION

This case highlights the rarity and complexity of Amyand's hernia in adults, emphasizing the need for prompt recognition and tailored management to achieve favorable outcomes.

Primary hydatid cyst in the axillary region: A case report

INTRODUCTION

Hydatid disease, caused by the larval stage of Echinococcus granulosus, is a significant zoonotic infection predominantly affecting the liver and lungs. While hydatid cysts are commonly found in internal organs, cases in the axillary region are rare.

PRESENTATION OF CASE

We report a unique case of a 52-year-old female patient presenting with a painless left axillary swelling for two years. Physical examination revealed a firm, mobile mass measuring 10 × 5 cm, with no associated lymphadenopathy. Laboratory tests indicated normal results, while ultrasound imaging confirmed a thick-walled cystic lesion. The patient underwent total cystectomy under general anesthesia, and histopathological analysis confirmed the diagnosis of a hydatid cyst.

DISCUSSION

Hydatid cysts typically originate in the liver or lungs, with axillary primary cysts being rarely documented, with less than 20 prior cases in English literature. The mechanism for larvae migration to the axillary region remains unclear. The patient exhibited a mobile, asymptomatic mass, and imaging studies were crucial for diagnosis, emphasizing that differential diagnoses should include various axillary masses such as lymphadenitis or neoplasms.

CONCLUSION

This case highlights the need for awareness of axillary hydatid cysts in endemic regions, which may be misdiagnosed due to their rarity. Prompt diagnosis and individualized treatment, including total cystectomy and adjunctive medical therapy with albendazole, are critical to prevent complications and recurrence of hydatid disease.

Inflammatory Myofibroblastic Tumor of the Esophagus and Stomach Successfully Treated With ALK Inhibitor in a Pediatric Patient: A Case Report and Concise Review of Literature

An inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal neoplasm of borderline malignant potential. Nearly half of all IMTs have rearrangement of anaplastic lymphoma kinase (ALK) locus on chromosome 2p23 which can be treated with targeted therapy. Herein, we describe an unusual presentation of IMT involving an anatomical region rarely implicated in this disease process. A 15-year-old male patient came to the ER with dysphagia and coffee ground emesis. On esophagogastroscopy, a nodular luminal obstructing 30 × 50 mm mass in the lower esophagus was found, which was continuous with a large, partially circumferential gastric mass extending from the mid-body to the proximal antrum. Biopsies from esophageal and gastric masses revealed submucosal lesions composed of cytologically bland spindle and epithelioid cells, intermingled with inflammatory infiltrate, for which several immunohistochemical (IHC) stains were performed. The molecular study demonstrated ATIC::ALK fusion. Based on morphological, IHC, and molecular study findings, the diagnosis of ALK-positive IMT was rendered. Because surgical excision was deemed infeasible, the patient was started on ALK-inhibiting therapy with crizotinib. The patient responded well with no evidence of residual or recurrent disease on follow-up imaging or surveillance esophagogastroduodenoscopy. Crizotinib was ultimately discontinued after 10 months of therapy, and the patient continues to undergo surveillance imaging for monitoring of disease burden.

Robotic extended total extraperitoneal transversus abdominus release for traumatic flank and abdominal intercostal hernias

PURPOSE

Traumatic abdominal intercostal/flank hernias present a perplexing challenge for surgeons seeking to repair them. There has been a paucity of studies describing robotic repairs of such hernias. We aim to evaluate the effectiveness of the Robotic-assisted Extended Total Extraperitoneal/Transversus Abdominus Release (rETEP/TAR) method in repairing traumatic abdominal intercostal and flank hernias.

METHODS

Patients with traumatic abdominal intercostal hernias at a high-volume hernia center between 2019 and 2022 were identified and retrospective data including patient demographics, perioperative parameters, postoperative complications and up to a three-year follow-up were collected for those undergoing rETEP/TAR. Robotic ETEP access was gained through the retro-rectus space ipsilateral to the hernia, using a transversus abdominis release performed laterally to the level of the posterior axillary line. Dissection was completed from the pelvis to the central tendon as necessary.

RESULTS

A total of 8 patients were analyzed. All patients suffered traumatic or Valsalvainduced hernias. The average age was 54 +/-15yrs. The mean defect size was 11x17cm. Heavyweight uncoated polypropylene mesh was placed in the retromuscular space and secured with transfascial suture. Mean mesh size was 34x30cm and mean operative time was 216 +/- 69 minutes. The median length of stay was 1 day. All patients reported improvement in pain without any evidence of recurrence at postoperative follow-up.

CONCLUSION

This study demonstrates that the Robotic-assisted ETEP/TAR technique is an effective way of repairing abdominal intercostal and flank hernias.

Improving Sternal Closure Outcomes in Cardiac Surgery: Polyethylene Suture Tapes vs. Steel Wires

Background: Steel wires are often inadequate for sternal closure for patients at high risk of sternal complications. This study compares a novel sternal closure system to conventional steel wires to assess its potential to reduce sternal complication rates and improve clinical outcomes. Methods: A retrospective study was conducted on 300 consecutive patients undergoing cardiac surgery via median sternotomy. A total of 150 patients underwent steel wire sternal closure, while 150 underwent suture tape closure. Preoperative, intraoperative, and postoperative data were collected and analyzed for both groups. Results: Rates of sternal wound infections (1% vs. 5%, p = 0.0363) and sternal dehiscence (0% vs. 5%, p = 0.0297) were lower in the suture tape group. Suture tape patients had significantly less pain at 14 and 30 days (p = 0.0002 and 0.0071). The requirement for sternal protection adjuncts was eliminated with suture tape closure. Sternal closure time was significantly shorter in the suture tape group (11 vs. 19 min, p < 0.0001). Conclusions: Suture tapes proved safe, feasible, and effective for sternal closure, demonstrating significant advantages for sternal closure over steel wires, with reduced rates of sternal dehiscence, infection, postoperative incisional pain, and closure time. These superior outcomes and the elimination of sternal protection adjuncts can potentially reduce healthcare costs. Our experiences suggest that this novel sternal closure system has significant potential, with larger prospective studies warranted to optimize sternal closure strategies.

A Novel Surgical Solution for Sciatic Hernia: Exploring the Totally Extraperitoneal Approach

Sciatic hernia, a rare type of pelvic floor hernia, presents significant diagnostic and therapeutic challenges. We report the first totally extraperitoneal (TEP) repair of a sciatic hernia, which was performed in a 63-year-old woman who presented with vomiting and poor dietary intake. Computed tomography revealed a strangulated femoral hernia and an incidental herniation of the sigmoid colon through the right sciatic foramen. Simultaneous TEP repair of both hernias was successfully performed. The TEP approach offered a wide field of view without disturbing the abdominal organs and facilitated the management of concurrent hernias, making it particularly beneficial when the diagnosis of sciatic hernia is certain.

Medication Blisters: A Rare Cause of Bowel Perforation

Foreign body ingestion is a common occurrence in vulnerable populations, predominantly at the ends of the age spectrum. While most cases are uncomplicated, some patients may require endoscopic or surgical intervention to prevent serious complications. Therefore, accurate and detailed radiological evaluation is essential for therapeutic decision-making. We present the case of an 80-year-old woman presenting with abdominal pain and radiological evidence of a foreign body in the small intestine. A conservative treatment approach was initially proposed due to the absence of complications and the hypothesis that a fishbone was the cause. However, her condition deteriorated due to bowel injury, complicated by bleeding and perforation. Multiplanar and 3D reconstructions identified the object as a medication blister located in the sigmoid colon. Urgent surgical intervention allowed for the retrieval of the object and the closure of the bowel perforation. This case highlights the importance of early, detailed, and accurate radiological evaluation to identify the characteristics of foreign bodies and guide timely intervention.

Open mesh repair of an iatrogenic post-nephrectomy Bochdalek hernia in an adult: a case study

Bochdalek hernias arise from a developmental failure of the pleuroperitoneal canal to close, allowing abdominal contents to herniate into the thorax and compress the developing lung parenchyma. In rare cases, Bochdalek hernias may arise in adults and usually present with symptoms related to the hernia. Treatment consists of either open, laparoscopic, or robotic repair to close the defect. We present an unusual case in which an elderly patient presented with a large left-sided Bochdalek hernia containing both an incarcerated stomach and spleen following an uncomplicated robotic left nephrectomy. The hernia was successfully reduced and reconstructed with mesh via open abdominal repair with minimal complications. Repairing these hernias is challenging and, as in this case, required a complex reconstruction of diaphragm with mesh attachment to the ribs. Further reports on acute management of iatrogenic Bochdalek hernias in adults are warranted to better understand long-term post-operative outcomes and optimize management.

Bodyweight affects mortality in an L-shape pattern in patients undergoing coronary bypass grafting

BACKGROUND

The role of body composition as a risk factor for adverse outcomesduring coronary artery bypass surgery (CABG) has been controversial. The goal of this study was to evaluate the effect of body weight on mortality in patients undergoing CABG.

METHOD

Using a large NIS database and ICD-10 coding for different bodyweight categories, we evaluated the effect of cachexia, overweight, obesity, and morbid obesity on in-hospital mortality after CABG.  We evaluated the available database containing ICD10 coding from 2016- 2020.

RESULTS

We found that cachexia was the strongest independent predictor of in-hospital mortality whereas obesity had a protective effect. Over the 4-year sample size, patients with cachexia had nearly a 4-fold increase in mortality compared to patients with normal weight despite adjusting for age and comorbidities (4.06 CI 2.7-6.0, p < 0.001). Patients with overweight and Obesity had the lowest mortality (OR = 0.44 CI 0.29-0.66, OR = 0.58 CI 0.52-0.63, p, 001). However, the mortality benefit disappeared in patients with morbid obesity (OR 0.9, CI 0.84-1.03, p = 0.15) with a trend of higher mortality in patients with morbid obesity after multivariate adjustment.

CONCLUSION

Cachexia is a powerful predictor for in-hospital mortality in patients undergoing CABG. Overweight and obesity have protective effect which disappears with morbid obesity.

Consumer Trends Reflected in the Contents of the Pediatric Esophagus: A 20-Year Review

OBJECTIVES

To evaluate epidemiological trends of pediatric esophageal foreign body (EFB) ingestion over two decades.

METHODS

A retrospective analysis was performed using data from the National Electronic Injury Surveillance System (NEISS) database for children <18 years who presented to a United States Emergency Department (ED) with EFB between 2003 and 2022. Number of cases and type of EFB were recorded. Rates of EFBs over time were analyzed via linear regression.

RESULTS

A total of 52,315 EFB cases were identified over the 20-year period, with a national estimate of 1,589,325 cases. The most frequently ingested objects were coins (37.6%), toys (13.5%), and batteries (6.8%). Overall incidence of EFB ingestion increased from 7.3 to 14.2/10,000 children from 2003 to 2022 (R2 = 0.8, p < 0.0001). Incidence of coin ingestion increased from 3 to 4.5/10,000 children (R2 = 0.06, p = 0.335) but represented a smaller proportion of all EFB over time (66% in 2003 versus 43% in 2022). Incidence of magnet, battery, and toy ingestion have increased from 0.3 to 1.0/10,000 (R2 = 0.9, p < 0.0001), 0.3 to 1/10,000 (R2 = 0.7, p < 0.0001), and 0.6 to 2.3/10,000 (R2 = 0.8, p < 0.0001) children, respectively, between 2003 and 2022. The proportion of magnet, battery, and toy ingestion have increased over time (3.2%, 6.5%, and 11.8%, respectively, in 2003 to 11.4%, 11.7%, and 22.2%, respectively, in 2022).

CONCLUSION

Magnet, battery, and toy ingestion have increased significantly in the past two decades, while the proportion of coin ingestion has decreased. This trend may reflect shifts within the consumer market and increased availability of electronics concurrent with the adoption of digital currency.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:438-444, 2025.

Management of a Patient With an Obstructed Inguinal Hernia With Amyand's Variety: A Report of a Rare Case With a Review of the Literature

Amyand's hernia is a rare form of inguinal hernia, where the appendix is located within the inguinal sac. A 66-year-old male presented with an obstructed, incarcerated right inguinal hernia. He underwent an emergency herniotomy under spinal anesthesia. Intraoperatively, the hernia sac contained a viable small bowel and part of the appendix. As the appendix appeared mildly inflamed, an appendicectomy was performed, and a synthetic mesh repair was done. He received a postoperative course of antibiotics and was discharged home on day 3 after an uneventful recovery. Histology of the appendix revealed a fecolith in the absence of acute inflammation. He did not have any procedure-related complications on follow-up. Preoperative diagnosis of Amyand's hernia is a challenge due to nonspecific symptoms and rarity. Lasanoff and Basson classify Amyand's hernia and provide surgical guidance for its management. Our case belonged to the type 2 category. Management of Amyand's hernia needs an individually tailored approach rather than strict adherence to conventional guidelines. The presence of an appendicular fecolith in the absence of inflammation provides an interesting area to explore in an Amyand's hernia.

First Report on Rigid Plate Fixation for Enhanced Sternal Closure in Minimally Invasive Cardiac Surgery: Safety and Outcomes

INTRODUCTION

This study reports of the use of a rigid-plate fixation (RPF) system designed for sternal closure after minimally invasive cardiac surgery (MICS).

METHODS

This retrospective analysis included all patients undergoing MICS with RPF (Zimmer Biomet, Jacksonville, FL, USA) at our institution. We analyzed in-hospital complications, as well as sternal complications and sternal pain at discharge and at follow-up 7 to 14 months after surgery.

RESULTS

Between June and December 2023, 12 patients underwent RPF during MICS, of which 9 patients were included in the study. The median (IQR) age was 64 years (63 to 71) and two patients (22%) were female. All patients underwent aortic valve replacement, with two patients (22%) undergoing concomitant aortic surgery. RPF was successfully performed in all patients. ICU and in-hospital stay were 1 day (1 to 1) and 9 days (7 to 13), respectively. Patients were first mobilized in the standing position on postoperative day 2 (2 to 2). Four patients (44%) required opiates on the general ward. In-hospital mortality was 0%. At discharge, rates of sternal pain, sternal instability or infection were 0%. After a follow-up time of 343.6 days (217 to 433), median pain intensity using the Visual Analog Scale was 0 (0 to 2). Forty-four percent (n = 4) of patients reported pain at rest. No sternal complications (sternal dehiscence, sternal mal-union, sternal instability, superficial wound infections and deep sternal wound infections) were reported.

CONCLUSIONS

In the evolving landscape of cardiac therapies with incentives to reduce surgical burden, RPF showed safety and feasibility. It might become an important tool for sternal closure in minimally invasive cardiac surgery.

Laparoscopic excision of a spontaneously infected mesenteric duplication cyst

Mesenteric cysts are rare intra-abdominal masses which can occur at any point in the gastrointestinal tract from the duodenum to the rectum. These cysts may remain asymptomatic or may present with an abdominal mass, abdominal pain, or fever. Management may be conservative, percutaneous, or surgical excision. Here we present a case of a spontaneously infected mesenteric cyst in a male in his early 70s who was undergoing surveillance of the cystic mass yearly following its incidental finding on CT 4 years prior.

Ileocolic Enteroenteric Fistula in Small Bowel Obstruction With Cecum Perforation in the Pediatric Age Group: A Case Report of a Rare Complication

Enteroenteric fistula in the pediatric age group is an unusual presentation. It can create a diagnostic dilemma for the physician, particularly in the absence of any previous surgery, prolonged abdominal symptoms, or inflammatory bowel disease. The patient is a 10-year-old girl who presented with mild-grade fever, abdominal distension, scanty stool passage, and foul-smelling vomiting for the past 10 days. Before this, the patient had received treatment for 20 days for her fever and diarrhea from a quack, and her symptoms had improved. There was no history of prolonged fever, chronic diarrhea, weight loss, blood in the stool, trauma, foreign body ingestion, or hospitalization for any medical or surgical condition. After resuscitation, the patient was evaluated with blood tests, serum tests, and other necessary investigations, and surgery was planned. Intraoperative findings included pyoperitoneum with dilated small bowel. The omentum was densely adhered to the distal ileum, causing distal ileal obstruction, with a perforation approximately 1 cm in diameter in the cecum. The appendix appeared normal. Ten centimeters proximal to the ileocecal junction, there was a nondistensible and redundant segment of the distal ileum with a nondissectible gangrenous omentum. This segment was causing complete obstruction of the small bowel contents. Just proximal to this segment, an ileotransverse colon fistula was present. A double-barrel ileostomy was created for the patient, and she was discharged on postoperative day 10. In pediatric intestinal obstruction, common causes include simple band obstruction, Meckel's band obstruction, intestinal adhesions, intussusception, and complicated appendicitis, among others. However, surgeons may encounter the unusual presentation of an enteroenteric fistula as a cause of intestinal obstruction.

Efficacy of Sternum Guard vs. bone wax in post-cardiac surgery patients: a randomized controlled trial

BACKGROUND

Median sternotomy offers the main access during cardiac surgery. However, a surgical site infection (SSI) of the sternum is a distressing complication following this procedure. The incidence of postoperative superficial and deep SSI in cardiac surgery varies from 1.3% to 12.8%. Bone wax, a nonabsorbable substance applied as a mechanical barrier following a median sternotomy, can increase the risk of postoperative sternal dehiscence. Sternum Guard (Vygon, Ecouen, France), a sternal protection device used to cover the sternum after a median sternotomy, offers mechanical protection to prevent lesions on the sternum. The aim of this study was to compare the effectiveness of Sternum Guard (Vygon) and bone wax in reducing SSI and facilitating hemostasis in post-cardiac surgery patients.

METHODS

This single-blinded, single center randomized controlled trial comprised 414 adult patients who underwent cardiac surgery. The postoperative outcomes assessed were SSI and the quantity of blood lost from the sternal edges in the Sternum Guard (Vygon; treatment) and bone wax (control) groups.

RESULTS

The superficial SSI prevalence in the Sternum Guard group was lower than that in the bone wax group (2.9% vs. 8.2%, respectively; P=0.018). The incidence of deep SSI was also lower in the Sternum Guard group (1%) compared to the control group (2.9%) although this was not statistically significant (P=0.284). In terms of intraoperative sternal bleeding, Sternum Guard (Vygon) absorbed more than the sterile drapes used in the control group (84.97±115.99 vs. 81.18±14.62, respectively; P=0.012).

CONCLUSIONS

Sternum Guard (Vygon) had a significantly lower incidence of postoperative infection and bleeding from the sternum compared to bone wax.

Effect of Parathyroidectomy After Renal Transplantation on Grafted Kidney Function Within One Year: A Meta-Analysis

OBJECTIVE

Secondary hyperparathyroidism (sHPT) is a common symptom of chronic kidney disease (CKD), and at the time of transplantation, more than two-thirds of patients with end-stage renal disease have secondary hyperparathyroidism. After kidney transplantation, parathyroid function is normalized in some kidney transplant recipients, but up to 50% of kidney transplant recipients develop tertiary hyperparathyroidism (tHPT) 1 year after kidney transplantation. The effect of parathyroidectomy on the grafts is currently unclear; thus, we conducted a meta-analysis of relevant studies to evaluate changes in graft function 1 year after parathyroidectomy, aiming to assess the procedure's safety in renal transplant recipients.

METHODS

A thorough exploration was conducted across Embase, PubMed, Web of Science, and the Cochrane Library databases to gather pertinent literature spanning from January 1, 2000, to December 31, 2023. The search criteria encompassed terms such as "kidney transplantation," "parathyroidectomy," and "hyperparathyroidism."

RESULTS

Twelve studies were scrutinized to assess alterations in graft functionality at 1, 3, 6, and 12 months postparathyroidectomy. The meta-analysis unveiled a notable decline in overall glomerular filtration rate and a concurrent elevation in serum creatinine 1 year postparathyroidectomy, signifying an impairment in graft function compared to the preoperative phase. Significant heterogeneity was observed among the studies.

CONCLUSION

Following parathyroidectomy in renal transplant recipients 1 year postsurgery, calcium and parathyroid hormone levels normalized. Nonetheless, there was evident impairment in graft function and an elevated risk of graft loss. Hence, the safety of parathyroidectomy in patients with secondary hyperparathyroidism postrenal transplantation necessitates meticulous consideration.

A Tale of Two Congenital Lesions: A Case Report of Congenital Diaphragmatic Hernia and Congenital Heart Disease Managed by Successful Surgical Outcome With Review of the Literature (Bhende-Pathak Hernia)

Congenital diaphragmatic hernia (CDH) is a diaphragmatic defect that is usually situated on the left side in the posterolateral region, named a Bochdalek hernia (BH), which allows abdominal organs to herniate into the thoracic cavity. BH is a prevalently observed birth anomaly in infants but is rare in adults. Right-sided BH that involves the colon is exceptionally rare, and no prior cases have described ileocecal appendix involvement. Here, we present a case of a preschooler with a right-sided BH and patent ductus arteriosus (PDA), requiring distinct surgical approaches: left open thoracotomy for PDA ligation and right open thoracotomy for CDH repair. Surgical intervention is associated with reduced morbidity and mortality, favorable long-term outcomes, and a low recurrence rate, irrespective of the selected approach. Reinforcement through suture repair with mesh application, as well as PDA ligation, reinforced with metallic clips as the preferred surgical operation in this case. To the best of our knowledge, this is the first reported instance of a pediatric patient with right-sided BH that involves the appendix, alongside concurrent congenital heart disease (CHD). We propose the term Bhende-Pathak hernia for this pediatric variant.

Effect of Adding Integrated Core and Graduated Upper Limb Exercises to Inpatient Cardiac Rehabilitation on Sternal Instability After Coronary Artery Bypass Grafting: A Randomized Controlled Trial

OBJECTIVE

To evaluate the effect of adding integrated core and graduated resistance upper limb exercises to an inpatient cardiac rehabilitation program in patients with acute sternal instability after coronary artery bypass grafting (CABG).

DESIGN

This was a single-center, randomized, controlled, parallel-group intervention study.

SETTING

This study was conducted at the National Heart Institute.

PARTICIPANTS

Forty patients with post-CABG with sternal instability aged 50-60 years completed this study and were randomized into 2 groups: an intervention group (n=20) and an active control group (n=20).

INTERVENTION

The intervention group (A) received a routine inpatient rehabilitation program from the first postoperative day plus integrated core and graduated resistance upper limb exercises, which started from the seventh postoperative day for approximately 4 weeks, whereas the control group (B) received only the routine inpatient rehabilitation program.

MAIN OUTCOME MEASURES

Sternal separation measured by ultrasonography, visual analog scale for measuring pain, and activities of daily living (ADL) index were main outcome measures.

RESULTS

Patients in the intervention group (A) showed a significant reduction in sternal separation from the supine and long sitting positions, whereas those in the control group (B) showed a significant increase in sternal separation (P=.0001). Both groups showed a reduction in pain, and an increase in the ADL score was observed in group A. There was a significant interaction between the time and group effects (P=.0001).

CONCLUSION

Adding integrated core and graduated upper limb exercises to inpatient cardiac rehabilitation for patients with sternal instability after coronary artery bypass grafting significantly improved sternal healing, pain, and ADL.

Partial coverage adhesive augmented sternal fixation and stabilization: A biomechanical analysis

Adhesive-augmented sternal fixation (AASF) has been investigated as an alternative to the clinical standard of cerclage wires; however, previous studies have focused on a full adhesive layer across the sternal midline, which acts as a barrier to bone healing. This study used a human cadaveric model to investigate if partial coverage AASF used in combination with wired fixation could provide adequate stability. Median sternotomies were performed on fifteen human cadaveric sterna. Three groups (n = 5) with varying adhesive coverage (50 %, 62.5 %, 75 %) of the sternal midline and traditional wiring were investigated. Cyclic lateral distraction loading of 10 N to 100 N was applied at 50 N/s. Every 30 cycles, the maximum load was increased by 100 N to a maximum of 500 N. Displacement was measured using transducers spanning the transection line at the manubrium, body, and xiphoid. Mean maximum total displacement (MMTD) for all groups was significantly below 2 mm (p < 0.001) with 1.49 mm ± 0.82 mm, 0.97 mm ± 0. 55 mm, and 0.67 mm ± 0.65 mm in the 50 %, 62.5 %, and 75 % groups respectively. MMTD in the 50 % group was significantly greater than MMTD in the 62.5 % and 75 % groups. AASF improved stability as coverage of the sternal surface with adhesive increased. Partial coverage of the sternal midline with adhesive may provide similar rigidity to a full layer while enabling earlier sternal ossification at the transection line compared to wiring alone.

Non-neoplastic findings in colon capsule endoscopy: Additional yield

Background and study aims Despite the common occurrence of non-neoplastic findings (NNFs) in individuals with a positive fecal immunochemical test (FIT), few studies have reported on these findings. The aim of this cross-sectional study was to determine the prevalence of colonic NNFs in three cohorts of Danish clinical trial participants who underwent colon capsule endoscopy (CCE). Patients and methods Retrospectively collecting NNFs from CCE reports of three Danish trials, we classified them into five categories: diverticula, vascular abnormalities, inflammation, erosions/ulcerations, and others. The statistical analysis included 516 participants from three trials, with a mean age ranging from 59.2 to 63.9 years. The participants in the three trials were FIT-positive screening or symptomatic individuals. Results NNFs were reported in more than half of the CCE procedures (50.6% to 77.9%), with colonic diverticula being the most common NNF appearing in 40.9% to 66.9% of the CCE reports. Vascular abnormalities and erosions/ulcerations were also common depending on the specific trial. Conclusions NNFs are common and may be an indicator of more widespread disease. Furthermore, NNFs may develop into clinically significant conditions despite their benign appearance. This paper expands on the limited literature about prevalence of NNFs and underscores the additional value of CCE video recordings beyond detecting polyps.

Intestinal Obstruction Due to Ingested Olive Pits

Intestinal obstruction after ingestion of foreign bodies is a rare condition. A wide variety of ingested foreign bodies has been reported as a cause of mechanical small bowel obstruction, with ingested fruit pits being rarely reported as causes of intestinal obstruction. Here, we report the case of a 70-year-old female diagnosed with intestinal obstruction due to swallowed olive pits tightly impacted in the distal ileum. A conclusive diagnosis was made preoperatively by computed tomography of the abdomen. After initial conservative treatment, the patient underwent laparotomy because of persistent obstruction. The ingested pits were removed through an enterotomy and the obstruction was successfully resolved.

Transgluteal approach for excision of pelvic lipoma causing sciatic pain

Sciatic nerve pain, affecting 12%-27% of the general population, often arises from a myriad of etiologies due to the complex anatomy of the sciatic region. The intricate relationship between the sciatic nerve and surrounding structures in the pelvis poses significant challenges in both diagnosis and surgical management. We report two cases of adult female patients presenting with chronic sciatic pain, refractory to conservative treatment. Imaging studies, including magnetic resonance imaging and computed tomography, identified retroperitoneal lipomas exerting compressive effects on the sciatic nerve. Both patients underwent surgical excision of the lipomas via a transgluteal approach with complete resection of the benign tumors in both cases. The successful outcomes in these cases underscore the potential of the transgluteal approach as a novel and effective treatment strategy in the management of complex retroperitoneal tumors causing sciatic pain.

A Case of Laparoscopic Transabdominal Pre-peritoneal Hernia Repair Using a 3D Mesh Inversion Technique for Bilateral Obturator and Femoral Hernias After Incarcerated Obturator Hernia Reduction

An obturator hernia (OH) is a rare type of hernia that accounts for a very small proportion of all hernias and cases of small bowel obstruction. This condition predominantly affects older, underweight individuals, with the vast majority of patients being women. Laparotomy with simple suture closure of the defect is commonly used as surgical treatment for OH. However, the closeness of the obturator nerve to the obturator defect causes difficulty in observing this nerve due to the deep operative field in laparotomy. Thus, transabdominal pre-peritoneal hernia repair (TAPP) has advantages over an open approach, and TAPP is now commonly performed for OH. In the case described here, an 86-year-old female patient presented with lower abdominal pain and vomiting. Abdominal computed tomography revealed a right-sided OH causing intestinal obstruction, and the patient was referred to our hospital. Her medical history included hypertension, dementia, and an artificial head replacement for a left femoral neck fracture. Laboratory tests showed elevated white blood cell (WBC) of 13,700/μL, but other results were normal. Manual reduction of the hernia was successful, leading to symptom improvement, and the patient was admitted for observation. She was discharged on day three after admission. After one month, laparoscopic TAPP was performed. Bilateral OHs and femoral hernias were observed. Using a recently proposed 3D mesh inversion technique, the mesh was fitted anatomically for the OH. This is the first reported case of elective TAPP using a 3D MAXTM Light Mesh (Bard, Warwick, RI, US) with an inversion technique for bilateral OH and femoral hernia after incarcerated OH reduction.

Leg Pain-An Unexpected Twist

BACKGROUND

Obturator hernia is a rare condition, often presenting with non-specific symptoms, such as thigh pain, groin pain, nausea, or vomiting. Obturator hernias are most common in thin, elderly women. Oftentimes, they are diagnosed late in the disease course resulting in complications and high morbidity and mortality.

CASE REPORT

We present the case of a 75-year-old female who presented with right thigh pain with no other symptoms. After computed tomography (CT) of the abdomen/pelvis, the patient was found to have an incarcerated obturator hernia complicated by a small bowel obstruction, ultimately requiring urgent surgical intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the very general symptoms associated with the condition, the diagnosis of obturator hernia can easily be missed, leading to a delayed diagnosis, more complications, and a higher morbidity and mortality rate. Due to the risk associated with a delayed diagnosis, it is important for emergency physicians to maintain a high clinical suspicion for the diagnosis.

Ogilvie's Syndrome Following Herpes Zoster Infection: A Comprehensive Review of the Literature

This systematic review explores the association between herpes zoster (HZ) infection and Ogilvie's syndrome (acute colonic pseudo-obstruction), evaluating how varicella-zoster virus (VZV) reactivation may contribute to autonomic dysfunction leading to intestinal obstruction. A comprehensive search was conducted in PubMed, Scopus, and Cochrane Library databases up to October 2024, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies included case reports, clinical images, and letters reporting Ogilvie's syndrome secondary to HZ or VZV infection. After screening 219 publications and additional grey literature, 27 studies describing 28 cases met the inclusion criteria. Data were extracted on patient demographics, clinical manifestations, diagnostic methods, and outcomes. The quality of studies was assessed using the Joanna Briggs Institute critical appraisal checklist. The results from 27 studies encompassing 28 patients with intestinal pseudo-obstruction secondary to VZV or HZ infection indicated a mean age of 60 years, predominantly affecting males (71.5%). Notably, 47.6% had underlying immunosuppressive conditions. The primary clinical manifestations included abdominal distention and severe constipation. Most patients (93%) exhibited a herpetiform rash, primarily in thoracic dermatomes. Symptoms of pseudo-obstruction often preceded the rash (58%), and imaging in the vast majority revealed colonic distension with no intra-abdominal pathology. Treatment focused on conservative management of both pseudo-obstruction and HZ symptoms, with 93% of patients achieving full recovery, while the mortality rate was identified at 7%. The findings suggest that HZ-induced Ogilvie's syndrome may be an underdiagnosed condition, requiring a high index of suspicion, particularly in immunocompromised patients. Early recognition and conservative treatment can prevent unnecessary surgical interventions. Further studies are needed to clarify the pathophysiological mechanisms linking VZV reactivation to colonic pseudo-obstruction.

Improved survival of pediatric deceased donor liver transplantation recipients after introduction of the pediatric prioritization system: Analysis of data from a Japanese national survey

BACKGROUND

In Japan, there has never been a national analysis of pediatric deceased donor liver transplantation (pDDLT) based on donor and recipient factors. We constructed a Japanese nationwide database and assessed outcomes of pDDLT focusing on the pediatric prioritization system introduced in 2018.

METHODS

We collected data on pDDLTs (<18 years) performed between 1999 and 2021 from the Japan Organ Transplant Network and Japanese Liver Transplantation Society, identified risk factors for graft survival and compared the characteristics and graft survival in pDDLTs conducted before and after the introduction of the pediatric prioritization system.

RESULTS

Overall, 112 cases of pDDLT were included, with a 1-year graft survival rate of 86.6%. Four poor prognostic factors were identified: recipient intensive care unit stay, model for end-stage liver disease/pediatric end-stage liver disease score, donor cause of death, and donor total bilirubin. After the introduction of the system, allografts from pediatric donors were more reliably allocated to pediatric recipients and the annual number of pDDLTs increased. The 1-year graft survival rate improved significantly as did pDDLT conditions indicated by the risk factors.

CONCLUSIONS

Under the revised allocation system, opportunities for pDDLT increased, resulting in favorable recipient and donor conditions and improved survival.

Giant cystic lymphangioma as a rare cause of acute abdomen in infancy: a case report and literature review

Lymphangioma, a benign mass of lymphatic origin, primarily affects the head, neck, and oral cavity, with the abdomen being an uncommon location. Clinical presentation is defined by site of origin and size. We present the case of a 10-month-old male infant with no previous medical history, admitted to our department with diffuse abdominal pain and distension. Physical examination revealed a huge, palpable mass arising from the left abdomen, abdominal tenderness, guarding, and rigidity. Abdominal ultrasound revealed a multilocular, non-measurable mass with both cystic and solid components that were suggestive of a giant cystic lymphangioma. Multidetector computed tomography and magnetic resonance imaging were performed to estimate the size and extension of the tumor for preoperative planning. Moreover, an elevated alpha-fetoprotein level further supported the neoplastic origin of the tumor. Exploratory laparotomy was performed, and a mass measuring approximately 13.9×16.7×15.4 cm was identified and completely excised in negative margins. Histopathological findings confirmed the initial diagnosis. Our patient had an uncomplicated postoperative course and recovery, with no signs of recurrence on a 6-month follow-up. Giant abdominal lymphangiomas in infants are extremely rare and close attention for complications is vital. Surgical intervention with complete resection is considered the optimal management.