Achieving clinically optimal balance between accuracy and simplicity of a formula for manual use: Development of a simple formula for estimating liver graft weight with donor anthropometrics

In developing a formula for manual use in clinical settings, simplicity is as important as accuracy. Whole-liver (WL) mass is often estimated using demographic and anthropometric information to calculate the standard liver volume or recommended graft volume in liver transplantation. Multiple formulas for estimating WL mass have been reported, including those with multiple independent variables. However, it is unknown whether multivariable models lead to clinically meaningful improvements in accuracy over univariable models. Our goal was to quantitatively define clinically meaningful improvements in accuracy, which justifies an additional independent variable, and to identify an estimation formula for WL graft weight that best balances accuracy and simplicity given the criterion. From the Japanese Liver Transplantation Society registry, which contains data on all liver transplant cases in Japan, 129 WL donor-graft pairs were extracted. Among the candidate models, those with the smallest cross-validation (CV) root-mean-square error (RMSE) were selected, penalizing model complexity by requiring more complex models to yield a ≥5% decrease in CV RMSE. The winning model by voting with random subsets was fitted to the entire dataset to obtain the final formula. External validity was assessed using CV. A simple univariable linear regression formula using body weight (BW) was obtained as follows: WL graft weight [g] = 14.8 × BW [kg] + 439.2. The CV RMSE (g) and coefficient of determination (R2) were 195.2 and 0.548, respectively. In summary, in the development of a simple formula for manually estimating WL weight using demographic and anthropometric variables, a clinically acceptable trade-off between accuracy and simplicity was quantitatively defined, and the best model was selected using this criterion. A univariable linear model using BW achieved a clinically optimal balance between simplicity and accuracy, while one using body surface area performed similarly.

Factors affecting women's decision between uterine-preserving versus hysterectomy-based surgery for pelvic organ prolapse

BACKGROUND

Given the prevalence of women seeking surgical treatment for pelvic organ prolapse (POP), there is a need to understand women's decision-making regarding uterine-preserving versus hysterectomy-based surgeries. Historically, hysterectomy-based surgeries have been the preferred treatment for pelvic organ prolapse; however, contemporary evidence supports uterine-preserving surgeries as equivalent. At present, the lack of information available to the general public and limited options presented at surgical consultation for pelvic organ prolapse may hinder women's autonomy as they navigate surgical treatment.

OBJECTIVES

To examine the factors affecting women's decision-making processes regarding uterine-preserving or hysterectomy-based surgery for pelvic organ prolapse.

DESIGN

This is a qualitative study.

METHODS

We conducted semi-structured, qualitative interviews with women seeking surgery for pelvic organ prolapse to explore the factors affecting women's decision-making between hysterectomy-based and uterine-preserving surgeries.

RESULTS

Women (n = 26) used clinical and personal factors to determine which surgery was best. Women noted that the lack of evidence (clinical and/or anecdotal) available to them hindered their decision-making, causing them to rely more on their own interpretations of the evidence, what they perceived to be "normal," and what their surgeon recommended. Even with standardized discussion regarding the existing clinical equipoise between surgeries at the clinical consultation, some women still had misperceptions that hysterectomy-based surgery would convey the lowest risk of prolapse recurrence and be best for severe prolapse.

CONCLUSION

There is a need for more transparency in discussions about prolapse and the factors affecting women's decision-making for surgical repair of pelvic organ prolapse. Clinicians should be prepared to offer the option of hysterectomy-based or uterine-preserving surgeries and to clearly explain the clinical equipoise between these procedures.

Port Site Metastasis After Minimally Invasive Surgery in Gynecologic Malignancies: Two Case Reports and a Review of the Literature

Port site metastasis (PSM) is considered an uncommon and rare complication in gynecologic malignancies with unclear treatment recommendations or guidelines. Thus, we report the treatment strategies and outcomes of two cases of PSMs following gynecologic malignancies and a review of the literature to provide much information about the most frequent sites of PSMs and the incidence of PSMs in different gynecological tumors. A 57-year-old woman underwent laparoscopic radical surgery for right ovarian serous carcinoma in June 2016 followed by postoperative chemotherapy. Because PSMs were present near the port site of the bilateral iliac fossa, the tumors were completely removed on August 4, 2020, and the patient received chemotherapy. She has shown no signs of relapse. During the same period, a 39-year-old woman underwent laparoscopic type II radical hysterectomy for endometrial adenocarcinoma involving the endometrium and cervix on May 4, 2014, without adjuvant treatment. In July 2020, a subcutaneous mass under her abdominal incision was removed, and chemotherapy plus radiotherapy was administered. Metastasis was found in the left lung in September 2022, but there was no abnormality in the abdominal incision. We showed the two cases of PSMs, reviewed articles to provide some new insights about the incidences of PSMs in the gynecologic tumors, and discussed the proper preventive strategies.

Late Onset Diaphragmatic Hernia: A Forgotten Etiology of Recurrent Vomiting in the Adolescent Population

Diaphragmatic hernia is a rare disorder in adolescents with oftentimes delayed diagnosis due to late-onset and non-specific clinical manifestations. In this report, we present a case of diaphragmatic hernia in an 18-year-old male, where initial diagnosis was complicated by confounding factors of type 1 diabetes mellitus and cannabinoid hyperemesis syndrome. This case highlights the importance of having a high index of suspicion for diaphragmatic hernia in patients with nonspecific gastrointestinal symptoms to ensure timely recognition and surgical intervention.

Preoperative estimation of hemi-liver volume using standard liver volume and portal vein diameter ratio in living donor liver transplantation

Backgrounds/Aims

Although body surface area (BSA)-based standard liver volume (SLV) formulae have been used for living donor liver transplantation and hepatic resection, hemi-liver volume (HLV) is needed more frequently. HLV can be assessed using right or left portal vein diameter (RPVD or LPVD). The aim of this study was to validate the reliability of using portal vein diameter ratio (PVDR) for assessing HLV in living liver donors.

Methods

This study included 92 living liver donors (59 males and 33 females) who underwent surgery between January 2020 and December 2020. Computed tomography (CT) images were used for measurements.

Results

Mean age of donors was 35.5 ± 7.2 years. CT volumetry-measured total liver volume (TLV), right HLV, left HLV, and percentage of right HLV in TLV were 1,442.9 ± 314.2 mL, 931.5 ± 206.4 mL, 551.4 ± 126.5 mL, and 64.6% ± 3.6%, respectively. RPVD, LPVD, and main portal vein diameter were 12.2 ± 1.5 mm, 10.0 ± 1.3 mm, and 15.3 ± 1.7 mm, respectively (corresponding square values: 149.9 ± 36.9 mm², 101.5 ± 25.2 mm², and 237.2 ± 52.2 mm², respectively). The sum of RPVD² and LPVD² was 251.1 ± 56.9 mm². BSA-based SLV was 1,279.5 ± 188.7 mL (error rate: 9.1% ± 14.4%). SLV formula- and PVDR-based right HLV was 760.0 ± 130.7 mL (error rate: 16.2% ± 13.3%).

Conclusions

Combining BSA-based SLV and PVDR appears to be a simple method to predict right or left HLV in living donors or split liver transplantation.

Abdominal cocoon syndrome (idiopathic sclerosing encapsulating peritonitis): An extremely rare cause of small bowel obstruction-Two case reports and a review of literature

Introduction

Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction in which the bowel and internal abdominal organs are wrapped with a fibrocollagenous cocoon-like encapsulating membrane [1,2]. SEP is divided into two entities: abdominal cocoons (AC), also known as idiopathic or primary sclerosing encapsulating peritonitis, which is of extremely rare type, and secondary sclerosing encapsulating peritonitis, which is the more common type.

Case presentation

Two male patients from India, a 26 year old and a 36 year old, presented to our hospital complaining about abdominal pain associated with nausea and vomiting without any history of previous surgical interventions; the patients' vitals were stable. Preoperative diagnosis of abdominal cocoon was established by abdominal computed tomography. It showed multiple dilated fluid-filled small bowel loops in the center of the abdominal cavity with thin soft tissue, non-enhancing capsules encasing the small bowel loops with mesenteric congestion involving small and large bowel loops. Both patients underwent complete surgical excision of the sac without intraoperative complications. Patients had a smooth postoperative hospital course and were discharged home in good conditions.

Conclusion

Patients with abdominal cocoons have a non-specific clinical presentation of intestinal obstruction. A high index of clinical suspicion in combination with the appropriate radiological investigation will increase the chance of preoperative detection of the abdominal cocoon. In patients with complete bowel obstruction, complete excision of the peritoneal sac is the standard of care.

Rare case of rectal perforation by an intrauterine device: Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Intrauterine devices (IUDs) are safe, highly effective and reversible forms of contraception. Reliance on IUD has been increasing and as such, it is the responsibility of the healthcare provider to be aware of the complications associated with it. IUD rectal migration is one of the rare but serious complications that may lead to detrimental sequelae.

CASE PRESENTATION

A 30-year-old asymptomatic woman presented to the gynaecology clinic two months after a difficult insertion of an IUD. On examination, the device was not localised in utero with transvaginal sonography. Computed tomography scan and colonoscopy revealed the position of the IUD within the rectum. It was successfully retrieved with a combined laparoscopic-colonoscopic approach. Follow-up flexible sigmoidoscopy showed a well-healed rectal wall.

CLINICAL DISCUSSION

IUD perforation can increase the risk of morbidity and necessitates early surgical intervention even if the patient is asymptomatic. Combined laparoscopic-colonoscopic approach allows for safe retrieval of IUD that has perforated the intraperitoneal rectal segment or is firmly embedded within the mucosa. Recognising the risk factors and adhering to the principles of IUD insertion could significantly lower the risk of perforation.

CONCLUSION

This case report highlights the importance of a physician's vigilance regarding a perforating IUD in a patient with a history of a difficult insertion. It is imperative to undertake additional steps to rule out such a complication in these cases. Uterine perforation can be avoided with implementation of safe IUD insertion practice.

A Case of Peritoneal Tuberculosis Mimicking Ovarian Cancer in a Young Female

Background

Tuberculosis causes significant morbidity and mortality globally. Peritoneal tuberculosis can have a similar presentation to ovarian cancer.

Case

We present a case of a 42-year-old female referred to gynecology oncology with imaging findings of enlarged right ovary, omental caking, and elevated CA-125 (1289 U/mL). A diagnostic laparoscopy revealed diffuse studding of intraperitoneal surfaces. Histopathological examination of omental and abdominal wall biopsies showed granulomas, but stains and cultures for mycobacteria were negative. Antimicrobial treatment for tuberculosis was initiated. Within eight weeks, there was clear clinical and radiographic improvement, consistent with a diagnosis of peritoneal tuberculosis.

Conclusion

This case highlights the importance of including peritoneal tuberculosis in the differential diagnosis when evaluating for ovarian cancer in women with epidemiologic risk factors for tuberculosis.

Implantation metastasis from sigmoid colon cancer to rectal anastomosis proved by whole exome sequencing and lineage inference for cancer heterogeneity and evolution analysis: Case report and literature review

It was estimated that 70% of patients with colorectal cancer were found to have viable exfoliated malignant cells in adjacent intestinal lumen. Exfoliated malignant cells had been reported to implant on raw surfaces, such as polypectomy site, anal fissure, anal fistula, hemorrhoidectomy wound, and anastomotic suture line. Tumors at anastomosis could be classified into four groups: local recurrence, local manifestation of widespread metastasis, metachronous carcinogenesis, and implantation metastasis. However, all of the previous studies only reported the phenomena of implantation metastasis at anastomosis. No study had proved the origin of anastomotic metastasis by genomic analysis. In this study, a 43-year-old woman presented with persistent hematochezia was diagnosed as having severe mixed hemorrhoids. She was treated by procedure for prolapse and hemorrhoids (PPH), without receiving preoperative colonoscopy. Two months later, she was found to have sigmoid colon cancer by colonoscopy due to continuous hematochezia and received radical sigmoidectomy. Postoperative histological examination confirmed the lesion to be a moderately differentiated adenocarcinoma (pT3N1M0). Six months later, she presented with hematochezia again and colonoscopy revealed two tumors at the rectal anastomosis of PPH. Both tumors were confirmed to be moderately differentiated adenocarcinoma without lymph node and distant metastasis and were finally removed by transanal endoscopic microsurgery (TEM). Pathological examination, whole exome sequencing (WES), and Lineage Inference for Cancer Heterogeneity and Evolution (LICHeE) analysis demonstrated that the two tumors at the rectal anastomosis were probably implantation metastases arising from the previous sigmoid colon cancer. This is the first study to prove implantation metastasis from colon cancer to a distal anastomosis by WES and LICHeE analysis. Therefore, it is recommended to rule out colorectal cancer in proximal large bowel before performing surgery with a rectal anastomosis, such as PPH and anterior resection. For patients with a suspected implanted tumor, WES and LICHeE could be used to differentiate implantation metastasis from metachronous carcinogenesis.

Splenocolic fistula in a patient with diffuse large B-cell lymphoma: A case report and review of literature

A fistula that connects the bowel to other organs, such as the urinary bladder or small intestine, is a relatively frequent complication, often associated with inflammatory diseases such as diverticulitis, Crohn's disease, colorectal cancer, or lymphoma. Splenocolic fistula is an extremely rare condition described in the literature. It can occur in cases of splenic tumors, including splenic diffuse large B cell lymphoma. We report the case of an 82-year-old man who presented with melaena, worsening asthenia, hypotension, and abdominal pain in the left flank and the ipsilateral lumbar region. Ultrasound and computed tomography documented splenomegaly, thickening of the splenic flexure of the colon, and the presence of a fistulous passage between the colon and the splenic hilum. The diagnosis of lymphoma was made following laparotomy and caudal splenopancreatectomy. Due to the aggressive clinical behavior of this type of lymphoma, splenectomy is the main treatment in patients with splenomegaly, abdominal pain, and tumor expansion.

Shulan Estimation Model: A New Formula for Estimation of Standard Liver Volume In Chinese Adults

BACKGROUND

To establish a new and accurate model for standard liver volume (SLV) estimation and graft size prediction in liver transplantation for Chinese adults.

METHODS

In this study, the data of morphologic indices and liver volume (LV) were retrospectively obtained on 507 cadaveric liver transplantation donors between June 2017 and September 2020 in Shulan (Hangzhou) Hospital. Linear regression analysis was performed to evaluate the impact of each parameter and develop a new SLV formula. The new formula was then validated prospectively on 97 donors between October 2020 and June 2021, and the prediction accuracy was compared with previous formulas.

RESULTS

The average LV in all subjects was 1445.68 ± 309.94 mL. Body weight (BW) showing the strongest correlation (r = 0.453, P < .001). By stepwise multiple linear regression analysis, BW and age were the only 2 independent correlation factors for LV. Shulan estimation model derived: SLV (mL) = 13.266 × BW (kg) - 4.693 × age + 797.16 (R2 = 0.236, P < .001). In the validation cohort, our new model achieved no significant differences between the estimated SLV and the actual LV (P > .05), and showed the lowest mean percentage error of 0.33%. The proportions of estimated SLV within the actual LV ± 20%, ± 15%, and ± 10% percentage errors were 69.1%, 55.7%, and 40.2%, respectively.

DISCUSSION

The Shulan SLV estimation model predicted LV more accurately than previous formulas on Chinese adults, which could serve as a simple screening tool during the initial assessment of graft volume for potential donors.

Parasites in surgically removed appendices as a neglected public health concern: a systematic review and meta-analysis

The role of various parasitic infections in the occurrence of appendicitis is illustrated through cases recorded all over the world. The purpose of the current study was to estimate the global prevalence of parasite infestation (other than E. vermicularis) in appendectomy specimens.In the setting of the PRISMA guidelines, multiple databases (Science Direct, Scopus, Web of Science, PubMed, and Google Scholar) were explored in articles published until 28 September 2020. Totally, 62 studies (106 datasets) with 77, 619 participants were included in the analysis.The pooled prevalence of parasites in appendectomy samples was as follows; 0.012% (95% CI; 0.004-0.025) for Ascaris lumbricoides, 0.004% (95% CI; 0.001-0.009) for Trichuris trichiura, 0.025% (95% CI; 0.007-0.052) for Schistosoma mansoni, 0.002% (95% CI; 0.001-0.005) for Taenia spp., 0.061% (95% CI; 0.020-0.122) for Entamoeba histolytica and 0.034% (95% CI; 0.018-0.056) for Giardia lamblia.Our results demonstrated that the risk of appendicitis may increase in the presence of helminth and protozoan infections. As such, the most cases of parasites in appendectomy specimens were reported in developing countries. Regular screening plans for diagnosis, treatment and prevention are needed for prevention of parasitic infection as well as parasitic associated appendicitis, especially in endemic regions of the world.

[Budd-Chiari syndrome, review and illustration]

Budd-Chiari syndrome is a rare vascular disorder characterized by obstruction of the hepatic venous outflow. Various diseases causing coagulopathy play a role in aetiology, such as myeloproliferative disorders. Acute vascular occlusion may lead to acute phlebitis with fever. The classic triad of acute liver failure may be present with ascites, hepatomegaly, and abdominal pain. However, subacute courses of disease were also observed. Because of the variable symptoms and severity extent, depending on the acuity of the course and the extent of the affected vessels, diagnosis is often difficult. Sonography, as a ubiquitously available and cost-effective diagnostic tool, plays a leading role. Doppler ultrasonography can be used to visualize hemodynamics in particular. In acute thrombotic occlusion, the affected hepatic veins usually cannot or only partially be visualized. In non-occluding thrombi, turbulent flow patterns may develop in the area of venous outflow obstruction, and flow velocity is then increased in the area of stenosis. Contrast enhanced ultrasound offers even better specificity of diagnosis. Computed tomography and magnetic resonance imaging can directly visualize thrombi and the cause of obstruction. Once the diagnosis is confirmed, anticoagulation must be initiated, but therapy of the underlying disease must also be started. If symptom-controlling measures are not sufficient, angioplasty/stenting to reopen short-segment stenoses or implantation of a TIPSS device may be considered. Liver transplantation remains ultima ratio. As studies on the precision of diagnostic methods are controversial, the characteristics of imaging for BCS are therefore summarized in this review on the basis of several illustrating case reports.

Plant metabolite diosmin as the therapeutic agent in human diseases

Plant-derived flavonoids have been the focus of research for many years mainly in the last decade owing to their therapeutic properties. So far, about 4000 flavonoids have been identified from plants and diosmin (a flavone glycoside) is one of them. Online databases, previous studies, and reviews have been used to gather information on anti-oxidant, immunomodulatory, anti-cancer, anti-parasitic, and anti-microbialproperties of diosmin. Effects of diosmin in combination with other flavonoids have been reviewed thoroughly and its administrative routes are also summarized. Additionally, we studied the effect of diosmin on critical protein networks. It exhibits therapeutic effects in diabetes and its associated complications such as neuropathy and dyslipidemia. Combination of diosmin with hesperidin is found to be very effective in the treatment of chronic venous insufficiency and haemorrhoids. Diosmin is an exquisite therapeutic agent alone as well as in combination with other flavonoids.

Complications of lymphoma in the abdomen and pelvis: clinical and imaging review

Involvement of the abdomen and pelvis is common in lymphoma. Nodal and extranodal abdominal and pelvic lymphoma may present with various complications. Complications are most common in high-grade lymphomas, especially diffuse large B-cell lymphoma. Complications may occur as the initial manifestation of lymphoma, during treatment course, or late following complete disease remission. Most complications are associated with worse prognosis and increased mortality. Imaging is essential in evaluation of disease extent and diagnosis of complications. Therefore, radiologists should be familiar with the clinical context and imaging features of abdominal and pelvic lymphoma complications. We provide a comprehensive, organ system-based approach, and clinical and imaging review of complications of abdominal and pelvic lymphoma along with radiologic images of illustrated cases of the most commonly encountered complications.

Practical Approach to Histological Diagnosis of Peripheral Nerve Sheath Tumors: An Update

Peripheral nerve sheath tumors encompass a wide spectrum of lesions with different biological behavior, including both benign and malignant neoplasms as well as the recent diagnostic category, i.e., “atypical neurofibromatous neoplasm with uncertain biologic potential” to be used only for NF1 patients. Neurofibromas and schwannomas are benign Schwann-cell-derived peripheral nerve sheath tumors arising as isolated lesions or within the context of classical neurofibromatosis or schwannomatoses. Multiple tumors are a hallmark of neurofibromatosis type 1(NF1) and related forms, NF2-related-schwannomatosis (formerly NF2) or SMARCB1/LZTR1-related schwannomatoses. Perineuriomas are benign, mostly sporadic, peripheral nerve sheath tumors that show morphological, immunohistochemical, and ultrastructural features reminiscent of perineurial differentiation. Hybrid tumors exist, with the most common lesions represented by a variable mixture of neurofibromas, schwannomas, and perineuriomas. Conversely, malignant peripheral nerve sheath tumors are soft tissue sarcomas that may arise from a peripheral nerve or a pre-existing neurofibroma, and in about 50% of cases, these tumors are associated with NF1. The present review emphasizes the main clinicopathologic features of each pathological entity, focusing on the diagnostic clues and unusual morphological variants.

Abdominal wall reconstruction using Omental Flap with Mesh repair following resection of Aggressive Abdominal Wall Neoplasms

BACKGROUND

Resection of large anterior abdominal wall tumors causes a large full-thickness abdominal wall defects, and the repair of these defects remains a challenging point.

METHODS

Between July 2016 and February 2021, we retrospectively reviewed the internal database registry of the Oncology Center, Mansoura University (OCMU) Egypt, for patients with large abdominal wall defects after abdominal wall tumors resection and repair with omental flaps and synthetic Polypropylene (PP) mesh. Thirty-two patients met the inclusion criteria. They were analyzed for demographics, operative data including defect size, mesh size, intrabdominal tumor extension and postoperative outcomes and complications.

RESULTS

Thirty-Two patients with abdominal wall neoplasm underwent local resection in our center and the defect was closed with omental flap and PP mesh. The mean operative time was 143.75 ± 30.77 mins. The mean size of the abdominal wall defect was 50.78 cm2 (range: 25 - 90 cm2). The meshes used in reconstruction had a mean size of 89.53 cm2 (range: 55 - 130 cm2). The median follow-up period of the patients was 13.5 months (range: 5-54 months). Post-operative complications included infection (n = 4 cases), seroma (n = 2 cases), hematoma (n =1 case) and abnormal sensation (n = 5 cases). Tumor recurrence was reported in two cases and no cases developed incisional hernia during the follow up period.

CONCLUSION

Immediate use of omental flap with synthetic (PP) mesh for reconstruction of abdominal wall defects is a feasible technique and has avoided the complications associated with the use of synthetic mesh alone.

Potential and Therapeutic Roles of Diosmin in Human Diseases

Because of their medicinal characteristics, effectiveness, and importance, plant-derived flavonoids have been a possible subject of research for many years, particularly in the last decade. Plants contain a huge number of flavonoids, and Diosmin, a flavone glycoside, is one of them. Numerous in-vitro and in-vivo studies have validated Diosmin's extensive range of biological capabilities which present antioxidative, antihyperglycemic, anti-inflammatory, antimutagenic, and antiulcer properties. We have presented this review work because of the greater biological properties and influences of Diosmin. We have provided a brief overview of Diosmin, its pharmacology, major biological properties, such as anti-cancer, anti-diabetic, antibacterial, anticardiovascular, liver protection, and neuroprotection, therapeutic approach, potential Diosmin targets, and pathways that are known to be associated with it.

Intussusception of the third portion of the duodenum secondary to a primary duodenal malignancy: A case report

Introduction and importance

Intussusception is invagination of the bowel and is rare in adults, representing only 5% of all cases of intussusception. Duodenal intussusception is also very rare. To the best of our knowledge, there is only one previous report of a malignant tumor in the fourth portion of the duodenum as the lead point of intussusception (Vaibhav et al., 2021 [1]). This reports a duodenal-duodenal intussusception caused by a malignant tumor in the third portion of the duodenum.

Case presentation

A 36-year-old woman with abdominal pain was diagnosed with duodenal intussusception by abdominal ultrasonography and computed tomography scan. Double balloon endoscopy showed that the intussusception had spontaneously reduced, and a tumor was found in the third portion of the duodenum. Open resection was performed because of the tumor location. Pathologic examination revealed adenocarcinoma with an adenoma of the duodenum. The patient had no evidence of recurrence for 4 years after resection.

Clinical discussion

This patient had a primary duodenal malignancy and presented with intussusception, Duodenal intussusception is a rare condition requiring prompt intervention, usually requiring surgery. In this patient, since endoscopic resection was difficult, partial resection of duodenum was performed by open surgery assisted by double balloon enteroscopy. The pathological diagnosis of the resected specimen was primary duodenal malignancy.

Conclusion

This is a report of adult duodenal intussusception caused by a primary duodenal malignancy. This rare condition posed an intriguing challenge for the optimal operative approach.

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Duodenal intussusception caused by a primary tumor is extremely rare.

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Intussusception is rare in adults.

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A duodenal tumor was identified with double balloon endoscopy and resected.

Surgical timing for primary encapsulating peritoneal sclerosis: A case report and review of literature

BACKGROUND

Primary encapsulating peritoneal sclerosis (EPS) is a rare but devastating disease that causes fibrocollagenous cocoon-like encapsulation of the bowel, resulting in bowel obstruction. The pathogenesis, prevention, and treatment strategies of EPS remain unclear so far. Since most patients are diagnosed during exploratory laparotomy, for the non-surgically diagnosed patients with primary EPS, the surgical timing is also uncertain.

CASE SUMMARY

A 44-year-old female patient was referred to our center on September 6, 2021, with complaints of abdominal distention and bilious vomiting for 2 d. Physical examination revealed that the vital signs were stable, and the abdomen was slightly distended. Computerized tomography scan showed a conglomerate of multiple intestinal loops encapsulated in a thick sac-like membrane, which was surrounded by abdominal ascites. The patient was diagnosed with idiopathic EPS. Recovery was observed after abdominal paracentesis, and the patient was discharged on September 13 after the resumption of a normal diet. This case raised a question: When should an exploratory laparotomy be performed on patients who are non-surgically diagnosed with EPS. As a result, we conducted a review of the literature on the clinical manifestations, intraoperative findings, surgical methods, and therapeutic effects of EPS.

CONCLUSION

Recurrent intestinal obstructions and abdominal mass combined with the imaging of encapsulated bowel are helpful in diagnosing idiopathic EPS. Small intestinal resection should be avoided.

Association Between Portal Vein Thrombosis and Pouchitis in Patients with Ulcerative Colitis

BACKGROUND

Pouchitis is the most common long-term complication in patients requiring colectomy ileal pouch-anal anastomosis with medically refractory ulcerative colitis or colitis-associated neoplasia. A previous small case series suggests associated between portal vein thrombosis (PVT) and ischemic pouchitis.

AIM

To evaluate the association between PVT and other demographic and clinical factors and pouchitis.

METHODS

We used Explorys Inc., a population-based database, to search medical records between 1999 and 2020 with SNOMED-CT code criteria for "construction of pouch" and "ileal pouchitis." Patients with pouchitis were compared to those with previous pouch construction without pouchitis. Factors associated with pouchitis identified with univariable analysis were introduced into a multivariable model. A post hoc analysis further stratified demographical findings of the association between PVT and pouchitis.

RESULTS

We identified 7900 patients with ileal pouchitis (7.5%) and 97,510 with pouch construction without pouchitis. In multivariate binary logistic regression, adjusted odds ratio (aOR) for the risk of pouchitis in patients with PVT was 10.78 (95% confidence interval [CI] 7.04-16.49, P < 0.001). Other significant factors associated with pouchitis included male gender (aOR 1.11, 95% CI 1.02-1.21, P = 0.018), deep vein thrombosis (aOR 1.46, 95% CI 1.23-1.72, P < 0.001), and the use of non-steroidal anti-inflammatory drugs (aOR 1.37, 95% CI 1.28-1.45, P < 0.001). Smoking was a protective factor (aOR 0.30, 95% CI 0.33-0.36, P < 0.001). Further sub-analysis showed a higher prevalence of younger patients with PVT and pouchitis.

CONCLUSIONS

We report PVT as an independent risk factor associated with pouchitis. Our findings support that PVT is a potentially manageable perioperative complication, and intervention may reduce the risk of pouchitis.

Colosplenic fistula presentation in the context of undiagnosed colon cancer: Case report and review of literature

Introduction and importance

Enteric fistulas commonly arise from inflammatory, infectious, or neoplastic processes. Colosplenic fistulas are rare with only several reported worldwide.

Case presentation

Herein, we present a case of colosplenic fistula in a 39-year-old gentleman with past history of rectal cancer previously in remission. He was admitted with severe abdominal pain and hemodynamic instability due to septic shock. The erect chest x-ray revealed pneumoperitoneum under the diaphragm.

Clinical discussion

Laparotomy was performed and ileum perforation was managed by resection and anastomosis. The post-op recovery was complicated by a febrile episode. To locate the source of infection a contrasted abdominal computed tomography was ordered, confirming the presence of a splenic abscess, suggestive of colosplenic fistula. We proceeded with laparotomy for drainage of the abscess, with splenectomy and splenic flexure resections. He was discharged 40 days post-op at a pre-morbid state.

Conclusion

Due to the high prevalence of colon cancer worldwide, novel complications such as the one reported here, are important to be reflected on. We hope this case can exemplify the significance of higher index of suspicion in at risk patient groups by the surgical teams and appropriate training on acute management of this rare complication.

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Critically unwell surgical patients require immediate septic work-up and management.

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Colosplenic fistula are formed due to an inflammatory or neoplastic response.

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Colosplenic fistula can be treated with en-block surgical resection of colon and spleen.

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We recommend early initiation of genetic testing in patients with early presentation of rectal adenocarcinoma.

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In young patients, we should consider total colo-proctectomy to minimize the burden on the patients and healthcare system.

Rectal Cancer Metastasis to the Anal Verge: An Unusual Case Presentation and Review of the Literature

Background

Anal metastasis of colorectal adenocarcinoma is very rare, represented by only a handful of case reports in the literature. Previously, reports of metastasis to this region had occurred following a history of anorectal disease, such as anal fistulae. Antecedent trauma to the area from hemorrhoidectomy, fissures, or perineal retractor injury have also been implicated.

Case Presentation

Herein we report the case of 69-year-old man without any history of anal disease presenting with a metachronous metastasis of a colorectal-type adenocarcinoma to the anal verge. He was previously treated for T1N0 rectal adenocarcinoma at the rectosigmoid junction with a low anterior resection 5 years prior, then had a T3N0 local recurrence at the colorectal anastomosis treated with neoadjuvant chemoradiation, and eventually a Hartmann's procedure 4 years later. Subsequently, on surveillance flexible sigmoidoscopy, a new tumor was identified on the perianal skin extending from the anal verge. Histopathology demonstrated colorectal-type adenocarcinoma. Flexible endoscopy identified no other residual or recurrent disease in the colon or rectal stump. The patient was treated with wide local excision and advancement flap reconstruction.

Conclusion

Isolated metastasis to the anus is an extremely rare occurrence for colorectal adenocarcinoma. There exists little evidence to inform management. One option is to treat like a locally recurrent rectal cancer with aggressive tri-modality management consisting of chemoradiation, abdominal perineal resection, and adjuvant chemotherapy. In the absence of metastatic disease, local resection and close surveillance remain an option. As always, patient factors should guide management.

The association between appendicitis severity and patient age with appendiceal neoplasm histology-a population-based study

PURPOSE

Recent studies have reported alarming appendiceal tumor rates associated with complicated acute appendicitis, especially in patients presenting with a periappendicular abscess. However, the data on histology of appendiceal tumors among acute appendicitis patients is limited, especially in patient cohorts differentiating between uncomplicated and complicated acute appendicitis. We have previously reported the association of increased appendiceal tumor prevalence with complicated acute appendicitis in this population-based study. The objective of this secondary analysis was to evaluate the association of both appendicitis severity and patient age with appendiceal tumor histology.

METHODS

This nationwide population-based registry study (The Finnish Cancer Registry) was conducted from 2007 to 2013. All appendiceal tumors (n = 840) and available medical reports (n = 504) of these patients at eight study hospitals were previously evaluated, identifying altogether 250 patients with both acute appendicitis and appendiceal tumor.

RESULTS

The severity of acute appendicitis was significantly associated with more malignant tumor histology. The risk of adenocarcinoma or pseudomyxoma was significantly higher among patients with periappendicular abscess (OR 15.05, CI 95% 6.98-32.49, p < 0.001) and patients presenting with perforated acute appendicitis (OR 4.09, CI 95% 1.69-9.90, p = 0.0018) compared to patients with uncomplicated acute appendicitis. Similarly, patient age over 40 years was significantly associated with the risk of adenocarcinoma and pseudomyxoma (OR 26.46, Cl 95% 7.95-88.09, p < 0.001). Patient sex was not associated with a more malignant appendiceal tumor histology (p = 0.67).

CONCLUSION

More malignant appendiceal tumor histology of adenocarcinoma or pseudomyxoma was significantly associated with patient age over 40 years and complicated acute appendicitis, especially periappendicular abscess.

A new formula for estimation of standard liver volume using liver height and thoracic width

Purpose

Precise estimation of the standard liver volume (SLV) is crucial in decision making regarding major hepatectomy and living donor liver transplantation. This study aimed to propose an accurate and efficient formula for estimating the SLV in the Korean population.

Methods

We created a regression model for SLV estimation using a data set of 230 Korean patients with healthy livers. The proposed model was cross validated using a different data set of 37 patients with healthy livers. The total liver volume (TLV), except for the volume of liver blood vessels, was measured through computed tomography volumetry as the dependent variable. Various anthropometric variables, liver height (LH), thoracic width (TW), age, and sex (0, female and 1, male) were considered as candidates for independent variables. We conducted stepwise regression analysis to identify variables to be included in the proposed model.

Results

A new formula was established; SLV = −1,275 + 9.85 × body weight (BW, kg) + 19.95 × TW (cm) + 7.401 × LH (mm). The proposed formula showed the best performance among existing formulas over the cross-validation data set.

Conclusion

The proposed formula derived using BW, TW, and LH estimated the TLV in the cross-validation data set more accurately than existing formulas.

Opioid Overdose and Serotonin Syndrome due to Gastric Bezoar in a Woman with Autism and Pica Behaviour

We are presenting the case of a 38-year-old woman with nonverbal autism and intellectual disability, hospitalized in a neurobehavioural unit because of a pica behaviour for 3 years. During the hospitalization, the patient presented an episode of pain, agitation, restlessness, rhabdomyolysis, coma, tachycardia, hyperthermia, shivering, and diarrhoea. The main hypothesis raised was tramadol overdose because of the immediate antidote response to the injection of naloxone 0,4 mg/mL. Even if we did not exceed the recommended prescription dosage of tramadol, the presence of gastric bezoar slowed the absorption of the drug, and the consequence was an opioid overdose and serotonin syndrome.

Endoscopy Capsule Retention in a Young Female with Small Bowel Strictures Secondary to Non-Steroidal Anti-Inflammatory Drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) can cause small bowel damage, which could present in different ways, including abdominal pain and occult gastrointestinal bleeding. NSAID use can also result in small bowel strictures, which can be challenging to diagnose and manage. Here, we describe a case of a 49-year-old female who presented with chronic anaemia and intermittent abdominal pain, with a history of NSAID use. She underwent capsule endoscopy as part of the workup for anaemia and subsequently had capsule retention due to a small bowel stricture.

PREOPERATIVE USE OF MICRO-FLAVONOID FRACTION (MMF) AS PART OF A MULTIMODAL ANALGESIA IN ANORECTAL SURGERY: PROSPECTIVE, RANDOMIZED, PLACEBO-CONTROLLED, DOUBLE-BLIND STUDY PROTOCOL

Aim: To assess the efficiency of the micro-flavonoid fraction (MMF) administration prior to anorectal surgery with spinal anesthesia on postoperative pain severity reduction.Methods: Patients of our clinic who meet the following inclusion criteria are included: they must be diagnosed with surgical treatment of anorectal diseases. All participants are randomly divided into 2 groups: the first one gets a tablet with 1000 mg MFF (Detralex®), the second one gets a tablet containing starch per os 14 days before surgery (72 participants per arm). Then patients of each group will continue MFF administration for 30 days after surgery. Patients of both arms receive spinal anesthesia and undergo surgery. Following the procedure the primary and secondary outcomes are evaluated: frequency of the opioid drugs intake, the severity of the postoperative pain syndrome, duration and frequency of other drugs intake, readmission rate, overall quality of life, time from the procedure to returning to work and the complications rate, C-reactive protein level.Discussion: the MFF intake allows reducing the severity of the hemorrhoidal disease symptoms during conservative treatment. In addition, the Detralex® efficacy has been proven in postoperative pain reduction for patients diagnosed with varicose veins of the lower extremities. We intend to evaluate the feasibility of the preoperative MFF administration for the postoperative pain reduction and the decrease of the postoperative complications in patients with hemorrhoidal disease.

Over-the-Scope Clip in the Treatment of Gastrointestinal Leaks and Perforations

While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized <1 cm. Ultimately, given the limited available data, prospective randomized trials are needed to better evaluate the utility of the over-the-scope clip in various clinical scenarios, including fistula and perforation management.

Risk of appendiceal neoplasm after interval appendectomy for complicated appendicitis: A systematic review and meta-analysis

BACKGROUND

Non-operative management is often the treatment of choice in cases of complicated appendicitis and routine interval appendectomy is not usually recommended. Actually, recent studies show an alarming number of appendiceal neoplasms following interval appendectomy. The aim of this study is to evaluate the prevalence of appendiceal neoplasms and their histological types after interval appendectomy for complicated appendicitis in adults.

METHODS

A comprehensive literature search of the PubMed, Scopus and Web of Science databases was conducted according to the PRISMA statement. Studies reporting appendiceal neoplasm rates after interval appendectomy and histopathological characteristics were included. The most recent World Health Organization (WHO) classification of malignant tumours was considered. A pooled prevalence analysis for both prevalence and pathology was performed.

RESULTS

A total of eight studies was included: seven retrospective series and one randomized controlled trial. The pooled prevalence of neoplasms after interval appendectomy was 11% (95% CI 7-15; I2 = 37.5%, p = 0.13). Appendiceal mucinous neoplasms occurred in 43% (95% CI 19-68), adenocarcinoma in 29% (95% CI 6-51), appendiceal neuroendocrine neoplasm in 21% (95% CI 6-36), globet cell carcinoma in 13% (95% CI -2-28), adenoma or serrated lesions in 20% (95% CI -0-41) of cases.

CONCLUSION

The risk of appendiceal neoplasm in patients treated with interval appendectomy for complicated appendicitis is 11%; mucinous neoplasm is the most common histopathological type. Further studies should investigate this association in order to clarify the biological pathway and clinical implications.

Left lateral segment liver volume is not correlated with anthropometric measures

BACKGROUND

Liver transplantation is definitive therapy for end stage liver disease in pediatric patients. Living donor liver transplantation (LDLT) with the left lateral segment (LLS) is often a feasible option. However, the size of LLS is an important factor in donor suitability - particularly when the recipient weighs less than 10 kg. In the present study, we sought to define a formula for estimating left lateral segment volume (LLSV) in potential LLS donors.

METHODS

We obtained demographic and anthropometric measurements on 50 patients with Computed Tomography (CT) scans to determine whole liver volume (WLV), right liver volume (RLV), and LLSV. We performed univariable and multivariable linear regression with backwards stepwise variable selection (p < 0.10) to determine final models.

RESULTS

Our study found that previously reported anthropometric and demographics variables correlated with volume were significantly associated with WLV and RLV. On univariable analysis, no demographic or anthropometric measures were correlated with LLSV. On multivariable analysis, LLSV was poorly predicted by the final model (R2 = 0.10, Coefficient of Variation [CV] = 42.2) relative to WLV (R2 = 0.33, CV = 18.8) and RLV (R2 = 0.41, CV = 15.8).

CONCLUSION

Potential LLS living donors should not be excluded based on anthropometric data: all potential donors should be evaluated regardless of their size.

Obscure Gastrointestinal Bleeding Due to Non-steroidal Anti-inflammatory Drug-Induced Colopathy

Obscure gastrointestinal (GI) bleeding poses a diagnostic challenge and is associated with high mortality. We report a case of life-threatening obscure GI bleeding precipitated by the ingestion of a non-steroidal anti-inflammatory drug (NSAID). The source of bleeding could not be identified preoperatively, and hence exploratory laparotomy was performed. An ileocaecal resection was undertaken based on the findings of the intraoperative enteroscopy. However, the bleeding recurred and repeated endoscopy examination identified the source to be multiple NSAID-induced ulcers that were scattered in the colo-rectum. The bleeding stopped spontaneously after a period of intensive supportive therapy and sulphasalazine enemas. This case highlights the diagnostic challenge of obscure GI bleeding. It also highlights the potentially life-threatening danger of GI bleeding secondary to NSAID-induced colopathy, even after a short course of treatment.

Single-center study: evaluation of sonography in Budd-Chiari syndrome

PURPOSE

Budd-Chiari syndrome (BCS) is a rare disease characterized by hepatic venous outflow tract obstruction. The study aimed to evaluate the diagnostic utility of ultrasound in confirming the diagnosis of BCS and to provide an overview of the clinical picture.

MATERIALS AND METHOD

In this retrospective single-center study, patients with an initial diagnosis of BCS were included. The files were analyzed concerning the ultrasound images and compared to computed tomography (CT) and magnetic resonance imaging (MRI). Main clinical signs of BCS were collected.

RESULTS

Data of 25 patients were analyzed. Doppler sonography showed the highest sensitivity (78.9%) with the highest specificity 97.4 (%) in confirming the correct diagnosis of BCS. Main imaging signs were obstruction in the hepatic veins (68.0%, 17/25 thrombotic), collaterals (91.7%, 11/12 intrahepatic), inhomogeneous liver parenchyma (7/21), and a hypertrophied lobus caudatus (18/21) (p < 0.01). All imaging signs could be detected with sonography. Hypertrophied lobus caudatus was seen exclusively in BCS. Furthermore, portal hypertension (9/25), liver cirrhosis (9/25), and ascites (19/25) can be diagnosed as non-specific signs of BCS (p < 0.01).The main clinical findings were elevated γ-GT levels in the laboratory (92.0%, 23/25, p < 0.01) and esophageal varices in endoscopy (12/25 p < 0.01). An association with myeloproliferative neoplasia (MPN) was frequently seen (10/25) (p < 0.01).

CONCLUSION

The present study demonstrates that sonography is an appropriate tool for the diagnosis of BCS and should be used as the first imaging procedure.

Contemporary trends in the level of evidence in general thoracic surgery clinical research

OBJECTIVES

The large volume of scientific publications and the increasing emphasis on high-quality evidence for clinical decision-making present daily challenges to all clinicians, including thoracic surgeons. The objective of this study was to evaluate the contemporary trend in the level of evidence (LOE) for thoracic surgery clinical research.

METHODS

All clinical research articles published between January 2010 and December 2017 in 3 major general thoracic surgery journals were reviewed. Five authors independently reviewed the abstracts of each publication and assigned a LOE to each of them using the 2011 Oxford Centre for Evidence-Based Medicine classification scheme. Data extracted from eligible abstracts included study type, study size, country of primary author and type of study designs. Three auditing processes were conducted to establish working definitions and the process was validated with a research methodologist and 2 senior thoracic surgeons. Intra-class correlation coefficient was calculated to assess inter-rater agreement. Chi-square test and Spearman correlation analysis were then used to compare the LOE between journals and by year of publication.

RESULTS

Of 2028 publications reviewed and scored, 29 (1.4%) were graded level I, 75 (3.7%) were graded level II, 471 (23.2%) were graded level III, 1420 (70.2%) were graded level IV and 33 (1.6%) were graded level V (lowest level). Most publications (94.9%) were of lower-level evidence (III-V). There was an overall increasing trend in the lower LOE (P < 0.001). Inter-rater reliability was substantial with 95.5% (95%, confidence interval: 0.95-0.96) level of agreement between reviewers.

CONCLUSIONS

General thoracic surgery literature consists mostly of lower LOE studies. The number of lower levels of evidence is dominating the recent publications, potentially indicating a need to increase the commitment to produce and disseminate higher-level evidence in general thoracic surgery.

Heart on the left, diaphragm on the right: A case of congenital diaphragmatic eventration

Congenital Diaphragmatic Eventration (DE) requires a prompt diagnosis to avert the potentially life-threatening complications. Herein, a 5-month-old male presented with recurrent respiratory infections due to a right-sided diaphragmatic eventration. Misdiagnosed from previous medical visits, timely surgical intervention by thoracoscopic plication of the diaphragm was crucial for our patient's survival.

The Value of Systematic Reviews and Meta-Analyses in Surgery

BACKGROUND

Systematic reviews and meta-analyses are generally regarded as sitting atop the hierarchy of clinical evidence. The unbiased summary of current evidence that a systematic review provides, along with the increased statistical power from larger numbers of patients, is invaluable in guiding clinical decision-making and development of practice guidelines. Surgical specialties have historically lagged behind other areas of medicine in the application of evidence-based medicine, perhaps due to the unique challenges faced in the conduct of surgical clinical trials. These challenges extend to the conduct of systematic reviews, due to issues with the quality and heterogeneity of the underlying literature.

SUMMARY

Recent years have seen an improvement in the quality of randomized controlled trials in surgical topics and an explosion in the publication of systematic reviews. This review explores recent trends in systematic reviews in surgery and discussed some of the aspects in conducting and interpreting reviews that are unique to surgical topics, including blinding, surgical heterogeneity and learning curves, patient and clinician preference, and industry involvement. Key Messages: Clinical trials, and therefore systematic reviews, of surgical interventions pose unique challenges which are important to consider when conducting them or applying the findings to clinical practice. Despite the challenges, systematic reviews still represent the best level of evidence for development of surgical practice guidelines.

Deep Learning CT-based Quantitative Visualization Tool for Liver Volume Estimation: Defining Normal and Hepatomegaly

Background Imaging assessment for hepatomegaly is not well defined and currently uses suboptimal, unidimensional measures. Liver volume provides a more direct measure for organ enlargement. Purpose To determine organ volume and to establish thresholds for hepatomegaly with use of a validated deep learning artificial intelligence tool that automatically segments the liver. Materials and Methods In this retrospective study, liver volumes were successfully derived with use of a deep learning tool for asymptomatic outpatient adults who underwent multidetector CT for colorectal cancer screening (unenhanced) or renal donor evaluation (contrast-enhanced) at a single medical center between April 2004 and December 2016. The performance of the craniocaudal and maximal three-dimensional (3D) linear measures was assessed. The manual liver volume results were compared with the automated results in a subset of renal donors in which the entire liver was included at both precontrast and postcontrast CT. Unenhanced liver volumes were standardized to a postcontrast equivalent, reflecting a correction of 3.6%. Linear regression analysis was performed to assess the major patient-specific determinant or determinants of liver volume among age, sex, height, weight, and body surface area. Results A total of 3065 patients (mean age ± standard deviation, 54 years ± 12; 1639 women) underwent multidetector CT for colorectal screening (n = 1960) or renal donor evaluation (n = 1105). The mean standardized automated liver volume ± standard deviation was 1533 mL ± 375 and demonstrated a normal distribution. Patient weight was the major determinant of liver volume and demonstrated a linear relationship. From this result, a linear weight-based upper limit of normal hepatomegaly threshold volume was derived: hepatomegaly (mL) = 14.0 × (weight [kg]) + 979. A craniocaudal threshold of 19 cm was 71% sensitive (49 of 69 patients) and 86% specific (887 of 1030 patients) for hepatomegaly, and a maximal 3D linear threshold of 24 cm was 78% sensitive (54 of 69) and 66% specific (678 of 1030). In the subset of 189 patients, the median difference in hepatic volume between the deep learning tool and the semiautomated or manual method was 2.3% (38 mL). Conclusion A simple weight-based threshold for hepatomegaly derived by using a fully automated CT-based liver volume segmentation based on deep learning provided an objective and more accurate assessment of liver size than linear measures. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Sosna in this issue.

Surgical resection of leiomyosarcoma of the inferior vena cava: A case series and literature review

OBJECTIVES

We review our institution's experience in treating leiomyosarcomas involving the inferior vena cava, and we offer guidance on the management.

METHODS

A text-based search was performed to identify all patients who underwent surgical resection between January 2002 and October 2020. Clinicopathologic data, intraoperative variables, and outcomes were extracted from chart review.

RESULTS

Twelve of 16 patients (75%) had localized disease; the remaining had limited metastatic disease. Seven of 16 patients (44%) received neoadjuvant chemotherapy or radiation; three patients had partial responses, and four patients had stable disease using RECIST 1.1 criteria. IVC reconstruction was performed in 14 of 16 patients (88%); IVC was ligated for the remaining two patients. Half of all patients had R0 resection on final pathology; the remaining had R1 resections. Progression-free survival (PFS) and overall survival (OS) were not statistically different between patients with R0 and R1 resection. Median PFS was 1.8 years (95% CI 0.89 - not reached); median OS was 6.5 years (1.8 - not reached). Only one patient (6%) experienced local disease recurrence; 4 of 16 patients (25%) experienced disease recurrence distally without local recurrence.

CONCLUSIONS

Resection of IVC leiomyosarcomas at a sarcoma referral center with experience in vascular reconstruction can lead to many years of recurrence-free survival. Surgical resection should be offered to patients with a low volume of metastatic disease to reduce local complications from the primary tumor, many of which exert significant mass effect on surrounding organs. For patients with metastatic disease or large, high-risk tumors, neoadjuvant chemotherapy can provide a biologic test of disease stability prior to resection.

Standard liver weight model in adult deceased donors with fatty liver: A prospective cohort study

BACKGROUND

Standard liver weight (SLW) is frequently used in deceased donor liver transplantation to avoid size mismatches with the recipient. However, some deceased donors (DDs) have fatty liver (FL). A few studies have reported that FL could impact liver size. To the best of our knowledge, there are no relevant SLW models for predicting liver size.

AIM

To demonstrate the relationship between FL and total liver weight (TLW) in detail and present a related SLW formula.

METHODS

We prospectively enrolled 212 adult DDs from West China Hospital of Sichuan University from June 2019 to February 2021, recorded their basic information, such as sex, age, body height (BH) and body weight (BW), and performed abdominal ultrasound (US) and pathological biopsy (PB). The chi-square test and kappa consistency score were used to assess the consistency in terms of FL diagnosed by US relative to PB. Simple linear regression analysis was used to explore the variables related to TLW. Multiple linear regression analysis was used to formulate SLW models, and the root mean standard error and interclass correlation coefficient were used to test the fitting efficiency and accuracy of the model, respectively. Furthermore, the optimal formula was compared with previous formulas.

RESULTS

Approximately 28.8% of DDs had FL. US had a high diagnostic ability (sensitivity and specificity were 86.2% and 92.9%, respectively; kappa value was 0.70, P < 0.001) for livers with more than a 5% fatty change. Simple linear regression analysis showed that sex (R2, 0.226; P < 0.001), BH (R2, 0.241; P < 0.001), BW (R2, 0.441; P < 0.001), BMI (R2, 0.224; P < 0.001), BSA (R2, 0.454; P < 0.001) and FL (R2, 0.130; P < 0.001) significantly impacted TLW. In addition, multiple linear regression analysis showed that there was no significant difference in liver weight between the DDs with no steatosis and those with steatosis within 5%. Furthermore, in the context of hepatic steatosis, TLW increased positively (non-linear); compared with the TLW of the non-FL group, the TLW of the groups with hepatic steatosis within 5%, between 5% and 20% and more than 20% increased by 0 g, 90 g, and 340 g, respectively. A novel formula, namely, -348.6 + (110.7 x Sex [0 = Female, 1 = Male]) + 958.0 x BSA + (179.8 x FLUS [0 = No, 1 = Yes]), where FL was diagnosed by US, was more convenient and accurate than any other formula for predicting SLW.

CONCLUSION

FL is positively correlated with TLW. The novel formula deduced using sex, BSA and FLUS is the optimal formula for predicting SLW in adult DDs.

Giant gastric lipoma as an uncommon cause of upper gastrointestinal bleeding

A 52-year-old male patient presented at the emergency room for melena. A gastroscopy was performed, which revealed a submucosal lesion in the antrum of the stomach. The lesion was lined with regular smooth mucosa except for an apical ulceration. Histology demonstrated gastric mucosa with foveolar hyperplasia. Abdominal computerized tomography showed a homogeneous, well-delimited fat-density mass measuring 5.9 x 4.3 cm. Laparoscopic surgery then found a solid tumor involving the whole thickness of the anterior wall at the prepyloric area, which was resected. Microscopic examination revealed a homogeneous, soft, ulcerated submucosal mass of yellowish adipose tissue that was 5 x 5 x 2 cm in size. Microscopically, the tumor was composed of mature fatty tissue with fibrous septa, and was partially encapsulated and circumscribed. It was reported as submucosal lipoma. The patient had a favorable outcome.

An unusual presentation of non-IBD related colorectal primary extranodal diffuse large B cell lymphoma with a colo-colonic fistula

Diffuse large B cell lymphoma of the sigmoid colon and rectum is relatively uncommon and aggressive. Due to its nonspecific symptomatology, patients are often diagnosed late into the disease and present with life-threatening complications, such as hemorrhage, obstruction, or perforation, requiring emergent surgical intervention. Patients with colorectal lymphoma typically have inflammatory bowel disease or immunosuppression. We present a case of a 79-year-old male with no known inflammatory bowel disease or immunosuppression, who had significant weight loss, diarrhea, and abdominal fullness, found by CT to have irregular wall thickening of the recto-sigmoid colon along with a colo-colonic fistula, concerning for bowel perforation. Endoscopic evaluation and biopsy confirmed the diagnosis of recto-sigmoid Diffuse large B cell lymphoma, with a PET/CT scan revealing stage IV disease. He had a partial response to six cycles of palliative reduced dose R-CHOP and is currently receiving palliative radiation to the sigmoid colon and rectum. Surgery and/or chemoradiation remain the mainstay therapy for this condition. Clinicians, however, must consider patient’s functional, nutritional, and clinical status prior to choosing an optimal therapeutic regimen. This case illustrates a unique clinical presentation of this condition and the associated diagnostic and therapeutic challenges that arise in order to prevent life-threatening complications.

Population-based and Personalized Reference Intervals for Liver and Spleen Volumes in Healthy Individuals and Those with Viral Hepatitis

Background Reference intervals guiding volumetric assessment of the liver and spleen have yet to be established. Purpose To establish population-based and personalized reference intervals for liver volume, spleen volume, and liver-to-spleen volume ratio (LSVR). Materials and Methods This retrospective study consecutively included healthy adult liver donors from 2001 to 2013 (reference group) and from 2014 to 2016 (healthy validation group) and patients with viral hepatitis from 2007 to 2017. Liver volume, spleen volume, and LSVR were measured with CT by using a deep learning algorithm. In the reference group, the reference intervals for the volume indexes were determined by using the population-based (ranges encompassing the central 95% of donors) and personalized (quantile regression modeling of the 2.5th and 97.5th percentiles as a function of age, sex, height, and weight) approaches. The validity of the reference intervals was evaluated in the healthy validation group and the viral hepatitis group. Results The reference and healthy validation groups had 2989 donors (mean age ± standard deviation, 30 years ± 9; 1828 men) and 472 donors (mean age, 30 years ± 9; 334 men), respectively. The viral hepatitis group had 158 patients (mean age, 48 years ± 12; 95 men). The population-based reference intervals were 824.5-1700.0 cm³ for liver volume, 81.1-322.0 cm³ for spleen volume, and 3.96-13.78 for LSVR. Formulae and a web calculator (https://i-pacs.com/calculators) were presented to calculate the personalized reference intervals. In the healthy validation group, both the population-based and personalized reference intervals were used to classify the volume indexes of 94%-96% of the donors as falling within the reference interval. In the viral hepatitis group, when compared with the population-based reference intervals, the personalized reference intervals helped identify more patients with volume indexes outside the reference interval (liver volume, 21.5% [34 of 158] vs 13.3% [21 of 158], P = .01; spleen volume, 29.1% [46 of 158] vs 22.2% [35 of 158], P = .01; LSVR, 35.4% [56 of 158] vs 26.6% [42 of 158], P < .001). Conclusion Reference intervals derived from a deep learning approach in healthy adults may enable evidence-based assessments of liver and spleen volume in clinical practice. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Ringl in this issue.

Clinical experience with the treatment of retroperitoneal vascular leiomyosarcoma originating from large veins

BACKGROUND

Retroperitoneal vascular leiomyosarcoma (RVLMS) is an extremely rare disease in clinical practice, and it has poor prognosis. This article is to explore the diagnosis and treatment of RVLMS and present our experience.

METHODS

Data of RVLMS patients were continuously collected in our hospital from August 2018 to February 2020: two males and two females with a median age of 56 (min-max = 33-61) years were included. Patients in whom paraganglioma could not be excluded were asked to take phenoxybenzamine before surgery. A multi-disciplinary team (MDT) meeting had been held and surgery was recommended. The operation procedures varied based on the tumor location, shape, and stage, and the core steps were "exposure of the retroperitoneum and tumor, identification of vital blood vessels, blocking the bloodstream, complete removal of the tumor and tumor thrombus, and release of blood flow". A Satinsky clamp was used to partially block the blood vessels. Follow-up was conveyed by revisits and phone calls.

RESULTS

One patient underwent open surgery, and three patients underwent laparoscopic surgery, one of whom underwent conversion to open surgery. The procedures were finished successfully, with a median operative time of 314.5 (min-max = 224-467) mins. The median amount of intraoperative bleeding was 550 (min-max = 200-1500) ml, and three patients had transfusion during the operation. The mass was irregular in shape, with a median maximum size of 7.45 (min-max = 4.2-10.7) cm, and the pathological examination confirmed RVLMS, which has spindle-shape, high mitotic activity and atypia. One week after the operation, the median serum creatinine level was 85 (min-max = 70-99) µmol/L. The median follow-up time was 16 (min-max = 13-21) months, and 1 case reported asymptomatic recurrence.

CONCLUSION

Uncharacteristic manifestations and imaging features contribute to the problematic diagnosis of RVLMS. Comprehensive preoperative evaluation and careful surgical planning are essential. Multicenter research is needed in the future to reach a dominant consensus.

Incorporation of Evidence-Based Surgery into the Curriculum

Surgeons have historically learned their craft through the apprenticeship model from their mentors. Knowledge and practices acquired this way can rapidly become outdated. Providing high-quality care to patients requires surgeons to keep their knowledge up to date in line with evolving new evidence. The principles of evidence-based medicine (EBM) and its application to surgery, evidence-based surgery (EBS), are pivotal in updating and refining surgical practice. Changing from the conventional practice of surgical education to a structured evidence-based format requires a transformative process in all the levels of surgical practice encompassing trainees and trainers. Equally important is providing an optimal environment to review the evidence and deliver the surgical teaching and incorporate effective assessment tools to monitor the process. In this article, we revisit the levels of evidence and explore the different issues related to EBS such as barriers to EBS, incorporation of EBS to the surgical curriculum and discuss practical ways to implement EBS in the surgical curriculum.

Implementation of a synoptic operative note for abdominal wall hernia repair: a statewide pilot evaluating completeness and communication of intraoperative details

Background

Variable approaches to intraoperative communication impede our understanding of surgical decision-making and best practices. This is critical among hernia repairs, where improved outcomes are reliant on understanding the impact of different patient characteristics and surgical approaches. In this context, a hernia-specific synoptic operative note was piloted as part of an effort to create a statewide hernia registry. We aimed to understand the impact of the synoptic operative note on variable missingness and evaluate barriers and facilitators to improved intraoperative communication and note adoption.

Methods

In January 2020, the Michigan Surgical Quality Collaborative (MSQC) registry was expanded to capture hernia-specific intraoperative variables. A synoptic operative note for hernia repair was piloted at 8 hospitals. The primary outcome was change in hernia variable communication, measured by missingness. Using a sequential explanatory mixed-methods design, we performed semi-structured interviews with data abstractors (n = 4) and surgeons (n = 4) at 5 pilot sites to assess barriers and facilitators of implementation. Interviews were iteratively analyzed using content analysis with both deductive and inductive approaches.

Results

From January to June 2020, 870 hernia repairs were performed across 8 pilot and 53 control sites. Pilot sites had significantly less missingness for all hernia-specific variables. At pilot sites, 46% of notes were fully complete in regard to hernia variables, compared to 21% at control sites (p value < 0.001). While collection of intraoperative variables improved after synoptic note implementation, low note adoption was reported. Facilitators of improved variable collection were (1) communication with data abstractors and (2) stakeholder acknowledgment of widespread benefit, while barriers included (1) surgeon resistance to practice change, (2) EMR/technology, and (3) interruptions to communication and implementation.

Conclusion

This mixed-methods evaluation of a synoptic operative note implementation suggests that sustained communication, particularly with abstractors, was the most impactful intervention. Future implementation efforts may have improved effectiveness with interventions supplementary to surgeon-level direction.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08614-8.

Benefits and Reduced Hospital Costs of Direct Surgery in Perforated Appendicitis With Abscess Cost-effectiveness Analysis of Treatment Complicated Appendicitis

PURPOSE

Elective interval appendectomy (IA) after percutaneous catheter drainage (PCD) is traditionally advocated for perforated appendicitis with an abscess. However, this is not the only way to manage these patients when we consider the cost-effectiveness of treatment. This study compared the outcomes and cost-effectiveness of patients who underwent IA and those who underwent direct surgery.

MATERIALS AND METHODS

A retrospective analysis of 79 patients who were diagnosed with perforated appendicitis with abscess was conducted. We compared the hospital course, outcomes, and total medical costs between the 2 groups.

RESULTS

Forty-three patients underwent PCD insertion for the management of appendiceal abscess (IA group), and 36 underwent appendectomy (DS group). There was no significant difference in abscess size (5.67 vs. 5.35 cm, P=0.15), appendectomy method (laparoscopic/open 39/4 vs. 37/5, P=0.523), or complications (7 vs. 6 cases, P=0.963) between the 2 groups. The operation time was longer in the DS group (83.8 vs. 112.7 min, P<0.001). However, length of hospitalization (15.4 vs. 7.7 d, P<0.001) and total hospital cost (US$2090.47 vs. US$3402.22, P<0.001) was greater in the IA group.

CONCLUSION

Direct surgery without PCD insertion in perforated appendicitis accompanied by abscess is more cost-effective and reduces the total length of hospitalization compared with the traditional IA.

Surgical Resection of Tumors Invading the Inferior Vena Cava at the Hepatic Vein and Thoracic Levels

BACKGROUND

Our aim was to describe the results of our program of surgical resection of tumors invading the inferior vena cava (IVC) at the hepatic and thoracic levels. We hypothesized that similar surgical outcomes may be obtained compared to tumor resection below the hepatic vein level if the liver function was preserved.

METHODS

We performed a single-center retrospective study of 72 consecutive patients who underwent surgical resection from 1996 to 2019 for tumors invading the IVC. We compared two groups based on tumor location below (group I/II) or above (group III/IV) the inferior limit of hepatic veins.

RESULTS

Tumor histology was similarly distributed between groups. In group III/IV (n = 35), sterno-laparotomy was used in 83% of patients, cardiopulmonary bypass in 77%, and deep hypothermic circulatory arrest in 17%; 23% underwent liver resection. Corresponding proportions in group I/II were 3%, 0%, 0%, and 8%. In group III/IV, 4 patients required emergency resection. Mortality on day 30 was 17% (n = 6) in group III/IV and 0% in group I/II (P = 0.01). There was no liver failure among the 66 postoperative survivors and 5 out of 6 patients who died postoperatively presented a preoperative or postoperative liver failure (P < 0.001). Overall survival was not significantly different between groups with a median follow-up of 15.1 months. R0 resection was achieved in 66% of group I/II and 49% of group III/IV patients (P = 0.03).

CONCLUSION

Surgical resection of tumors invading the inferior vena cava at hepatic vein and thoracic levels should be reserved to carefully selected patients without preoperative liver failure to minimize postoperative mortality.