The SCARE Statement: Consensus-based surgical case report guidelines

[Diagnostic difficulties in a patient with a combined gunshot injury involving non-penetrating abdominal wound and injury of superficial femoral artery]

Non-penetrating gunshot abdominal wounds are rare in peacetime and mainly caused by firearm traumatic weapons. The main therapeutic measure in this case is primary surgical debridement with adequate drainage. At the same time, such injuries may be accompanied by damage to internal organs. Timely diagnosis of these lesions may be difficult, and surgical treatment may be necessary. We report a patient with combined gunshot injury, damage to superficial femoral artery and non-penetrating abdominal wound followed by contusion and necrosis of small bowel. When providing medical care in patients with non-penetrating gunshot abdominal wounds, one should remember possible damage to internal organs due to high kinetic energy of the wounding projectile resulting contusion-induced necrosis.

Safety and Performance Evaluation of Su2ura Approximation, a New Suturing Device, in Pigs

One of the challenging aspects of minimal invasive surgery (MIS) is intracorporal suturing, which can be significantly time-consuming. Therefore, there is a rising need for devices that can facilitate the suturing procedure in MIS. Su2ura Approximation Device (Su2ura Approximation) is a novel device developed to utilize the insertion of anchors threaded with stitches to allow a single action placement of a suture. The objective of this study was to evaluate the long-term safety and tissue approximation of Su2ura Approximation in comparison to Endo Stitch + Surgidac sutures in female domestic pigs. All incision sites were successfully closed by both methods. Firm consolidation within and around the incision site was noted in several animals in both treatment groups, which corresponded histopathologically to islands of ectopic cartilage or bone spicules within the fibrotic scar. These changes reflect heterotopic ossification that is commonly seen in the healing of abdominal operation sites in pigs. No other abnormal findings were observed throughout the study period. In conclusion, the use of Su2ura Approximation under the present experimental conditions revealed no safety concerns.

Idiopathic ascites following laparoscopic appendicectomy: a case report

Appendicitis is a common condition and is frequently treated with a laparoscopic appendicectomy. We present a rare case of delayed, idiopathic ascites following laparoscopic appendicectomy for histologically confirmed appendicitis. While the complications of this condition and this procedure are well documented, this case demonstrates very rare sequelae following a laparoscopic appendicectomy.

Laparoscopic dorsal subsegmentectomy 8: Exploit the 3d technology to plan liver resection, and predict intraparenchymal pedicles. A case report. (With video explanation)

INTRODUCTION

Laparoscopic liver surgery is spreading, encouraged by technical and technological improvement. Both the obligated narrow space and the difficulty to modify it lead to a more complex approach to the lesions located in the posterosuperior portion of the liver. Surgical strategies such as the Caudal approach or the Diamond technique could ameliorate surgical procedure, but these areas remain a challenge and are still classified as complex.

CLINICAL CASE

We discuss the case of a 68 year old man with metachronous liver metastasis in the dorsal part of segment 8. We used portal phase CT-scan Dicom data to create Three-dimensional reconstruction, which was able to show the more distal branches of intraparenchymal structures. The reconstructed images were subsequently used to plan laparoscopic liver resection.

DISCUSSION

The capability of three-dimensional reconstruction to create a realistic image allows us to use ultrasound as a navigation tool. Exploiting these two technologies together, we arrived to regulate the resection stages by recognizing previously marked structures and searching them at every intervention phase. The strategy performed demonstrates both a high level of precision and the capability to predict intraparenchymal structures.

CONCLUSION

The advantages obtained from three-dimensional reconstruction are numerous in terms of either anatomical comprehension and technical precision, suggesting a potential improvement in surgical skill. Three-dimensional technology should be encouraged and spread to understand, in every single aspect, the potential of its use.

Osteochondroma Presenting Clinically with Carpal Tunnel Syndrome in a 12-Year-old Boy

Introduction

An exostosis is a benign growth of bone, which when capped with cartilage is called osteochondroma, which can appear as solitary or multiple, mostly affecting the long bones, pelvis, and shoulder region. The prevalence of known solitary exostosis is 1-2% in the general population. They are slow growing lesions with rare malignant transformation. In patients with a solitary exostosis, the chance of developing a chondrosarcoma out of an exostosis is around 1%.

Case Report

A 12-year-old boy presented to our outpatient department with complaints of pain, and swelling at the right wrist since 1 year and tingling numbness on and around palmar aspect of index and middle finger since 6 months. The swelling was of size 3 cm × 2 cm, Tinel's sign was positive. His blood parameters were normal. X-ray showed exostoses. Magnetic resonance imaging was suggestive of osteochondroma. Nerve conduction study was normal. Excision biopsy confirmed the diagnosis and also relieved all symptoms.

Conclusion

Our case report is unique in its own way as it reminds us that when presented with a case of osteochondroma of the distal radius in children, carpal tunnel syndrome can also occur.

A Huge Carotid Space Schwannoma Arising from The Cervical Sympathetic Chain - A Case Report

The Rationale:

Although 25%–45% of schwannomas are originating from the neck, carotid space schwannomas are extremely rare.

Patient Concerns:

We report a rare case of huge-sized schwannoma in a 20-year-old student who presented with a symptomless large carotid space mass.

Diagnosis:

Cervical magnetic resonance imaging (MRI) with contrast revealed a huge, well-defined mass measuring 13.7 cm × 6.4 cm × 4.1 cm. Cervical MRI along with brain MRI were consistent with neurofibromatosis type II.

Treatment and Outcomes:

Preoperative tracheostomy and wide local excision of schwannoma via a transcervical approach were performed with nerve preservation.

Takeaway Lessons:

The scarceness of cervical sympathetic chain schwannoma made this case of our patient very interesting to report. Moreover, our patient's huge tumour size is extremely rare, and we could not find any similar cases in the literature.

Left paraduodenal hernia - A diagnostic challenge: Case report

Introduction and importance

Internal hernias represent the penetration of intestinal loops through congenital or acquired openings within the mesentery or peritoneum. One such hernia is the paraduodenal hernia, which is the most common type of internal hernia (53%) (Yun et al., 2010) [1]. Due to the variable and non-specific clinical presentation, it is difficult to make a correct diagnosis. Preoperative computed tomography of the abdomen facilitates diagnosis and timely surgical intervention, which can be performed openly or laparoscopically (Coakley et al., 2012) [2].

Case presentation

In this paper, the case of a 39-year-old patient with left paraduodenal hernia will be presented. He arrived in the emergency department with sudden onset of abdominal pain. The diagnosis was established using computed tomography and an open surgical procedure was successfully performed.

Discussion

Clinical presentation of paraduodenal hernia ranges from asymptomatic to manifest. The greatest difficulty regarding management of paraduodenal hernias lies in their diagnosis. Many studies have shown that the best option for diagnosis is computed tomography (CT). Open and laparoscopic techniques are used in treatment of paraduodenal hernias with similar results.

Conclusion

The case of a 39-year-old male patient with LPDH with non-specific symptomatology was presented. CT scan is the best diagnostic option for this condition. Open surgical approach was used with great success.

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Internal hernias represent the penetration of intestinal loops within the mesentery.

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Most common internal hernias are paraduodenal hernias.

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Best diagnostic tool for internal hernias is computed tomography.

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Surgical options for internal hernias include open and laparoscopic approach.

Microvascular free tissue transfer in the setting of COVID-19 associated coagulopathy: A case report

In the era of this pandemic, the use of free flaps for elective reconstruction should proceed with caution in the COVID-19 positive patient given the associated coagulopathy. In those who require free tissue transfer in an urgent or non-elective manner, it is advisable to consider systemic anticoagulation with an associated hematologic consultation given the theoretic higher risk of flap vascular complication.

We present a case report of a young healthy and otherwise asymptomatic COVID-19 positive patient whose associated coagulopathy resulted in free flap loss and need for further operations.

Upper Lumbar Intradural Disc Herniation: A Rare Case Report and Etiologic Analysis

Background

Intradural disc herniation (IDH) is a rare type of disc degeneration that infrequently affects the upper lumbar spine. Pre- and intraoperative diagnosis and surgical management of IDH are challenging. The present case study provides insight into these aspects of upper lumbar IDH and discusses possible mechanisms.

Case Description

A 63-year-old female with a history of chronic lower back and leg pain presented with an acute lumbar sprain that had occurred 1 month prior. The pain progressed and spread to the front of the left thigh, which affected her ability to lift her leg when ascending/descending stairs. Sagittal gadolinium-enhanced magnetic resonance imaging (MRI) revealed a disc protruding into the ventral dural sac showing a hawk-beak sign, and the posterior edge of the disc annulus and local posterior longitudinal ligament was broken. Total L2 laminectomy was performed, and the dorsal side of the dural sac was exposed and incised to enable exploration of the ventral side of the dura. We found two free fragments protruding into the inner wall of the dura through the left ventral dura mater defect. After carefully and completely removing the mass, we repaired the defect and performed internal fixation. Postoperative pathologic analysis confirmed that the mass was nucleus pulposus tissue from the degenerated disc. The patient’s pain significantly improved after surgery, and she was able to walk normally at the 1-month follow-up.

Conclusion

Upper lumbar IDH is an extremely rare type of disc degeneration. An enhanced MRI scan can provide diagnostic evidence, but the final diagnosis requires surgical exploration of the path of herniation and pathologic examination of the mass lesion.

Non-functional retroperitoneal paraganglioma: A report of case with literature review

INTRODUCTION

Retroperitoneal paragangliomas are rare tumors, they arise from ganglia along the sympathetic and parasympathetic chain. We report a rare case of a non functional paraganglioma in whom surgical resection was performed.

PRESENTATION OF CASE

A 35 years-old female presented with chronic abdominal pain, A contrast magnetic resonance imaging (MRI) of abdomen showed a well-defined Left latero-aortic cystic retro-peritoneal surgical resection using laparotomy was performed, The patiente recovered well and was discharged three days after surgery. Histological examination and immunohistochemical revealed a retroperitoneal paraganglioma.

DISCUSSION AND CONCLUSION

Non-functioning retroperitoneal paragangliomas are rare and are most often Isolated. Radiological techniques including, Contrast-enhanced computed tomography (CT) and Magnetic resonance imaging (MRI) are useful for identifying and locating retroperitoneal paragangliomas. surgical excision is still the most effective treatment when it possible.

Bailing out the bowel and bladder - A rare case report of rectal impalement injury with iatrogenic bladder rupture

INTRODUCTION AND IMPORTANCE

Rectal perforations due to foreign body impalement are infrequently encountered in practice. Accidental or intentional foreign body insertions pose a diagnostic challenge to surgeons and put them in demanding circumstances for successful extraction.

CASE PRESENTATION

We report a case of a 60-year-old male with alleged history of accidental foreign body insertion into the rectum. Radiographs showed a linear metallic foreign body with crooked end. Computed Tomography (CT) with rectal contrast revealed contrast extravasation indicating anterior wall perforation of upper rectum. Patient was taken urgently for exploration and foreign body removal. Intra-operatively, bladder was injured inadvertently. Primary repair of enterotomy and loop sigmoid-ostomy was done besides bladder repair. Patient tested positive for COVID-19. Patient was observed in critical care unit for two days. Post-operative period was unremarkable apart from midline abdominal wound gape for which secondary closure was done. Patient was discharged with urinary catheter in-situ. Patient followed-up with a normal cystourethrogram and a well-functioning stoma. Stoma closure after two months was uneventful.

CLINICAL DISCUSSION

A thorough history and clinical examination is required and one should raise a high index of suspicion of perforation in patients with rectal foreign bodies, which should be managed appropriately and promptly to prevent sepsis and multi-organ dysfunction. Inadvertent bladder injuries are common with lower-midline incisions. However, give good results when repaired suitably.

CONCLUSION

The rationale behind this report is to explicate the complexity and hurdles in the surgical management of rectal foreign bodies causing impalement injury.

Synchronous solid pseudopapillary neoplasm of the pancreas with intrahepatic cholangiocarcinoma in a young male patient: An unusual deadly occurrence

INTRODUCTION AND IMPORTANCE

Solid pseudopapillary neoplasm of the pancreas (SPN) is a tumour with low malignant potential, albeit with good prognosis. Intrahepatic cholangiocarcinoma (iCCA) is a malignant and aggressive tumour with poor prognosis.

CLINICAL PRESENTATION

We report a case of a 38 years old African male patient with abdominal pain for 5 years that worsened in the preceding 5 months. Radiology showed pancreatic and liver lesions which were thought to be malignant and benign, respectively. However, intra-operative and histopathological assessment confirmed SPN and iCCA which were contrary to radiological findings. Whilst surgery was uneventful, the patient died after 15 days.

CLINICAL DISCUSSION

Whilst SPN is commonly seen in young females, it is rare in males and has been associated with aggressive behaviour. The prognosis is good, albeit the presence of metastasis. iCCA is rare in younger population notwithstanding the presence of risk factor. Combination of iCCA and SPT has not been described. Both these tumours do not share risk factors, pathogenesis or molecular alterations.

CONCLUSION

The concomitant occurrence of these two pathologies in young male patient is unusual and preoperative diagnosis may be very difficult.

Achieving precision surgery in laparoscopic liver resection with the aid of preoperative three-dimensional reconstruction: A case report

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Laparoscopic liver surgery is evolving and its spread is now starting to take place.

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Three-dimensional reconstruction imaging still remains a scarcely used technique.

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Considering the difficulty of liver resection surgery, a precise knowledge of the patient’s anatomy is essential in the preoperative planning of the intervention. Three-dimensional reconstruction imaging provides useful information in addition to conventional imaging, allowing a more accurate preoperative planning, and being used as a navigation instrument during liver resection.

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The use of three-dimensional reconstruction imaging allows to predict the precise location and direction of anatomical structures with high approximation, allowing to reach a high degree of precision surgery.

Introduction

The use of three-dimensional image reconstruction in liver surgery is well-known and has got many applications: It was first developed for vein reconstruction in liver transplantation and for liver volumetry to prevent post hepatectomy liver failure (PHLF) after major resections. There are many other advantages described in the literature provided by three-dimensional reconstruction, however its diffusion is currently limited.

Clinical case

We present the case of a woman with a single colon cancer metastasis in segment 5 of the liver. Using CT scan images we created a three dimensional reconstruction of the patient’s liver and its inners structures. The rendering was used to hypothesize the plan of dissection and to predict the pedicles that needed to be dissected during the procedure.

Discussion

We try to demonstrate that, thanks to three dimensional image reconstruction, all the structures that need to be dissected could be effectively located prior to the the surgery with a high grade of approximation. Furthermore the 3D reconstruction could be used as a step by step guide during the whole surgical procedure, showing all the pedicles To be encountered and dissected at every stage.

Conclusion

3d reconstruction of the liver is a valid aid in the interpretation of preoperative imaging and intraoperative ultrasound, both for the surgeon and for the entire equipe, facilitating comprehension of patient’s liver anatomical features. It allows to predict the location and direction of the pedicles that need to be dissected and resected with high approximation, in order to achieve a more precise and tailored surgery.

Zygomatic implant penetration to the central portion of orbit: a case report

Background

Zygomatic implants have been proposed in literature for atrophic maxillary fixed oral rehabilitations. The aim of the present research was to evaluate, by a clinical and tomography assessment, a surgical complication of a zygomatic implant penetration to the orbit.

Case presentation

A 56 year-old female patient was visited for pain and swelling in the left orbit after a zygomatic implant protocol. The orbit invasion of the zygomatic implant screw was confirmed by the CBCT scan. The patient was treated for surgical implant removal and the peri- and post-operative symptoms were assessed. No neurological complications were reported at the follow-up. The ocular motility and the visual acuity were well maintained. No purulent secretion or inflammatory evidence were reported in the post-operative healing phases.

Conclusion

The penetration of the orbit during a zygomatic implant positioning is a surgical complication that could compromise the sight and movements of the eye. In the present case report, a zygomatic implant removal resulted in an uneventful healing phase with recovery of the eye functions.

Clinical manifestation and maternal complications and neonatal outcomes in pregnant women with COVID-19: a comprehensive evidence synthesis and meta-analysis

OBJECTIVES

There is little known about pregnancy-related complications and comorbidity in this group of women. Therefore, this systematic review and meta-analysis were performed to find out whether COVID-19 may cause different manifestations and outcomes in the antepartum and postpartum period or not.

MATERIAL AND METHODS

We searched databases, including Medline (PubMed), Embase, Scopus, Web of sciences, Cochrane library, Ovid, and CINHAL to retrieve all articles reporting the prevalence of maternal and neonatal complications, in addition to clinical manifestations, in pregnant women with COVID-19 that published with English language January to November 2020.

RESULTS

Seventy-four studies with total 5560 pregnant women included in this systematic review. The results show that the pooled prevalence of neonatal mortality, lower birth weight, stillbirth, premature birth, and intrauterine fetal distress in women with COVID-19 was 4% (95% Cl: 1 - 9%), 21% (95% Cl: 11 - 31%), 2% (95% Cl: 1 - 6%), 28% (95% Cl: 13 - 43%), and 14% (95% Cl: 4 - 25%); respectively. Moreover, the pooled prevalence of fever, cough, diarrhea, and dyspnea were 56% (95% Cl: 32 - 81%), 29% (95% Cl: 21 - 38%), 9% (95% Cl: 2 - 16%), and 3% (95% Cl: 1 - 6%) in pregnant women with COVID-19. Two studies reported that pregnant women with severe COVID pneumonia have higher levels of d-dimer. Also, COVID pneumonia is more common in pregnant women than non-pregnant.

CONCLUSION

According to this meta-analysis, pregnant women with COVID-19 with or without pneumonia, are at a higher risk of preeclampsia, preterm birth, miscarriage and cesarean delivery. Furthermore, the risk of LBW and intrauterine fetal distress seems to be increased in neonates. In addition, our evaluations are investigative of higher risk of COVID-19 in the third trimester in pregnant women comparing to the first and second trimester. It can be due to higher BMI in the third trimester causing to increase the likelihood of disease deterioration, which can trigger a cascade of side effects starting with coagulation, pneumonia, hypoxemia affecting the placenta leading to ICU admission, fetal distress, premature birth and higher rates of C-section.

Prolonged survival with systemic chemotherapy in an advanced malignant mesothelioma: A case report

Peritoneal mesotheliomas are very rare tumors. Their prognosis is poor, average survival does not exceed 1 year after peritoneal cytoreduction. Systemic chemotherapy is considered to have no proven value in the management of peritoneal mesotheliomas. Objective responses with systemic chemotherapy are very rare. We report here a case of an advanced peritoneal mesothelioma which achieved an unexpected partial response with chemotherapy, allowing the patient to have a right colectomy. The patient was referred to a specialized center on HIPEC, but taking in account the long awaiting interval, the HIPEC was judged to be inefficient and then the poursuit of 6 cycles of systemic chemotherapy was decided. The patient is still alive without any symptom and with a good performance status at 59 months after diagnosis. Throughout our case, we provide an encouraging evidence of the role of initial systemic chemotherapy in the downstaging of initially unresectable primary malignant mesothelioma and in the improvement of overall survival.

Rectum migration of an intrauterine device

Intrauterine device (IUD) is a well-accepted means of contraception. Although it is safe and effective, some serious complications may occur. It should be paid attention to a 45-year-old female admitted to the hospital for aggravated abdominal pain and dyspareunia for 2 months. She was found to have two IUDs in her body, one in the uterine cavity and the other outside. They were removed through laparoscopic and hysteroscopy. When IUD perforation occurs, whether symptomatic or not, surgical removal is necessary. Laparoscopy is thought to be the first choice. However, when serious adhesions coexist, laparotomy would be recommended.

Ruptured mycotic common iliac aneurysm due to Capnocytophaga canimorsus, acquired from dog saliva: A case report

INTRODUCTION

Mycotic arterial aneurysm occurs secondary to infection of the arterial wall Dubois et al. (2010). It is a serious clinical condition associated with significant morbidity and mortality. Various pathogens can be responsible but the most commonly isolated causative organisms are Staphylococcus spp. and Salmonella spp. Brown et al. (1984). An extremely uncommon causative pathogen is Capnocytophaga canimorsus, a commensal bacterium found in the normal gingival flora of canines.

PRESENTATION OF CASE

We describe the case of a ruptured mycotic common iliac aneurysm presenting with acute haemodynamic instability and femoral nerve impairment due to compression secondary to extensive haematoma. Rupture was preceded by a four-week history of left hip/groin discomfort with an abrasion to the left upper limb exposed to dog saliva in the weeks prior to symptom onset. Open debridement, revascularisation, and aggressive antimicrobial therapy was utilised with microbiological culture revealing Capnocytophaga canimorsus as the causative pathogen.

DISCUSSION

Successful repair was achieved surgically with a prosthetic bypass, followed by a 6-week course of intravenous antibiotics. Lifelong oral suppressant antibiotic treatment was then commenced. At 6-month follow up, the patient was free from clinical or radiological recurrence of infection or aneurysm.

CONCLUSION

This case highlights an extremely rare aetiology for ruptured common iliac aneurysm in the form of Capnocytophaga canimorsus. It highlights the importance of a thorough history, including pet exposures, for patients with infected aneurysms and the need to ensure appropriate specimens are collected when a mycotic aneurysm is suspected.

A giant splenic hydatid cyst: Why calcified cysts should not be considered as a dead cyst

Our case report showed that peripheral wall calcification of the hydatid cyst does not mean inactivation of the cyst and calcification of cyst wall may occur in all stages of disease.

Efficacy and Safety of Robotic Dor Fundoplication on Severe Gastroesophageal Reflux Disease in Patients With Scleroderma

Systemic sclerosis (SSc) is a disease that affects the gastrointestinal tract resulting in its atrophy and fibrosis of smooth muscles. Approximately 80% of SSc patients develop both gastroesophageal reflux disease (GERD) and dysphagia. The nocturnal GERD can cause regurgitation and aspiration, which can further aggravate the pulmonary fibrosis from SSc. Also, their dysphagia is further worsened by performing standard Nissen fundoplication. Therefore, we aimed to investigate whether Dor fundoplication (a 180° anterior wrap) can reduce nocturnal heartburn and regurgitation without worsening dysphagia in patients with SSc and severe GERD. Five SSc patients with drug-refractory severe GERD underwent a Dor fundoplication procedure with a median follow-up of 2 years (range: 1-5 years). In all 5 patients, the preoperative high-resolution manometry showed significant impairment of esophageal motility. Patients were interviewed postoperatively to assess for nocturnal and diurnal GERD symptoms, treatment response, the status of dysphagia, and adverse effects of surgery. The average age of 5 patients was 50 years and all were females. Four of the 5 patients (80%) reported 90% improvement in both diurnal and nocturnal GERD symptoms since surgery, with no nocturnal reflux, heartburn, or regurgitation, and reports to sleep at night without requiring any more pillows or wedges. About 50% of patients reported a decrease in their proton pump inhibitor dosage after surgery compared to before surgery. No surgical complication was reported and specifically, no worsening of dysphagia. The Dor fundoplication performed for refractory GERD in SSc patients substantially decreases heartburn and regurgitation, primarily nocturnal, without affecting dysphagia, thus improving the quality of life.

The first commercial use of the Valiant Navion stent graft system for endovascular repair of a descending thoracic aortic aneurysm

Objectives

Thoracic endovascular aortic repair (TEVAR) is the standard of care for descending thoracic aortic aneurysms (DTAA), and newer generation stent grafts have significant design improvements compared to earlier generation devices.

Methods

We report the first commercial use of the Medtronic Valiant Navion stent graft for treatment of an 85-year-old woman with a 5.8 cm DTAA and a highly tortuous thoracic aorta.

Results

A percutaneous TEVAR was performed using a two-piece combination of the Valiant Navion FreeFlo and CoveredSeal stent graft configurations for zones 2–5 coverage. The devices were successfully delievered through highly tortuous anatomy and deployed, excluding the entire length of the aneurysm with precise landing, excellent apposition and no evidence of endoleak. The patient tolerated the procedure well and has had no stent graft-related complications through one-year follow-up.

Conclusions

Design enhancements such as a lower profile delivery system, better conformability, and a shorter tapered tip are some of the improvements to this third-generation TEVAR device. Coupled with the multiple configuration options available, this gives physicians a better tool to treat thoracic aortic pathologies in patients with challenging anatomy. The early results are encouraging, and evaluation of long-term outcomes will continue.

Clinical features of multiple gastrointestinal stromal tumors: A pooling analysis combined with evidence and gap map

BACKGROUND

Multiple gastrointestinal stromal tumors (MGISTs) are a very rare type of gastrointestinal stromal tumor (GIST) and are usually observed in syndrome.

AIM

The paper aimed to describe the clinical and oncological features of MGISTs and to offer evidence for the diagnosis and treatment.

METHODS

Data of consecutive patients with MGISTs who were diagnosed at Peking University People’s Hospital (PKUPH) from 2008 to 2019 were retrospectively evaluated. Further, a literature search was conducted by retrieving data from PubMed, EMBASE, and the Cochrane library databases from inception up to November 30, 2019.

RESULTS

In all, 12 patients were diagnosed with MGISTs at PKUPH, and 43 published records were ultimately included following the literature review. Combined analysis of the whole individual patient data showed that female (59.30%), young (14.45%), and syndromic GIST (63.95%) patients comprised a large proportion of the total patient population. Tumors were mainly located in the small intestine (58.92%), and both CD117 and CD34 were generally positive. After a mean 78.32-mo follow-up, the estimated median overall survival duration (11.5 years) was similar to single GISTs, but recurrence-free survival was relatively poorer.

CONCLUSION

The clinical and oncological features are potentially different between MGISTs and single GIST. Further studies are needed to explore appropriate surgical approach and adjuvant therapy.

Proximal intestinal obstruction syndrome (PIOS) in a patient with cystic fibrosis: A case report

Introduction

Distal Intestinal Obstruction Syndrome is a rare complication in patients with cystic fibrosis, which characterized by the accumulation of viscid fecal material, combined with sticky mucous secretions located in the distal ileum adhere to the intestinal wall, causing complete bowel obstruction.

Presentation of case

We report a case of a 45 years old patient with cystic fibrosis, who presented bowel obstruction secondary to accumulation of fecal material, combined with mucous secretions, in the mid-jejunum. A diagnostic laparoscopy was performed where a dilated jejunum was encountered with impaction of fecal content. Surgery was converted to open surgery, where a longitudinal enterotomy of 5 cm after the transition zone was created, evacuating manually the fecal material with mucous secretion. The patient evolved favorably, without complications.

Discussion

We present a case of a patient with cystic fibrosis presenting with bowel obstruction due to a proximal intestinal obstruction syndrome, which can be diagnosed with the DIOS definition, with the only distinction of a more proximal location in the gastrointestinal tract, such as the stomach, the duodenum, or the jejunum.

Conclusion

It is important for the clinician to know the existence of this syndrome at its different locations in the small bowel to treat accordingly.

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Proximal Intestinal Obstruction Syndrome is a rare complication in patients with cystic fibrosis.

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It is the accumulation of viscid feces with mucous secretions in the small bowel.

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It is important to know the existence of this syndrome to treat accordingly.

A case report of double cystic duct during laparoscopic cholecystectomy in patient with chronic calcular cholecystitis

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Gall bladder and cystic duct anomalies are not uncommon.

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Double cystic duct with a single gall bladder is an extremely rare anomaly.

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Knowledge of that anomaly is curial not to interpret it as a transected CBD.

Introduction

Abnormal anatomy of the biliary tree predisposes patients to higher risks of ductal injury and postoperative complications. One of the extremely rare abnormalities of the cystic duct is the duplication of the cystic duct with a single gallbladder. The diagnosis is usually established during surgery. we report a case of double cystic duct with literature review.

Presentation of case

A forty-two years old female patient who complained of recurrent biliary colic 9 months prior to the presentation. Murphy’s sigh was negative and with no other relevant clinical signs.

Diagnosis and therapeutic intervention

Abdominal ultrasound showed multiple gall stones; the largest one was about 11 mm in diameter. Laparoscopic cholecystectomy was done under general anesthesia with 4 ports insertion. A double cystic duct accidentally encountered after clipping and cutting what was apparently a single cystic duct. Intraoperative cholangiogram was done to confirm the anomaly and exclude CBD injury.

Conclusion

Double cystic duct is a very rare variant of the cystic duct anomaly. Proper knowledge of this anomaly should be kept in mind to avoid any unnecessary steps.

Splenic lymphoma with complex gastro-spleno-diaphragmatic fistula: 3D laparoscopic multivisceral resection. The first literature case report

INTRODUCTION

Gastrosplenic fistula is a rare disease involving stomach and spleen that can lead to dangerous complications like massive gastrointestinal bleeding. Diffuse large B-cell lymphoma (DLBC) is the principal pathological cause of gastrosplenic fistula.

CASE REPORT

We report a case of A 76-year-old caucasian woman came to the emergency room with fever for two week and gravative pain in left upper quadrant of the abdomen. CT scan of thorax and abdomen demonstrated an inhomogeneous hypodense large lymphomatous mass (10 × 6 cm) of upper pole of the spleen deformating medial profile and infiltrating gastric fundus and left diaphragm. with the diagnosis of complex gastro-splenic-diaphragmatic fistula we performed an en-block resection using a 3D laparoscopic vision system.

DISCUSSION

Gastrosplenic fistula is a rare complication of several clinical conditions. Among the different causes diffuse large B-cell lymphoma is the most frequent although diffuse histiocytic lymphoma, Hodgkin's lymphoma and extranodal NK/T-cell lymphoma are also described. After a literature review we found less then 30 cases of gastrosplenic fistula secondary to lymphoma. In our case report we do the first description of three-organs fistula envolvement, stomach, spleen and diaphragmatic dome, managed with 3D laparoscopic approach.

CONCLUSION

Gastrosplenic fistula can represent a fatal evolution of splenic or gastric lymphoma independently from chemotherapy treatment. The diagnosis of this condition is very difficult and related to its rarity. To our opinion, laparoscopy represents a valid and safe alternative to open surgery in management of these patients.

A case of Type 2 appendiceal diverticulum perforated and a review of the literature

BACKGROUND

Appendiceal diverticulosis disease is a rare entity. An perforated appendiceal diverticulosis mimicking acute appendicitis is a extremely unusual surgical finding and the reported prevalence is between 0.014 and 3.7%.

CASE REPORT

We report the case of an elderly man, who presented with a typical clinical image of acute appendicitis and underwent laparoscopic surgery. Intraoperative an acute appendicitis with localized peritonitis was identified and a laparoscopic appendectomy was performed, but pathologic analysis demonstrated a type 2 appendiceal diverticulitis.

CONCLUSION

Appendiceal diverticulosis disease should be included in differential diagnosis of patients presenting with clinical signs of an acute appendicitis and prompt surgical treatment is essential in order to avoid severe complications.

Unusual giant chromophobe renal cancer totally managed with laparoscopic technique: Report of a case

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We describe a case report of giant renal cell chromophobe carcinoma totally treated by laparoscopic surgery.

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The size of renal lesion represents a critical point in surgical approach because to perform a laparoscopic radical nephrectomy can be challenging even for skilled surgeons in giant renal tumors.

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A brief review of literature was performed to identify outcomes and potentially surgical advantages of laparoscopic approach for retroperitoenal liposarcoma.

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The possibility of the laparoscopic approach derives from from the preoperative identification of adipose cleavage, from the absence of invasion of major vascular axes, from the absence of distant metastatic lesions.

Introduction

Chromophobe carcinoma of the kidney is a rare pathological entity generally smaller and asymptomatic than other renal cell carcinomas and with a lower risk of metastatic disease. We describe a case of a giant renal chromophobe carcinoma successfully treated by laparoscopy.

Case report

A 37-years-old Caucasian man presented at physical examination a rigid elastic mass in right upper abdominal quadrant. CT abdominal scan revealed an enhancing well-defined heterogeneous large mass measuring 17 × 15 cm and originating from the upper pole of the right kidney, with necrotic and solid areas within the lesion. Considering the young age of the patient and the absence of local invasiveness, despite the large size of the lesion, we decided to perform a laparoscopic transperitoneal right nephrectomy. The morphological and immunophenotypic characteristics (CK7+, CD10+, CD117+) confirmed the diagnosis of chromophobe renal cell carcinoma.

Results

Chromophobe renal cell cancer is an unusual hystological entity. The pathological diagnosis of chromophobe tumor is based on atypia with nuclear irregularities, binucleation, and nucleolar prominence. In our case reports the pathological examination showed no tumor necrosis, mitosis or sarcomatoid differentiation and perirenal tissues were free from tumor infiltration with low risk of tumor progression after surgery.

Conclusion

Laparoscopic approach is today considered the standard treatment for localized renal cancer. Nevertheless, the size of renal lesion represents a critical point in surgical approach because to perform a laparoscopic radical nephrectomy can be challenging even for skilled surgeons in giant renal tumors.

Acute appendicitis in a patient with situs viscerum inversus totalis: Role of laparoscopic approach. A case report and brief literature review

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Abdominal pain due to acute appendicitis in one of the most causes of access to Emergency Room requiring surgical consult and treatment.

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The occurrence of anatomical anomalies should be considered especially when clinical and imaging features are misleading. In these cases laparoscopic surgery can be a safe tool in order to confirm uncertain diagnosis.

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We report a case of acute appendicitis in a 23-year-old Caucasian men with situs viscerum inversus detected on radiological investigation.

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Laparoscopic approach was used to confirm the diagnosis and to perform appendectomy. Trocars placement was tailored for this peculiar case.

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Situs viscerum inversus and midgut malrotation should be taken into consideration in patients with findings of the physical examination suspicious for left-sided acute appendicitis.

Introduction

Abdominal pain due to acute appendicitis in one of the most causes of access to Emergency Room requiring surgical consult and treatment. The occurrence of anatomical anomalies should be considered especially when clinical and imaging features are misleading. In these cases laparoscopic surgery can be a safe tool in order to confirm uncertain diagnosis.

Case report

We report a case of acute appendicitis in a 23-year-old Caucasian men with situs viscerum inversus detected on radiological investigation. Laparoscopic approach was used to confirm the diagnosis and to perform appendectomy. Trocars placement was tailored for this peculiar case.

Discussion

One third of patient with acute appendicitis complains abdominal pain in an unexpected location due to various anatomical position of appendix. Left-sided acute appendicitis is a cause of misdiagnosis and it can occur in association with anatomical anomalies such as situs viscerum inversus and midgut malrotation. Laparoscopic surgery may represent a valuable approach in terms of differential diagnosis and treatment in these patients.

Conclusion

Left-sided acute appendicitis should always be considered in young male patients with left lower quadrant pain. Laparoscopic approach is useful and safe procedure both for diagnosis and treatment of these unclear clinical pictures.

Laparoscopic near-total splenectomy. Report of a case

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We describe a case report of near total splenectomy managed by laparoscopy for a large lesion of the upper pole of the spleen.

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When total splenectomy is performed, an increased risk of potentially lethal infections arises. Asplenia and impaired splenic function are related to the increase of morbidity and mortality from infectious complications.

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The overwhelming post splenectomy infections (OPSI) are mostly represented by fulminating sepsis, meningitis or pneumonia.

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laparoscopic near total splenectomy is an innovative partial splenectomy technique consisting on preserving a residual spleen volume.

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The comparison between other spleen preserving techniques shows that LNTS is associated with a lower rate of secondary surgery and postoperative recurrence of anaemia.

Introduction

Splenectomy is a surgical procedure indicated for the treatment of most benign and malignant splenic diseases, especially hematologic disorders. Laparoscopic approach is preferable to the open surgery for most indications because it reduces intra- and post-operative complications and shortens hospital stay. Laparoscopic approach is also feasible for partial splenectomy. Spleen-preserving techniques reduce the risk of severe infections and thromboembolic events that can occur after total splenectomy

Case presentation

We report a case of a 50-year old woman with an incidentally discovered voluminous lesion in the superior pole of spleen. A laparoscopic near-total splenectomy was performed.

Discussion

The evidence about the potential complications in splenectomised patients speaks in favour of performing spleen-sparing surgical techniques whenever possible. Most common indications for laparoscopic partial splenectomy are non-parasitic splenic cystic, benign splenic tumors, splenic haematological diseases, non-cystic intraparenchymal lesions, spleen rupture, splenic abscess, vascular abnormalities. Laparoscopic near total splenectomy is an innovative partial splenectomy technique consisting on preserving a residual spleen volume.

Conclusion

LNTS seems to be a safe and effective technique for the management of benign spleen diseases. The comparison between other spleen preserving techniques shows that LNTS is associated with a lower rate of secondary surgery and postoperative recurrence of anaemia.

A case of endovascular therapy for treating idiopathic arterial deteriorations of unknown etiology

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A 50-year-old patient presented with multiple idiopathic arterial deteriorations.

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He had a renal artery tear and a pseudoaneurysm of the left internal iliac artery.

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Previous direct intervention failed and we suspected vascular fragility.

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The two lesions were treated by simultaneously placing endografts.

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Endovascular treatment is a desirable option in the case of vascular fragility.

Introduction

Peripheral artery pseudoaneurysm as a consequence of arterial deterioration is relatively rare in young populations, who typically lack an atherosclerotic background. Such pseudoaneurysms are known to pose a risk of rupture, which is correlated with high mortality and morbidity rates. Pseudoaneurysms are more prone to rupture than true aneurysms are, as their vessel walls tear more easily. We present the case of a 50-year-old patient who had multiple arterial deteriorations.

Case presentation

The patient experienced backache, and computed tomography revealed a tear of the right renal artery, and a pseudoaneurysm of the left internal iliac artery. He had a history of graft replacement for the right superficial artery pseudoaneurysm, which had been occluded. Although various tests were performed for differential diagnosis, the etiology was unidentified. Considering the suspected vascular fragility and failure of previous direct intervention, these 2 lesions were treated by placing endografts simultaneously.

Discussion

We investigated various diseases causing vascular fragility in the reported case, such as vascular Behçet disease, vascular Ehlers-Danlos syndrome, fibromuscular dysplasia, and segmental arterial mediolysis. However, these were all excluded and the etiology remains unclear. Progress in endovascular techniques enables the use of minimally invasive treatment in patients with vascular fragility.

Conclusion

When vascular fragility may exist, endovascular treatment is a desirable option, as it can be performed repetitively and is less invasive.

Laparoscopic treatment of mesenteric avulsion and intestinal perforation after blunt abdominal trauma: A report of a case

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Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen.

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The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

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We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion treated with laparoscopic approach.

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Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment.

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The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Introduction

Intestinal injuries are quite involved in non-penetrating abdominal trauma after liver and spleen. The incidence of small bowel injury after blunt abdominal trauma has increased nowadays, since high-energy transfer impacts producing large abdominal wall displacements are more frequent, such as car crash.

Case report

We report a case of a 49-year-old Caucasian woman, victim of a violent car crash, resulting in multiple small bowel perforations and mesenteric avulsion. Since the patient was hemodynamically stable, a laparoscopic approach was carried on.

Discussion

Blunt abdominal trauma are responsible of 6–14.9% of all traumatic injuries (Galia et al., 2017). The frequency of small bowel lesions ranges from 5% to 15%, while small bowel mesenteric injuries are approximately found in 5% of patients after blunt abdominal trauma. There are different biomechanical reasons explaining how a blunt trauma can cause damages to small bowel and its mesentery. Clinical diagnosis of small bowel perforation after blunt abdominal trauma is often challenging for non-specific objective clinical signs and because peritoneal irritation symptoms are present only in collaborative patients.

Conclusion

Laparoscopy is a safe and feasible tool in selected patients with blunt abdominal trauma, both for diagnosis and treatment. The prerequisites for applying mini invasive approach are both the hemodynamic stability of the patient and an adequate surgical expertise in advanced laparoscopy.

Secondary Implant Augmentation in the Subpectoral Plane following Abdominal-based Perforator Flaps for Breast Reconstruction

BACKGROUND

Abdominal-based perforator flaps are the gold standard for autologous breast reconstruction. However, among patients with a small-to-medium amount of redundant abdominal tissue, this may result in an inadequate breast mound. Secondary implant augmentation has been reported as one method to augment volume, address breast mound asymmetry, and enhance overall aesthetic outcome. We aim to analyze postoperative complications associated with the secondary implant augmentation following a primary breast reconstruction with abdominal perforator flaps.

METHODS

This retrospective study included patients who underwent secondary implant augmentation following abdominal-based perforator flap breast reconstruction. Patient characteristics, immediate versus delayed reconstruction, type of flap used, indication for secondary augmentation as well as perioperative and postoperative complication including flap or implant loss were reviewed and analyzed.

RESULTS

Twenty-four patients met inclusion criteria. Forty flaps were performed (16 bilateral and 8 unilateral). A total of 36 implants were placed in subpectoral plane in a secondary revision procedure. The mean time between secondary augmentation and index procedure was 22 months. Average implant volume was 270 g. No intraoperative complication or flap loss was recorded. Postoperative surgical site infection occurred in a total of 4 patients (17%) with 3 patients requiring explantation of a total of 4 implants.

CONCLUSIONS

Secondary augmentation of abdominal-based perforator flap using a permanent implant is an effective method to address volume and asymmetry and to enhance aesthetic outcome. In our study, however, we observed a higher than expected rate of postoperative infection.

Duodenal perforation as presentation of gastric neuroendocrine tumour: A case report

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Gastric neuroendocrine neoplasms (g-NENs) represent the most frequent digestive NENs and are increasingly recognized thanks to diffusion of upper gastrointestinal endoscopy.

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g-NENs can be sporadic or associated with multiple endocrine neoplasia type 1 (MEN-1) and present with a functional Zollinger-Ellison syndrome.

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We described a case of a 60 years old Caucasian male came to emergency room with diffuse abdominal pain and leukocytosis on blood tests.

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At the level of the pyloric portion we found irregularly thickened walls associated with a small fluid collection and bubbles of free air. On exploratory laparoscopy we found a large perforation (about 5 cm of size) in the first duodenum portion.

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Histological examination revealed a gastric NET perforation as a consequence of hypergastrinemia secondary to gastrinoma.

Introduction

Neuroendocrine tumors (NETs) represent uncommon neoplasms with different characteristics. They can be asymptomatic and benign or they can also proliferate and manifest themselves with neoplastic mass symptoms such as intestinal occlusion or with carcinoid syndrome. Gastric neuroendocrine neoplasms (g-NENs) are the most frequent digestive NENs while duodenal neuroendocrine neoplasms (d-NENs) may be sporadic or associated with multiple endocrine neoplasia type 1 (MEN-1) and present a functional syndrome (e.g. gastrinoma with Zollinger-Ellison syndrome).

Presentation of case

We report a case of duodenal perforation due to a unknown gastrinoma responsible of Zollinger-Ellison Syndrome. He underwent an emergency contrast enhanced CT abdominal scan that showed a perforation. We performed a distal gastrectomy. The histopathological examination revealed a g-NET configuring a possible picture of Zollinger-Ellison Syndrome.

Discussion

The management of NETs is diffulcult and controversial because of their rarity. It is useful to know the pathologic assessment of tumor differentiation and/or grade, evaluate surgical resectability and control the carcinoid syndrome symptoms.

Conclusion

This case report shows that gastric NETs can be found in cases of duodenal perforation. Our future goal is to evaluate the possibilities to diagnose the Zollinger Ellison Syndrome as early as possible and to treat it with targeted therapy in order to prevent its related complications.

Combined endo-laparoscopic treatment of large gastrointestinal stromal tumor of the stomach: Report of a case and literature review

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We report a case of 75-year-old Caucasian men with unknown voluminous gastric GIST, who came to our attention complaining melena. We decided to perform a laparoscopic-endoscopic combined surgical approach.

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Intraoperative endoscopy identified gastric GIST and confirmed the submucosal origin and the integrity of the capsule. A 10 cm laparoscopic gastrotomy was carried out along the gastric found in order to realize a laparo-endoscopic rendez-vous technique.

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Laparoscopy has rapidly become a preferable approach for gastric GISTs surgical treatment. The magnified view and the lesser invasiveness of laparoscopic technique allow the surgeon to perform a more meticulous dissection, preventing unexpected bleeding and causing less muscular trauma and less bowel manipulation. All these favourable short-term outcomes associated with laparoscopy do not compromise oncologic results.

Introduction

Gastrointestinal stromal tumours (GISTs) are the most common malignant subepithelial lesions of gastrointestinal tract, originating from Cajal’s cells and characterized by the over expression of tyrosine kinase receptor C-KIT. The prognosis of this disease is associated with tumour size and mitotic index. Standard treatment of a GIST with no metastasis is surgical resection.

Presentation of case

We report a case of a 75-year-old Caucasian man with unknown voluminous gastric GIST, who came to our attention complaining black stool. We decided to perform a laparoscopic-endoscopic combined surgical approach. Intraoperative gastroscopy identified the gastric GIST and confirmed the submucosal origin and the integrity of the tumor capsule. A 10 cm laparoscopic gastrotomy was carried out along the gastric fundus in order to realize a laparo-endoscopic rendez-vous procedure.

Discussion

Laparoscopic approach is feasible and safe for Gastric GIST both in elective and urgent settings. Even for lesions greater than 5 cm, laparoscopy shows a recurrence rate similar to open surgery when radical resection are performed. An important point to take in consideration is surgical team experience, which seems to be one of the most important factors reducing the incidence of operative complications with better long-term outcomes, both postoperative and oncological.

Conclusion

Mini-invasive approaches for gastric GIST are safe and feasible. The combined approach both laparoscopic and endoscopic has shown to be an effective technique and it may allow a better exposure of the tumour which ensure a radical resection.

Small bowel volvulus due to a large intestinal lipoma: A rare case report

INTRODUCTION

A lipoma of the small bowel mesentery is a uncommon clinical entity. It rarely causes obstruction and volvulus of the small bowel.

CASE REPORT

A 63 year old man was admitted to the emergency department with acute abdominal pain. Contrast-enhanced CT abdominal scan revealed small bowel obstruction due to a large fat density lesion suspected to be a lipoma. We performed a laparotomy in urgent setting that confirmed a small bowel volvulus secondary to a large antimesenteric lipoma. En-bloc resection with antiperistaltic side-to-side ileal anastomosis was done.

DISCUSSION

Mesenteric lipoma is rare. They are usually asymptomatic but when have large sizes can cause several symptoms related to small bowel obstruction or volvulus. The diagnosis is difficult and is rarely made prior to exploratory laparoscopy or laparotomy. CT scan is the gold-standard imaging technique. It can shows the typical characteristics of tumor and may demonstrate the typical "vortex" pattern of a volvulus. In patients with acute clinical presentation en-bloc resection of the lipoma with the affected small bowel loops is often necessary. This treatment may also be reserved in asymptomatic patients with large mesenteric lipomas to avoid future complications.

CONCLUSION

Volvulus of the small bowel caused by an antimesenteric lipoma is a very rare entity. It is diagnosed by CT scan and surgery represents the standard treatment.

Colonic mucinous adenocarcinoma with secondary in the breast: A case report and literature review

INTRODUCTION

Secondary breast metastasis from the colonic origin is a rare phenomenon in the literature, and an estimation of an increase in the incidence has been reported in the literature to reach approximately 7%.

PRESENTATION OF CASE

We report a case of a 56-year-old male with constipation who underwent extended right hemicolectomy after confirmation of adenocarcinoma of the right colon. The patient was diagnosed with multiple metastases over 5 years and endured numerous resections of the costal margins, ribs, diaphragm, liver wedges, abdominal wall, and the small bowel. Eventually, the patient's right breast mass measured about 2.1 cm on ultrasonography and revealed metastatic adenocarcinoma of the same colonic origin. The patient started on palliative chemotherapy and was deceased after 11 months.

DISCUSSION

Comparing this case to the 56 similar cases, we found our case with an almost average time to metastasize but unfortunately with aggressive metastatic behavior to various organs. Nevertheless, the triple assessment of the breast by physical examination, radiological, and pathological studies assisted in diagnosis and early establishment of the treatment. Currently, there is no definitive guideline for the management of secondary breast metastasis from the colonic origin. We estimated the average survival rate as 6.1 months, and it was reported to reach an average of 8-10 months in the literature.

CONCLUSION

During the surveillance program of colorectal cancer, a full-body examination is warranted. Secondary breast cancer metastasis from colorectal origin behaves aggressively and a multidisciplinary approach is essential for the establishment of personalized treatment.

CARE for COVID-19: A Checklist for Documentation of Coronavirus Disease 2019 Case Reports and Case Series

Coronavirus disease 2019 (COVID-19) is a new, rapidly spreading pandemic that can lead to a life-threatening disease. Accurate and transparent COVID-19 case reports provide systematic clinical observations supporting researchers designing clinical trials and clinicians delivering health care. The checklist described here is designed to systematically and accurately capture data from case reports and case series for documentation on COVID-19. It is aligned with the CARE guidelines, available from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network.

Congenital Forearm Pseudarthrosis, a Systematic Review for a Treatment Algorithm on a Rare Condition

BACKGROUND

A congenital forearm pseudarthrosis is a rare condition and is strongly associated with neurofibromatosis type 1. Several surgical techniques are described in the literature, but the most optimal treatment strategy remains unclear. This systematic review aims to develop a treatment algorithm that may aid in clinical decision making.

METHODS

The PROSPERO registration number for this study was CRD42018099602 and adheres to the PRISMA guidelines for systematic reviews. Embase, MEDLINE, Cochrane Central, Web of Science, and Google Scholar databases were searched for published studies reporting on congenital forearm pseudarthrosis not related to other underlying pathologies like bacterial infection or fibrous dysplasia. Results were not restricted by date or study type, only English literature was allowed. Studies were assessed for quality using the critical appraisal checklist for case reports from the Joanna Briggs Institute. Patient characteristics, underlying disease, type of surgery, union rate, and functional outcome were extracted from included studies.

RESULTS

Of 829 studies identified, 47 were included in this review (17 case series and 30 case reports, a total of 84 cases). A one-bone forearm procedure showed highest union rates (92%), however, it results in loss of forearm rotation. Free vascularized fibula grafting showed high union rates (87%) and was related to good functional outcome of elbow flexion and forearm rotations. Other procedures showed disappointing outcomes.

CONCLUSIONS

Congenital forearm pseudarthrosis is best treated with a free vascularized fibula grafting, a one-bone forearm procedure should be used as a salvage procedure. Evidence extracted from the case reports was sufficient to generate a treatment algorithm to be used in clinical pediatric practice.

LEVEL OF EVIDENCE

Level IV-therapeutic.

Small bowel obstruction after caesarean section: Laparoscopic management. Two case reports

Introduction

Caesarean section is the most common abdominal surgery performed on women worldwide. Adhesions represent a severe complication of cesarean section and can cause different degrees of bowel obstruction.

Case reports

We report two unusual cases of small bowel obstruction treated with laparoscopic approach after caesarean section performed for gynecological pathologies. In the first one small bowel obstruction was due to volvulus caused by a severe pelvic adhesion syndrome; in the second one, occlusive picture was related to presence of multiple adhesion phenomena between the sigmoid colon and the right ovary as result of abdominal hysterectomy.

Discussion

The incidence of small bowel obstruction after caesarean section is very low and postoperative adhesions represent the main cause. Diagnosis was established by clinical signs, radiological and intraoperative findings. Laparoscopic approach can be the treatment of choice only in selected patients. In presence of dense adhesions, inability to visualize the site of obstruction, iatrogenic intestinal perforation, bowel necrosis and technical difficulties, conversion to open surgery is mandatory.

Conclusion

In selected patients with small bowel obstruction laparoscopy is a safe and feasible procedure if conservative measures fail.

Recurrent intussusception of small bowel in a young patient due to metastases from cardiac undifferentiated pleomorphic sarcoma: A first ever case report

INTRODUCTION

Undifferentiated metastatic pleomorphic sarcoma (Malignant Fibrous Histiocytoma) is a rare entity in the small intestine, especially when the primary tumor is of cardiac origin.

CASE REPORT

We report a case of metastatic intestinal undifferentiated pleomorphic sarcoma in a young patient with a history of primary cardiac tumor in the left atrium and recurrent small bowel intussusception. He was admitted for abdominal pain and constipation. A segmental resection of the small intestine was performed with side-to-side entero-enteroic anastomosis.

DISCUSSION

Intussusception of the small bowel is rare in adults and it represents about 1-3% of intestinal obstructions. It mainly affects the fifth decade with a male/female ratio of 1:5 More than 60% of patients with intussusception have a tumor with 50% being malignant. This type of intussusception can be diagnosed on the CT abdominalscan. Radiological features include a typical "target" sign with overdistention of the proximal intestine and air-fluid levels, but the diagnosis of certainty is made by exploratory laparotomy.

CONCLUSION

The metastatic tumors that cause intussusception represent a rare clinical condition in adult patients, but much more common than primary ones. Metastasis to the small intestine are part of differential diagnosis in patient with a history of tumor who present with intussusception.

An Unexpected Case of Late Fatal Central Venous Catheter Sepsis: A Case Report

Introduction  Central venous catheters (CVC) are associated with risks and complications. Complications like vessel perforation, thrombosis, infection with significant morbidity and mortality, knotting, and ventricular perforation have been described. Another less-frequent complication is retained CVC fragments. We present a case of a very late but fatal complication after a CVC placement. This report is written in line with the consensus-based surgical case report guidelines (SCARE).

Case  A 46-year-old male presented to the emergency department in a critical (septic) shock. The patients' medical history featured a long–intensive care admission 28 years ago. The cause of this sepsis was not evident until a computed tomography scan was performed to exclude a pulmonary embolism, revealing a remnant of a central catheter in both pulmonary arteries. Despite extensive resuscitation, the patient died within 24 hours after admission. An autopsy was performed confirming that the catheter remnant was the only possible cause of the fatal sepsis.

Discussion  CVC's are associated with (fatal) complications; however, retainment of remnants are described unfrequently but do occur in almost 2% of the cases. Endovascular removal of these remnants has been performed successfully and should be the first treatment of choice if removal is considered. No evidence is available that suggests that routine removal has to be attempted but some longer term complications can be expected, so awareness of possible remnants after CVC removal should exist.

Conclusion  Retained fragments of CVC's are rare but are described after prolonged use. This case shows that these retained intravascular fragments can cause fatal complications on the long-term. Upon removal of CVC's, there should be awareness that retainment of fragments can occur.

Malignant metastatic melanoma to the gallbladder: Report of a peculiar case

INTRODUCTION

Melanoma is one of the most aggressive and one of the fastest growing types of cancer. The occurrence of a malignant melanoma in the gastrointestinal tract, either primary or metastatic, is a rare event. Metastatis from cutaneous malignant melanoma to the gallbladder are a highly uncommon finding, usually associated with diffuse metastatic disease and observed during autopsy. The event of a solitary metastasis of malignant melanoma to gallbladder is barely reported.

CASE REPORT

We report a case of a 35-year old Caucasian woman with isolated metastasis of gallbladder from cutaneous primary malignant melanoma managed with laparoscopic cholecystectomy.

DISCUSSION

Gallbladder metastasis as a first site of recurrence represents a rare condition for all cancers. Since the occurrence of an isolated gallbladder metastasis of cutaneous melanoma is an uncommon circumstance, no therapeutic guidelines have yet been proposed. Nevertheless cholecystectomy appears to be the standard of care for the treatment of this unusual condition, especially when symptomatic and for palliative purpose. The surgical approach is still debated, with no unanimous consent between mini-invasive surgery and open technique.

CONCLUSION

In our case, we decided to carry out a three-port laparoscopic cholecystectomy, preferring a mini-invasive approach considering the good performance status of our patient and her young age.

Medical education from the point of view of medical students: Results from four participatory Delphi panels in Quito, Ecuador

BACKGROUND

Medical curricula have historically been designed in a top-down approach, usually excluding students. While Delphi panels have been used as a tool for medical education curricula design, none have been conducted in Ecuador. In addition, no such approach has ever included students both as panelists and researchers.

MATERIAL AND METHODS

Four Delphi panels were developed and conducted using a participatory approach that allowed medical students to take part both as expert panelists and researchers: specifically, students developed the questionnaire and conducted a qualitative synthesis. Questionnaire responses were anonymized and dispatched online to panelists. The information was organized and collected to develop the qualitative syntheses and prepare the final statements.

RESULTS

Thirty-two medical students participated between February and May 2018. A total of 32 questions were developed, corresponding to five different categories. For some questions, consensus was reached; for other questions, general statements were obtained.Discussion and conclusion: Developing the questionnaire, responding to it and analyzing the answers allowed students to raise significant concerns regarding medical education topics proposing relevant policy and curricula change. Participatory Delphi panels can be an efficient tool to obtain organized feedback, improve student class involvement, and promote research skills.

Adult patient living 32 years with postduodenal remnant small bowel of only 35 cm in jejunocolic anastomosis type II weaned off parenteral nutrition. A case report

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The small intestine is an essential constituent of the digestive system and plays a major role in the absorption of nutrients.

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Acute mesenteric ischemia remains an emergency case.

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Failure to adapt and the inadequate nutritional supply result in Short bowel syndrome.

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A minimal indispensable length is required for nutritional autonomy.

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Parenteral Nutrition still presents a pertinent problem of complications, charges and impairment in quality of life.

Introduction

The small bowel is an essential organ for maintaining adequate nutrition. Decrease in length could be associated with malnutrition and may require that the patient receives parenteral nutritional support. We report a case of a 59-year-old man who survived32 years with a short bowel of 35 cm length without any parenteral nutrition.

Case presentation

A 59-year-old gentleman, with a history of hypercoagulable state, presented for severe abdominal pain and obstipation of one day's duration. Upon presentation, the patient was hemodynamically unstable, with abdominal guarding and tenderness upon physical examination. Laboratory studies showed metabolic acidosis with leukocytosis and electrolyte disturbances, and an abdominal CT scan showed thickening of the sigmoid and multiple air-fluid levels. The patient was operated urgently for suspicion of mesenteric ischemia, however, he was found intraoperatively to have a very short dilated small bowel with jejunotransverse anastomosis.

Discussion

The necessity for surgical resection of the small bowel can arise for a sum of reasons. However, the removal of a big amount of small bowel may not be adaptive and appropriate digestion will no more be possible. In the aftermath of the resection, patients require parenteral nutrition for a certain period after which they may switch to enteral and oral nutrition, and subsequently intestinal adaptation by thickening and growth of the remaining intestinal villi.

Conclusion

Patients with a short bowel, particularly those surgically removed, can survive even with a very short remaining bowel length, as a result of intestinal adaptation, nutrition enhancement, and elimination of parenteral nutrition.

Small bowel obstruction after laparoscopic gastrectomy: An atypical clinical presentation. Report of a case

INTRODUCTION

Postoperative adhesions represent the most common cause of acute small bowel obstruction (80%) and are usually a consequence of abdomino-pelvic surgery performed with open technique.

PRESENTATION OF CASE

A 45-year-old black man arrived at the emergency room with abdominal pain and distension three months after laparoscopic distal gastrectomy with Roux-en-Y anastomosis performed for benign pyloric stenosis. CT abdominal scan revealed some air-fluid levels in the center of the abdomen with distension of proximal jejunal loops caused by intestinal adhesions. Laparoscopic adhesiolysis was performed to restore the intestinal transit.

DISCUSSION

The formation of adhesions is more frequent after abdomino-pelvic surgery. CT abdominal scan is very useful tool to identify the level and the aetiology of obstruction and it may predict the need for surgery, the location of different adhesive bands in order to identify wich patients are likely candidates for laparoscopic treatment.

CONCLUSION

In selected cases, laparoscopic approach for small bowel obstruction is a good surgical option. In patients with adbominal dense adhesions or clinical signs of intestinal ischemia, conversion to laparotomy should be considered an alternative.

Case report of Tourniquet ALPPS and simultaneous sleeve gastrectomy: A valuable association to achieve an adequate future liver remnant in obese patients

INTRODUCTION

Obesity represents a risk factor in case of major hepatectomy, because the future liver remnant (FLR) must be proportional with body weight. To avoid post-hepatectomy liver failure, and further increase the ratio between FLR and body weight, we performed a bariatric procedure in the first stage of the ALPPS technique.

PATIENT CONCERNS

Fifty-four-year-old woman, with morbid obesity (BMI 58.5) and type II diabetes mellitus, was scheduled for a major hepatectomy due to multiple colorectal liver metastases DIAGNOSIS:: Six months before, the patient was diagnosed with colorectal cancer and synchronous liver metastases. She was initially treated with sigmoidectomy and chemotherapy. After partial response of the liver metastases, we considered a liver resection but the FLR was very low, especially in relation to her BMI.

INTERVENTION

We planned a novel approach and, for the first time, we performed a sleeve gastrectomy during the first stage of Tourniquet ALPPS (T-ALPPS). After achieving an adequate FLR, we successfully completed the major hepatectomy during the second stage of T-ALPPS.

OUTCOME

The association between sleeve gastrectomy and T-ALPPS produced an increase of FLR/body weight ratio up to 0.8 that allowed completing a right trisectionectomy in the second stage of ALPPS. The major hepatectomy was performed without severe complications, and several months after surgery the patient is still alive without any recurrence Conclusion: Despite obesity represents a risk factor involved in the carcinogenesis, the role of the bariatric surgery in the oncological setting is not well established. In this clinical case, we benefited from the weight loss produced by bariatric surgery combined with an effective hypertrophy technique and chemotherapy. These findings suggest that bariatric surgery could be useful for obese patients with liver malignancy and need for extended hepatectomy.