Selection criteria and colpotomic approach for safe minimally invasive radical hysterectomy in early-stage cervical cancer

OBJECTIVE

To evaluate oncologic outcomes of minimally invasive radical hysterectomy (RH) in early cervical cancer before and after the application of parametrial invasion (PMI) criterion on magnetic resonance imaging (MRI) and vaginal colpotomy (VC).

METHODS

A total of 216 International Federation of Gynecology and Obstetrics stage IB-IIA cervical cancer patients who underwent minimally invasive RH was identified between April 2006 and October 2018. Patients were classified into the pre-PMI intracorporeal or VC (IVC) (n=117) and post-PMI VC groups (n=99). In the pre-PMI IVC group, PMI criterion (intact stromal ring) on MRI was not applied and the patients received IVC. In the post-PMI VC group, surgical candidates were selected using the PMI criterion on MRI and all patients received VC only. Oncologic outcomes and prognostic factors associated with disease recurrence were analyzed.

RESULTS

The rate of positive vaginal cuff margins in the pre-PMI IVC group was higher than that in the post-PMI VC group (11.1% vs. 1.0%, p=0.003). Two-year disease-free survival was different between the 2 groups (84.5% in pre-PMI IVC vs. 98.0% in post-PMI VC groups, p=0.005). Disrupted stromal ring on MRI (hazard ratio [HR]=20.321; 95% confidence interval [CI]=4.903-84.218; p<0.001) and intracorporeal colpotomy (HR=3.059; 95% CI=1.176-7.958; p=0.022) were associated with recurrence.

CONCLUSION

The intact cervical stromal ring on MRI might identify the low-risk group of patients in terms of PMI and lymphovascular/stromal invasion in early cervical cancer. Minimally invasive RH should be performed in optimal candidates with an intact stromal ring on MRI, using VC.

Refractory cutaneo-gastric conduit fistula after esophagectomy repaired by a pectoralis major muscle flap and split-thickness skin graft

BACKGROUND

Gastric conduit ulcer after esophagectomy is not uncommon. In cases where a gastric conduit ulcer penetrates the adjacent organs, it is difficult to select a suitable treatment strategy. The treatment depends on the adjacent organs penetrated.

CASE PRESENTATION

We report a case in which a reconstructed gastric conduit ulcer penetrated the precordial skin in a patient who had undergone esophagectomy due to spontaneous esophageal rupture 28 years previously. To treat the cutaneo-gastric conduit fistula, we resected the fistula, covered the site of anastomosis with a major pectoralis muscle flap, and applied a split-thickness skin graft to the skin defect.

CONCLUSIONS

In cases of gastric conduit trouble in patients treated via the antesternal route, a major pectoralis muscle flap is useful because of its rich blood supply and easy mobilization. In addition, a split-thickness skin graft should be applied to the skin defect.

The Inflammatory Response to Surgery in Sickle Cell Disease Patients Undergoing Cholecystectomy

Background and Objectives:

Patients with sickle cell anemia (SCA) may have elevated inflammatory markers in health, and this may be heightened after open operations. The inflammatory response of patients with SCA after minimally invasive surgeries has not been fully explored.

Patients and Methods:

Consecutive patients with SCA and with hemoglobin AA (HbAA) undergoing laparoscopic cholecystectomy for acute cholecystitis were recruited into the study. Blood samples were taken before induction of anesthesia (0-h); at 4, 12, 24, and 48 h; and on postoperative day 7. Samples were analyzed for serum C-reactive protein and interleukin (IL)-1 through IL-18.

Results:

Twenty-three patients, including 9 with SCA and 14 with HbAA, were recruited with 4 cases performed by open laparotomy. At 0-h, proinflammatory IL-1 levels (6.1 versus 4.8) and C-reactive protein levels (32.5 versus 26.6) were higher in patients with hemoglobin SS (HbSS) than in patients with HbAA, respectively. Over time, inflammatory markers were generally higher at each time-point for patients with HbSS compared with patients with HbAA for both proinflammatory and anti-inflammatory cytokines, rising immediately after surgery and up to 48 hours, then returning to baseline by postoperative day 7. There was a higher mean IL-1 level across all time-points in the HbSS group than in the HbAA group (P = .04).

Conclusion:

This exploratory study found an enhanced inflammatory response to cholecystectomy in patients with SCA compared with patients with HbAA. Minimally invasive surgical strategies for this patient group may help to mediate this response.

Recurrent Desmoid Tumor with Intra-Abdominal Extension After Abdominoplasty: A Rare Presentation

BACKGROUND Desmoid tumors are fibrous neoplasms that originate from the musculoaponeurotic structures in the body. Abdominal wall desmoid tumors are rare, but they can be locally aggressive, with high incidence of recurrence. These tumors are more common in young, fertile women. They frequently occur during or after pregnancy. CASE REPORT We present the case of a 63-year-old post-menopausal woman with a desmoid tumor of the anterior abdominal wall. She had no relevant family history. During abdominoplasty, an incidental mass was excised and biopsied, and was identified as a desmoid tumor with free margins. One year later, the patient presented with vague abdominal discomfort and feeling of heaviness. An incision was made through the previous abdominoplasty scar to maintain the aesthetic outcome. A large mass, arising from the abdominal wall and extending intra-abdominally, was excised and was determined to be a recurrent desmoid tumor. CONCLUSIONS Recurrent anterior abdominal wall desmoid tumors in post-menopausal women are rare and locally aggressive, with a high risk of recurrence. During abdominal wall repair in abdominoplasty, desmoid tumor filaments might seed deep intra-abdominally. Therefore, it is necessary to take adequate safe margins before abdominal wall repair. Post-operatively, surgeons should keep a high index of suspicion for tumor recurrence.

Hematogenous intestinal metastases from sigmoid colon cancer presenting as iliopsoas abscess and bowel obstruction

Intestinal metastases from colorectal cancer typically occur by intraperitoneal spread, whereas those occurring via hematogenous route are exceedingly rare. We report a case of intestinal metastases from sigmoid colon cancer that presented as iliopsoas abscess and ileus. A 78-year-old man who had undergone sigmoidectomy for sigmoid colon cancer 5 years ago was referred to our hospital with recurrent ileus and fever. Abdominal computed tomography showed a left iliopsoas abscess and a mass near the abscess that had ostensibly caused ileus. The patient underwent segmental resection of the jejunum including the mass. Histopathological examination of the resected specimen revealed moderately differentiated adenocarcinoma proliferating mainly in the submucosal and muscular layers, which was pathologically identical to the colon cancer resected 5 years ago. He died 18 months after the surgery because of liver metastases. This case report highlights the delayed occurrence of colorectal metastases at unusual sites, such as the small bowel, more than 5 years after the resection of the primary cancer. Intestinal metastases should be considered in patients with a history of colon cancer, particularly in those with recurrent ileus or abdominal abscess with no obvious cause.

WITHDRAWN: Endoscopic intervention for acute appendicitis: retrospective study of 101 cases

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Abdominal cocoon: preoperative diagnosis on CT

A 23-year-old man presented to the emergency department with a history of recurrent episodes of subacute intestinal obstruction. Palpation revealed a firm, non-tender, mobile, non-pulsatile mass of size 8-10 cm with indistinct margins and smooth surface in the hypogastrium. Contrast-enhanced CT scan of the abdomen showed clumping of the small bowel loops within a well-defined membrane-like structure without dilatation or thickening of bowel loops. The patient underwent a laparotomy with incision of the membrane and separation of all the small bowel loops inside the cocoon. Abdominal cocoon is the idiopathic variety of sclerosing encapsulating peritonitis and is an unusual cause of acute or subacute intestinal obstruction. Clinical diagnosis is difficult because of non-specific symptoms. CT has facilitated accurate preoperative diagnosis, long before the patient presents with full-fledged symptoms of acute intestinal obstruction. CT scan plays a significant role in excluding the secondary causes and helps in patient management.

Single-Center Retrospective Study of Clinical and Laboratory Features That Predict Survival of Patients With Budd-Chiari Syndrome After Liver Transplant

OBJECTIVES

Budd-Chiari syndrome is a rare but critical condition that can progress to liver failure and death. For severe cases, orthotopic liver transplant remains the only curative option. The present study aimed to identify predictive parameters to assess outcomes of liver transplant.

MATERIALS AND METHODS

Medical records of 33 individuals with Budd-Chiari syndrome who received orthotopic liver transplant were retrospectively assessed. Twenty-seven eligible patients were identified and grouped by outcome (survived/deceased) after transplant for Budd-Chiari syndrome. Demographic, clinical, and serum parameters taken at the time of Budd-Chiari syndrome diagnosis were evaluated for prognostic value.

RESULTS

Differences between patients who survived and those who died were found for nausea/vomiting (P < .01) and splenomegaly (P < .01), which were both more common in patients who died after transplant. In addition, patients in the deceased group exhibited significantly lower serum cholinesterase levels (P < .01) and higher alkaline phosphatase levels (P < .01). Scoring systems to assess liver status or Budd-Chiari syndrome severity (Model for End-Stage Liver Disease and Child-Pugh scores, Rotterdam score, and the transjugular intrahepatic portosystemic shunting prognostic index) did not differ between groups.

CONCLUSIONS

Nausea/vomiting, splenomegaly, low serum cholinesterase, and high alkaline phosphatase were associated with adverse outcomes after orthotopic liver transplant for Budd-Chiari syndrome. These factors may be surrogate markers for a severely impaired health status at time of diagnosis and should be evaluated prospectively in larger cohorts.

Benefits of Enhanced Recovery After Surgery for fusion in degenerative spine surgery: impact on outcome, length of stay, and patient satisfaction

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) proposes a multimodal, evidence-based approach to perioperative care. Thanks to the improvement in care protocols and the fluidity of the patient pathway, the first goal of ERAS is the improvement of surgical outcomes and patient experience, with a final impact on a reduction in the hospital length of stay (LOS). The implementation of ERAS in spinal surgery is in the early stages. The authors report on their initial experience in applying an ERAS program to several degenerative spinal fusion procedures.

METHODS

The authors selected two 2-year periods: the first from before any implementation of ERAS principles (pre-ERAS years 2012–2013) and the second corresponding to a period when the paradigm was applied widely (post-ERAS years 2016–2017). Patient groups in these periods were retrospectively compared according to three degenerative conditions requiring fusion: anterior cervical discectomy and fusion (ACDF), anterior lumbar interbody fusion (ALIF), and posterior lumbar fusion. Data were collected on patient demographics, operative and perioperative data, LOSs, 90-day readmissions, and morbidity. ERAS-trained nurses were involved to support patients at each pre-, intra-, and postoperative step with the help of a mobile application (app). A satisfaction survey was included in the app.

RESULTS

The pre-ERAS group included 1563 patients (159 ALIF, 749 ACDF, and 655 posterior fusion), and the post-ERAS group included 1920 patients (202 ALIF, 612 ACDF, and 1106 posterior fusion). The mean LOS was significantly shorter in the post-ERAS group than in the pre-ERAS group for all three conditions. It was reduced from 6.06 ± 1.1 to 3.33 ± 0.8 days for the ALIF group (p < 0.001), from 3.08 ± 0.9 to 1.3 ± 0.7 days for the ACDF group (p < 0.001), and from 6.7 ± 4.8 to 4.8 ± 2.3 days for posterior fusion cases (p < 0.001). There was no significant difference in overall complications between the two periods for the ALIF (11.9% pre-ERAS vs 11.4% post-ERAS, p = 0.86) and ACDF (6.0% vs 8.2%, p = 0.12) cases, but they decreased significantly for lumbar fusions (14.8% vs 10.9%, p = 0.02). Regarding satisfaction with overall care among 808 available responses, 699 patients (86.5%) were satisfied or very satisfied, and regarding appreciation of the mobile e-health app in the perceived optimization of care management, 665 patients (82.3%) were satisfied or very satisfied.

CONCLUSIONS

The introduction of the ERAS approach at the authors’ institution for spinal fusion for three studied conditions resulted in a significant decrease in LOS without causing increased postoperative complications. Patient satisfaction with overall management, upstream organization of hospitalization, and the use of e-health was high. According to the study results, which are consistent with those in other studies, the whole concept of ERAS (primarily reducing complications and pain, and then reducing LOS) seems applicable to spinal surgery.

Malignant peripheral nerve sheath tumor of thigh with sphenoid and brain metastases: Extremely rare occurrence with dismal prognosis despite significant response to palliative chemoradiotherapy

Malignant peripheral nerve sheath tumor (MPNST) is a neurogenic tumor arising from peripheral nerves or nerve sheaths. MPNSTs are highly aggressive sarcomas mainly associated with neurofibromatosis type-1 (NF-1) with high rates of local recurrence and distant metastasis carrying a dismal prognosis. Lung is the most common metastatic site. Bone metastasis although documented in the literature is still very rare, while dissemination to brain without the involvement of lungs and that too in a non-NF-1 case is extremely unusual. A 48-year-old female was diagnosed with a case of non-NF-1 MPNST left thigh with bone metastases including sphenoid. Despite showing complete resolution of skeletal and primary lesions postpalliative chemoradiotherapy, she developed brain metastases and succumbed to her disease. This case is discussed to highlight an unusual scenario we encountered, the clinical course of the disease with its management, and overall poor prognosis. To the best of our knowledge, this may be the earliest case of MPNST with sphenoid metastases detected by 18-fluorodeoxyglucose positron-emission computed tomography scan and a sporadic case of brain metastases reported in the world literature.

Complicated appendicitis and considerations for interval appendectomy

Acute appendicitis is one of the most common surgical emergencies. Of the 300,000 appendectomies performed each year, 25% are due to complicated appendicitis. This article reviews the incidence and pathophysiology of acute appendicitis, the nonoperative management of complicated appendicitis, and the rationales for and against interval appendectomy.

Flavonoid mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) in the treatment of I-III degree hemorroidal disease: a double-blind multicenter prospective comparative study

PURPOSE

We evaluated the efficacy of new flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) to reduce bleeding from I-III degrees hemorrhoidal disease in the short and medium time.

METHODS

One hundred fifty-four consecutive patients with hemorrhoidal disease recruited in four colorectal units were enrolled to the study. Exclusion criteria were allergy to the flavonoids, inflammatory bowel disease, obstructed defecation syndrome, pregnancy and puerperium, associated anal disease or hemorrhoidal thrombosis, proctologic surgical procedures within 1 year before recruitment, contemporary cancer or HIV, previous pelvic radiotherapy, patients receiving oral anticoagulant therapy, or contemporary administration of other therapy for hemorrhoids. Patients with inability to understand the study or mental disorders were also excluded.

RESULTS

Seventy-eight were randomized to receive the mixture of diosmin, troxerutin, rutin, hesperidin, and quercetin (study group, SG), and 76 a mixture of diosmin in combination with hesperidin, diosmetin, isoroifolin, and linarin in purified micronized fraction (control group, CG). Bleeding, number of pathological piles, and Golligher's grade were assessed at each scheduled visit and compared using the Chi-square test. During the study period, bleeding improved after 1 and 6 months both in the SG (79.5 and 70.5%) and in the CG (80.2 and 75%) without significant differences between two groups. Satisfaction degree after 6 months was greater in the patients of the SG (4.05) towards the CG (3.25): this result was statistical significant (p 0.003).

CONCLUSIONS

Use of flavonoids mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) is a safe and effective mean of managing bleeding from hemorrhoidal disease and minimal adverse events are reported.

Patient-specific devices and population-level evidence: evaluating therapeutic interventions with inherent variation

Designing and manufacturing medical devices for specific patients is becoming increasingly feasible with developments in 3D printing and 3D imaging software. This raises the question of how patient-specific devices can be evaluated, since our 'gold standard' method for evaluation, the randomised controlled trial (RCT), requires that an intervention is standardised across a number of individuals in an experimental group. I distinguish several senses of patient-specific device, and focus the discussion on understanding the problem of variations between instances of an intervention for RCT evaluation. I argue that, despite initial appearances, it is theoretically possible to use RCTs to evaluate some patient-specific medical devices. However, the argument reveals significant difficulties for ensuring the validity of such trials, with implications for how we should think about methods of evidence gathering and regulatory approaches for these technologies.

Budd-Chiari Syndrome and Esophageal Achalasia: Unrecognized Intrahepatic Cholangiocarcinoma Invading Multiple Organs

Intrahepatic cholangiocarcinoma (ICC) is the second-most common primary liver cancer, although its occurrence is relatively rare. Budd-Chiari syndrome (BCS) is characterized by outflow obstruction from the liver, with hepatocellular carcinoma being the most common cause of malignant BCS. In this case report, we describe the occurrence of an unrecognized ICC that induced BCS and esophageal achalasia.

Estimation of Standard Liver Volume Using CT Volume, Body Composition, and Abdominal Geometry Measurements

PURPOSE

The present study developed formulas for estimation of standard liver volume (SLV) with high accuracy for the Korean population.

MATERIALS AND METHODS

SLV estimation formulas were established using gender-balanced and gender-unbalanced measurements of anthropometric variables, body composition variables, and abdominal geometry of healthy Koreans (n=790). Total liver volume excluding blood volume, was measured based on CT volumetry.

RESULTS

SLV estimation formulas as preferred in various conditions of data availability were suggested in the present study. The suggested SLV estimation formulas in the present study were found superior to existing formulas, with an increased accuracy of 4.0-217.5 mL for absolute error and 0.2-18.7% for percentage of absolute error.

CONCLUSION

SLV estimation formulas using gender-balanced measurements showed better performance than those using gender-unbalanced measurements. Inclusion of body composition and abdominal geometry variables contributed to improved performance of SLV estimation.

Nonsteroidal anti-inflammatory drugs induced diaphragm disease: a report of 3 cases and literature review

Multiple strictures of small bowel induced by nonsteroidal anti-inflammatory drugs (NSAIDs), were known as diaphragm disease. The purpose of these case reports is to present 3 cases of diaphragm disease of small bowel and summarize the clinical features of this disease entity. A 34-year-old man, a 63-year-old man, and a 66-year-old woman were admitted to Daegu Catholic University Medical Center because of recurrent intestinal obstructions. Two of these patients had taken heavy NSAIDs use. Capsule endoscopy was performed in all cases and the all capsules were retained by circumferential strictures of the ileum. Segmental resection of the strictures was performed in 2 patients and 1 underwent just enterotomy and capsule removal. In conclusion, clinicians should be aware that diaphragm disease might be a cause of small bowel obstruction especially in patients receiving long term NSAIDs therapy.

Perioperative Management of Sickle Cell Disease

Over 30 million people worldwide have sickle cell disease (SCD). Emergent and non-emergent surgical procedures in SCD have been associated with relatively increased risks of peri-operative mortality, vaso-occlusive (painful) crisis, acute chest syndrome, post-operative infections, congestive heart failure, cerebrovascular accident and acute kidney injury. Pre-operative assessment must include a careful review of the patient’s known crisis triggers, baseline hematologic profile, usual transfusion requirements, pre-existing organ dysfunction and opioid use. Use of preoperative blood transfusions should be selective and decisions individualized based on the baseline hemoglobin, surgical procedure and anticipated volume of blood loss. Intra- and post-operative management should focus on minimizing hypoxia, hypothermia, acidosis, and intravascular volume depletion. Pre- and post-operative incentive spirometry use should be encouraged.

Low-impact laparoscopic cholecystectomy is associated with decreased postoperative morbidity in patients with sickle cell disease

BACKGROUND

Laparoscopic cholecystectomy (LC) is one of the most frequent surgeries performed in patients with sickle cell disease (SCD). LC in SCD patients is associated with a particularly high postoperative morbidity. The aim of the present study is to assess the safety and feasibility of cholecystectomy performed by mini-laparoscopy with low- and stable-pressure pneumoperitoneum (MLC + LSPP) and to compare the rate of postoperative SCD-related morbidity with standard LC.

METHODS

Thirty-five consecutive SCD patients admitted between November 2015 and March 2017 for cholelithiasis requiring surgery were compared with an historical cohort of 126 SCD patients who underwent LC for the same indication. Operative variables, postoperative outcomes, patient and surgeon satisfaction, and costs were evaluated.

RESULTS

MLC + LSPP exhibited a mean operative time comparable to LC (p = 0.169). Operative blood loss was significantly reduced in the MLC + LSPP group, and the suction device was rarely used (p = 0.036). SCD-related morbidity (including acute chest syndrome) was significantly higher in the LC group compared with the MLC + LSPP group (18.3 vs. 2.9%; p = 0.029). The mean times to resume ambulation (p = 0.018) and regular diet (p = 0.045) were significantly reduced in the MLC + LSPP group. The mean incision length (all trocars combined) was 28.22 mm for MLC + LSPP and 49.64 mm for LC patients (p < 0.0001). Multivariate regression analysis demonstrated that the only significant predictor of postoperative SCD-related morbidity was the surgical approach (odds ratio: 9.24). Patient and surgeon satisfaction were very high for MLC + LSPP. The mean total cost per patient (surgery and hospitalization) was not different between groups (p = 0.084).

CONCLUSION

MLC + LSPP in SCD patients appears to be safe and feasible. Compared with LC, MLC + LSPP in SCD patients is associated with a significantly reduced incidence of postoperative SCD-related morbidity and more rapid ambulation and return to regular diet without increasing the total costs per patient.

Unusual Presentation of Duodenal Ulcer Presenting with Duodenal Intussusception

We present a unique case of duodeno-duodenal intussusception from a duodenal bulb ulcer. A 38-year-old man presented with nausea, vomiting, and abdominal pain. Computed tomography showed duodenal intussusception. Esophagogastroduodenoscopy (EGD) showed a linear gastric ulcer and a duodenal bulb ulcer with an overlying blood clot. Helicobacter pylori status was positive. Intussusception resolved spontaneously without intervention. He completed treatment for H. pylori infection, and repeat EGD showed ulcer healing. Duodenal intussusception is rarely reported; intussusception from an edematous duodenal ulcer with an overlying blood clot mimicking a mass lesion acting as lead point has never been reported to our knowledge.

Gastric lipoma: a rare cause of haematemesis

Gastric lipomas are rare benign tumours of the stomach, representing less than 3% of all benign gastric neoplasms. They are usually asymptomatic but larger lesions can present with abdominal pain, gastric outlet obstruction and haematemesis. Malignant transformation is extremely rare. Accurate preoperative diagnosis can be established with computed tomography. Being benign, extensive surgery is not necessary and simple excision of the lesion is adequate. Small asymptomatic lesions can be followed up. We present a case of 80-year-old woman with gastric submucosal lipoma who presented with haematemesis.

Splenic tuberculosis in an immunocompetent patient can be managed conservatively: a case report

Tuberculosis is a significant health problem in developing countries. Splenic tuberculosis usually occurs as a part of miliary tuberculosis, and ranks third after lung and liver involvement, respectively. Splenic involvement is more common in immunocompromised patients and is very rarely found in immunocompetent patients. Here we report a case of splenic tuberculosis in an immunocompetent patient, which was managed successfully with conservative treatment.

Assessing the Non-tumorous Liver: Implications for Patient Management and Surgical Therapy

INTRODUCTION

Hepatic resection is performed for various benign and malignant liver tumors. Over the last several decades, there have been improvements in the surgical technique and postoperative care of patients undergoing liver surgery. Despite this, liver failure following an extended hepatic resection remains a critical potential postoperative complication. Patients with underlying parenchymal liver diseases are at particular risk of liver failure due to impaired liver regeneration with an associated mortality risk as high as 60 to 90%. In addition, live donor liver transplantation requires a thorough presurgical assessment of the donor liver to minimize the risk of postoperative complications.

RESULTS AND CONCLUSION

Recently, cross-sectional imaging assessment of diffuse liver diseases has gained momentum due to its ability to provide both anatomical and functional assessments of normal and abnormal tissues. Various imaging techniques are being employed to assess diffuse liver diseases including magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound (US). MRI has the ability to detect abnormal intracellular and molecular processes and tissue architecture. CT has a high spatial resolution, while US provides real-time imaging, is inexpensive, and readily available. We herein review current state-of-the-art techniques to assess the underlying non-tumorous liver. Specifically, we summarize current approaches to evaluating diffuse liver diseases including fatty liver alcoholic or non-alcoholic (NAFLD, AFLD), hepatic fibrosis (HF), and iron deposition (ID) with a focus on advanced imaging techniques for non-invasive assessment along with their implications for patient management. In addition, the role of and techniques to assess hepatic volume in hepatic surgery are discussed.

Neural and neurogenic tumours of the gastroenteropancreaticobiliary tract

Neural lesions occur uncommonly in the gastroenteropancreaticobiliary tract. However, due to the growing number of screening colonoscopy procedures, polypoid neural lesions of the colon are being recognised increasingly and range from benign tumours to high-grade malignant neoplasms. Morphological variability of neural tumours can be wide, although some entities share pathological features, and, as such, these lesions can be diagnostically challenging. We review the spectrum of pathology of neural tumours in the gastroenteropancreaticobiliary tract, with the goal of providing a practical approach for practising surgical pathologists.

Port site desmoid tumour following laparoscopic cholecystectomy: A case report

Desmoid tumours are locally aggressive tumours occurring either spontaneously or in familial conditions. History of trauma is invariably present with surgical trauma being a common cause. Port site desmoid tumours are extremely rare conditions. Inadequate treatment results in high recurrence rate and substantial morbidity. Reconstruction, if required, by the appropriate technique is vital to avoid an incisional hernia. Adjuvant therapy may be useful in large locally advanced or recurrent tumours. We describe a young female with large port site desmoid tumour following laparoscopic cholecystectomy managed with wide local excision and mesh placement.

Tubular sigmoid duplication in an adult man: an interesting incidental finding

A 61-year-old man attended an outpatient colorectal clinic for a chronic, non-specific abdominal pain, associated with rectal bleeding. He underwent a number of investigations including a CT pneumocolon, which revealed an incidental finding of 20 cm of additional sigmoid colon. This case is interesting because tubular sigmoid duplication is an extremely unusual condition, rarely diagnosed in adults; only a few cases have been reported of this condition in the adult population. Our team chose to treat this patient conservatively, in order to avoid putting the patient at risk of an unnecessary surgery.

Multimodal ultrasonographic assessment of leiomyosarcoma of the femoral vein in a patient misdiagnosed as having deep vein thrombosis: A case report

RATIONALE

Primary leiomyosarcoma (LMS) of the vein is a rare tumor that arises from the smooth muscle cells of the vessel wall and has an extremely poor prognosis. This tumor can occur in vessels such as the inferior vena cava, great saphenous vein, femoral vein, iliac vein, popliteal vein, and renal vein; the inferior vena cava is the most common site. LMS of the femoral vein can result in edema and pain in the lower extremity; therefore, it is not easy to be differentiated from deep vein thrombosis (DVT). Moreover, virtually no studies have described the ultrasonographic features of LMS of the vein in detail.

PATIENT CONCERNS

We present a case of a 55-year-old woman with LMS of the left femoral vein that was misdiagnosed as having deep vein thrombosis (DVT) on initial ultrasonographic examination. The patient began to experience edema and pain in her left leg seven months previously. She was diagnosed as having DVT on initial ultrasonographic examination, but the DVT treatment that she had received for 7 months failed to improve the status of her left lower limb.

DIAGNOSES

She subsequently underwent re-examination by means of a multimodal ultrasonographic imaging approach (regular B-mode imaging, color Doppler imaging, pulsed-wave Doppler imaging, contrast-enhanced ultrasonography), which confirmed a diagnosis of LMS.

INTERVENTIONS

This patient was treated successfully with surgery.

OUTCOMES

This case demonstrates that use of multiple ultrasonographic imaging techniques can be helpful to diagnose LMS accurately. Detection of vasculature in a dilated vein filled with a heterogeneous hypoechoic substance on ultrasonography is a sign of a tumor.

LESSONS

The pitfall of misdiagnosing this tumor as DVT is a useful reminder.

A Formula to Calculate Standard Liver Volume Using Thoracoabdominal Circumference

Background

With the use of split liver grafts as well as living donor liver transplantation (LDLT) it is imperative to know the minimum graft volume to avoid complications. Most current formulas to predict standard liver volume (SLV) rely on weight-based measures that are likely inaccurate in the setting of cirrhosis. Therefore, we sought to create a formula for estimating SLV without weight-based covariates.

Methods

LDLT donors underwent computed tomography scan volumetric evaluation of their livers. An optimal formula for calculating SLV using the anthropomorphic measure thoracoabdominal circumference (TAC) was determined using leave-one-out cross-validation. The ability of this formula to correctly predict liver volume was checked against other existing formulas by analysis of variance. The ability of the formula to predict small grafts in LDLT was evaluated by exact logistic regression.

Results

The optimal formula using TAC was determined to be SLV = (TAC × 3.5816) − (Age × 3.9844) − (Sex × 109.7386) − 934.5949. When compared to historic formulas, the current formula was the only one which was not significantly different than computed tomography determined liver volumes when compared by analysis of variance with Dunnett posttest. When evaluating the ability of the formula to predict small for size syndrome, many (10/16) of the formulas tested had significant results by exact logistic regression, with our formula predicting small for size syndrome with an odds ratio of 7.94 (95% confidence interval, 1.23-91.36; P = 0.025).

Conclusion

We report a formula for calculating SLV that does not rely on weight-based variables that has good ability to predict SLV and identify patients with potentially small grafts.

Giant gastric lipoma presenting as GI bleed: Enucleation or Resection?

INTRODUCTION

Gastric lipomas are unusual benign lesions and account for less than 1% of all tumours of the stomach and 5% of all gastrointestinal lipomas (Thompson et al.2003; Fernandez et al. 1983 [1,2]). Although predominantly asymptomatic and indolent; they may present with gastric outlet obstruction and upper gastrointestinal (GI) bleeding owing to size and ulceration. Only a few cases have been reported, presenting large in size with massive GI bleeding (Alcalde Escribano et al. 1989; Johnson et al. 1981 [3,4]).

PRESENTATION OF CASE

We report the case of a 62-year-old gentleman who presented to the emergency department with massive upper GI hemorrhage. He was initially resuscitated and stabilized. Later gastroscopy showed a large submucosal tumour (Fig. 1). Biopsy revealed adipose tissue. Computed tomography (CT) scan of the abdomen and pelvis showed a huge well defined oval soft tissue lesion measuring about 16×8×8cm. The mass noted a homogenous fat density arising from the posterior wall of stomach with no extramural infiltration (Fig. 2). The tumour was completely enucleated through an explorative gastrotomy incision (Fig. 4).

DISCUSSION AND CONCLUSION

Massive bleeding secondary to a giant gastric lipoma is a rare finding of a rare disease. The majority of cases in the literature result in major gastric resection. Familiarity with its radiological findings and a high index of suspicion can lead to proper diagnosis in the acute setting. If malignancy is carefully ruled out, stomach preserving surgery is an optimal treatment option.

A new formula for estimation of standard liver volume using computed tomography-measured body thickness

The objective of this article is to derive a more accurate and easy-to-use formula for finding estimated standard liver volume (ESLV) using novel computed tomography (CT) measurement parameters. New formulas for ESLV have been emerging that aim to improve the accuracy of estimation. However, many of these formulas contain body surface area measurements and logarithms in the equations that lead to a more complicated calculation. In addition, substantial errors in ESLV using these old formulas have been shown. An improved version of the formula for ESLV is needed. This is a retrospective cohort of consecutive living donor liver transplantations from 2005 to 2016. Donors were randomly assigned to either the formula derivation or validation groups. Total liver volume (TLV) measured by CT was used as the reference for a linear regression analysis against various patient factors. The derived formula was compared with the existing formulas. There were 722 patients (197 from the derivation group, 164 from the validation group, and 361 from the recipient group) involved in the study. The donor's body weight (odds ratio [OR], 10.42; 95% confidence interval [CI], 7.25-13.60; P < 0.01) and body thickness (OR, 2.00; 95% CI, 0.36-3.65; P = 0.02) were found to be independent factors for the TLV calculation. A formula for TLV (cm3 ) was derived: 2 × thickness (mm) + 10 × weight (kg) + 190 with R2 0.48, which was the highest when compared with the 4 other most often cited formulas. This formula remained superior to other published formulas in the validation set analysis (R2 , 5.37; interclass correlation coefficient, 0.74). Graft weight/ESLV values calculated by the new formula were shown to have the highest correlation with delayed graft function (C-statistic, 0.79; 95% CI, 0.69-0.90; P < 0.01). The new formula (2 × thickness + 10 × weight + 190) represents the first study proposing the use of CT-measured body thickness which is novel, easy to use, and the most accurate for ESLV. Liver Transplantation 23 1113-1122 2017 AASLD.

Patient autonomy and doctor's concern - a case of intravenous drug abuser

Intravenous substance abuse is often associated with physical and psychological harm, and often requires urgent medical attention. We report a case of a young male who presented with life-threatening complications of intravenous drug abuse, but refused to give details or agree to the proposed treatment, raising concerns for the team of doctors. A compos mentis patient has a right to decide what should be done to his body. Medical management or surgical interventions cannot be initiated without the patient's consent even if these are lifesaving procedures, or a procedure meant to benefit the patient. Medical practitioner can be liable for assault (criminal law), medical negligence (law of tort), damages (civil action) and even human rights issues may be raised if a patient's autonomy is not respected.

Systematic review of giant gastric lipomas reported since 1980 and report of two new cases in a review of 117110 esophagogastroduodenoscopies

AIM

To systematically review the syndrome of giant gastric lipomas, report 2 new illustrative cases.

METHODS

Literature systematically reviewed using PubMed for publications since 1980 with following medical subject heading/keywords: ("giant lipoma") AND ("gastric") OR [("lipoma") and ("gastric") and ("bleeding")]. Two authors independently reviewed literature, and decided by consensus which articles to incorporate. Computerized review of pathology/endoscopy records at William Beaumont Hospitals, Royal Oak and Troy, Michigan, January 2005-December 2015, revealed 2 giant gastric lipomas among 117110 consecutive esophagogastroduodenoscopies (EGDs), which were thoroughly reviewed, including re-review of original endoscopic photographs, radiologic images, and pathologic slides.

RESULTS

Giant gastric lipomas are extremely rare: 32 cases reported since 1980, and 2 diagnosed among 117110 consecutive EGDs. Average patient age = 54.5 ± 17.0 years old (males = 22, females = 10). Maximal lipoma dimension averaged 7.9 cm ± 4.1 cm. Ulcerated mass occurred in 21 patients. Lipoma locations: antrum-17, body-and-antrum-4, antrum-intussuscepting-into-small-intestine-3, body-2, fundus-1, and unspecified-5. Intramural locations included submucosal-22, subserosal-2, and unspecified-8. Presentations included: acute upper gastrointestinal (UGI) bleeding-19, abdominal pain-5, nausea/vomiting-5, and asymptomatic-3. Symptoms among patients with UGI bleeding included: weakness/fatigue-6, abdominal pain-4, nausea/vomiting-4, early-satiety-3, dizziness-2, and other-1. Their hemoglobin on admission averaged 7.5 g/dL ± 2.8 g/dL. Patients with GI bleeding had significantly more frequently ulcers than other patients. EGD was extremely helpful diagnostically (n = 31 patients), based on characteristic endoscopic findings, including yellowish hue, well-demarcated margins, smooth overlying mucosa, and endoscopic cushion, tenting, or naked-fat signs. However, endoscopic mucosal biopsies were mostly non-diagnostic (11 of 12 non-diagnostic). Twenty (95%) of 21 abdominal CTs demonstrated characteristic findings of lipomas, including: well-circumscribed, submucosal, and homogeneous mass with attenuation of fat. Endoscopic-ultrasound showed characteristic findings in 4 (80%) of 5 cases: hyperechoic, well-localized, mass in gastric-wall-layer-3. Transabdominal ultrasound and UGI series were generally less helpful. All 32 patients underwent successful therapy without major complications or mortality, including: laparotomy and full-thickness gastric wall resection of tumor using various surgical reconstructions-26; laparotomy-and-enucleation-2; laparoscopic-transgastric-resection-2; endoscopic-mucosal-resection-1, and other-1. Two new illustrative patients are reported who presented with severe UGI bleeding from giant, ulcerated, gastric lipomas.

CONCLUSION

This systematic review may help standardize the endoscopic and radiologic evaluation and therapy of patients with this syndrome.

Intraluminal rectal cancer metastasis to the small bowel: An extremely rare case report

Prolonged survival in patients suffering from colorectal cancer (CRC) may lead to the emergence of rare metastatic sites that are not well-documented in the literature. We herein describe a very rare case of an intraluminal small intestinal metastasis in a patient with previously resected CRC. A 71-year-old Caucasian male patient with a history of rectosigmoid junction cancer was initially treated with anterior resection. The tumor was classified as pT3pN0 (0/26) M0, stage II. Eighteen months after the primary surgery, local recurrence was detected in the presacral region, and the patient received combined image-guided radiotherapy and chemotherapy. Two months later, due to residual disease at the level of the anastomosis, the patient underwent additional low anterior resection with a diverting stoma. During extensive adhesiolysis, a small palpable intraluminal mass was identified in the jejunum, and segmental small bowel resection was performed. Pathological examination of the resected specimen confirmed that the lesion was a metastasis from the CRC primary. The precise mechanism and clinical significance of CRC metastasis to the small bowel remain unclear. There is limited clinical experience with this condition, as <20 cases have been reported in the literature to date. The main symptoms leading to evaluation, diagnosis and surgical resection are bowel obstruction and bleeding. The present case highlights the possibility of uncomplicated presence of metastatic CRC in the small bowel. Therefore, dilligent inspection of the peritoneal cavity, including the entire length of the gastrointestinal canal, is of paramount importance, particularly in cases of recurrent CRC.

Hand-assisted laparoscopic surgery versus conventional open surgery in intraoperative and postoperative outcomes for colorectal cancer: An updated systematic review and meta-analysis

AIM

This meta-analysis aims to compare hand-assisted laparoscopic surgery (HALS) and conventional open surgery (OS) for colorectal cancer (CRC) in terms of intraoperative and postoperative outcomes, and to explore the safety, feasibility of HALS for CRC surgery.

METHODS

A systematic literature search with no limits was performed in PubMed, Embase, and Medline. The last search was performed on April 23, 2017. The outcomes of interests included intraoperative outcomes (operative time, blood loss, length of incision, transfusion, and lymph nodes harvested), postoperative outcomes (length of hospital stay, length of postoperative hospital stay, time to first flatus, time to first liquid diet, time to first soft diet, time to first bowel movement, postoperative complications, reoperation, ileus, anastomotic leakage, wound infection, urinary complication, pulmonary infection, and mortality).

RESULTS

Fifteen articles published between 2007 and 2017 with a total of 1962 patients with CRC were included in our meta-analysis. HALS was associated with longer operative time, less blood loss, smaller length of incision, shorter hospital days and postoperative hospital days, less time to first flatus, less wound infection, and less postoperative complications. There was no difference in blood transfusion, lymph node harvested, time to first liquid or soft diet, time to first bowel movement, reoperation, ileus, anastomotic leakage, pulmonary infection, urinary complications, or mortality.

CONCLUSIONS

Our meta-analysis suggests that HALS in CRC surgery improves cosmesis and results in better postoperative recovery outcomes by reducing postoperative complications and hospital days. Furthermore, a large randomized control study is warranted to compare the short-term and long-term outcomes of those 2 techniques for CRC treatment.

New formula for predicting standard liver volume in Chinese adults

AIM

To obtain a reference range of morphological indices and establish a formula to accurately predict standard liver volume (SLV) in Chinese adults.

METHODS

Computed tomography (CT)-estimated total liver volume (CTLV) was determined in 369 Chinese adults. Age, sex, body weight, body height, body mass index, and body surface area (BSA) were recorded using CT. Total splenic volume, portal venous diameter (PVD), splenic venous diameter (SVD), and portal venous cross-sectional area (PVCSA) were also measured by CT. Stepwise multiple linear regression analysis was performed to evaluate the impact of each parameter on CTLV and to develop a new SLV formula. The accuracy of the new formula was compared with the existing formulas in a validation group.

RESULTS

The average CTLV was 1205.41 ± 257.53 cm³ (range, 593.80-2250.10 cm³). The average of PVD, SVD and PVCSA was 9.34 ± 1.51 mm, 7.40 ± 1.31 mm and 173.22 ± 48.11 mm², respectively. The CT-estimated splenic volume of healthy adults varied markedly (range, 46.60-2892.30 cm³). Sex, age, body height, body weight, body mass index, and BSA were significantly correlated with CTLV. BSA showed the strongest correlation (r = 0.546, P < 0.001), and was used to establish a new model for calculating SLV: SLV (cm³) = 758.259 × BSA (m²)-124.272 (R² = 0.299, P < 0.001). This formula also predicted CTLV more accurately than the existing formulas, but overestimated CTLV in elderly subjects > 70 years of age, and underestimated liver volume when CTLV was > 1800 cm³.

CONCLUSION

Our new BSA-based formula is more accurate than other formulas in estimating SLV in Chinese adults.

Retrospective review of laparoscopic versus open surgery in the treatment of appendiceal abscess in pediatric patients: Laparoscopic versus open surgery for appendiceal abscess

Laparoscopic appendectomy (LA) has become well accepted, but the role of LA for appendicitis upon presentation with an abscess remains undefined. This study was to assess the postoperative recovery and complications following LA in pediatric patients with appendiceal abscess in comparison with open appendectomy (OA).We conducted a retrospective review of patients presented with appendiceal abscess between 2005 and 2016. Propensity score matching (PSM) was conducted to adjust for any potential selection bias for the surgical approaches. In 108 matched patients, operative outcomes and surgical complications were evaluated based on LA or OA.The patients with LA experienced prompt postoperative gastrointestinal function recovery, like first bowel movement (risk ratio [RR], 0.52; 95% confidence interval [CI], 0.44-0.69; P < .001), so spend the lower mean length of hospitalization (RR, 0.53; 95% CI, 0.41-0.76; P < .001) in comparison with patients with OA. Furthermore, the immunologic and inflammatory variable white blood cell (WBC) (RR, 0.56; 95% CI, 0.46-0.73; P < .001) and C-reactive protein (CRP) (RR, 0.58; 95% CI, 0.43-0.86; P = .011) on postoperative days (POD) 5 was reduced in patients undergone LA compared with that of OA. A lower overall postoperative complication rate, including surgical wound infection (odds ratio [OR], 0.38; 95% CI, 0.18-0.81; P = .008) and incision dehiscence (OR, 0.06; 95% CI, 0.01-0.45; P < .001) was noted in patients with LA compared with OA.LA was feasible and effective for appendicitis upon presentation with an abscess and associated with beneficial clinical effects, such as postoperative gastrointestinal function recovery and reduced postoperative complications. LA should be seriously considered as the first line procedure of choice.

Minimally Invasive Treatment for Appendiceal Mass Formed After Acute Perforated Appendicitis

The optimal treatment for appendiceal mass formed after appendiceal rupture due to acute appendicitis is surrounded with controversy. The treatment strategy ranges from open surgery (emergency or interval appendectomy), laparoscopic appendectomy, and image-guided drainage, to conservative treatment with or without antibiotics. Nonsurgical treatment (including conservative and drainage treatment), followed by interval appendectomy to prevent recurrence, is the traditional management of these patients. The need for interval appendectomy after a successful conservative or/and image-guided drainage treatment, has recently been questioned as the risk of recurrence is relatively small. Several authors consider that even in cases involving only ambulatory follow-up observation, without interval surgery after conservative management, the recurrence rate and risks of missing underlying pathologies were not high. This article evaluates the minimally invasive treatment modalities in the management of appendiceal mass, risk of undetected serious disease, and the need for interval appendectomy to prevent recurrence.

Laparoscopic cholecystectomy for cholelithiasis in children with sickle cell disease

Patients with sickle cell disease (SCD) suffer from an increased incidence of gallstone formation due to hemolysis of sickled red blood cells; this leads to an increased level of bilirubin in secreted bile that becomes a nidus for pigment stone formation. Laparoscopic cholecystectomy (LC) is considered a standard operative procedure for gallstone disease mainly due to lower postoperative wound complaints, faster recovery, better postoperative cosmetic results, shorter hospital stay, and earlier return to work. Although numerous studies have been published addressing both the advantages and complications of LC in acute calcular cholecystitis, there is still limited evidence concerning the safety and efficacy of LC for the management of cholelithiasis in pediatric patients with SCD, and controversies remain unresolved. In this review, we aim to comprehensively study the available literature and propose evidence-based practice recommendations for the optimal management of gallstones in pediatric SCD patients. The current practice differs greatly depending on the prevalence of SCD in a particular geographic area. We acknowledge the limited number of patients reported, the lack of randomized control trials addressing the practice of specific recommendations, and the need for further evidence-based studies.

Comparison of hand-assisted laparoscopic surgery (HALS) and conventional laparotomy in patients with colorectal cancer: Final results from a single center

In recent years, the use of laparoscopic surgery has been expanded to include radical curative resection. In a previous study, 212 patients with primary colorectal cancer (stages I-III) underwent radical curative resection by hand-assisted laparoscopic surgery (HALS) (n=98) or conventional laparotomy (CL) (n=114) and were compared with respect to 3-year relapse-free survival (3Y-RFS) and 3-year overall survival (3Y-OS). The study included 210/212 patients who were followed up to 5 years, including 96 patients who underwent HALS and 114 treated with CL. The two groups were matched for stage, clinical background, and postoperative management. Patient characteristics were compared and the 5Y-RFS and 5Y-OS were determined. The 5-year follow-up rate was 97.6%. In stage I-III patients, 5Y-RFS and 5Y-OS showed no significant differences between HALS and CL. The patients with stage I disease accounted for 41.7% (40/96) of the patients undergoing HALS, while stage I patients only accounted for 23.7% (27/114) of the patients undergoing CL, and the difference was significant (P=0.005). Stage II patients undergoing CL were older than those treated with HALS (P=0.017). However, there were no differences in the characteristics of stage III patients undergoing HALS or CL. In conclusion, HALS achieved a similar survival to CL in patients with stage I to III colorectal cancer. Compared with CL, HALS was performed more safely and achieved superior cosmetic results.

Laparoscopy for Rectal Cancer

It is evident that the use of laparoscopy in the management of rectal cancer has gained popularity in the last few years. It is still, however, not widely accepted as the standard of care. Multiple randomized trials have shown that short-term outcomes and perioperative morbidity and mortality of laparoscopic proctectomy are equivalent to open surgery. However, data regarding long-term oncologic outcomes are still scarce, with only a few randomized trials reporting similar outcomes in both laparoscopic and open group. A more recent trial failed to replicate those results in patients with locally advanced rectal cancer. In this article, we will look at the most recent evidence regarding the use of laparoscopy for patients with rectal cancer. We will also briefly discuss the different approaches and new minimally invasive techniques used in this field, and we will talk about the challenges facing the widespread adoption of laparoscopic surgery in the management of rectal cancer.