Small bowel volvulus and mesenteric ischemia induced by mesenteric cystic lymphangioma in an adult and literature review; a case report

INTRODUCTION AND IMPORTANCE

Mesenteric cystic lymphangioma (MCL) is a rare benign intraperitoneal mass with congenital origin, and it is extremely rare in adults. Mesentery is an unusual location for cystic lymphangioma too. Clinical presentations are nonspecific, and diagnosis is challenging. It can mimic other surgical complications like appendicitis or any acute abdomen causes, so the review of cases is necessary for the best management and surgical planning.

CASE PRESENTATION

We have presented a 22-year-old man presented with complaints of abdominal pain, nausea and vomiting. In laparotomy, a cyst was found with large size around the small intestine which caused mesenteric ischemia and changed the color of the small bowel to an ischemic view. The resected cyst was sent and confirmed by the pathology as lymphangiomatosis. MCL is a rare cause of obstruction, which was found accidentally in this case.

CLINICAL DISCUSSION

MCLs are clinically challenging lesions with unspecific broad spectrum of clinical presentation ranges. We discuss a rare finding in an adult with intestinal volvulus and mesenteric ischemia. Medical literature and reviews have been searched to find more relevant information about MCLs for the better optimal planning in surgery.

CONCLUSION

MCL is a challenging and infrequent case of surgery. Most of the time, it does not cause any complications, but it can also cause some life-threatening conditions like mesenteric ischemia or volvulus and lead to emergent surgery. Complete tumor removal is optimal for managing intra-abdominal cystic lymphangioma with the slightest chance of recurrence.

Ureterosciatic hernia with gluteal abscess: A case report

A woman in her 90's developed pain in the left buttock, along with a left buttock mass. Contrast-enhanced computed tomography revealed a mass in the left gluteus muscle, ureteral dilation, and pelvic ureteral disconnection. Retrograde urography revealed bending of the left ureter at the sciatic foramen. The patient was diagnosed with a ureterosciatic hernia and gluteal abscess and treated with ureteral stent placement and antibiotics. The patient experienced no recurrence during the follow-up period. The gluteal abscess was probably caused by urinary leakage due to ureteral obstruction, because the abscess and urine culture results were consistent.

The Potential Role of Microorganisms on Enteric Nervous System Development and Disease

The enteric nervous system (ENS), the inherent nervous system of the gastrointestinal (GI) tract is a vast nervous system that controls key GI functions, including motility. It functions at a critical interface between the gut luminal contents, including the diverse population of microorganisms deemed the microbiota, as well as the autonomic and central nervous systems. Critical development of this axis of interaction, a key determinant of human health and disease, appears to occur most significantly during early life and childhood, from the pre-natal through to the post-natal period. These factors that enable the ENS to function as a master regulator also make it vulnerable to damage and, in turn, a number of GI motility disorders. Increasing attention is now being paid to the potential of disruption of the microbiota and pathogenic microorganisms in the potential aetiopathogeneis of GI motility disorders in children. This article explores the evidence regarding the relationship between the development and integrity of the ENS and the potential for such factors, notably dysbiosis and pathogenic bacteria, viruses and parasites, to impact upon them in early life.

Mesh erosion into the colon following repair of parastomal hernia: A case report

BACKGROUND

In recent years, mesh has become a standard repair method for parastomal hernia surgery due to its low recurrence rate and low postoperative pain. However, using mesh to repair parastomal hernias also carries potential dangers. One of these dangers is mesh erosion, a rare but serious complication following hernia surgery, particularly parastomal hernia surgery, and has attracted the attention of surgeons in recent years.

CASE SUMMARY

Herein, we report the case of a 67-year-old woman with mesh erosion after parastomal hernia surgery. The patient, who underwent parastomal hernia repair surgery 3 years prior, presented to the surgery clinic with a complaint of chronic abdominal pain upon resuming defecation through the anus. Three months later, a portion of the mesh was excreted from the patient’s anus and was removed by a doctor. Imaging revealed that the patient’s colon had formed a t-branch tube structure, which was formed by the mesh erosion. The surgery reconstructed the structure of the colon and eliminated potential bowel perforation.

CONCLUSION

Surgeons should consider mesh erosion since it has an insidious development and is difficult to diagnose at the early stage.

Obstructed Descending Colon Mass Presented With Bochdalek Hernia: A Case Report

The adult Bochdalek hernia is one of the right-sided diaphragmatic hernias that less than 30 cases reported until now. Here, we report a 64-year-old female patient who presented with dyspnea, abdominal pain, and nausea. Primary imaging showed a right-sided diaphragmatic hernia that contained the liver and right colon. At first, the patient underwent a right posterior thoracotomy, and the diaphragmatic defect was repaired. After 2 days, abdominal peritonitis happened then a midline laparotomy was performed. Finally, it was clear that the main problem was the obstructed and perforated descending colon mass that was presented with Bockdalek hernia. Unfortunately, the patient passed away 2 days after the operation. It should be considered that an increase in intra-abdominal pressure like the presence of obstructed colon mass can cause this rare hernia and It is important to determine the reason for the presentation of the symptomatic Bochdalek hernia in adult patients.

Evolution of degradation mechanism and fixation strength of biodegradable Zn-Cu wire as sternum closure suture: An in vitro study

This work reports the first in vitro study on the in-situ biodegradation behaviour and the evolution of fixation strength of Zn-Cu alloy wires in a simulated sternum closure environment. Zn-Cu wires were used to reapproximate the partial bisected sternum models, and their fixation effect was compared with traditional surgical grade 316 L stainless steel (SS) wires in terms of fixation rigidity, critical load, first/ultimate failure characteristics. The metal sutures were then immersed in Hank's balanced salt solution for 12 weeks immersion period, and their corrosion behaviours assessed. Zn-Cu wires showed similar fixation rigidity at 70.89 ± 6.97 N/mm as SS, but the critical load, first failure and ultimate failure characteristics were inferior to SS. The key challenges that limited the fixation effect of the Zn-Cu wires were poor mechanical strength, short elastic region, and strain softening behaviours, which resulted in poor load-bearing capabilities and reduced the knot security of the sutures. The in-situ biodegradation of the Zn-Cu suture was accompanied by the early onset of localised corrosion within the twisted knot and the section located next to the incision line. Crevice corrosion and strain-induced corrosion were the dominant mechanisms in the observed localised corrosion. The localised corrosion on the Zn-Cu sutures did not lead to a significant shift in fixation rigidity, critical load and the first failure characteristics. The findings suggest that the Zn-based biodegradable metallic wires could be a promising sternum closure suture material once the limitations in mechanical characteristics are addressed.

Intra-Abdominal Abscess of Unusual Origin

This article describes the case of a woman who unknowingly swallowed several fishbones, one of which perforated the intestinal wall and subsequently formed an intra-abdominal abscess due to the foreign body reaction.

[Robot-assisted extraperitoneal ventral hernia repair-Experience from the first 61 consecutive operations with eTEP and eTAR techniques]

BACKGROUND

As in many other fields of surgery, robotically assisted surgical procedures have been established in the treatment of ventral hernias in recent years. The use of the robot can combine the demands of a minimally invasive approach and retromuscular mesh placement. In addition to a transabdominal approach, these procedures can also be performed using an extraperitoneal approach.

OBJECTIVES

The purpose of this study is to demonstrate that robotic total extraperitoneal management of abdominal wall hernias is safe and efficient.

MATERIALS AND METHODS

A retrospective analysis of all robotically operated patients on ventral hernia using extraperitoneal eTEP technique from September 2019 to May 2022 was performed.

RESULTS

A total of 61 ventral hernias were operated on using the robotic eTEP technique during the study period. In 14 patients retro-rectal dissection was extended laterally by an extraperitoneal transversus abdominis release (eTAR) because of the hernia size or a lateral hernia localization. In all cases, an uncoated synthetic mesh was placed in the retromuscular position with complete closure of the hernia defects. The median hernia defect area was 30 cm² (4-308 cm²). The median mesh size was 540 cm² (300-1350 cm²). The median mesh defect ratio (MDR) was 17.78 (3.06-145). One intraoperative and three postoperative complications were encountered. Neither conversion nor reoperation were required.

CONCLUSION

The robotic extraperitoneal eTEP technique enables the required retromuscular mesh placement in a minimally invasive approach. With the possibility of a combination with a transversus abdominis release, even complex findings can be treated using this technique.

An appraisal of technical variant grafts compared to whole liver grafts in pediatric liver transplant recipients: Multicenter analysis from the SPLIT registry

BACKGROUND

Shortages of liver allografts for children awaiting transplantation have led to high LT waitlist mortality. Prior studies have shown that usage of TVG can reduce waiting time and waitlist mortality, but their use is not universal. We sought to compare patient and graft survival between WLG and TVG and to identify potential associated risk factors in a contemporary pediatric LT cohort.

METHODS

We performed a retrospective analysis of patient survival, graft survival, and biliary and vascular complications for LT recipients <18 years old entered into the Society of Pediatric Liver Transplantation prospective multicenter database.

RESULTS

Of 1839 LT recipients, 1029 received a WLG and 810 received a TVG from either a LD or a DD. There was no difference in patient survival or graft survival by graft type. Three-year patient survival and graft survival were 96%, 93%, and 96%, and 95%, 89%, and 92% for TVG-LD, TVG-DD, and WLG, respectively. Biliary complications were more frequent in TVG. Hepatic artery thrombosis was more frequent in WLG. Multivariate analysis revealed primary diagnosis was the only significant predictor of patient survival. Predictors for graft survival included time-dependent development of biliary and vascular complications.

CONCLUSIONS

There were no significant differences in patient and graft survival based on graft types in this North American multi-center pediatric cohort. Widespread routine use of TVG should be strongly encouraged to decrease mortality on the waitlist for pediatric LT candidates.

Incarcerated left-sided Amyand's hernia and synchronous ipsilateral femoral hernia: first case report

BACKGROUND

The finding of a vermiform appendix within the peritoneal sac of an inguinal hernia is called Amyand's hernia. The reported incidence of Amyand's hernia and femoral hernia is 1% and 3.8%, respectively. To our knowledge, no cases have been reported in the literature that associate these two entities. We present the first case of incarcerated left-sided Amyand's hernia and synchronous ipsilateral femoral hernia found during emergency surgery.

CASE PRESENTATION

A 72-year-old woman was admitted to the Emergency Department for a complicated left inguinal hernia. An inguinotomy was performed that detected a large direct hernial sac and a synchronous femoral hernia. The opening of the inguinal hernia showed the presence of the cecum and the appendix, both without signs of inflammation. The femoral space was evaluated transinguinally, identifying the larger omentum that had slipped into the femoral canal. The primary closure of the posterior wall defect was performed with the McVay technique due to its large size, and then the hernioplasty was completed with a polypropylene mesh. No postoperative complications were reported.

CONCLUSIONS

In the context of an incarcerated Amyand's hernia, the decision to perform an appendectomy in addition to hernia repair with or without mesh will depend on intraoperative findings.

The impact of portal vein reconstruction on portal vein complications after pediatric living-donor liver transplantation with left lobe graft

BACKGROUND

This study aimed to determine whether the different methods of portal vein reconstruction have an impact on the occurrence of portal vein complications after pediatric living-donor liver transplantation with left lobe graft.

METHODS

A total of 567 recipients were eligible for enrollment in this study and were divided into the following 2 groups according to the type of portal vein reconstruction: group 1 underwent anastomosis of the left and right bifurcations of the recipient portal vein to the donor portal vein (type 1), whereas group 2 underwent anastomosis of the bevel formed by the main trunk and right branch of the recipient portal vein to the donor portal vein (type 2). Postoperative portal vein complications and recipient and graft survival rates were compared between the 2 groups before and after propensity score matching.

RESULTS

Portal vein complications occurred in 53 (9.3%) patients, including 46 recipients with portal vein stenosis and 7 with portal vein thrombosis. After propensity score matching, the incidence of portal vein stenosis in group 2 was lower than that in group 1 (P = .035). The first diagnosis time of portal vein stenosis in group 2 was later than that in group 1 (P = .033), and the incidence of early portal vein stenosis was lower than that in group 1 (P = .009). There were no statistically significant differences in the incidence of portal vein thrombosis and recipient and graft survival rates between the 2 groups.

CONCLUSIONS

Type 2 portal vein reconstruction appears to be a viable technique in pediatric living-donor liver transplantation with left lobe graft that can effectively reduce the incidence of portal vein stenosis.

[A new paradigm for the treatment of sternomediastinitis]

OBJECTIVE

To analyze the results of simultaneous surgical treatment of sternomediastinitis compared to stage-by-stage approach.

MATERIAL AND METHODS

The study included 27 patients between October 2022 and March 2023. All patients underwent heart surgery through median sternotomy. There were 11 (40.7%) women and 16 (59.3%) men. Mean age of patients was 68.4±9.8 years. All patients were divided into 2 groups: 12 patients underwent partial necrectomy and vacuum wound therapy (or long-term dressings) before surgery (group 1), 15 patients underwent surgery without prior conservative treatment (group 2).

RESULTS

The most common causative agent of infection was staphylococcus (48.1%). In all patients, we found histological signs of osteomyelitis. Preoperative clinical status was similar in both groups. There were differences in the following indicators: C-reactive protein upon admission - 74.9±18.6 versus 94.8±23.8 mg/l, procalcitonin - 0.13 [0.02; 1.43] versus 0.21 [0.02; 0.94] ng/ml. Postoperative outcomes were similar in both groups. Mortality was 8.3% (n=1) and 13.3% (n=2), respectively.

CONCLUSION

Simultaneous combined surgical treatment (sequestrectomy + muscle flap grafting) demonstrates optimal results in the treatment of sternomediastinitis.

A single-patient-use ECG system for cardiothoracic surgery admissions in the UK: A cost-consequence analysis

Background

Deep sternal wound infections (DSWI) are severe complications in up to 1.36% of coronary artery bypass grafting (CABG) procedures in the United Kingdom. Each event adds between £4,000 and £11,000 in healthcare costs, owing primarily to prolonged hospitalisations. ECG devices have been shown to convey infection throughout perioperative CABG. On the other hand, single-patient ECG devices (spECG) can effectively reduce the incidence of surgical site infections (SSI), including DSWI, but no assessment of spECG impact in NHS cardiac units has been conducted.

Methods

To estimate the impact of spECG on NHS cardiac units, we conducted a cost-consequence analysis modeling the CABG care pathway in the United Kingdom using Simul8 software for a probabilistic, individual-patient simulation. The simulation time was 1 year, with each patient followed from admission through 30 days post-discharge. The base case simulation mirrors the cardiac unit of Bart Health NHS Trust, London. A total of 2,183 patients are generated with demographic and clinical attributes from probabilistic distributions informed by hospital-specific inputs from NHS Digital Data. The Brompton Harefield Infection Score (BHIS) is allocated to gauge the risk of SSI. Results are averaged across 50 independent and randomly seeded iterations.

Results

Simulation results indicate a base-case savings of £388 per patient, determined by the incidence of infections rather than the number of CABG procedures. In the base-case simulation, the mean cost of care with rECG was £13,096, whereas the mean cost with spECG was £12,708, resulting in a cost saving of £388 (2021 GBP). The simulation yielded an overall 8.6% SSI incidence rECG, whereas the incidence of SSIs with spECG was 6.9%. The model was most sensitive to changes in general ward and ICU costs, and infection incidence was a stronger predictor of potential per-patient savings than annual CABG volume.

Conclusion

Single-patient ECG is a sustainable and effective alternative to reusable ECG cables and lead wires in terms of patient safety and resource allocation.

Amyand's Hernia: A Radiological Solution of a Surgical Dilemma

Amyand's hernia is a rare condition whereby the appendix lies within the sac of an inguinal hernia; rarer still, the appendix can become inflamed (acute appendicitis) and is frequently misdiagnosed as a strangulated inguinal hernia. We report a case of Amyand's hernia complicated with acute appendicitis. In this case an accurate preoperative diagnosis was provided by a preoperative Computerised Tomography (CT) scan, permitting planning of treatment by a laparoscopic approach.

Laparoscopic management of obturator hernia in the setting of intestinal obstruction: A report of two cases and review of literature

Owing to its rarity and non-specific clinical features, a diagnosis of obturator hernia is often delayed until the patient presents with intestinal obstruction. Often the diagnosis is made on a Computed Tomography (CT) scan or during exploratory laparotomy. While a laparoscopic approach is well described in an elective scenario, open surgery through a midline laparotomy has been the preferred approach for obturator hernia with intestinal obstruction. However, a few cases of obstructed obturator hernia have been reported that have been managed laparoscopically. We present our experience of two elderly patients who presented with intestinal obstruction. A CT scan helped clinch the diagnosis of obturator hernia as the cause and both were managed laparoscopically.

Traumatic abdominal intercostal hernia: A rare experience

Traumatic abdominal intercostal hernias (AIHs) are an extremely rare surgical encounter, with amorphous literature. A case report of recurrent AIHs, evident only at surgery, and its management is presented. The inadequacy of experience and data translates to frequent missed diagnosis and suboptimal surgical management with high recurrence rates.

Management of severe symptomatic abdominal lymphatic malformation complicated by abscess formation, protein-losing gastroenteropathy, and bleeding

Background

The optimal strategy for the management of patients with severe symptomatic abdominal lymphatic malformation (ALM) complicated by abscess formation, protein-losing gastroenteropathy, and bleeding has not yet been established. The present study aimed to determine an appropriate management for patients with severe symptomatic ALM, particularly for those with abdominal complications.

Materials and methods

Eight infants and young adults who underwent emergency surgery for ALM in our department, between the years 1997 and 2020, were selected for the study. We also evaluated and compared the operative procedures, operative timing, and postoperative surgical outcomes.

Results

Emergency resection was performed in all patients with bleeding. Some patients presented with ALMs that invaded the adjacent organs. Resections that included the involved organs were necessary to achieve full resolution in three patients. After evaluating the diagnostic modalities for symptomatic ALM, we also performed elective surgery for patients without bleeding.

Conclusions

Clinicians should be aware of severe symptomatic ALM with or without bleeding, as well as its associated complications, in order to select the best surgical management plan.

Complications of rabbit anti-thymocyte globulin induction immunosuppression in HIV-infected kidney transplant recipients

Background

Kidney transplantation in HIV-infected individuals with end-stage kidney disease is associated with improved survival compared to dialysis. Rabbit anti-thymocyte globulin (rATG) induction in HIV-infected kidney transplant recipients has been associated with a lower risk of acute rejection, but data on the rates of de novo malignancy and BK viremia in these patients is lacking.

Methods

We performed a single-center retrospective cohort study of adult HIV-infected individuals who underwent kidney transplantation with rATG induction between January 2006 and December 2016. The primary outcome was the development of de novo malignancy. Secondary outcomes included the development of BK viremia, infections requiring hospitalization, HIV progression, biopsy-proven acute rejection, and patient and allograft survival.

Results

Twenty-seven HIV-infected individuals with end-stage kidney disease received deceased (n=23) or living (n=4) donor kidney transplants. The cumulative rate of malignancy at five years was 29%, of whom 29% died because of advanced malignancy. BK viremia was detected in six participants (22%), of whom one had biopsy-proven BK virus-associated nephropathy and all of whom cleared the BK viremia. Five-year acute rejection rates, patient survival and death-censored allograft survival were 17%, 85% and 80% respectively.

Conclusion

rATG induction in HIV-infected kidney transplant recipients was associated with a low risk of acute rejection, but a potentially higher risk of de novo malignancies and BK viremia in this cohort. Screening strategies to closely monitor for BK virus infection and malignancy post-transplantation may improve outcomes in HIV-infected kidney transplant recipients receiving rATG induction.

Amyand's hernia combined with contralateral recurrent inguinal hernia: A case report

INTRODUCTION

Amyand's hernia (AH)-where the appendix becomes incarcerated within the inguinal hernia (IH) sac-is rare, particularly if detected and operated concurrent with a contralateral recurrent IH.

PRESENTATION OF CASE

A 65-year-old man presented with symptomatic bilateral IH; the left IH was recurrent. Abdominopelvic computed tomography (CT) revealed a right IH with appendiceal herniation and left recurrent IH with omental fat. Using the prolene hernia system (PHS) mesh, the left recurrent IH underwent operation, followed by the right AH. The patient was in a good state with no recurrence 16 months postsurgery.

DISCUSSION

If AH is accidentally encountered during surgery, the procedure should differ depending on the inflammatory state of the appendix. Simultaneously operating AH and contralateral recurrent IH is complicated; it is necessary to preoperatively decide which side to operate on first and whether to use an anterior or laparoscopic posterior surgical approach. If the planned operation is unattainable, alternative surgery should be considered. Fortunately, herein CT was performed prior to surgery, and the surgical plan was properly established.

CONCLUSION

Prior to simultaneous AH and contralateral recurrent IH surgery, the surgical plan should be established. If the planned surgical technique for recurrent hernia repair is not feasible, an alternative should be performed. In AH repair, different surgical methods are required depending on the presence and severity of inflammation of the appendix.

Spontaneous posterior rectus sheath hernia: A case report and literature review

INTRODUCTION

Hernias of the posterior rectus sheath are very rare abdominal wall hernias with only around 15 reported cases to date.

CLINICAL PRESENTATION

This case report examines a 27-year-old female who is presented with epigastric abdominal pain and vomiting. An Abdomen CT scan was done and showed signs of SBO and herniation of the small bowel at the posterior rectus sheath. The patient underwent exploratory laparotomy that showed right-sided posterior rectus sheath obstructed hernia, which was repaired with primary closure. Postoperatively, the patient was doing well and was discharged on postoperative day 3 in good general condition.

CONCLUSION

The patient had no complaints during her follow-up at one month. Due to its rarity and potential complications, it is also important to report this case to enhance the evidence base for posterior rectus sheath hernia and to familiarise this uncommon condition to radiologists, clinicians, and surgeons.

Case Report: Endoscopic manifestations and clinical features of small intestinal lymphangioma-A report of two cases

Objective

The aims of this study were to analyze the clinical characteristics, auxiliary examinations, and treatment measures of small intestinal lymphangioma and to improve the clinical diagnostic ability of clinicians.

Methods

This paper reports two cases of small intestinal lymphangioma in the Department of Gastroenterology, the First Affiliated Hospital of Soochow University, and makes a comprehensive analysis.

Results

A 31-year-old woman went to the hospital with complaints of dizziness, fatigue, and anemia. A 52-year-old woman complained of upper abdominal pain and went to the hospital with abdominal pain awaiting investigation. Both patients were subjected to three major routine examinations, tumor complete set, CT, capsule endoscopy, and deep enteroscopy, and both of them underwent complete resection of the affected intestinal segment. Pathology showed that both patients had small intestinal lymphangioma.

Conclusions

The clinical manifestations of small intestinal lymphangioma lack specificity. Capsule endoscopy and deep enteroscopy are helpful for clinical diagnosis, and pathological examination is still the gold standard. Surgical treatment can achieve better results.

Risk factors for recurrence in blunt traumatic abdominal wall hernias: A secondary analysis of a Western Trauma association multicenter study

BACKGROUND

Few studies have investigated risk factors for recurrence of blunt traumatic abdominal wall hernias (TAWH).

METHODS

Twenty trauma centers identified repaired TAWH from January 2012 to December 2018. Logistic regression was used to investigate risk factors for recurrence.

RESULTS

TAWH were repaired in 175 patients with 21 (12.0%) known recurrences. No difference was found in location, defect size, or median time to repair between the recurrence and non-recurrence groups. Mesh use was not protective of recurrence. Female sex, injury severity score (ISS), emergency laparotomy (EL), and bowel resection were associated with hernia recurrence. Bowel resection remained significant in a multivariable model.

CONCLUSION

Female sex, ISS, EL, and bowel resection were identified as risk factors for hernia recurrence. Mesh use and time to repair were not associated with recurrence. Surgeons should be mindful of these risk factors but could attempt acute repair in the setting of appropriate physiologic parameters.

Long-term outcomes of pediatric liver transplantation using organ donation after circulatory death: Comparison between full and reduced grafts

BACKGROUND

The shortage of donors' livers for pediatric recipients inspired the search for alternatives including donation after cardiac death (DCD).

METHODS

Retrospective review of pediatric liver transplant (PLT) using DCD grafts. Patients were divided into either FLG or RLG recipients. Pre-transplant recipient parameters, donor parameters, operative parameters, post-transplant recipient parameters, and outcomes were compared.

RESULTS

Overall, 14 PLTs from DCD donors between 2005 and 2018 were identified; 9 FLG and 5 RLG. All donors were Maastricht category III. Cold ischemia time was significantly longer in RLG (8.2 h vs. 6.2 h; p = .038). Recipients of FLG were significantly older (180 months vs. 7 months; p = .012) and waited significantly longer (168 days vs. 22 days; p = .012). Recipients of RLG tended to be sicker in the immediate pre-transplant period and this was reflected by the need for respiratory or renal support. There was no significant difference between groups regarding long-term complications. Three patients in each group survived more than 5 year post-transplant. One child was re-transplanted in the RLG due to portal vein thrombosis but failed to survive after re-transplant. One child from FLG also died from a non-graft-related cause.

CONCLUSIONS

Selected DCD grafts are an untapped source to widen the donor pool, especially for sick recipients. In absence of agreed criteria, graft and recipient selection for DCD grafts should be undertaken with caution.

Treatments and outcomes of intra-operative portal vein thrombosis in living-donor liver transplantation due to biliary atresia

BACKGROUND

Pediatric living-donor liver transplantation (LDLT) has become one of the most effective therapies for pediatric end-stage liver diseases. We aim to investigate the risk factors for intra-operative portal vein thrombosis (PVT) and the short- and long-term outcomes in children post LDLT.

METHODS

This was a retrospective analysis from 584 cases of biliary atresia (BA) patients who had undergone LDLT from January 2014 to December 2019 at our hospital. Patients were divided into PVT and non-PVT groups according to the occurrence of PVT during LDLT.

RESULTS

The median age of recipients at transplantation was 7.22 (quartiles, 6.03, 9.50) months, the incidence of intra-operative PVT was 5.31% (31/584). The independent risk factors for intra-operative PVT were the diameter of the recipient's PV not greater than 4 mm and a higher ratio of graft-to-recipient PV diameter. The cumulative survival rates of grafts and recipients were 93.5% and 93.5% in the PVT group, and 94.9% and 95.3% in the non-PVT group, respectively, without significant difference. The recovery of graft function was similar in recipients with or without interposed graft vessel (IGV). However, the incidence of PV stenosis was higher in recipients with IGV after LDLT.

CONCLUSION

Intra-operative PVT is a common complication in pediatric LDLT, but an excellent prognosis can be achieved by appropriate and individualized surgical treatment. We noted that intra-operative PVT did not affect the survival rates of grafts and recipients, but there was a higher incidence of PV complications after LDLT.

LEVEL OF EVIDENCE

Ⅲ.

Trifoliate mesenteric lymphatic malformation

Mesenteric lymphatic malformations are rare lesions and its diagnosis can cause dilemma in spite of imaging studies. A laparotomy revealed this diagnosis in a five-year-old child who presented with abdominal pain.

Accidental duodenal foreign body of toothbrush removed laparoscopically: a case report

Background

Foreign body ingestion is a common case in daily medical care, and it usually passes through the entire gastrointestinal tract naturally and is excreted in the feces. However, long and sharp foreign bodies may be difficult to pass naturally due to their shape. Here, we present a rare case of a duodenal foreign body, a toothbrush, that required laparoscopic surgical removal after a failed endoscopic attempt.

Case presentation

A 51-year-old male with intellectual disability presented to our hospital due to fever. Initially, he was diagnosed with aspiration pneumonia by chest X-ray and blood examination. However, abdominal X-ray examination suggested a foreign body, and a computed tomography scan revealed a toothbrush in the duodenum. Therefore, upper gastrointestinal endoscopy was immediately attempted to remove it, but it could not be safely removed because the handle part of the toothbrush seemed deeply embedded in the duodenal mucosa. Therefore, this case was diagnosed as duodenal incarceration of the toothbrush, and it was removed by laparoscopic surgery. The operation was performed safely, and the patient’s postoperative course was good without any complications. The extracted toothbrush was 15 cm in length.

Conclusion

We experienced a rare case of a duodenal foreign body, which was a toothbrush. The duodenal foreign body was safely removed by laparoscopic surgery for the first time.

Epidemiology and outcomes of surgical site infections among pediatric liver transplant recipients

INTRODUCTION

Surgical site infections (SSI) are a significant cause of morbidity in liver transplant recipients, and the current data in the pediatric population are limited. The goal of this study was to identify the incidence, classification, risk factors, and outcomes of SSIs among children undergoing liver transplantation (LT).

METHODS

A single-center, retrospective descriptive analysis was performed of patients age ≤18 years undergoing LT between September 2007 and April 2017. SSI identified within the first 30 days were analyzed. Primary endpoints included incidence, classification, risk factors, and outcomes associated with SSIs.

RESULTS

We included 86 patients, eight patients (9.3%) developed SSIs. Among segmental grafts (SG) recipients, 7/61 (11.4%) developed SSI. Among whole grafts recipients, 1/25 (4%) developed SSI. SSIs were associated with the presence of biliary complications (35% vs. 3%, p < .01; odds ratios 24, 95% CI: 3.41-487.37, p<.01). There were no differences in long term graft or patient survival associated with SSI. Patients who developed SSI were more likely to undergo reoperation (50% vs. 16.7%, p = .045) and had an increased total number of hospital days in the first 60 days post-transplant (30.5 vs. 12.5 days, p = .001).

CONCLUSIONS

SSIs after pediatric LT was less frequent than what has been previously reported in literature. SSIs were associated with the presence of biliary complications without an increase in mortality. SG had an increased rate of biliary complications without an association to SSIs but, considering its positive impact on organ shortage barriers, should not be a deterrent to the utilization of SGs.

Small bowel obstruction secondary to a plastic bezoar

We present a case of a small bowel obstruction secondary to a rare plastic bezoar. A man in their early 20s with autism and an intellectual disability presented with symptoms of small bowel obstruction. CT revealed very subtle signs and, despite passage of gastrografin, ongoing clinical suspicion led to operative management which confirmed the diagnoses of plastic bezoar.

Agenesis of the left hemi-diaphragm, the cause of a neglected dyspnea in a 65-year-old female; case report and literature review

Introduction and importance

In its complex way of embryonic evolvement, the diaphragmatic membrane can be involved with various disorders that may partially or entirely not develop. Agenesis of the diaphragm is the term that refers to this maldevelopment. It is the more severe form of congenital diaphragmatic hernia in which intra-abdominal viscera protrude into the thoracic cavity, causing respiratory and gastrointestinal problems. Most neonates delivered with diaphragmatic agenesis do not live more than hours to days of the severity of lung immaturity. However, less than 20 affected cases have been reported so far that survived to childhood and even their adulthood period treated surgically or conservatively. We have reported a case of neglected left hemi-diaphragmatic agenesis for more than six decades, then reviewed all adult diaphragmatic agenesis cases available in the literature for 74 years.

Case presentation

A 65-year-old female complaining of worsened dyspnea during the last four months, a chronic history of short breath since her fourth decade of life, and recent surgery with the diagnosis of a diaphragmatic hernia, underwent the thoracotomy twice in which unilateral diaphragmatic hernia was diagnosed then repaired.

Clinical discussion

For the recurrence of her symptoms, she underwent a second thoracotomy, in which the final diagnosis of left hemi-diaphragmatic agenesis was made. A dual mesh patch constructed the defect. The post-operation period was uneventful. We only found 17 cases of adult hemi or bilateral agenesis of the diaphragm reviewing the main medical literature such as Medline and Web of Science. The conservative and operative treatment managements were equal for eight patients in each of them. One of them refused therapy, and one was non-declared in the study. As in congenital diaphragmatic hernia, the most typical side was the left in 10 out of 18. The most complaints patients had followed by coughing and bowel obstruction was dyspnea and dyspepsia.

Conclusion

Near the total of the diaphragmatic agenesis cases die in the neonatal population; remained undiagnosed or during an autopsy found. However, typically rare in the adult population, respiratory and digestive disorders are the most prevalent. It is difficult initially because diagnosing is intraoperatively, and no modality is available to help the examiner physician diagnose perinatally.

Case report: A mesocolic lymphangioma in a 14-year-old child resected by laparoscopic surgery

INTRODUCTION

Cystic lymphangioma is a benign malformation tumor of the lymphatic system. Its location is variable, and mesocolic localization remains extremely rare.

CASE PRESENTATION

We report a case of right mesocolon giant cystic lymphangioma in a previously healthy 14-year-old boy who was successfully managed through a minimally invasive laparoscopic excision. The patient presented with 8 months of dull abdominal pain, sporadic, located on the peri-umbilicus, exacerbated for a month. An abdominal computed tomography (CT) revealed a large, multiseptated cystic mass on the right mesocolon. Right mesocolic excision using a laparoscope was performed on this patient. He was discharged on the fifth day without complications. Recurrence was not detected in three months of follow-up.

CONCLUSION

Cystic lymphangiomas in the mesocolon are rare benign neoplasms that pose diagnostic challenges. Complete resection is the optimal option for diagnostic confirmation and recurrence prevention. Laparoscopic surgery is feasible for children with mesocolic lymphangioma.

Congenital diaphragmatic hernia in adults: a decade of experience from a single tertiary center

INTRODUCTION

Congenital diaphragmatic hernias (CDHs) in adults remain rare, with limited data on them available. However, CDHs can cause respiratory and gastrointestinal symptoms in adults, even resulting in the strangulation of the bowel when incarcerated. Here, we aimed to analyze surgical outcomes among adult patients. The primary outcome of interest was the complication rate, reoperations and 90-day mortality after laparoscopic and open hernia repair.

METHODS

We identified all adult patients diagnosed with a Morgagni or Bochdalek hernia treated operatively between 2010 and 2019 in a single tertiary care hospital. Data on patient demographics, surgical characteristics, mortality and morbidity were collected.

RESULTS

In total, we identified 37 patients (67.6% female; average age, 57 years). Overall, 78.4% patients underwent minimally invasive operations, while 35.1% underwent emergency operations. A Clavien-Dindo grade II-V complication was experienced by 18.9% of patients. No deaths occurred within 90 days of surgery, and we detected no recurrences in short-term or long-term follow-up. A minimally invasive technique correlated with a shorter hospital stay of 3.6 days versus 6.8 days in the open surgery group (p = .007, t = 3.3, 95% confidence interval = 1.04-5.21).

CONCLUSION

Our findings indicate that the laparoscopic repair of a congenital diaphragmatic hernia is safe and effective, offering short hospital stay and a low amount of complications.

The Role of Imaging in Portal Vein Thrombosis: From the Diagnosis to the Interventional Radiological Management

PURPOSE

To illustrate diagnostic and interventional imaging for the characterization and treatment of portal vein thrombosis (PVT).

INTRODUCTION

The broad spectrum of congenital and acquired PVT manifestations is illustrated, with a focus on the pediatric population; diagnostic and interventional imaging techniques are described.

DESCRIPTION

PVT frequently presents as an incidental finding at imaging in the screening for liver diseases or for other unrelated reasons. PVT can be classified based on: extension (intrahepatic, extrahepatic, involving the spleno-mesenteric tract, etc.); degree (partial or complete); onset (acute or chronic); and with or without cavernomatous transformation. This comprehensive review relies on the experience gained from a large series of congenital and acquired PVT in a referral center for pediatric and adult liver transplantation. Diagnostic and interventional imaging techniques are described, including: color-Doppler and contrast-enhanced Ultrasound; CT and MR angiography; retrograde portography; percutaneous transhepatic, transplenic, and transmesenteric portography; transjugular intrahepatic portosystemic shunt creation. Pre- and post-operative imaging assessment of the surgical meso-rex bypass is discussed. The description is enriched with an original series of pictorial imaging findings.

CONCLUSION

PVT is a clinical condition associated with significant morbidity and mortality. Diagnostic and interventional imaging plays a crucial role in both conservative and operative management.

A systematic review and risk matrix of plastic litter impacts on aquatic wildlife: A case study of the Mekong and Ganges River Basins

Plastic litter is a pollutant of aquatic environments worldwide, with some of the world's highest litter densities occurring in freshwater ecosystems. Little information about the risk that plastic litter poses to aquatic wildlife is available across the world's most polluted waterways. To help assess the risk to aquatic species where empirical data is lacking, our review presents i) a risk assessment methodology for predicting plastic litter impacts on aquatic wildlife in data poor environments, ii) a case study demonstrating this risk assessment methodology for wildlife across two heavily polluted river basins in Asia, the Mekong and Ganges River Basins; and iii) a broad review summarising common trends in litter interactions and risk to freshwater fish, aquatic birds, cetaceans and raptors. This risk analysis unites a systematic review approach with risk matrices following International Standards Organization's risk assessment criteria, evaluating the risk of plastic entanglement and ingestion and the potential for harm to the animal. In the Mekong and Ganges River Basins, we found that the risk of litter entanglement is higher than litter ingestion. Four species were forecast to be at high risk of entanglement: Ganges River dolphin, Gharial, Mekong giant catfish and Irrawaddy dolphin. The eastern imperial eagle and greater spotted eagle were noted to be at moderate risk of entanglement. Both the Ganges River dolphin and Irrawaddy dolphin were predicted to have a moderate risk of plastic ingestion. Interestingly, cranes, waterfowl and wading birds were deemed at low or negligible risk from plastic litter. This risk matrix methodology can be applied to other waterways and taxa to assess the risk posed by plastic. It can also be readily updated as more information becomes available. This review enables decision makers to bridge a data gap by providing a tool for conservation and management before comprehensive empirical data is available.

Choleperitoneum secondary to isolated subserosal gallbladder injury due to blunt abdominal trauma – A case report

When dealing with rare traumatic injuries, surgeons might have difficulty diagnosing them and choosing the most appropriate management when no consensus exist on the best course of action. In such circumstances, drawing on the experience of colleagues can be of great value. Traumatic injuries of the gallbladder are unusual and might not be readily identifiable neither in imaging studies nor during surgery. Retrograde cholangiography plays an important role in correctly diagnosing these injuries and guiding decision-making. We report a case of a subserosal perforation due to blunt trauma to the abdomen, which was identified intraoperatively after a transcystic retrograde cholangiogram was performed and managed successfully with formal cholecystectomy.

Liver transplantation of partial grafts after ex situ splitting during hypothermic oxygenated perfusion-The HOPE-Split pilot study

Partial liver grafts from ex situ splitting are considered marginal due to prolonged static cold storage. The use of ex situ hypothermic oxygenated perfusion (HOPE) may offer a strategy to improve preservation of ex situ split grafts. In this single-center pilot study, we prospectively performed ex situ liver splitting during HOPE (HOPE-Split) for adult and pediatric partial grafts over a 1-year period (November 1, 2020 to December 1, 2021). The primary safety endpoint was based on the number of liver graft-related adverse events (LGRAEs) per recipient, including primary nonfunction, biliary complications, hepatic vascular complications, and early relaparotomies and was compared with consecutive single-center standard ex situ split transplantations (Static-Split) performed from 2018 to 2020. Secondary endpoints included preservation characteristics and early outcomes. Sixteen consecutive HOPE-Split liver transplantations (8 HOPE-Split procedures) were included and compared with 24 Static-Splits. All HOPE-Split grafts were successfully transplanted, and no graft loss nor recipient death was encountered during the median follow-up of 7.5 months (interquartile range, 5.5-12.5). Mean LGRAE per recipient was similar in both groups (0.31 ± 0.60 vs. 0.46 ± 0.83; p = 0.78) and split duration was not significantly increased for HOPE-Split (216 vs. 180 min; p = 0.45). HOPE-Split grafts underwent perfusion for a median of 125 min, which significantly shortened static cold storage (472 vs. 544 min; p = 0.001), whereas it prolonged total ex vivo preservation (595 vs. 544 min; p = 0.007) and reduced neutrophil infiltration on reperfusion biopsies (p = 0.04) compared with Static-Split. This clinical pilot study presents first feasibility and safety data for transplantation of partial liver grafts undergoing ex situ split during HOPE and suggests improved preservation compared with static ex situ splitting. These preliminary results will allow to set up large-scale trials on the use of machine perfusion in pediatric and split-liver transplantation.

Early thrombotic and hemorrhagic complications associated with a risk-adjusted postoperative anticoagulation protocol after pediatric liver transplantation

BACKGROUND

Systemic anticoagulation after pediatric liver transplantation (pLT) is believed to reduce the incidence of vascular thrombosis, but it may also cause an increase in hemorrhagic complications.

PROCEDURE

A 5-year retrospective review of pLT done at our institution was performed (2014-2018). The occurrence of early hemorrhagic and thrombotic complications was compared when using low-dose or high-dose anticoagulation after transplant (p < .05 considered significant).

RESULTS

Sixty-nine patients received 73 transplants during the study period. Median age at transplant was 2.3 years (40 days to 18.5 years). Low-dose anticoagulation was utilized in 71% cases. Additionally, six patients were converted from low-dose to high-dose anticoagulation because of a thrombotic event or concerns for suboptimal vascular inflow. Postoperative anticoagulation was discontinued in 18 occurrences due to bleeding (low dose 19%, high dose 47% vs. low dose to high dose 17%, p = .085). Surgical take back for bleeding occurred in 17 occasions (low dose 13.5%, high dose 53% vs. low dose to high dose 33%, p = .005). The overall incidence of hepatic artery thrombosis (HAT) and portal vein thrombosis were each 5.5%, respectively. While patient survival was not statistically different between groups, graft survival was significantly lower in the high-dose group (low dose 93%, high dose 73% vs. low dose to high dose 100%, p = .046). However, graft losses from HAT were similar between groups (low dose 2%, high dose 7% vs. low dose to high dose 0%, p = .56).

CONCLUSION

The use of a standardized risk-adjusted anticoagulation protocol after pLT is associated with a low occurrence of thrombotic and hemorrhagic complications. High-dose anticoagulation leads to more bleeding, but those risks outweigh the risks of possible graft loss.

Amyand's hernia: non incarcerated, inflamed appendix in inguinal sac case report

Inguinal hernia is described as protrusion of abdominal structures into inguinal canal, such as intestinal loop and abdominal fascia. Appendix rarely bulges into inguinal canal which is called Amyand's hernia. A 55-year-old diabetic male presented to an outpatient clinic with right inguinal bulging since 2 years ago which was non-tender, without erythema and became non reducible since 2 days ago. Also bulging worsened by physical activity. The patient went through operation and an inflamed appendix was found stuck in hernia sac. Non incarcerated inguinal hernia can be diagnosed with physical examination and there is no need of further imaging which makes it hard to diagnose the nature of protrusion. Amyand's hernia usually presents with pain due to appendicitis which mimics incarcerated hernia and makes it easier to suspect the etiology and request for further investigation. However in this case, pain was suppressed and this patient was candidate for elective inguinal herniotomy.