An incidentally diagnosed primary pancreatic body hydatid cyst: A case report and literature review

INTRODUCTION AND IMPORTANCE

Primary pancreatic hydatid cysts are exceptionally rare as they have an incidence rate ranging from 0.14 % to 2 %. Due to their extreme rarity, the patient's clinical manifestations are nonspecific. This leads to misdiagnosis and delay in treatment. Therefore, a multidisciplinary approach is necessary for the proper treatment of this pathology.

CASE PRESENTATION

Herewith, we present the rare case of a 46-year-old Middle Eastern female who sought medical attention at our surgical clinic complaining of an acute on-top-of chronic epigastric pain that radiated to the back. It was associated with a reported dark and pale discoloration of the urine and stool, respectively. The preoperative investigative radiological analysis identified a primary pancreatic body mass formation.

CLINICAL DISCUSSION

A meticulous surgical resection of the pancreatic body, tail, and the spleen was performed. Subsequent histopathological analysis of the excised specimens decisively established the diagnosis of a primary pancreatic body hydatid cyst.

CONCLUSION

Primary pancreatic hydatid cysts are profoundly rare, and their occurrence in the pancreatic body is even rarer. The profound scarcity of published literature on primary pancreatic body hydatid cysts highlights the imperative need for documentation, epidemiological studies, and the development of crucial interventional protocols. After a meticulous review of the published literature, we deduced that ours is the third documented case from our country of a primary pancreatic body hydatid cyst. Furthermore, no other cases beyond these three have been published from our country involving primary pancreatic hydatid cysts.

Differences in neonatal gastric tubes during insertion into a 3D model in relation to risk of potential perforation

OBJECTIVES

Perforation of esophagus or stomach is a potential complication during and after insertion of a gastric tube in neonates. The aim of this study was to analyze different types of gastric tubes in a three-dimensional (3D) model of neonatal esophagus and stomach regarding potential perforations.

METHODS

A 3D model of esophagus and stomach was created based on computed tomography data of a term neonate. Three types of gastric tubes were inserted into the 3D model, the localization was examined by radioscopy and the behavior, stiffness and manageability of each gastric tube was evaluated.

RESULTS

Insertion of gastric tubes with higher stiffness was easier. The rates of correct localization differed significantly between the gastric tubes with the highest rate of correct localization in the softest tube (48.5%) and the lowest rate in the tube with the highest stiffness (21.2%). Additionally, the softest tube showed the lowest rate of localization of its tip at the stomach wall.

CONCLUSIONS

The study illustrates differences between various types of gastric tubes regarding stiffness, behavior and resiliency. Softer gastric tubes may be beneficial. These differences may be relevant in neonatal care of very immature and very sick infants.

Clinical value of endoscopic ultrasound sound speed in differential diagnosis of pancreatic solid lesion and prognosis of pancreatic cancer

BACKGROUND

Differential diagnosis of pancreatic solid lesion (PSL) and prognosis of pancreatic cancer (PC) is a clinical challenge. We aimed to explore the differential diagnostic value of sound speed (SS) obtained from endoscopic ultrasonography (EUS) in PSL and the prognostic value of SS in PC.

METHODS

Patients with PSL in The Third Xiangya Hospital of Central South University from March 2019 to October 2019 were prospectively enrolled, who obtained SS from PSL. Patients were divided into the PC group and the pancreatic benign lesion (PBL) group. SS1 is the SS of lesions and SS2 is the SS of normal tissues adjacent to lesions. Ratio1 is equal to SS1 divided by SS2 of PSL (ratio1 = SS1/SS2).

RESULTS

Eighty patients were enrolled (24 PBL patients, 56 PC patients). SS1 and ratio1 in PC group were higher compared with PBL group (SS1:1568.00 vs. 1550.00, Z = -2.066, p = 0.039; ratio1: 1.0110 vs. 1.0051, Z = -3.391, p = 0.001). The SS1 in PC (Z = -6.503, p < 0.001) was higher compared to SS2. In the nonsurgical group of PC, low ratio1 predicted high overall survival (OS) (7.000 months vs. 4.000 months; p = 0.039). In the surgical group of PC, low SS1 was associated with low median OS (4.000 months vs. 12.000 months; p = 0.033).

CONCLUSIONS

SS plays a vital role in distinguishing between PBL and PC. Higher SS1 and ratio1 obtained by EUS are more related to PC than PBL. In PC patients, high SS1 may predict pancreatic lesions. In the nonsurgical group of PC, low ratio1 may predict high OS. However, in the surgical group of PC, low SS1 may predict low OS.

A comprehensive review of anal cancer-with a special focus on anal cytology

The diagnosis of anal cancer is relatively uncommon, but its incidence has been steadily increasing in high-risk populations. In the 2001 Bethesda System for Reporting Cervical Cytology, anal cytology was introduced as a component. Since then, it has been recognized as a potential tool for screening anal cancer, often in conjunction with high-resolution anoscopy. There are notable similarities between anal cancer and cervical cancer, including the causative role of human papillomavirus. However, there are also significant differences, particularly in terms of disease prevalence. Anal cytology may be used as a primary screening test, and in the event of abnormalities, patients are subsequently directed for high-resolution anoscopy. However, the best approach for anal cancer screening is yet to be determined and uniformly implemented. This comprehensive review article provides an in-depth analysis of the epidemiology and incidence of anal precursor and malignant lesions. It explores the various methods of sample procurement, preparation, interpretation (including sensitivity and specificity), and reporting terminology in anal cytology. The article also addresses the significance of concurrent high-risk human papillomavirus screening in anal cytology and its role in screening programs. Furthermore, it discusses the follow-up, prevention, and subsequent management strategies for anal cancers. By synthesizing current knowledge in these areas, this review aims to provide a comprehensive understanding of anal cytology and its implications in the early detection, prevention, and management of anal neoplasia and cancer.

Perirectal Mucinous Adenocarcinoma After Subtotal-Colectomy for Crohn's Disease: A Case Report

Colorectal carcinoma (CRC) represents the third most common cancer and the second highest cause of cancer-related death in the United States. CRC is particularly prevalent in patients with underlying inflammatory bowel disease. Adenocarcinoma represents more than 90% of new CRC diagnoses. The mucinous subtype of colorectal adenocarcinoma is found in approximately 10-20% of all colorectal cancer patients and is most frequently located in the proximal colon. We report a case of mucinous adenocarcinoma arising from the rectal stump of a patient who had previously undergone subtotal-colectomy with end ileostomy for Crohn's disease. She initially presented with gradually worsening chronic abdominal pain and gelatinous rectal discharge. She was found to have a complex cystic lesion communicating with her Hartman's pouch. She ultimately underwent a completion proctectomy, radical hysterectomy, and bilateral salpingo-oophorectomy in conjunction with gynecology oncology. To the best of our knowledge, this case represents the first description of a perirectal mucinous adenocarcinoma arising in a patient after subtotal-colectomy for Crohn's disease.

The future of artificial intelligence in clinical nutrition

PURPOSE OF REVIEW

Artificial intelligence has reached the clinical nutrition field. To perform personalized medicine, numerous tools can be used. In this review, we describe how the physician can utilize the growing healthcare databases to develop deep learning and machine learning algorithms, thus helping to improve screening, assessment, prediction of clinical events and outcomes related to clinical nutrition.

RECENT FINDINGS

Artificial intelligence can be applied to all the fields of clinical nutrition. Improving screening tools, identifying malnourished cancer patients or obesity using large databases has been achieved. In intensive care, machine learning has been able to predict enteral feeding intolerance, diarrhea, or refeeding hypophosphatemia. The outcome of patients with cancer can also be improved. Microbiota and metabolomics profiles are better integrated with the clinical condition using machine learning. However, ethical considerations and limitations of the use of artificial intelligence should be considered.

SUMMARY

Artificial intelligence is here to support the decision-making process of health professionals. Knowing not only its limitations but also its power will allow precision medicine in clinical nutrition as well as in the rest of the medical practice.

Association of prognostic nutritional index with mortalities in American adult cancer survivors: A cohort study based on NHANES, 1999-2018

The prognostic nutritional index (PNI) has been associated with disease progression and overall survival among cancer patients. Nonetheless, the association between PNI and mortality risk in adult cancer patients within the United States remains unexplored. This study aims to elucidate the connection between PNI and prognostic outcomes in American adult cancer patients. This cohort study derived data from the National Health and Nutrition Examination database, involving 4366 American adults diagnosed with cancer between 1999 and 2018. The nutritional status was assessed using the PNI, with higher PNI scores indicating a more favorable nutritional status. The study employed Kaplan-Meier curves and Cox proportional hazard regression to investigate the impact of PNI on various outcomes, including all-cause mortality (ACM), cardiovascular mortality (CAM), and malignancy tumor mortality (MTM) among adult cancer patients. Furthermore, restricted cubic spline models were used to examine the potential nonlinear relationship between the variables by creating hazard ratio (HR) curves at four specific points. The median follow-up duration was 84 months, during which 1530 (35.04%) cases of ACM occurred, including 331 (13.67%) CAM and 449 (10.45%) MTM. COX regression analysis revealed a significant inverse association between PNI and patient prognosis, with HRs of 0.95 (95% CI: 0.93-0.96, p < .001) for ACM, 0.93 (95% CI: 0.90-0.96, p < .001) for CAM, and 0.94 (95% CI: 0.91-0.97, p < .001) for MTM. Both Kaplan-Meier analyses and restricted cubic spline curves showed significant differences in mortality rates related to PNI (p < .001, nonlinear p < .001). Our study provides compelling evidence of a clear association between PNI and reduced risk of ACM, CAM, and MTM in adult cancer patients in the United States. These findings underscore the significance of incorporating PNI as a possible prognostic indicator for individuals diagnosed with cancer.

A case of severe ureteral injury repaired by renal autotransplantation with an iliac vein patch using bovine pericardium

Introduction

Renal autotransplantation is considered a surgical procedure for extensive ureteral defects. Herein, we report a case of severe ureteral injury repaired by laparoscopic nephrectomy and renal autotransplantation with an iliac vein patch using bovine pericardium.

Case presentation

A 56-year-old woman who had previously undergone gynecological surgery complained of right-sided abdominal pain. She was then later diagnosed with a right middle ureteral injury with a 5-cm long defect. We performed retroperitoneal laparoscopic nephrectomy and renal autotransplantation. As the iliac vein was fragile, venous patching using bovine pericardium was performed. The patient's renal function was well preserved after surgery.

Conclusion

Laparoscopic nephrectomy and renal autotransplantation is an effective method for repairing severe ureteral injury with the preservation of renal function. A venous patch using bovine pericardium might be considered as a replacement for a fragile vein.

Electrohydraulic lithotripsy treatment with mother-baby endoscopic system useful for gallstone impacted in ileum

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Retrospective comparison of outcomes of patients undergoing omental patch versus falciform patch repair of perforated peptic ulcers

BACKGROUND

The omental patch repair is the gold standard for the repair of perforated peptic ulcers. This can be performed open or laparoscopically. However, in the event of non-viable or inadequate omentum available at the time of surgery the falciform ligament has been reportedly used to as an alternative. Nonetheless, evidence for its safety is scant. This study aims to determine differences in patient outcomes when comparing the two repair techniques.

METHODS

Following ethics approval, patients who underwent surgical repair of perforated peptic ulcers using omental or falciform patch repair, between 1 January 2010 and 31 December 2017, across all three Western Australian tertiary hospital services and at least 18 years of age were included. Data were collected by reviewing medical records of included patients.

RESULTS

Three hundred twenty-nine patients who underwent either open or laparoscopic repairs were included. Thirty-seven patients had falciform repairs and were mostly ASA of 2 compared to 292 patients receiving omental patch repair who were mostly ASA 3. Falciform patch repairs were more commonly used in duodenal ulcer perforations. There were no statistically significant differences in patient outcomes between the omental patch and falciform ligament groups. This included post-operative intra-abdominal sepsis, return to theatre, post-operative ICU admission, inpatient mortality, 30-day readmission and ulcer healing on follow-up gastroscopy.

CONCLUSIONS

This study demonstrates safety, efficacy and similar outcomes for patients receiving the falciform ligament patch repair compared with omental patch repair.

Post Cholecystectomy Bile Duct Injury in an Acute Setting: Categorization, Triaging, and Management Algorithm

Background Postcholecystectomy bile duct injury (BDI) is a management challenge with significant morbidity, mortality, and effects on long-term quality of life. Early referral to a specialized hepatobiliary center and appropriate early management are crucial to improving outcomes and overall quality of life. In this retrospective analysis, we examined patients who were managed at our center over the past 10 years and proposed a triage and management algorithm for BDI in acute settings. Methods Patients referred to our center with BDI from January 2011 to December 2020 were reviewed retrospectively. The primary objective of initial management is to control sepsis and minimize BDI-related morbidity and mortality. All the patients were resuscitated with intravenous fluid, antibiotics (preferably culture-based), correction of electrolyte deficiencies, and organ support if required. A triage module and management algorithm were framed based on our experience. All the patients were triaged based on the presence or absence of bile leaks. Each group was further subdivided into red, yellow, and green zones (depending on the presence of sepsis, organ failure, and associated injuries), and the results were analyzed as per the proposed algorithm. Results One hundred twenty-eight patients with acute BDI were referred to us during the study period, and 116 patients had BDI with a bile leak and 12 patients were without a bile leak. Out of bile leak patients, 106 patients (91.38%) had sepsis with or without organ failure (red and yellow zone) and required invasive intervention in the form of PCD insertion (n=99, 85.34%) and/or laparotomy, lavage, and drainage (n=7, 6.03%). Another 10 patients (8.62%) had controlled external biliary fistula (green zone), of which four were managed with antibiotics, four underwent endoscopic retrograde cholangiopancreatography stenting, and only two (1.7%) patients could undergo Roux-en-Y hepaticojejunostomy upfront due to late referral. Among patients with BDI without bile leaks, nine (75%) had cholangitis (red and yellow zones). Out of these, five required PTBD along with antibiotics and four were managed with antibiotics alone. Only three (25%) patients in this group could undergo definitive repair without any restriction on the timing of referral and were sepsis-free at presentation (green zone). A total of nine patients had a vascular injury, and four of them required digital subtraction angiography and coil embolization. There were three (2.34%) mortalities; all were in the red zone of rest and had successful initial management. In total, five patients were managed with early repair in the acute setting, and the rest underwent definitive intervention at subsequent admissions after being converted to green zone patients with initial management. Conclusion The presented categorization, triaging, and management algorithm provides optimum insight to understand the severity, simplify these complex scenarios, expedite the decision-making process, and thus enhance patient outcomes in early acute settings following BDI.

Specialized Laparoscopic Devices in the Treatment of Hydatic Hepatic Cysts: A Retrospective Analysis and Review of the Literature

Background and objective While hydatid disease is associated with a high prevalence only in certain endemic areas, it can be encountered in any geographical region. The characteristics of this parasitic disease, and its implications during development, such as the risk of seeding, and the complications caused by cyst rupture, means that its therapeutic management should adhere to strict principles and may sometimes require approaches specially tailed for this type of pathology. In this study, we aimed to provide a comparative analysis of conventional laparoscopic techniques vs. treatment with specialized instrumentation in these patients. Methods Our study involved a retrospective evaluation of a cohort comprising 41 patients diagnosed with hepatic hydatid cysts, who underwent procedures with both conventional laparoscopic techniques and specialized instrumentation tailored for this particular pathology. Furthermore, we conducted a comprehensive review of the literature examining alternative types of laparoscopic instrumentation specifically crafted for the management of hydatid cysts. This review employed an extensive search utilizing PubMed and Google Scholar databases. Results The examination of cases within our study revealed a high prevalence of hydatid disease among male patients (63.41%) and a predominance of instances originating from rural regions necessitating emergent admissions (p<0.05). Notably, in 58.54% of cases, surgical interventions employed specialized instrumentation, with a notable discrepancy in conversion rates to open surgery favoring the standard approach: 12.2% vs. 2.44% (p=0.025). Additionally, the laparoscopic approach was associated with prolonged surgical durations compared to the dedicated technique (p=0.002), besides a higher incidence of postoperative complications (12.2% vs 7.32%). Furthermore, patients undergoing laparoscopic procedures with standard instrumentation experienced lengthier hospital stays (p=0.002). Our comprehensive review of the literature identified six distinct surgical methodologies utilizing specifically tailored instrumentation for addressing hydatid cysts. Analysis of these findings underscored a preference for single localizations and selective cases. Postoperative complication rates ranged from 6.66% to 22.22%, with conversion rates to open surgery reaching up to 23.33%, and recurrence rates observed to be as high as 7.81%. Conclusions The patented approach, which uses special trocars that provide stable anchorage and allow a safe puncture-aspiration, reaspiration, and fragmentation processes, has superior characteristics compared to the laparoscopic approach with standard instrumentation. Comparative analysis with other similar procedures described in the literature has shown similar results regarding the frequency of complications, with our technique being superior in terms of approaching multiple cysts and recurrence rate. It has been successfully applied even in unselected cases.

Impact of hyperoxia on the gut during critical illnesses

Molecular oxygen is typically delivered to patients via oxygen inhalation or extracorporeal membrane oxygenation (ECMO), potentially resulting in systemic hyperoxia from liberal oxygen inhalation or localized hyperoxia in the lower body from peripheral venoarterial (VA) ECMO. Consequently, this exposes the gastrointestinal tract to excessive oxygen levels. Hyperoxia can trigger organ damage due to the overproduction of reactive oxygen species and is associated with increased mortality. The gut and gut microbiome play pivotal roles in critical illnesses and even small variations in oxygen levels can have a dramatic influence on the physiology and ecology of gut microbes. Here, we reviewed the emerging preclinical evidence which highlights how excessive inhaled oxygen can provoke diffuse villous damage, barrier dysfunction in the gut, and gut dysbiosis. The hallmark of this dysbiosis includes the expansion of oxygen-tolerant pathogens (e.g., Enterobacteriaceae) and the depletion of beneficial oxygen-intolerant microbes (e.g., Muribaculaceae). Furthermore, we discussed potential impact of oxygen on the gut in various underlying critical illnesses involving inspiratory oxygen and peripheral VA-ECMO. Currently, the available findings in this area are somewhat controversial, and a consensus has not yet to be reached. It appears that targeting near-physiological oxygenation levels may offer a means to avoid hyperoxia-induced gut injury and hypoxia-induced mesenteric ischemia. However, the optimal oxygenation target may vary depending on special clinical conditions, including acute hypoxia in adults and neonates, as well as particular patients undergoing gastrointestinal surgery or VA-ECMO support. Last, we outlined the current challenges and the need for future studies in this area. Insights into this vital ongoing research can assist clinicians in optimizing oxygenation for critically ill patients.

Microvascular reconstruction in salvaging the gastric conduit post-esophagectomy after iatrogenic right gastroepiploic vessel injury

The preservation of the right gastroepiploic vessels is essential to ensure proper perfusion of the gastric conduit following esophagectomy. The loss of these vessels can lead to conduit ischemia or necrosis, resulting in significant postoperative complications. Traditional approaches such as colonic or jejunal interposition require extensive surgery and multiple anastomoses. In this report, we present our successful experience of salvaging the gastric tube through microvascular reconstruction following iatrogenic injury to the right gastroepiploic vessels in two cases. The first case involved re-anastomosis of the right gastroepiploic vein, while the second case required reconstruction of both the artery and vein during esophagectomy in a single setting. The procedures were performed by an experienced surgical team using microvascular techniques. Both patients had uneventful postoperative courses without any anastomotic leakage or major complications. Adequate perfusion of the salvaged gastric tube was confirmed intraoperatively using indocyanine green fluorescence perfusion imaging. In conclusion, immediate microvascular reconstruction offers a viable solution by restoring perfusion of the gastric tube in cases of right gastroepiploic vessel injury during esophagectomy.

Comparison of the perioperative outcomes of using the Firefly system with indocyanine green during robotic-assisted cystectomy with urinary diversion

INTRODUCTION

Use of indocyanine green (ICG) with near-infrared fluorescence (NIRF) has been demonstrated to be an effective tool for intraoperative assessment of bowel and ureteric vascularity. This study aimed to evaluate the impact of ICG on postsurgical outcomes such as anastomotic bowel leak and uretero-enteric stricture formation during robot-assisted cystectomy (RAC) and intracorporeal urinary diversion (ICUD).

METHODS

We identified 238 patients who underwent RAC at the University of Louisville between September 2012 and August 2021. Patients were divided into two groups based on the utilization of ICG. Demographic, perioperative outcomes, and rate of anastomotic bowel leak were compared.

RESULTS

In total, 138 patients were in the ICG group and 100 patients were in the non-ICG group. More intracorporeal urinary diversions and more simple cystectomies were observed in the ICG group (p < 0.001 and p = 0.015, respectively). The ICG group patients initiated an oral diet sooner than the control group (4.9 vs. 7.1 days, p < 0.001). The mean length of stay of the ICG group was shorter than the non-ICG group (8.3 vs. 12.8 days, p < 0.001). The rate of postoperative ileus was not significantly different between cohorts. No patients in the ICG group experienced a bowel leak compared with five patients in the non-ICG group (p = 0.008).

CONCLUSIONS

In our study, the use of ICG for intraoperative assessment of bowel and ureteric vascularity was associated with earlier bowel recovery and a shorter length of stay. It was also significantly correlated with a lower rate of anastomotic bowel leak.

A multi-institutional prospective observational study to compare postoperative quality of life of patients who undergo total or proximal gastrectomy for early gastric cancer (CCOG1602)

BACKGROUND

Proximal gastrectomy (PG) has become an increasingly preferred procedure for treating early cancer in the upper third of the stomach. However, advantages of PG in postoperative quality of life (QOL) over total gastrectomy (TG) has not fully proven.

METHODS

We conducted a multi-institutional prospective observational study (CCOG1602) of patients who undergo TG or PG for cStage I gastric cancer. We used the PGSAS-37 and EORTC-QLQ-C30 to evaluate the changes in body weight and QOL over a 3-year postoperative period. The primary endpoint was the weight loss rate 3 years after surgery.

RESULTS

We enrolled 109 patients from 18 institutions and selected 65 and 19 patients for inclusion in the TG and PG groups, respectively. Mean postoperative weight loss rates were 16.0% and 11.7% for the TG and PG groups, respectively (p = 0.056, Cohen's d 0.656) during postoperative year 1% and 15.0% and 10.8% for TG and PG (p = 0.068, Cohen's d 0.543), respectively, during postoperative year 3, indicating that the PG group achieved a better trend with a moderate effect size. According to the PGSAS-37, the PG group experienced a better trend in the indigestion subscale (p < 0.001, Cohen's d -1.085) and total symptom score (p = 0.050, Cohen's d -0.59) during postoperative year 3 compared with the TG group. In contrast, the EORTC-QLQ-C30 detected no difference between the groups at any time point during 3-year postoperative period.

CONCLUSIONS

This prospective study demonstrates that PG tended to be more favorable compared with TG with respect to postoperative weight loss and QOL, particularly regarding indigestion.

Chemotherapy-induced pneumatosis intestinalis followed by hepatic portal venous gas. A case report

Pneumatosis intestinalis (PI) is a rare disease, and there are many theories about its pathogenesis. Hepatic portal venous gas (HPVG), is thought to occur secondary to intramural intestinal gas emboli migrating through the portal venous system via the mesenteric veins. PI accompanied by HPVG is usually a sign of bowel ischaemia and is associated with a high mortality rate. We report here, a patient with liver metastases from colorectal cancer who developed PI followed by HPVG after treatment with 5-Fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6). Timely attention and management of gastrointestinal symptoms following chemotherapy are essential in the treatment of this type of patient.

Unraveling the Puzzle: Health Benefits of Probiotics-A Comprehensive Review

A growing number of probiotic-containing products are on the market, and their use is increasing. Probiotics are thought to support the health of the gut microbiota, which in turn might prevent or delay the onset of gastrointestinal tract disorders. Obesity, type 2 diabetes, autism, osteoporosis, and some immunological illnesses are among the conditions that have been shown to possibly benefit from probiotics. In addition to their ability to favorably affect diseases, probiotics represent a defense system enhancing intestinal, nutritional, and oral health. Depending on the type of microbial strain utilized, probiotics can have variable beneficial properties. Although many microbial species are available, the most widely employed ones are lactic acid bacteria and bifidobacteria. The usefulness of these bacteria is dependent on both their origin and their capacity to promote health. Probiotics represent a valuable clinical tool supporting gastrointestinal health, immune system function, and metabolic balance. When used appropriately, probiotics may provide benefits such as a reduced risk of gastrointestinal disorders, enhanced immunity, and improved metabolic health. Most popular probiotics, their health advantages, and their mode of action are the topic of this narrative review article, aimed to provide the reader with a comprehensive reappraisal of this topic matter.

Long‑term survival prognosis of function‑preserving curative gastrectomy for early gastric cancer

Segmental gastrectomy, mini-distal gastrectomy and local resection of the stomach are function-preserving curative gastrectomies (FPGs), which are used to treat gastric cancer in specialized centers. These surgical options are less invasive and can alleviate postgastrectomy symptoms more than standard gastrectomy; however, their association with prognosis remains to be fully elucidated. The present study aimed to compare the survival prognosis of patients diagnosed as node-negative by sentinel node biopsy (SNB) treated via FPG with reduced lymph node dissection with that of patients who underwent guideline gastrectomy (GL). This retrospective study was conducted between April 1999 and March 2016. The inclusion criteria were a diagnosis of gastric cancer type 0, of ≤5 cm, located in L or M areas, and pT1N0. Patients who underwent distal gastrectomy and pylorus-preserving gastrectomy were included as controls in the GL group. Among the 146 and 300 patients in the FPG and GL groups, respectively, only 1 patient in the GL group experienced recurrence. The overall survival (OS) of the FPG group was 96.6% at 5 years and 92.5% at 10 years, which was significantly higher than that of the GL group (P<0.05). In addition, the cumulative incidence of non-cancer-related deaths, especially pulmonary diseases, was lower in the FPG group than that in the GL group (P<0.05). Notably, the OS and non-cancer death rate in the FPG group remained significantly better after propensity score-matching analysis. In conclusion, for early gastric cancer located in M or L areas, patients treated via FPG guided by SNB have a better prognosis and fewer deaths caused by respiratory disease than those treated via GL. The present clinical trial was registered under the following trial registration numbers: UMIN000010154 (2013/3/4), UMIN000023828 (2016/8/29), jRCTs041180006 (2018/10/9).

Management of Surgically Accessible Lymph Nodes Beyond Normal Resection Planes

This article discusses the management of isolated metastatic lymph nodes for colon and rectal cancer. There are traditionally significant differences in how certain regions of lymph nodes for colon and rectal cancer are managed in the East and West. This has led to the development of the lateral lymph node dissection for rectal cancer and extended lymphadenectomy techniques for colon cancer. This article will evaluate the literature on these techniques and what the surgical and oncological outcomes are at this time. In addition, colon and rectal cancers can occasionally have isolated distant lymph node metastases. These would traditionally be treated as systemic disease with chemotherapy. There is consideration though that these could be treated as similar to isolated liver or lung metastases which have been shown to be able to be treated surgically with good oncological results. The literature for these isolated distant lymph node metastases will be reviewed and treatment options available will be discussed.

Transjugular Intrahepatic Portosystemic Shunt for Advanced Hepatocellular Carcinoma With Main Portal Vein Tumor Thrombus-Related Symptomatic Portal Hypertension

Background and aims

The safety and efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of symptomatic portal hypertension (SPH) caused by hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) of main trunk remains unclear. The purpose of this study was to initially explore the safety and efficacy of TIPS for SPH caused by HCC with PVTT of main trunk.

Methods

This retrospective study analyzed 16 patients who underwent TIPS for SPH caused by HCC with PVTT of main trunk. The evaluated outcomes were technical success rate, SPH control rate, stent patency rate, overall survival (OS), and complications.

Results

From July 2018 to February 2023, sixteen consecutive HCC patients with PVTT of main trunk and SPH were retrospectively identified. Technical success was 93.75 %. All patients had complete or partial remission of clinical symptoms, and there were no incidents of acute variceal rebleeding and re-exacerbation of ascites during follow-up. There had no intraoperative TIPS-related complications occurred. One patient developed mild hepatic encephalopathy after TIPS placement during the follow-up period. During follow-up, 13 of 16 patients died of advanced HCC progression, the median OS was 10.0 months, and the cumulative OS of 0.5-, 1-, and 2 years were 66.67 %, 45.00 %, and 11.25 %, respectively.

Conclusions

TIPS for SPH caused by HCC with PVTT of main trunk may be safe and effective.

Maximizing mesh mileage: evaluating the long-term performance of a novel hybrid mesh for ventral hernia repair

PURPOSE

The objective of this study is to evaluate the safety and long-term outcomes of GORE Synecor™ in ventral hernia repair (VHR).

METHODS

This retrospective, single-center case review analyzed outcomes in patients who underwent VHR with Synecor from May 2016 to December 2022. Primary outcomes were hernia recurrence and mesh infection rates. Secondary outcomes were 30-day morbidity, 30-day mortality, 30-day readmission, re-operation, surgical-site infection (SSI) and occurrence (SSO) rates, and occurrences requiring intervention (SSOI).

RESULTS

278 patients were identified. Mean follow-up was 24.1 (0.2-87.1) months. Mean hernia defect size was 63.4 (± 77.2) cm2. Overall hernia recurrence and mesh infection rates were 5.0% and 1.4% respectively. No mesh infections required full explantation. We report the following overall rates: 13.3% 30-day morbidity, 4.7% 30-day readmission, 2.9% re-operation, 7.2% SSI, 6.1% SSO, and 2.9% SSOI. 30-day morbidity was significantly higher in non-clean (42.1% vs 11.2%, p < 0.01), onlay (OL) mesh (37.0% vs preperitoneal (PP) 16.4%, p = 0.05 vs retrorectus (RR) 15.0%, p < 0.05 vs intraperitoneal (IP) 5.2%, p < 0.001), and open cases (23.5% vs 3.1% laparoscopic vs 4.4% robotic, p < 0.01). SSI rates were significantly higher in non-clean (31.6% vs 5.4%, p < 0.001), OL mesh (29.6% vs RR 11.3%, p < 0.05 vs PP 5.5%, p < 0.01 vs IP 0.0%, p < 0.001), and open cases (15.2% vs 0% laparoscopic vs 0% robotic, p < 0.05).

CONCLUSION

Long-term performance of a novel hybrid mesh in VHR demonstrates a low recurrence rate and favorable safety profile in various defect sizes and mesh placement locations.

Should surgeon-performed intraoperative ultrasound be the preferred test for detecting main pancreatic duct injuries in operative trauma cases?

BACKGROUND

The diagnostic performance of multiple tests for detecting the presence of a main pancreatic duct injury remains poor. Given the central importance of main duct integrity for both subsequent treatment algorithms and patient outcomes, poor test reliability is problematic. The primary aim was to evaluate the comparative test performance of computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and intraoperative ultrasound (IOUS) for detecting main pancreatic duct injuries.

METHODS

All severely injured adult patients with pancreatic trauma (2010-2021) were evaluated. Patients who received an IOUS pancreas-focused evaluation, with Grades III, IV, and V injuries (main duct injury) were compared with those with Grade I and Grade II trauma (no main duct injury). Test performances were analyzed.

RESULTS

Of 248 pancreatic injuries, 74 underwent an IOUS. The additional mix of diagnostic studies (CT, MRCP, ERCP) was variable across grade of injury. Of these 74 IOUS cases for pancreatic injuries, 48 (64.8%) were confirmed as Grades III, IV, or V main duct injuries. The patients were predominantly young (median age = 33, IQR:21-45) blunt injured (70%) males (74%) with severe injury demographics (injury severity score = 28, (IQR:19-36); 30% hemodynamic instability; 91% synchronous intra-abdominal injuries). Thirty-five percent of patients required damage-control surgery. Patient outcomes included a median 13-day hospital length of stay and 1% mortality rate. Test performance was variable across groups (CT = 58% sensitive/77% specific; MRCP = 71% sensitive/100% specific; ERCP = 100% sensitive; IOUS = 98% sensitive/100% specific).

CONCLUSION

Intraoperative ultrasound is a highly sensitive and specific test for detecting main pancreatic duct injuries. This technology is simple to learn, readily available, and should be considered in patients who require concurrent non-damage-control abdominal operations.

LEVEL OF EVIDENCE

Diagnostic Test/Criteria; Level III.

Small-for-size syndrome in a 9.7 kg pediatric recipient with a whole liver graft

BACKGROUND

Small-for-size syndrome (SFSS) in pediatric liver transplant recipients, particularly those weighing less than 10 kg, is rare. This report describes a case of a 15-month-old whole liver transplant recipient who suffered SFSS, and systematic literature review was performed to identify outcomes of such cases and potential risk factors for SFSS.

CASE PRESENTATION

A 15-month-old toddler with a history of biliary atresia underwent a deceased donor whole liver transplant. The graft weighed 160 g, resulting in a graft-to-recipient weight ratio (GRWR) of 1.6%. The post-operative course was complicated by SFSS, characterized by massive ascites causing hemodynamic instability and compromised hepatic artery flow. Pharmacological intervention with octreotide was initiated, and the patient eventually recovered.

CONCLUSION

In small pediatric recipients, especially those weighing less than 10 kg, the native liver body weight ratio (LBWR) is significantly higher. When selecting an appropriately sized graft for these recipients, this higher ratio should be taken into consideration. The literature review suggests that a GRWR of less than 2% is associated with a higher incidence of small-for-size syndrome in small pediatric recipients weighing less than 10 kg.

A Novel Use of a Schanz Pin-Rectal Foreign Body Extraction: A Case Report

Introduction

Retained rectal foreign bodies (RFBs) can be difficult to extract, forcing the surgeon to get creative. This is the first case report utilizing orthopedic drilling and joystick manipulation techniques for foreign body extraction.

Case Report

A 63-year-old male presented to the emergency department with a pool ball in his rectum for two days. Extraction attempts under anesthesia both transanally and through a low midline laparotomy were unsuccessful due to the patient's pelvic anatomy. Orthopedic surgery was consulted to see if any manipulation or resection of the pelvis might aid in extraction. Ultimately, a Schanz pin was drilled retrogradely from the rectum into the pool ball and successfully manipulated the pool ball out of the patient.

Conclusion

Techniques such as drilling and joystick manipulation are common in orthopedic surgery but rarely used in other surgical fields. This case presented a novel use of a Schanz pin in RFB extraction. Application of orthopedic surgical technique in a colorectal surgery in this case saved the patient from more invasive interventions such as pubic symphysiotomy or ischial tuberosity resection.

Jejunal Diverticulosis Presenting With Small Bowel Obstruction: A Diagnostic Challenge

We report the case of a woman presenting with small bowel obstruction secondary to an enterolith that formed within a jejunal diverticulum. Prior to this acute presentation, the patient had experienced regular abdominal pain albeit not as severe as the current episode. The CT scan on admission required review by two consultant radiologists before the cause of the small bowel obstruction was diagnosed. Successful surgical management was performed involving a laparotomy, small bowel enterotomy, and removal of the enterolith. Although complications secondary to jejunal diverticula are documented, there is minimal literature on the complexities of making the diagnosis and the best management approach that should be adopted.

A Conservative Management of Perforated Peptic Ulcer: A Case Report

Peptic ulcer disease (PUD) is a surgical emergency that affects the mucosal lining of the stomach or proximal intestine. Complications of PUD include upper gastrointestinal hemorrhage, perforation, and obstruction. The primary management approach for perforated peptic ulcers is surgery, but conservative management can be conducted in selected cases. A 54-year-old female was referred to the surgical unit with a history of severe upper abdominal pain and repeated vomiting. No other symptoms were reported and there was no significant medical or family history except the history of non-steroidal anti-inflammatory drugs. Examination revealed that the patient had a medical condition. was vitally stable with tenderness in the upper abdomen, in particular the epigastric and right hypochondrial, but no signs of generalized peritonitis. Her white cell count was elevated at 24,000x10^3/UL, and a C-reactive protein of 45.5 mg/dL. An upright CXR revealed the classic gas under the diaphragm. Abdominal CT with oral gastrograffin identified the diagnosis of perforated duodenal ulcer without ulcer leak. The case was treated by conservative management started with resuscitation, nil per os, IV fluid, IV antibiotics, and close observation and the patient was stable with no complications and completed the nonoperative management successfully till discharge after 10 days of hospital stay. The case illustrates that although this condition is uncommon to be treated without surgical intervention, there are some factors and criteria for successful NOM. Peptic ulcer perforation is a life-threatening surgical emergency. Surgery is the standard treatment for PPU and NOM can be conducted safely and successfully in highly selected cases. the surgeon should keep a wide safety window while providing nonstandard management with readiness to operate at any time. We believe that the main factor in successful nonsurgical management of our case is being fasted for a long time before perforation.

Complete circumferential endoscopic submucosal dissection for early Barrett's neoplasia

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is carving out an increasing role in the treatment of esophageal neoplasia in the Western world. Contrary to Asia, most esophageal cancers in North America are associated with Barrett's esophagus. Patients with circumferential advanced neoplasia were previously managed by esophagectomy, but an increased experience with ESD has allowed for an endoscopic alternative. We present our experience with complete circumferential esophageal ESD at a North American referral center.

METHODS

All patients undergoing 100% circumferential esophageal ESD between October 2016 and January 2023 at a single tertiary care center in Canada were included in the cohort. Demographics, procedural data, and lesion characteristics are presented in this series.

RESULTS

Eleven patients underwent 100% circumferential esophageal ESD during this period for Barrett's neoplasia. All patients had technically successful procedures with en-bloc resection. Nine patients (82%) had R0 resections, defined as clear lateral and deep margins on histologic examination. Two patients had positive deep margins on histologic examination and proceeded to esophagectomy. Seven patients (64%) had adenocarcinoma on the final pathology, of which 6 (86%) had upstaging from their initial biopsy sampling results. The median area of resected specimen was 48 cm2 (interquartile range [IQR], 26-80), and the median procedure time was 231 minutes (IQR, 180-246). Procedural efficiency was 4.0 min/cm2 (IQR, 2.7-5). Two patients (18%) developed refractory strictures after the procedure, which were endoscopically managed to resolution.

CONCLUSIONS

Multifocal dysplastic Barrett's esophagus remains a challenging entity to treat. Circumferential ESD is a possible therapeutic option, with high procedural success and a low rate of adverse outcomes. This should be balanced against the risk of stricture development, as the optimal postprocedural prophylaxis regimen is investigated.

Negative impact of sarcopenia on survival in elderly patients with colorectal cancer receiving surgery: A propensity‑score matched analysis

Sarcopenia is a prognostic factor for patients with colorectal cancer and is commonly seen in elderly patients. The purpose of the present study was to demonstrate the impact of preoperative sarcopenia on the short- and long-term outcomes of curative surgery for treating colorectal cancer in elderly patients. Between 2016 and 2020, patients aged ≥80 years with colorectal cancer were investigated. The total muscle cross-sectional area was calculated using computed tomography imaging at the mid-3rd lumbar vertebra. Elder sarcopenia was identified using sex-specific cut-offs. Out of 106 elderly colorectal cancer patients, 27 patients were diagnosed with elder sarcopenia. Patients with elder sarcopenia had a reduced body mass index (19.7±2.5 vs. 22.5±2.9 kg/m2; P<0.01), an advanced pN stage (P<0.01) and an advanced stage (stage 3) (P=0.029). Elder sarcopenia had a negative impact on relapse-free survival (3-year, 78.4 vs. 91.1%; P=0.049) and overall survival (3-year, 73.0 vs. 93.9%; P=0.022). Propensity score-matched analysis was performed, matching 27 patients in each group to remove selection bias, which demonstrated elder sarcopenia had a negative impact on overall survival (3-year, 73.0 vs. 100%; P<0.01). Overall, elder sarcopenia was prevalent in 25% of elderly patients with colorectal cancer that received curative surgery, and it was a poor prognostic indicator in this patient population.

Relation between frailty and adverse outcomes in elderly patients with gastric cancer: a scoping review

Background

Playing an exemplary role, frailty have crucial effect on the preoperative evaluation of elderly patients. Previous studies have shown that frailty is associated with complications and mortality in patients with gastric cancer (GC). However, with the development of the concept of "patient-centered", the range of health-related outcomes is broad. The differences in relation between frailty and various adverse outcomes will be further explored.

Method

The PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature databases were searched for keywords, including frailty (such as frail) and gastric cancer (such as stomach neoplasms or stomach cancer or gastrectomy or gastric surgery). The search period is until August 2023. The included studies were observational or cohort studies with postoperative related adverse outcomes as primary or secondary outcome measures. Valid assessment tools were used. The Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess methodological quality in the included literature.

Result

Fifteen studies were included, including 4 cross-sectional studies, 8 retrospective cohort studies, and 3 prospective cohort studies. Among them, 6 studies were rated as "Good" and 9 studies were rated as "Fair," indicating that the quality of the literature was high. Then, 10 frailty assessment tools were summarized and classified into two broad categories in accordance with frailty models. Results of the included studies indicated that frailty in elderly patients with GC was associated with postoperative complications, mortality, hospital days, readmissions, quality of life, non-home discharge, and admission to the intensive care unit.

Conclusion

This scoping review concludes that high levels of preoperative frailty increase the risk of adverse outcomes in elderly patients with GC. Frailty will be widely used in the future clinical evaluation of elderly gastric cancer patients, precise risk stratification should be implemented for patients, and frailty management should be implemented well to reduce the occurrence of adverse treatment outcomes.

Metformin and risk of hematological cancers in patients with diabetes: a systematic review and meta-analysis

FUNDING

No external funding.

Telomere length and TERT polymorphisms as biomarkers in asbestos-related diseases

BACKGROUND

Asbestos exposure has been proposed as a risk factor for shorter telomere length. The aim of our study was to investigate whether telomere length in leukocytes and hTERT genetic polymorphisms may serve as potential biomarkers for the risk of developing asbestos-related diseases and as biomarkers of progression and chemotherapy response rate in malignant mesothelioma (MM).

SUBJECTS AND METHODS

We conducted two retrospective studies. In the first study, a case-control study, telomere length and hTERT polymorphisms were determined in patients with MM, subjects with pleural plaques and controls without the asbestos related disease, who were occupationally exposed to asbestos. In the second study, a longitudinal observational study, telomere length was also determined in samples from MM patients before and after chemotherapy. Telomere length was determined by monochromatic multiplex quantitative polymerase chain reaction (PCR), while competitive allele-specific PCR was used to genotype hTERT rs10069690, rs2736100 and rs2736098. Logistic regression and survival analysis were used in statistical analysis.

RESULTS

Patients with MM had shorter telomere length than subjects with pleural plaques (p < 0.001). After adjustment for age, rs2736098 CT, and rs10069690 TT and CT+TT genotypes were significantly associated with a higher risk of MM (padj = 0.023; padj = 0.026 and padj = 0.017), while rs2736100 AA and CA+AA genotypes conferred to a lower risk for MM compared to all other subjects (padj = 0.017, and padj = 0.026). Telomere length was not associated with a response to chemotherapy (p > 0.05) or time to disease progression (p > 0.05). Carriers of one or two polymorphic rs10069690 T alleles had a good response to chemotherapy (p = 0.039, and p = 0.048), these associations remained statistically significant after adjustment for age (padj = 0.019; padj = 0.017). Carriers of two polymorphic rs2736100 A alleles had a longer time to disease progression (p = 0.038).

CONCLUSIONS

Shorter telomere length and hTERT polymorphisms may serve as a biomarker for the risk of developing MM. Additionally, rs10069690 and rs2736100 polymorphisms, but not telomere length, were associated with a chemotherapy response or MM progression.

Developing sarcopenia during neoadjuvant therapy is associated with worse survival in esophageal adenocarcinoma patients

BACKGROUND

Sarcopenia in cancer patients has been associated with mixed postoperative outcomes. The aim of this study was to evaluate whether the development of sarcopenia during the neoadjuvant period is predictive of postoperative mortality in esophageal adenocarcinoma patients.

METHODS

We queried a prospective database to retrieve the sarcopenic status of patients with esophageal adenocarcinoma who underwent cross-sectional imaging of the third lumbar vertebra at diagnosis and within 2 months of undergoing an esophagogastrectomy between 2014 and 2022.

RESULTS

Of the 71 patients included in the study, 36 (50.7%) presented with sarcopenia at diagnosis. Of the 35 non-sarcopenic patients, 14 (40%) developed sarcopenia during the neo-adjuvant period. Patients who were not sarcopenic at diagnosis but developed sarcopenia preoperatively had significantly worse overall survival than patients sarcopenic at diagnosis and not sarcopenic preoperatively and patients experiencing no change in sarcopenic status (median 18 vs 47 vs 31 months; P = .02). Diagnostic and preoperative sarcopenic status alone were not significantly associated with overall survival (P = .48 and P = .56, respectively). Although 37 (52.1%) patients died, the cause of death was often not cancer-related (54.1%) and included acute respiratory failure, pneumonia, and cardiac arrest. No significant survival difference was observed when stratified by >10% weight loss (P = .9) or large loss in body mass index (P = .8).

CONCLUSION

Developing sarcopenia during the neo-adjuvant period may be associated with worse overall survival in patients requiring esophagogastrectomy.

Emergency Department Utilization for Pediatric Gastrostomy Tubes Across the United States

INTRODUCTION

Emergency Department (ED) visits for gastrostomy tube complications in children represent a substantial health-care burden, and many ED visits are potentially preventable. The number and nature of ED visits to community hospitals for pediatric gastrostomy tube complications is unknown.

METHODS

Using the 2019 Nationwide Emergency Department Sample, we performed a retrospective cross-sectional analysis of pediatric patients (<18 y) with a primary diagnosis of gastrostomy tube complication. Our primary outcome was a potentially preventable ED visit, defined as an encounter that did not result in any imaging, procedures, or an inpatient admission. Univariate and multivariable logistic regression analyses were used to determine the associations between patient factors and our primary outcome.

RESULTS

We observed 32,036 ED visits at 535 hospitals and 15,165 (47.3%) were potentially preventable. The median (interquartile range) age was 2 (1, 6) years and 17,707 (55%) were male. Compared to White patients, patients with higher odds of potentially preventable visits were Black (adjusted odds ratio (aOR) [95% confidence interval {CI}]: 1.07 [1.05-1.11], P < 0.001) and Hispanic (aOR [95% CI]: 1.05 [1.02-1.08], P = 0.004). Patients with residential zip codes in the first (aOR [95% CI]: 1.08 [1.04, 1.12], P < 0.001), second (aOR [95% CI]: 1.07 [1.03, 1.11], P < 0.001), and third (aOR [95% CI]: 1.09 [1.05, 1.13], P < 0.001) median household income quartiles had higher odds of potentially preventable visits compared to the highest.

CONCLUSIONS

In a nationally representative sample of EDs, 47.3% of visits for pediatric gastrostomy tubes were potentially preventable. Efforts to improve outpatient management are warranted to reduce health-care utilization for these patients.

A rare case of cecal foreign body leading to cecal perforation in 12-year-old child: a clinical case report and review of literature

Introduction and importance

Cecal foreign bodies are uncommon causes of acute abdomen, and their presentation can often mimic acute appendicitis (AA), making it challenging to diagnose. The authors present the case of a 12-year-old male from Ethiopia who initially presented with symptoms suggestive of AA. However, during surgery, the authors found a multiple magnetic fields result in perforation. This case highlights the importance of considering unusual etiologies.

Case presentation

A 12-year-old boy with AA associated with anorexia, nausea, and low-grade fever was referred from a private clinic. Otherwise, no history of recent respiratory infection and diarrhea, and was previously in good health. The patient did not report any history of a foreign body (FB), even to his own family, and, except for himself, no one was aware of the ingested FB. The work has been reported in line with the Surgical CAse REport (SCARE) 2023 criteria.

Discussion

In this case, the authors experienced multiple magnetic FB in the cecum, which were not observed on ultrasound (U/S). However, this case closely resembled appendicitis. U/S can aid in differentiation. However, it may not always identify the underlying etiology, specifically in a resource-limited setting.

Conclusion

Based on the patient's presentation, AA was diagnosed and emergency surgery was presumed to be inflamed. However, three magnetic FB were the underlying cause of the presentation, which created pressure on the cecal wall, and the authors successfully performed surgical management. This case reminds us of uncommon etiologies, such as magnets in patients with symptoms of appendicitis. This underscores the importance of an open-minded approach to unexpected findings during surgery.

The synergistic effect of oxaliplatin and punicalagin on colon cancer cells Caco-2 death

Objectives

The objectives of the study are to investigate the synergistic effect of oxaliplatin (oxa) and punicalagin (pun) on the death of colon cancer cells (Caco-2) by apoptosis and autophagy.

Methods

The effects of the combined treatments (5 μM oxa + 50 μM pun, 5 μM oxa + 75 μM pun, 20 μM oxa + 50 μM pun, and 5 μM oxa + 75 μM pun) were compared with untreated Caco2 cells (control) or cells treated with oxa alone. Apoptosis was detected using an Annex in V FITC flow cytometry assay and poly (ADP-ribose) polymerase cleavage by western blotting. Light chain 3 was detected by western blotting as an autophagy marker.

Results

The combined treatments significantly increased the number of apoptotic cells in comparison to untreated cells or cells treated with oxa alone. By contrast, the combined treatments had no significant effect on autophagy.

Conclusion

The combined treatment significantly promoted cell death through apoptosis while maintaining a basal level of autophagy.

A Case of Severe Lower Extremity Lymphedema Caused by Postoperative Intraperitoneal Lymphatic Leakage Treatment

In the present study, we encountered a patient who developed intraabdominal lymphatic leakage after surgery for gastric cancer, underwent lymphangiography and lymphatic mass embolization, and developed severe lymphedema. The patient was a 55-year-old woman with gastric cancer with pancreatic invasion. Total gastrectomy and lymph node dissection were performed as conversion procedures. Six liters of ascites was detected postoperatively. Lymphangiography with Lipiodol injections into the bilateral inguinal lymph nodes was done three times, and Histoacryl embolization of the lymphatic leak was performed. However, edema of the lower extremities rapidly worsened. Lymphatic venous anastomosis was performed under general anesthesia. Anastomosis was performed at seven sites on the right and eight sites on the left. Postoperatively, the patient underwent compression therapy using the multilayer bandage method. The edema continued to improve further, and at 2 weeks postoperatively, the patient's weight had decreased by 21.4 kg from the preoperative weight, which was the same as that before the onset of edema. In this case, the patient's general condition was unstable due to cardiac insufficiency and other factors. Therefore, we aimed for an operation time of less than 3 hours. In addition, two surgeons performed the surgery to ensure an immediate therapeutic effect, and more anastomoses were performed than usual. After lymphatic venous anastomosis, not only the edema of both lower extremities but also the edema of the entire body improved promptly. One of the reasons for the improvement in general edema was thought to be due to increased intravascular protein and enhanced intravascular return of interstitial fluid.

A systematic review of failed endoscopic hemostasis for nonvariceal upper gastrointestinal bleeding

BACKGROUND

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a surgical emergency, usually managed via endoscopy. Approximately 2% of patients will have another significant bleed after therapeutic endoscopy and may require either transarterial embolization (TAE) or surgery. In 2011, the National Institute for Health and Care Excellence guidelines recommended that TAE should be the preferred option offered in this setting.

METHODS

This study aimed to conduct an appraisal of guidelines on NVUGIB using the Appraisal of Guidelines for Research and Evaluation II tool. A specific review of their recommendations on the management of adult patients with failed endoscopic hemostasis that required TAE or surgery was conducted.

RESULTS

The quality of the guidelines was moderate; most could be recommended with changes. However, their recommendations regarding TAE vs surgery were widely heterogeneous. A closer review of the underpinning evidence showed that most studies were retrospective, with a small sample size and missing data.

CONCLUSION

Because of the heterogeneity in evidence, the decision regarding TAE vs surgery requires further research. Deciding between these modalities is primarily based on TAE availability and patient comorbidities. However, surgery should not be dismissed as a key option after failed endoscopic hemostasis.

A rare case of eosinophilic jejunitis: diagnosis and management strategies

Eosinophilic gastroenteritis is a rare disease with an unknown cause, which can manifest independently or as part of a hyper-eosinophilic syndrome. The severity of the condition depends on the extent of eosinophilic infiltration and damage to the digestive tract. Diagnosis relies on histological examination, which reveals a significant presence of eosinophilic polymorphonuclear leukocytes in the digestive wall. The authors present a new case of eosinophilic gastroenteritis in a 28-year-old patient who exhibited obstructive symptoms but lacked peripheral eosinophilia. Esophagogastroduodenoscopy showed no abnormalities, but barium transit imaging revealed gastro-duodeno-jejunal dilation upstream of a tight jejunal stenosis. Surgical examination of the affected area confirmed a diffuse and transparietal eosinophilic infiltrate, with no evidence of parasitic or granulomatous lesions. Fortunately, the patient had a swift recovery following surgery. Biopsies conducted at other locations, including the gastric, hepatic, and medullary levels, produced negative results, indicating the localized nature of the condition.

Complicated pancreatic fistula after gynecologic surgery for left fallopian tube carcinosarcoma: A case report

Pancreatic fistulas are rare after gynecologic surgeries but are sometimes difficult to manage. A 62-year-old woman was admitted to a local hospital with acute abdominal pain. Computed tomography (CT) images showed subileus and an obstruction site in the transverse/descending colon, with invasion of peritoneal metastasis. A metal stent was placed in the bowel through colonoscopy. Suspecting advanced-stage ovarian cancer, the patient was referred to a tertiary hospital. Diagnostic laparoscopy was performed prior to neoadjuvant chemotherapy. Due to concerns raised by gastrointestinal surgeons regarding the high risk of stent perforation during chemotherapy, an abdominal colectomy of the transverse/descending colon was performed along with the removal of the disseminated tumor and the stent. Post-surgery, the patient was histologically diagnosed with stage IVB left fallopian tube carcinosarcoma. On postoperative day 3, the patient developed a fever, and CT images showed an abscess around the pancreas/spleen, prompting the placement of a drainage tube. The amylase level in the drained fluid was 258,111 U/L, leading to a diagnosis of a pancreatic fistula. Conservative management was undertaken, with drainage, fasting, and octreotide administration. After two months, the drainage tube was removed as the volume of drained fluid had decreased. After four cycles of carboplatin/paclitaxel chemotherapy, CT images showed partial response to chemotherapy, and interval debulking surgery was performed. The necessity of metallic stent placement should be carefully considered as the subileus caused by peritoneal metastasis might be alleviated by the induction of chemotherapy for gynecologic cancer.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

Internal Hernia as a Rare Complication of Acute Appendicitis

Appendicitis is a well-known and highly common surgical emergency disease, yet it presents with a wide variety of manifestations. This is a case report of a 47-year-old female who presented with a complaint of having constant crampy right lower abdominal pain for two weeks. The patient reported having a sudden onset of symptoms that went with the typical picture of acute appendicitis that occurred two weeks ago. Our pre-op workup was inconclusive; therefore, we planned to go for a diagnostic laparoscopy, where surprisingly, the appendix was long, inflamed, and attached to the posterior wall of the cecum. Thus, a ring-like structure was developed, in which 8 to 10 cm of the terminal ileum (the last part of the small bowel) was going through and causing an internal hernia. Although blood and radiology workups provide valuable assistance in diagnosing common cases, a highly suspicious sense and skillful surgeons with good clinical experience play a major role in managing such rare presentations.

Shifting paradigms: a pivotal study on laparoscopic resection for colovesical fistulas in diverticular disease

Background

Colovesical fistulas (CVFs) pose a challenge in diverticulitis, affecting 4% to 20% of sigmoid colon cases. Complicated diverticular disease contributes significantly, accounting for 60%-70% of all CVFs. Existing studies on laparoscopic CVF management lack clarity on its effectiveness in diverticular cases compared to open surgery. This study redefines paradigms by assessing the potentiality, adequacy, and utility of laparoscopy in treating CVFs due to complicated diverticular disease, marking a paradigm shift in surgical approaches.

Methods

Conducting a retrospective analysis at Ospedale Monaldi A.O.R.N dei Colli and University Federico II, Naples, Italy, patients undergoing surgery for CVF secondary to diverticular disease between 2010 and 2020 were examined. Comprehensive data, including demographics, clinical parameters, preoperative diagnoses, operative and postoperative details, and histopathological examination, were meticulously recorded. Patients were classified into open surgery (Group A) and laparoscopy (Group B). Statistical analysis used IBM SPSS Statistic 19.0.

Results

From January 2010 to December 2020, 76 patients underwent surgery for colovesical fistula secondary to diverticular disease. Laparoscopic surgery (Group B, n = 40) and open surgery (Group A, n = 36) showed no statistically significant differences in operative time, bladder suture, or associated procedures. Laparoscopy demonstrated advantages, including lower intraoperative blood loss, reduced postoperative primary ileus, and a significantly shorter length of stay. Postoperative morbidity differed significantly between groups. Mortality occurred in Group A but was unrelated to surgical complications. No reoperations were observed. Two-year follow-up revealed no fistula recurrence.

Conclusion

This pivotal study marks a paradigm shift by emphasizing laparoscopic resection and primary anastomosis as a safe and feasible option for managing CVF secondary to diverticular disease. Comparable conversion, morbidity, and mortality rates to the open approach underscore the transformative potential of these findings. The study's emphasis on patient selection and surgeon experience challenges existing paradigms, offering a progressive shift toward minimally invasive solutions.

Safety and adverse events of EUS-guided gallbladder drainage using lumen-apposing metal stents and percutaneous cholecystostomy tubes: a systematic review and meta-analysis

BACKGROUND AND AIMS

EUS-guided gallbladder drainage using lumen-apposing metal stents (EUS-GBD-LAMSs) and percutaneous cholecystostomy for gallbladder drainage (PTGBD) are the alternative treatment modalities in high-risk surgical patients with acute cholecystitis (AC). The aim of this study was to compare the safety of these procedures for AC in surgically suboptimal candidates.

METHODS

Six studies compared the 2 groups' early, delayed, and overall adverse events; they also compared length of hospital stay, re-interventions, and re-admissions rate. A random effect model calculated odds ratios (ORs) with a 95% confidence interval (CI).

RESULTS

The 2 groups had similar early adverse events; however, EUS-GBD-LAMS was associated with a lower rate of delayed (OR, .21; 95% CI, .07-.61; P ≤ .01) and overall (OR, .43; 95% CI, .30-.61; P ≤ .01) adverse events. Patients with EUS-GBD-LAMSs had a shorter hospital stay than PTGBD.

CONCLUSIONS

EUS-GBD-LAMS is a safer option than PTGBD and is associated with a shorter hospital stay in nonsurgical candidates with AC.

Association Between Nil Per Os Status and Intubated Patients Undergoing Surgery

INTRODUCTION

Patient outcomes heavily rely on nutritional support. However, holding enteric feeds prior to surgical operations in critically ill patients is still a common practice in intensive critical units. Our objective is to describe the relationship between duration of nil per os (NPO) and respiratory outcomes in intubated, critically ill patients requiring operative intervention.

METHODS

We conducted a retrospective analysis on intubated, critically ill patients who underwent operative intervention between January 1, 2016, and December 31, 2018, to investigate how the duration of NPO status may affect respiratory outcomes. We compared adverse respiratory events among patients who maintain NPO ≥6 h (NPO group) versus those who were NPO <6 h (non-NPO group) prior to surgery.

RESULTS

Two hundred patients met inclusion criteria: 104 for NPO and 96 for non-NPO. Aspiration event was found in 5.8% of NPO patients and 7.3% in non-NPO patients, P = 0.66. Desaturation event was found in 16.3% for NPO and 14.6% in non-NPO, P = 0.73. Pneumonia was found in 18.3% of NPO patients and 19.8% in non-NPO patients, P = 0.78. Reintubated rates were 13.5% for NPO and 16.7% for non-NPO, P = 0.57. Median (range) hours of NPO for non-NPO was 1.0 h (0-3.0) and 13.0 h (6.0-20.0) for NPO, P < 0.05.

CONCLUSIONS

For intubated, critically ill patients requiring operative intervention, there was no difference observed in adverse respiratory events between those kept NPO for 6 h or greater compared to those kept NPO for less than 6 h. Patients were commonly without enteric nutrition for periods of time much greater than the American Society of Anesthesia's recommended 6-h period.

Cancer snap-shots: Biochemistry and glycopathology of O-glycans: A review

Cancer pathogenesis is strongly linked to the qualitative and quantitative alteration of the cell surface glycans, that are glycosidically linked to proteins and lipids. Glycans that are covalently linked to the polypeptide backbone of a protein through nitrogen or oxygen, are known as N-glycans or O-glycans, respectively. Although the role of glycans in the expression, physiology, and communication of cells is well documented, the function of these glycans in tumor biology is not fully elucidated. In this context, current review summarizes biosynthesis, modifications and pathological implications of O-glycans The review also highlights illustrative examples of cancer types modulated by aberrant O-glycosylation. Related O-glycans like Thomsen-nouveau (Tn), Thomsen-Friedenreich (TF), Lewisa/x, Lewisb/y, sialyl Lewisa/x and some other O-glycans are discussed in detail. Since, the overexpression of O-glycans are attributed to the aggressiveness and metastatic behavior of cancer cells, the current review attempts to understand the relation between metastasis and O-glycans.

Perioperative outcomes for single-port robotic versus single-incision laparoscopic surgery: a comparative analysis in colorectal cancer surgery

BACKGROUND

Single-incision laparoscopic surgery (SILS) may offer improved cosmesis, reduced postoperative pain and faster recovery than conventional platforms, but widespread implementation was limited by technical demands. A single-port robotic platform was recently introduced, with components that further enhance SILS benefits without the technical challenges. No study to date has compared the two platforms to validate benefits. Our goal was to compare outcomes of SP robotics and SILS in colorectal cancer (CRC).

METHODS

A prospective cancer registry was reviewed for CRC patients undergoing curative resection through a SILS or SP robotic approach from 2010 to 2022. Patient and cancer demographics, intraoperative, and postoperative outcomes were compared in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. The main outcome measures were complications, operative time, and oncologic quality measures.

RESULTS

Matching resulted 50 SP robotic and 50 SILS patients. Cohorts were well matched in all demographics, but SP robotic rectal cancer cases were significantly closer to the anorectal ring than SILS (1.8 cm vs. 3.4 cm, p = 0.018). SP robotic and SILS platforms had similar operative times. Intraoperative conversions was comparable, but more SILS cases required additional ports to be placed (p = 0.040). The intraoperative complications rate, complete total mesorectal excision rates, and lymph node yield were not statistically significantly different. There were no positive margins in either group. Postoperatively, groups had analogous day of return of bowel function, comparable morbidity, and discharge destination. There was no mortality in either group. The length of stay was significantly shorter with SP robotics than SILS (mean 4.135 vs. 5.282 days, median 4 (2-8) vs. 5 (2-14) days; p = 0.045).

CONCLUSIONS

Single-port robotics provided high quality oncologic surgery, adding the technical benefits of robotics to clinical and cosmetic benefits of single-port surgery. There were comparable operative time, complication rates, and oncologic outcomes in CRC cases, with shorter hospital stays with SP robotics. This early data is encouraging for expansion SP robotic technology.

Dynamics of Serum CA19-9 in Patients Undergoing Pancreatic Cancer Resection

BACKGROUND

Carbohydrate antigen (CA) 19-9 is an established perioperative prognostic biomarker for pancreatic ductal adenocarcinoma (PDAC). However, it is unclear how CA19-9 monitoring should be used during postoperative surveillance to detect recurrence and to guide the initiation of recurrence-focused therapy.

OBJECTIVE

This study aimed to elucidate the value of CA19-9 as a diagnostic biomarker for disease recurrence in patients who underwent PDAC resection.

METHODS

Serum CA19-9 levels at diagnosis, after surgery, and during postoperative follow-up were analyzed in patients who underwent PDAC resection. All patients with at least two postoperative follow-up CA19-9 measurements before recurrence were included. Patients deemed to be nonsecretors of CA19-9 were excluded. The relative increase in postoperative CA19-9 was calculated for each patient by dividing the maximum postoperative CA19-9 value by the first postoperative value. Receiver operating characteristic analysis was performed to identify the optimal threshold for the relative increase in CA19-9 levels to identify recurrence in the training set using Youden's index. The performance of this cutoff was validated in a test set by calculating the area under the curve (AUC) and was compared to the performance of the optimal cutoff for postoperative CA19-9 measurements as a continuous value. In addition, sensitivity, specificity, and predictive values were assessed.

RESULTS

In total, 271 patients were included, of whom 208 (77%) developed recurrence. Receiver operating characteristic analysis demonstrated that a relative increase in postoperative serum CA19-9 of 2.6× was predictive of recurrence, with 58% sensitivity, 83% specificity, 95% positive predictive value, and 28% negative predictive value. The AUC for a 2.6× relative increase in the CA19-9 level was 0.719 in the training set and 0.663 in the test set. The AUC of postoperative CA19-9 as a continuous value (optimal threshold, 52) was 0.671 in the training set. In the training set, the detection of a 2.6-fold increase in CA19-9 preceded the detection of recurrence by a mean difference of 7 months ( P <0.001) and in the test set by 10 months ( P <0.001).

CONCLUSIONS

A relative increase in the postoperative serum CA19-9 level of 2.6-fold is a stronger predictive marker for recurrence than a continuous CA19-9 cutoff. A relative CA19-9 increase can precede the detection of recurrence on imaging for up to 7 to 10 months. Therefore, CA19-9 dynamics can be used as a biomarker to guide the initiation of recurrence-focused treatment.