Preferred Reporting Of Case Series in Surgery (PROCESS) 2023 guidelines

Tooth autotransplantation with adjunctive application of enamel matrix derivatives using a digital workflow: A prospective case series

OBJECTIVES

Digital protocols and bioactive materials may reduce complications and improve tooth autotransplantation (ATT) success and survival rates. This prospective study assesses the performance of a fully digital autotransplantation protocol of close-apex molars with the adjunctive application of Enamel Matrix Derivatives (EMD).

METHODS

Twelve adult patients with 13 hopeless molar teeth were replaced with autotransplantation of closed apex third molars. Outcomes, including success and survival rates, clinical, endodontic, radiographic, patient-reported outcome measures (PROMs), and digital image assessments, were conducted over a two-year follow-up period.

RESULTS

Survival and success rates were 100% and 91.2%, respectively, with no progressive inflammatory or replacement root resorption (ankylosis) except for one tooth presenting radiographic furcation involvement. A significant probing depth reduction of 2.4 ± 2.58 mm and CAL gains of 2.8 ± 3.03 mm were observed in transplanted teeth compared to the hopeless receptor teeth. Radiographic bone levels remained stable throughout the study period (-0.37 ± 0.66 mm), and digital image assessments showed minimal alveolar ridge width changes (-0.32 to -0.7 mm) and gingival margin changes (-0.95 to -1.27 mm) from baseline to last visit. PROMs indicated very high patient satisfaction.

CONCLUSION

The use of a digital ATT protocol with adjunctive use of EMD in closed-apex third molars demonstrated promising short-term high success and survival rates. Additionally, this type of therapy adequately preserves the dimensions of the alveolar ridge in the receptor site.

CLINICAL SIGNIFICANCE

This is the first prospective clinical study examining the effect of a digital tooth autotransplantation protocol combined with the application of EMD. It demonstrates that this approach is an effective treatment for replacing hopeless teeth and also validates the digital assessment of ATT alveolar ridge preservation at the recipient site.

Post-traumatic pseudoaneurysm of the right hepatic artery: Two case reports - New Ukrainian reality

INTRODUCTION AND SIGNIFICANCE

The diagnostics and treatment management in conditions of massive sanitary losses with the use of staged treatment have their own specifics and require a multidisciplinary approach with the involvement of a wide range of specialists and the use of modern technologies. The number of sources covering the ultrasound diagnostics and clinical course of hepatic artery pseudoaneurysm as a complication of gunshot wounds is quite limited in world literature.

CASE PRESENTATION

We present the experience of the observation and management of the right hepatic artery pseudoaneurysm in case of the blast injury of liver in two patients: the example of successful resolution with spontaneous occlusion and the example with the occurrence of internal bleeding as a result of pseudoaneurysm rupture.

CLINICAL DISCUSSION

Clinical cases presented here belong to the category of severe injuries caused by high-energy weapons, which are characterized by a syndrome of mutual aggravation and need for simultaneous treatment of several damaged organs. The use of contrast methods in severely injured patients requires instrumental justification, and results of daily ultrasound monitoring with the use of color Doppler program can be the one.

CONCLUSION

Pseudoaneurysm of hepatic arteries is a dangerous complication of severe liver wounds and injuries, which occurs in 3·2 % of patients according to our data. The method of ultrasound examination with the use of color Doppler mapping program allows to visualize pseudoaneurysms and monitor their progress. When identifying patients with pseudoaneurysm of hepatic arteries at the level II-III medical care (Role II-III), their further evacuation should be carried out to medical institutions equipped with endovascular correction technologies.

Isolated posterior capsule rupture secondary to blunt ocular trauma: Case presentation and literature review

INTRODUCTION

An isolated posterior capsule rupture (PCR) is a rare complication associated with traumatic cataracts. We report our findings in three cases of traumatic cataracts with isolated PCR caused by blunt ocular trauma.

PRESENTATION OF CASES

Case 1: A 1.5-year-old boy was examined after his parents noticed that the center of the pupil of the left eye was white. The mother reported that the boy had fallen and bruised his left forehead 4 months earlier. Case 2: An 18-year-old boy had a traumatic cataract that developed one month after a blow to his eye. Case 3: A 13-year-old boy was treated for hyphema and high intraocular pressure after blunt trauma to his eye. Ten days later, a total cataract developed. Anterior segment optical coherence tomography revealed an isolated PCR with a protruding lens cortex, and ultrasonography showed vitreous opacities.

DISCUSSION

An isolated PCR was observed intraoperatively in the center of the posterior lens capsule. The lens cortex was prolapsed into the PCR or into the vitreous cavity in Case 3. An intraocular lens (IOL) was implanted in the lens capsule or to the ciliary sulcus after vitrectomy in Case 3. Vision improved in all eyes.

CONCLUSIONS

Our findings indicated that the external force by a trauma to the eye can lead to an isolated PCR with a protruded lens cortex in young patients. These PCRs can be successfully treated with the IOL implanted in or out of the capsular bag.

Global utilization of biportal spinal endoscopy: Case series on management of lumbar pathology in Soddo, Ethiopia

INTRODUCTION

Biportal spinal endoscopy is a safe and cost-effective methodology for the management of lumbar pathology in rural underserved hospitals that have standard orthopaedic arthroscopic equipment, but lack access to microscopy.

METHODS

This is a case series noting 1-year outcomes from 5 patients managed with biportal spinal endoscopy during an 11-day mission trip to Soddo, Ethiopia in November 2022. Surgical complications, postoperative assessments, and patient-reported outcomes (PROs) were retrospectively collected and analyzed. Surgical techniques and equipment utilized were shared with residents and faculty at the hospital.

RESULTS

Five Ethiopian patients (4:1, female:male) with no prior spine surgery history elected to undergo biportal surgery for the diagnoses of lumbar stenosis and disc herniation, averaging 31 years of age with Body-Mass-Indices (BMI) <35. Two patients underwent endoscopic discectomy, and three patients underwent endoscopic unilateral laminotomy and bilateral decompression (ULBD). There were no complications. No postoperative functional deficits, infections, readmissions, revisions, or wound dehiscences were noted at 12 months follow-up. VAS-back and VAS-leg scores improved to <2/10 for 80 % of patients. All patients returned to work/activities of daily living. No patients required postoperative pain management beyond the 2-week post-operative follow-up.

CONCLUSION

With these five patients, we found that biportal spinal endoscopy can be safely applied in rural hospital settings with limited resources. This supports biportal spinal endoscopy as a viable minimally invasive modality for the management of lumbar pathology. For hospitals with limited resources, but access to arthroscopic equipment, biportal spinal endoscopy is a feasible option.

LEVEL OF EVIDENCE

IV.

Intramuscular lipomas posing diagnostic and pre-operative counselling challenges in a low-resource setting: A case series

INTRODUCTION

Intramuscular lipomas (IMLs) are uncommon primary adipose tissue tumours deep within the muscle. A high likelihood of misdiagnosing them as other benign and malignant masses necessitates imaging studies to confirm the diagnosis and plan treatment. Ultrasonography is useful but CT and MRI provide a more accurate diagnosis. While diagnostic tests are suitable, they may not always be accessible or affordable in low-resource settings. We present three cases of IMLs that emphasise the difficulties posed by limited resources and the significance of a comprehensive medical history and physical examination in low-resource settings.

PRESENTATION OF CASES

The patients included a 57-year-old male with a distal right thigh mass, a 65-year-old female with a proximal right thigh mass, and a 60-year-old female with a mass at the left scapular area. The three patients underwent surgical excision and had an uneventful postoperative course, with no reported recurrence during their ongoing follow-up.

DISCUSSION

The management of IMLs is not complicated if the requisite resources are available. Conversely, in low-resource settings with limited diagnostic facilities and human expertise, management may take a challenging path. Patient 1, despite undergoing diagnostic tests confirming IML, initially declined treatment due to challenges with pre-operative counselling. Patients 2 and 3 lacked health insurance and could not afford diagnostic imaging tests.

CONCLUSION

Healthcare professionals in low-resource settings should familiarise themselves with the clinical characteristics and pathology of IMLs to minimise misdiagnosis and ensure appropriate counselling is provided to patients. IMLs are slow-growing mostly asymptomatic benign swelling. On physical examination, they are usually non-tender, soft, masses, not fixed to the bed or overlying tissue. The overlying skin is normal and lymphadenopathy is absent.

Clinical and histopathological spectrum of congenital pulmonary airway malformations: A case series

BACKGROUND

Congenital pulmonary airway malformations (CPAM) are a spectrum of cystic and non-cystic anomalies arising from abnormal airway development in utero, with an incidence of 1 in 25,000 to 35,000 births. CPAM can present prenatally or postnatally with respiratory distress, recurrent infections, or occasionally as an incidental finding. This case series aims to highlight the clinical, radiological, and histopathological characteristics of CPAM through three pediatric cases, which include types 1, 2, and 3 CPAM.

CASE PRESENTATION

Case 1: A four-month-old male presented with cough, cold, and respiratory distress. Imaging revealed hypoattenuation and overinflation of the left upper lobe with mediastinal shift. Left upper lobectomy confirmed CPAM type 2. Case 2: A one-month-old female presented with recurrent respiratory distress and infections. Imaging showed a large cystic lesion in the right middle lobe. Right middle lobectomy confirmed CPAM type 3. Case 3: A two-month-old male presented with dyspnea. Imaging showed a large bullae in the right chest with mediastinal shift. Right upper lobectomy confirmed CPAM type 1.

CLINICAL DISCUSSION

CPAM is a rare congenital lung malformation characterized by abnormal bronchial development and localized glandular overgrowth. Management involves surgical resection, with the timing of surgery dependent on symptomatology. Early identification and intervention are crucial for preventing complications such as pulmonary hypoplasia and recurrent infections. Histopathological examination post-resection is essential for accurate classification and management of CPAM.

CONCLUSION

This case series provides valuable insights into the clinical, radiological, and histopathological features of CPAM, including the types encountered in each case. It underscores the importance of early diagnosis and timely surgical intervention, advocating for routine prenatal and postnatal screenings to effectively identify and manage CPAM.

Experience in the use of circular incision bi-pedicled vertical flap based mastectomy for grade III gynecomastia: A case series

INTRODUCTION AND IMPORTANCE

Surgical management of grade III gynecomastia with excess redundant skin is challenging. The choice of the surgical technique is mainly decided upon the size of the gynecomastia, the skin redundancy and correction of nipple position.

CASE PRESENTATION

We report our experience in the use of the circular incision bi-pedicled vertical flap based mastectomy for grade III gynecomastia according to Simon classification. This is a retrospective study conducted between January 2022 and April 2023 at two selected units in Sri Lanka.

CLINICAL DISCUSSION

A total of 7 patients with bilateral grade III gynecomastia were included in this study with a median age of 24 years (range: 18-42 years). The mean BMI was 23.2 kg/m2. All patients exhibited near symmetrical breasts and large areolar diameters. All patients complained of physical and psychological dissatisfaction with their condition and sought an aesthetic correction. Two patients were diagnosed with Klinefelter syndrome and others were apparently healthy. The main complication was seroma formation (7/7). No patients developed haematoma. Nipple hypothesia was noted in two patients which improved on follow up. The mean follow- up duration was 4-9 months. The survey of patient satisfaction showed 9 for contour, 8.6 for wound scars, 9.2 for overall satisfaction and 9.6 for improvement in self-confidence.

CONCLUSION

The above surgical technique achieved satisfactory aesthetic results while avoiding unsightly scars or serious complications and can be considered in the surgical decision making for grade III gynecomastia.

Surgical management strategies for unstable sacral fractures: Case series and surgical guideline

INTRODUCTION

Unstable sacral fractures usually have posterior pelvic and spinopelvic instability, which usually be classified as AO type C. There are many controversial points concerning the management of these fractures due to their rarity. Herein, we retrospectively review cases of this injury and propose a surgical guideline.

CASE PRESENTATION

A 37-year-old female experienced back pain after a motor vehicle accident. Diagnostic imaging revealed an AO type C1 sacral fracture, Isler subtype 2a (case No. 7). Preoperative CT scan and CT reconstruction images showed a longitudinal fracture with a simple intraarticular fracture of the left S1 superior facet. Although the patient sustains a lumbosacral facet joint injury, the lumbosacral motion seems preservable after healing. The triangular osteosynthesis was chosen because it provides both transverse plane and vertical plane stability. The patient was allowed to continue weight-bearing ambulation after the operation. To maintain lumbosacral motion, the spinopelvic rod was removed in the postoperative seventh month.

DISCUSSION

The unstable sacral fracture might have instability in both the vertical and transverse planes. The fixation construct should provide both vertical and transverse stability. Regarding vertical fixation, it might cost a loss of lumbosacral motion, which the treating surgeon has to consider. The lumbosacral injury is sometimes trivial, and long-term lumbosacral motion is expectable. So, permanent spinopelvic fixation is not necessary. The patient's character is also an important factor. Whether the patient needs or does not need early progressive weight bearing after the operation determines the fixation method.

CONCLUSION

Unstable sacral fractures are rare conditions usually resulting from a high-energy injury. We have proposed a surgical management strategy for this group of fractures with an optimal fixation method based on three factors: 1) fracture morphology, 2) lumbosacral integrity, and 3) concomitant injury.

Peutz-Jeghers syndrome: A case series

INTRODUCTION

Peutz-Jeghers syndrome (PJS) is a rare hereditary disorder characterized by gastrointestinal hamartomatous polyps, due to mutation of the STK11/LKB1 gene located on chromosome 19p. The polyps are most commonly found in the small bowel followed by colon.

CASE PRESENTATION

Our case series includes 4 patients, three being male and one female. Each of them either presented with abdominal pain and other associated symptoms. Oral cavity and lip melanin pigmentation were common. CT abdomen revealed multiple large jejunal, ileal, gastric and colon polyps. Cancer was found in one patient. Different surgical approaches were adopted. All recovered well.

DISCUSSION

PJS is an autosomal dominant disorder with an estimated incidence of 1:50,000 to 1:200,000 cases with a significant family history. Mostly found in small bowel followed by colon, it can also occur in a rare organ like gall bladder as evident in our case. PJS carries a substantial risk for gastrointestinal cancer. The treatment modality depends on the site of polyp, mode of presentation and availability of the expertise.

CONCLUSION

PJS is a common disease in our part which is usually observed in teen age groups male. They have a varied presentation, from intestinal obstruction (due to intussusception) to GI bleeding. Colonic malignancy at young age may be the first presentation of the disease. Observation of melanin pigmentations on lips helps diagnose the disease; and one should always look at this findings in a young patient with pain abdomen or in intestinal obstruction to confirm/exclude the disease.

Embolization of the hypogastric artery after surgical ligation: A case series of two patients

INTRODUCTION

The increasing incidence of obstetric complications, such as post-partum hemorrhage in the case of placenta accreta spectrum, calls for innovative and adapted therapeutic approaches. This presentation highlights the effectiveness of arterial embolization of the hypogastric artery, properly known as the internal iliac artery, in managing obstetric bleeding, even after initial surgical ligation. An approach never described in the literature.

PRESENATION OF CASES

1st Case: A 38-year-old patient, in her fourth pregnancy with two previous caesarean sections, was admitted for moderate metrorrhagia at 19 weeks gestation. Ultrasound showed a monofetal pregnancy at 17 WG with a 6 cm placental abruption and an anterior placenta with accretion signs. An emergency subtotal hysterectomy with triple Tsirulsikov arterial ligation was performed after transfusion. Due to persistent bleeding, bilateral hypogastric artery ligation and abdominal packing were added, but without improvement. The patient was referred for embolization after hemodynamic stabilization. The procedure was carried out successfully and no complications were reported. 2nd Case: A 35-year-old patient with vaginal bleeding from placenta accreta at 25 WG required hemostasis hysterectomy. Despite the procedure, bleeding continued, leading to bilateral hypogastric artery ligation and pelvic packing. The patient was hemodynamically stabilized and transferred for hypogastric artery ligation, which was successfully performed without complication.

DISCUSSION

The role of interventional radiology in managing postpartum hemorrhage (PPH) is well established, with substantial literature supporting the benefits of uterine artery embolization as a lifesaving and often uterine-sparing procedure in PPH. While its indication for prevention is well-known, what about post-operatively? Our experience indicates that consulting a radiologist specializing in pelvic embolization can yield satisfactory outcomes despite technical difficulties.

CONCLUSION

Embolization of the hypogastric arteries as well as embolization followed by surgical ligation of these arteries have been well described in the literature, the originality in our case reports is the embolization performed after surgical ligation which has not been described before according to our knowledge and which despite its technical difficulty can be a satisfactory alternative for the control of post-partum hemorrhage.

Hydatid cyst at unusual locations: Report of three cases

INTRODUCTION

Hydatidosis is an anthropozoonosis due to the development in humans of the larval form of Echinococcus granulosus and is endemic in many countries of the Mediterranean region such as Morocco.

CASES PRESENTATION

We report three cases of hydatid cyst at unusual locations such as the peritoneum, and the retroperitoneum.

DISCUSSION

Hydatid disease usually involves the liver (75 %), the lungs (15.4 %), and the spleen (5.1 %). Almost any anatomic location can be the host site of the parasitic cysts.

CONCLUSION

Multiple locations of hydatid cyst often pose a problem of differential diagnosis. Surgery is the mainstay of treatment.

Case series on resection of symptomatic bifid ribs: A successful and safe treatment option

INTRODUCTION

Bifid ribs are a type of, generally asymptomatic, congenital chest wall abnormality. However, patients sometimes complain about chronic chest pains, deformities and respiratory difficulty. There is limited literature regarding treatment of symptomatic bifid ribs. We present the results of two cases of symptomatic bifid ribs causing intercostal nerve impingement who underwent surgery.

PRESENTATION OF CASE

Two patients aged 22 and 33 presented to the outpatient clinic with chronic chest pains. After physical examination and 3D CT-scans they were diagnosed with intercostal nerve impingement caused by a bifid rib. Both patients underwent surgery to resect the upper arch of the bifid rib. Upon follow-up nine and seven months post-operatively patients reported complaints had been completely resolved and follow-up was ended.

DISCUSSION

Although bifid ribs are generally asymptomatic they can sometimes cause intercostal nerve impingement. These cases demonstrate that these symptoms might only start after experiencing minor trauma or a growth spurt. Intercostal nerve blockades might me a useful tool in diagnostic work-up to confirm the diagnosis.

CONCLUSION

Resection of symptomatic bifid ribs is a safe and viable treatment option.

Pathologic features of head and neck adult rhabdomyosarcoma: Case series

INTRODUCTION

Adult Head and neck Rhabdomyosarcomas (HNRMS) are exceedingly rare and remain challenging for pathologists.

CASES PRESENTATION

Five cases of adult HNRMS (≥19 years) were retrieved from the archives of the Department of Pathology of Hospital of Specialities in Rabat (HSR) in Morocco, over 5 years. Clinical and pathologic findings from hematoxylin and eosin slides and immunohistochemistry for Desmin and Myogenin were reviewed.

CLINICAL DISCUSSION

The median age was 33, with a men's predominance (3 M/2F). Histological analysis revealed three cases of Alveolar Rhabdomyosarcoma (RMS), one Pleomorphic RMS, and one spindle cell/sclerosing RMS. In addition to the typical histology observed in each RMS, we found tricky growth patterns that could be a source of misdiagnosis. All five cases demonstrated variable positivity for Desmin and Myogenin.

CONCLUSION

HNRMS cases have different pathological features than pediatric RMS cases. We identified rare subtypes such as pleomorphic and spindle cell/sclerotic RMS, which exhibit unusual morphological patterns.

Ghost complications in biliary surgery: A case series on pneumobilia

INTRODUCTION

Laparoscopic cholecystectomy is a commonly performed surgical procedure and there are instances where complications may occur intraoperatively which can go undiagnosed or unreported and the patient can present at a later time with the manifestations of those complications. This study presents a case series comprising three instances of "ghost complications" following laparoscopic cholecystectomy, emphasizing the utmost significance of careful follow-up care and efficient communication to promptly recognize and manage any complications arising after the surgery.

CASE PRESENTATION

Three cases of ghost complications post-biliary surgery are presented. These complications were initially overlooked or dismissed due to factors such as atypical symptom presentation and inadequate follow-up. The cases involve retained stones leading to secondary complications, bile leak masked by postoperative symptoms, and post-cholecystectomy syndrome mistaken for unrelated conditions.

CLINICAL DISCUSSION

Diagnosing ghost complications is challenging when symptoms diverge from the expected postoperative course. Meticulous clinical suspicion and interdisciplinary collaboration are crucial for accurate diagnoses and timely intervention. Effective communication between patients and surgeons is pivotal in ensuring appropriate management.

CONCLUSION

This study illuminates the concept of "ghost complications" after biliary surgery, highlighting challenges in their recognition and management. Through three distinct cases, the study underscores the significance of vigilant follow-up care, early symptom recognition, and open communication to prevent and address such complications. Transparent communication and meticulous monitoring are vital for enhancing patient outcomes and mitigating the occurrence of "ghost complications."

Primary urethral carcinoma in female: An extremely rare case series at a single tertiary referral hospital and literature review

INTRODUCTION AND IMPORTANCE

Primary urethral carcinoma (PUC) is exceedingly uncommon and accounts for 0.02 % of all female cancers and <1 % of female genitourinary tract malignancy. PUC in female usually presents late with a higher disease stage and, hence, has higher cancer-specific mortality. Due to its rarity, the current recommendation for the management of PUC is still unclear.

CASE PRESENTATION

This study reports two rare cases of 59-year-old and 65-year-old women with PUC, presenting with chief complaint of hematuria. Urethrocystoscopy and biopsy were performed. Pathology results revealed mucinous adenocarcinoma (AC) and urothelial carcinoma (UC) of the urethra, respectively. Radiological imaging was conducted for staging. Both were diagnosed with cT4N2M0. The first patient underwent anterior pelvic exenteration with bilateral ureterocutaneoustomy (UCS), while the second patient received cisplatin-based chemotherapy before the surgery. Radiological follow-up was planned 3 months after the surgery.

CLINICAL DISCUSSION

Both mucinous AC and UC are considered incredibly unusual subtypes, with no defined treatment guidelines. Anterior exenteration with or without neoadjuvant chemotherapy may be opted for advanced PUC affecting the proximal urethra and adjacent organs. Following the previous studies, in this case series, both patients (locally advanced) underwent anterior exenteration. Additionally, the UC subtype received multimodal treatment with neoadjuvant chemotherapy which was shown to improve overall survival.

CONCLUSION

In conclusion, PUC is extremely rare, and the choice of management remained various. Long-term follow-up for these patients is mandatory to improve understanding of this incredibly uncommon disease.

The results of femoral lengthening using domestic unilateral external fixation and then plating: the first case series in Vietnam

Introduction and importance

This study aimed to assess the results of femoral lengthening using an external fixator and then plating.

Case presentation

This prospective case series study enrolled 11 patients who underwent femoral lengthening and then plating (LATP) between January 2019 and April 2023. The average age of patients was 14.45 ± 7.54 years. One patient with a femur was lengthened and plated, and one tibia was lengthened over a nail simultaneously. The average femoral lengthening was 8.41 ± 1.35 cm.

Clinical discussion

The femoral healing result was excellent in seven femurs and good in four femurs; the functional outcome was excellent in five patients and good in six patients. Pin-track infection occurred in all patients. A limited range of motion of knee flexion occurred in eight patients. Femoral varus and procurvatum deviation occurred during distraction in four and two patients. Femoral LATP was considered an attractive alternative to intramedullary lengthening nails in a low-income country.

Conclusion

Our research suggests that femoral LATP was an effective method. However, the most common complications were pin-site infection and extensive knee contracture. Further research should be done with a larger sample size and longer follow-up time.

Level of evidence

Level IV-prospective observational case series study.

Carotid artery penetrating trauma: Report of 4 cases and literature revision

INTRODUCTION AND IMPORTANCE

In penetrating neck trauma, carotid artery penetrating trauma is considered one of the most complicated injuries to treat. Active bleeding, large hematomas, and rapid occlusion of the airways make the surgical approach to controlling bleeding and repairing the vessel much more complex, constituting an essential clinical challenge to every surgeon.

CASE PRESENTATION

We present 4 cases of patients with carotid artery penetrating trauma. Two patients were treated with endovascular therapy, one with surgery, and the fourth one treated conservatively. None of the patients had posterior neurological impairment.

CLINICAL DISCUSSION

Carotid artery penetrating trauma is uncommon yet is associated with high rates of mortality and neurological impairment. The common carotid artery is the most frequently injured, and gunshot wounds (GSW) are the most frequent trauma mechanism. Angiotomography (CTA) is the first-line exam for diagnosing these injuries. Treatment should be prompt and individualized and may include conservative techniques, endovascular therapy, and traditional surgical repair.

CONCLUSION

Carotid artery penetrating trauma is an uncommon but complex injury that requires a timely diagnosis and treatment to avoid potentially devastating consequences, particularly in hemodynamically unstable patients. Traditionally, the treatment strategies for these injuries used to be limited to vascular repair or ligation. However, endovascular therapy and conservative management are viable alternatives, which have become more and more useful in selected patients, allowing less invasive approaches with fewer morbidity and acceptable results.

Referred otalgia in patients with thyroid cancer: Case series from Saudi Arabia

INTRODUCTION AND IMPORTANCE

Referred Otalgia is very unlikely to be the first presentation of thyroid carcinoma, however, it is important to examine thyroid in cases of otalgia lacking any evidence of primary origin.

CASE PRESENTATION

We report five cases of thyroid carcinoma, variant types, presented by secondary otalgia in Al-Baha region, KSA followed by proper surgery and patient relief during the last eight years. Patients' ages ranged from 25 to 65 years old.

CLINICAL DISCUSSION

Thyroid inflammation, including acute and subacute thyroiditis, was reported as a possible cause of the pain referred to the ear and the angle of the mandible, however otalgia caused by thyroid cancer is an extremely rare presentation.

CONCLUSION

Otolaryngologists should be aware that thyroid cancer may be associated with otalgia in any age group, however extremely rare. With very limited sources for this clinical entity, we recommend further studies on the different varieties of thyroid cancer presentations and the possibilities of the unexplained otalgia.

Infraorbital nerve block for pain management in pediatric cleft lip surgery in resource-limited areas of Indonesia: A case series

INTRODUCTION AND IMPORTANCE

Cleft lip and palate (CLP) are congenital anomalies of the craniofacial region, commonly found in low- and middle-income countries, including Indonesia. Surgical correction of clefts typically begins at around three months of age to support infant growth. An infraorbital nerve block is an option for regional anesthesia in CLP surgery. This case series aims to determine the effectiveness of infraorbital nerve block in pain management for pediatric CLP surgery.

CASE PRESENTATION

This case series includes five patients who fulfilled the Millard criteria for CLP surgery. All patients received general anesthesia followed by an infraorbital nerve block with 0.2 % ropivacaine in the infraorbital foramen area using the intraoral approach. Data were collected preoperatively, intraoperatively, and postoperatively.

DISCUSSION

The combination of general anesthesia and infraorbital nerve block resulted in stable hemodynamics, low delirium scores, low pain intensity, and adequate oral intake postoperatively.

CONCLUSION

Infraorbital nerve block with ropivacaine provides intraoperative hemodynamic stability, decreased delirium, and effective postoperative pain management in pediatric patients undergoing CLP surgery.

Challenges and outcomes of upper cervical spinal tuberculosis surgery in pandemic-Case series study

INTRODUCTION AND IMPORTANCE

Tuberculosis is a bacterial infection caused by Mycobacterium tuberculosis, primarily affecting the lungs. Conversely, the incidence of spinal tuberculosis (TB) was limited to a mere 6 % of cases of extrapulmonary tuberculosis. Upper cervical spinal TB is an exceptionally uncommon condition, with an incidence rate of approximately 0.3-1 % among all cases of spinal tuberculosis.

CASE DESCRIPTION

Three patients diagnosed with upper cervical spinal tuberculosis who underwent Anterior Cervical Corpectomy Fusion (ACCF) or Occipitocervical fusion surgery were reviewed retrospectively. The data was obtained during the pandemic period in Indonesia. The patients were evaluated using pre-operative and post-operative Cobb's angles, Visual Analog Scale (VAS), Frankel scale, and Neck Pain and Disability (NPAD) scale.

CLINICAL DISCUSSION

The ACCF surgery was more favourable when the compression was extended to the vertebral body; it showed good clinical and radiological outcomes. Multilevel ACCF and pathologies affecting bone quality seemed to be risk factors for material subsidence and instability. In this case, all the patients had performed ACCF surgery. The mean Cobb's angle pre-operative was 15.30, and Cobb's angle post-operative was 6.50. The mean pre-operative VAS value was 6.3, and the post-operative VAS value was 3. Compared to the post-operative scale, the pre-operative Frankel scale experienced an average increase of 2 levels. In contrast, the mean value of good post-operative NPAD is 29.3.

CONCLUSION

Operative procedures on upper cervical spinal tuberculosis cases can improve patient's quality of life significantly, clinically and radiologically.

Overcome intraoperative difficulties of ALPPS procedure: a single-center outcomes and technical experience

Backgrounds/aims

Recently, the ALPPS (Associating liver partition and portal vein ligation for staged hepatectomy) has become widely known to achieve hepatic resection by rapid future liver remnant hypertrophy, but it comes with intraoperative difficulties, followed by increased complications. This study aimed to report the outcomes of an oncology center in a low-income and middle-income country with ALPPS in patients with liver tumors and its technical variants, which were invented to overcome intraoperative difficulties of the ALPPS procedure.

Patients and methods

A retrospective analysis of patients undergoing ALPPS from September 2022 to December 2023 was performed.

Results

A total of 25 patients underwent the ALPPS procedure: 21 procedures for hepatocellular carcinoma (HCC), 3 combined hepatocellular-cholangiocarcinoma (cHCC-CCA), and 1 for small cell neuroendocrine carcinoma (SNEC). The mean postoperative stay was 29.6 ± 9.3 days (range 16-58 days). After stage 1, we counted 8 complications, all of grade II; after stage 2, the number of complications was decreased to 3:2 were of grade I and 1 were of grade IIIB. 3 (12%) patients failed to proceed to ALPPS stage 2. After a median follow-up of 9 months (range 2-25), disease recurrence has been recorded in 3 patients (12%), while 1 patient (4%) died, affected by HCC. The entire group's 2-year overall survival (OS) and disease-free survival (DFS) were 83.3% and 82.5%, respectively.

Conclusion

The ALPPS procedure is an approach for large liver tumors with small future liver remnant with acceptable OS and DFS in a low-income and middle-income country.

Perineal discomfort caused by the sitting position as a rare manifestation of ectopic testicle: About two cases

BACKGROUND AND IMPORTANCE

Perineal ectopic testis (PET) is a rare congenital anomaly; the diagnosis is typically made by conducting a physical examination of the ectopic areas and noting an empty scrotum on the corresponding side. We report two pediatric cases of PET in whom this condition was diagnosed by a discomfort induced by the sitting position.

CASES PRESENTATION

Two cases of PET were operated on in our pediatric surgery department over the past three years. Patients were referred for perineal discomfort in the sitting position. Children had difficulty staying seated at home or school, this was described by parents as an abnormal fussiness after sitting. The age at diagnosis was five and three years. The diagnosis of perineal testicular ectopia was made through physical examination. Orchidopexies to the corresponding scrotum were performed in both cases via an inguinal approach. No postoperative complication was noted with a follow-up of 24 months.

CLINICAL DISCUSSION

PET is typically diagnosed through clinical examination, characterized by an empty scrotum and a palpable perineal mass. The exact aetiology is unclear, but it involves abnormalities in testicular descent mechanisms, particularly the gubernaculum. PET can cause perineal discomfort when sitting, a symptom observed in the two pediatric cases presented. Early surgical intervention via orchidopexy is crucial to prevent complications. Both reported cases were successfully treated with no postoperative complications and resolution of discomfort. Prompt diagnosis and treatment are essential for preserving testicular function.

CONCLUSION

Perineal discomfort on sitting was the defining diagnostic element in our cases. In practice, this symptom should be a prompt for a thorough perineal examination in children with an empty scrotum. However, the patient's age and ability to express himself determine the significance of the symptom.

Management of abdominal textilomas: A retrospective study

INTRODUCTION

Textilomas are an infrequent but well-known surgical complication. The authors report a series of cases to describe the frequency of abdominal textilomas, the circumstances in which they occur, their clinical and morphological characteristics, and their management, to contextualise these data, which may serve as a basis for preventive measures.

SETTING AND METHOD

This was a monocentric, retrospective, descriptive study conducted over 10 years at a tertiary hospital. The circumstances of the initial intervention, the diagnosis, and the treatment of textiloma cases treated in the said centre were documented.

RESULTS

Twenty-one (21) cases of abdominal textiloma were collected, with an annual frequency of 2.1 cases/year. The cases were predominantly female, with a female-to-male sex ratio of 1.62. The median age of the patients was 37 years. The initial operation was performed in a public facility in 80.95 % of cases. Myomectomy was the main indication (23.81 %). The time for signs to develop before consultation was 16.47 ± 8.82 days. Textiloma extraction was performed in an emergency in 61.90 % of cases. We noted morbidity (38.10 %) and mortality (9.52 %) in our patients.

CONCLUSION

Textilomas are a rare surgical complication, albeit with a high morbidity and mortality rate. Their clinical polymorphism and the difficulties of diagnosis and management mean that prevention is of prime importance.

Transcutaneous oxygen tension-guided hyperbaric oxygen therapy for preventing skin necrosis after hyaluronic acid filler injections

Introduction

Hyaluronic acid (HA) fillers, popular for facial cosmetic enhancements, pose risks of vascular complications like skin necrosis due to arterial blockage, necessitating effective treatments such as hyperbaric oxygen therapy (HBOT).

Methodology

This study presents a series of cases where measurements of transcutaneous oxygen pressure (TcPO2) informed the application of HBOT for skin necrosis induced by HA.

Clinical presentation and outcomes

In cases 1 and 3, following the injection of HA, potential skin necrosis was observed. In addition to standard treatment, TcPO2 revealed values below 40 mmHg, indicating tissue hypoxia. Treatment with HBOT increased TcPO2 levels to above 200 mmHg, suggesting that HBOT could correct the hypoxia. Monitoring TcPO2 levels also aided in determining the optimal time to discontinue HBOT. In cases 2 and 4, patients received standard treatment, resulting in TcPO2 levels above 40 mmHg, indicating adequate tissue oxygenation, and no additional HBOT was administered. All four patients mentioned above showed good clinical recovery.

Conclusion

This study investigates the application of TcPO2 measurement technology in aiding decisions on whether to utilize HBOT in the treatment of complications arising from HA fillers, as well as in optimizing HBOT protocols.

Three twisted tales: A case series of caecal volvulus

INTRODUCTION

Caecal volvulus is a form of intestinal obstruction with life-threatening potential. While rare, it represents a perilous aetiology of intestinal blockage, with clinical manifestations spanning from abdominal discomfort to mortality.

CASE SERIES

We report the cases of three young adults (two males and one female) who presented to the emergency department with different manifestations of severe abdominal pain. All occurred within one month in a tertiary referral centre. Radiological evaluations confirmed the diagnosis of caecal volvulus in all. Subsequently, these individuals underwent right hemicolectomies with end-to-end anastomosis. All experienced an uncomplicated perioperative course.

CLINICAL DISCUSSION

Caecal volvulus is uncommon, but its yearly incidence is increasing. Early detection and a heightened level of suspicion lead to a timely diagnosis, reducing morbidity and mortality rates.

CONCLUSION

We report a case series of caecal volvulus, emphasizing its variable presentation and highlighting the critical importance of an early diagnosis. Typically, patients have a history of similar episodes that resolve without any medical intervention. Definitive treatment involves right hemicolectomy while conservative management is associated with very high recurrence rates. Early detection allows for prompt intervention, resulting in reduced morbidity and mortality rates.

Lateral transorbital neuroendoscopic approach for tumors of the orbital apex and spheno-orbital region: Technique, feasibility, efficacy, and safety based on a consecutive case series

Introduction

Surgical approaches for tumors of the orbital apex and the spheno-orbital region (SOR) comprehend medial and lateral corridors. The TransOrbital NeuroEndoscopic (TONE) approach has recently been reported as a possible effective alternative to the classic lateral corridors, but literature about is still underestimated.

Research question

The aim of this study was to make a critical appraisal of the results of using the lateral TONE approach in a monocentric consecutive series of SOR tumors.

Material and methods

Data from 38 consecutive patients managed surgically by means of a lateral TONE approach for a tumor involving the orbital apex and the SOR were collected and retrospectively reviewed from 2016, January 1st to 2023, December 31st.

Results

Mean age was 57 ± 14,9 years (23 female). 20 tumors were intraconal, with intradural involvement of SOR in 5 cases. Gross total resection was achieved in 82,9% of the 35 cases treated with a curative intent. Average operative time was 94,8 ± 28,5 and 140,2 ± 43,3 min for extraconal and intraconal tumors, respectively. Meningiomas had an overall prevalence of 31,6%. The complication rate was 21%, of which 87,5% transient. The recurrence rate was 0 for meningiomas and 14,3% for malignant tumors based on a follow-up of 55,3 ± 26,3 and 68,6 ± 17 months, respectively.

Discussion and conclusion

The lateral TONE approach is the approach of choice for tumors involving the lateral compartment of the orbital apex. It is also an effective and minimal invasive option in selected cases of spheno-orbital intradural tumors with no encasement of intracranial vessels.

Mesocolic hernia, a case series

INTRODUCTION AND IMPORTANCE

Paraduodenal hernias are difficult to diagnose due to their unusual presentation. Herein, five new cases are added to the literature.

CASE PRESENTATION

Four male and one female child complained of paraduodenal hernias, two on the right side and three on the left side. The intestinal part that herniated inside the hernia sac was also malrotated in four patients. One patient had Meckel's diverticulum with a herniated intestine. One infant had extrahepatic biliary disease, a single atrium, polysplenia, intestinal malrotation, and a left paraduodenal hernia. Exploratory labarotomy was done for reduction of the intestine, reorientation, and repair of hernia orifices.

CLINICAL DISCUSSION

Paraduodenal hernia is a component of malrotation. Cautious dissection of the hernia orifice is required to keep away from injuries to the inferior mesenteric vein or left colic artery in the course of the restoration of the left paraduodenal hernia. Also, the superior mesenteric vessels may be injured in the course of the restoration of the right paraduodenal hernia.

CONCLUSION

There is a correlation between the occurrence of PDH with malrotation. The diagnosis of malrotation can be made with an ultrasound abdomen; however, it is true that ultrasound cannot make a confirmed diagnosis in all patients. Once the diagnosis of a mesocolic hernia has occurred, surgical repair is mandatory by closure of the defect.

Delayed Wound Healing Resulting from Inflammatory Process in Craniectomy Patients Treated with BioGlue: A Case Series with Literature Review

Background  BioGlue is touted as a safe and effective sealant for various surgical procedures. This article describes five cases of delayed wound healing associated with the use of BioGlue after craniectomies. Case Description  Five patients of different genders and ages who had undergone craniectomy with BioGlue were presented to our medical center with wound dehiscence and purulent discharge. The first attempt to solve this problem by incision and drainage was unsuccessful. The removal of BioGlue is necessary to eliminate these problems. Discussion  The presence of wound dehiscence and aseptic cystic contents may indicate a chronic inflammatory process following the application of BioGlue. This problem usually occurs within a few months after wound closure. For rapid intervention, it is recommended to perform an incision and drainage and remove the BioGlue. The main risk factor is directly applying BioGlue to the skin, subcutaneous tissue, or titanium material. Conclusion  Neurosurgeons should exercise caution and be aware of a possible delayed chronic inflammatory process in surgical wounds associated with the use of BioGlue as a sealant, especially when the product is used without cranial coverage or in cases where it comes into direct contact with subcutaneous tissue or titanium material. To resolve this issue quickly, BioGlue should be completely removed at the first attempt at incision and drainage.

Right anatomical hepatectomy using extrahepatic glissonean pedicle approach combined liver hanging for hepatocellular carcinoma: surgical approach in a developing country

Backgrounds/aims

To evaluate the outcomes of hepatocellular carcinoma (HCC) patients who underwent right anatomical hepatectomy using the combination of the extrahepatic Glissonean pedicle approach (Takasaki's technique) and liver hanging maneuver (LHM) (Belghiti's technique).

Patients and methods

A retrospective analysis of 30 cases of HCC treated with right hepatectomy using extrahepatic Glissonean pedicle approach and LHM by only one surgeon at our department from March 2020 to August 2023. Clinical characteristics, pathological results, postoperative outcomes, and survival rate were analyzed.

Results

Among the 30 HCC patients analyzed, males accounted for 96.7% of patients. The mean age was 54.9±11 years. 96.7% had normal preoperative liver function (Child-Pugh A). LHM with an extrahepatic Glissonean approach was feasible in 100% of cases with minor blood loss, no blood transfusion, intraoperative complications, or perioperative mortality. The mean operative time was 123.8±29.0 min. The mean hospital stay was 9.37±4.02 days. Postoperative liver failure accounted for 6.7%. Pathological results: 63.3% moderately differentiated HCC; 36.7% poorly differentiated HCC. 1-year, 2-year, and 3-year survival rates were 86.1, 73.8, and 59.0%, respectively. Recurrence was witnessed in 13 (43.3%) cases, with 6 (20%) cases in remnant liver. 1-year, 2-year, and 3-year disease-free survival were 69.3, 42.0, and 28.0%, respectively.

Conclusion

Right anatomical hepatectomy using extrahepatic Glissonean pedicle approach combined LHM for HCC was feasible and safe at our high-volume oncology center in a developing country.

Rehabilitation of mandibular resected patients using fixed immediately loaded corticobasal implant -supported prostheses. A case series

INTRODUCTION AND IMPORTANCE

Aliments such as congenital conditions, pathological, and iatrogenic circumstances may result in mandibular defects that can severely disturb the patients' oral health, functions (mastication, speech), aesthetics, and quality of life and present a rehabilitating challenge.

CASE PRESENTATION

we present a multidisciplinary treatment approach for three cases presented with mandibular resection as a consequence of cystic, benign, and malignant tumour eradication that were rehabilitated with immediately loaded fixed corticobasal implant-supported prostheses and a follow-up period of 5,5 and 4 years. The reported cases present with excellent implant survival, along with healthy peri-implant tissues, stable prostheses, enhanced speech, chewing ability, aesthetics, superior patient satisfaction, and improved overall self-esteem.

CLINICAL DISCUSSION

A multidisciplinary oral and maxillofacial team is mandatory for the successful rehabilitation of patients with mandibular resection and to restore soft and hard tissue loss. The reported treatment modality offers the patient immediate fixed implant-supported prostheses omitting the need for a bone grafting procedure, with optimum peri-implant tissue health, excellent biomechanical and prosthetic results, and significant improvement in function and satisfaction.

CONCLUSION

Corticobasal fixed implant-supported prostheses can be a reliable treatment modality for mandibular resection, resulting in notable enhancements in the patients' oral health, appearance, mastication, speech, and self-esteem.

Treatment of histiocytic neoplasms with intralesional steroids: A case series report

INTRODUCTION AND IMPORTANCE

Rosai-Dorfman disease was first described in the 1960s and is characterized by hyperproliferation of histiocytes, which presents as painless lymphadenopathy with fever, night sweats, and weight loss. This disease often affects young adults and children of African descent. Different types of RDD exist, including familial, classical (nodal), extranodal, neoplasia-associated, and immune-associated. While this disease can cause significant pain, there is currently no consensus on treatment.

CASE PRESENTATION

This case series outlines three cases of bony involvement of histiocytic neoplasms and our technique for intralesionoal steroid injections. Two cases were successfully treated with intralesional steroid injections and one patient was treated with oral steroids.

CLINICAL DISCUSSION

Histiocytic neoplasms can cause significant pain for patients and there is no standardized treatment as of yet. An interesting finding on MRI was a characteristic peripheral edema we termed the "Halo Sign". Steroids are believed to exert their benefit in treating this disease by apoptosis and reducing tumoral swelling.

CONCLUSION

This case series demonstrates the successful management of bony involvement of RDD with intralesional steroids similar to eosinophilic granuloma. While intralesional steroid injection has previously been described for other types of RDD, this is the first description of bony RDD treated with this technique to our knowledge.

Can we improve therapeutic compliance in cancer patients? Report of a cross-sectional case series study in Morocco

Therapeutic compliance (TC) refers to the patient's compliance with the prescriptions and recommendations of a doctor. Patients with cancer often exhibit unsatisfactory TC. The objective of our study was to assess TC levels in cancer patients and identify predictors of poor compliance. The authors conducted a cross-sectional study in March 2023 at the oncology centre, where the vast majority of medical activity is performed in the day hospital. TC was measured using a questionnaire or survey. Various parameters were analyzed to identify predictive factors of poor therapeutic compliance. The authors' study included 175 cancer patients with a mean age of 55 years. The study revealed that 85% exhibited good compliance (GC) as indicated by the CI [8.500 ± 0.075], signifying patients who consistently adhered to their medication schedule. Conversely, 15% demonstrated poor compliance (PC), as indicated by the confidence interval [0.825 ± 0.750]. Compliance status was assessed by considering patients who adhered to the prescribed medication timing as good compliance (GC) and those who did not adhere as poor compliance (PC). The analysis of our study results indicated that poor therapeutic compliance was associated with low socio-economic and educational levels. Therefore, it is important to utilize all available resources to improve therapeutic compliance. The majority of factors contributing to poor compliance can be mitigated through effective coordination between the patient and their support network.

Encysted spermatic cord hydrocele: A case series

INTRODUCTION AND IMPORTANCE

Encysted spermatic cord hydrocele is a rare anomaly characterized by obstruction of processus vaginalis closure. Clinically, it presents as a swelling in the inguinal region extending to the upper scrotum and does not communicate with the peritoneal cavity. It is often mistaken for indirect inguinal hernias, inguinal lymphadenopathy, undescended testis, and primary tumors of the cord in infants and children, making the diagnosis challenging.

CASE PRESENTATION

We report the cases of five male patients aged nine months to 12 years who presented with painless swelling on the right side of the scrotal region. Physical examination revealed firm masses in the right inguinal region with positive transillumination, negative cough impulse tests, and irreducibility. Inguinal and scrotal ultrasonography showed an anechoic cystic lesion with thin walls, without any signs suggestive of a hernia. Patients were diagnosed with encysted spermatic cord hydrocele and advised to undergo cyst excision. The postoperative periods were uneventful, and expected recovery was observed at one-week and one-month follow-ups.

CLINICAL DISCUSSION

Encysted spermatic cord hydroceles are rare causes of painless inguinal swelling. The medical history and clinical findings can be used to establish a diagnosis, which can be confirmed using ultrasonography. Management depends on differentiating between spermatic cord hydrocele and scrotal hydrocele and involves considering the type. Treatment options range from conservative measures to surgery, particularly for non-communicating hydroceles that persist beyond 12-18 months or enlarge in size.

CONCLUSION

Encysted hydrocele of the cord is rare and is often mistaken for indirect inguinal hernias in infants and children. This similarity makes the diagnosis challenging and necessitates vigilance from clinicians. Surgical intervention results in optimal outcomes, especially in cases where the hydrocele persists beyond 12-18 months or with size progression.

Liver pucker sign: predictor of difficult laparoscopic cholecystectomy: a case series

Introduction

Pucker sign is the depression of the liver in the region of the gallbladder due to a high degree of chronic contractive inflammation of the gallbladder. It usually develops in patients who have a delayed cholecystectomy after acute cholecystitis due to a high degree of chronic contractive inflammation of the gallbladder and contraction of the cystic plate. It is an essential finding either preoperatively or intraoperatively as it can act as a stopping rule during cholecystectomy (act as a guide that cholecystectomy will be difficult).

Case series

The authors here report three cases of pucker sign that were incidentally discovered during laparoscopy.

Discussion

Chronic cholecystitis is a prolonged, subacute condition caused by inflammation of the gallbladder, which mostly occurs in the setting of cholelithiasis. Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Hence, it would be beneficial to be aware of reliable signs that predict difficult Laparoscopic cholecystectomy. Pucker sign usually predicts increased operative difficulty as there is an operative danger of biliary or vascular injury.

Conclusion

The pucker sign is a novel indicator of significant persistent inflammation and heightened difficulty during surgery. It might establish a halting rule that modifies the procedure's management and raises its level of safety.

Management of high-grade pediatric renal trauma in tertiary referral hospital in Indonesia: A case series and literature review

INTRODUCTION AND IMPORTANCE

Genitourinary tract injuries constitute 10 % of all traumas, with renal injuries being common in pediatric cases due to reduced perirenal fat and abdominal wall muscle development. However, very few reports of pediatric renal trauma in Indonesia have been reported. In this case series, We present a case series of high-grade renal injury and review the literature on pediatric renal trauma in Indonesia.

CASE PRESENTATION

We present four cases with renal trauma as the subjects of this case study. The 13-year-old boy, who was the initial patient, complained of hematuria and abdominal pain after falling from a tree. The second patient, the 13-year-old boy, presented with left lower back pain and hematuria after being elbowed in the left waist. The third patient, a 14-year-old boy, had been in a motorcycle accident and got grade 5 renal injury according to AAST classification. The final case involved a 4-year-old boy who experienced recurrent hematuria caused by a pseudoaneurysm following blunt renal trauma.

DISCUSSION

Trauma is the leading cause of morbidity and mortality in children, with approximately 3 % of children assessed in pediatric hospital trauma departments having had trauma. With appropriate management according to guidelines, mortality can be avoided.

CONCLUSION

The case series highlights the significance of treating pediatric renal trauma patients individually according to their hemodynamic state and degree of impairment.

The resolute Onyx in TIA management (ROTIA)

BACKGROUND

First-line treatment for symptomatic intracranial atherosclerotic disease (ICAD) is medical management; however, interventional approaches are increasingly considered for refractory disease. The Resolute Onyx in TIA management (ROTIA) study is a post-market evaluation of the Resolute Onyx (R-Onyx) drug-eluting stent in the treatment of recurrent transient ischemic attacks (TIAs) due to refractory ICAD (off-label use).

METHODS

This is a single-center, retrospective case series of consecutive patients who underwent angioplasty and stenting with R-Onyx for treatment of recurrent TIAs due to refractory ICAD from October 2019 to November 2022. Included patients were ages 22-80, had a baseline modified Rankin Scale of ≤2, and had recurrent TIAs attributed to intracranial artery stenosis >70% despite maximal medical therapy. Primary outcomes of interest were peri-procedural complications (TIA, stroke, intracranial hemorrhage, mortality) up to 72 h post-stenting and ischemic stroke up to 18 months post-stenting.

RESULTS

Twenty patients (mean age 66.84 ± 14; 25% female; 80% Hispanic) were included. A total of 21 stents were successfully deployed with no peri-procedural complications. There were no recurrent ischemic events at 30 days post-stenting. At 18 months post-stenting, there were no ischemic events and no patient exhibited in-stent restenosis.

CONCLUSION

ROTIA demonstrates the feasibility of using the Resolute Onyx drug-eluting stent for the management of TIAs due to refractory ICAD, with high technical success and low peri-procedural complications. Limitations include the retrospective and single-center nature of this study. Future prospective, multi-center, randomized trials with extended observation periods are needed.

Enhancing the quality of evidence, comparability, and reproducibility in brain arteriovenous malformations treated with open surgery research: a systematic review and proposal of a reporting guideline for surgical and clinical outcomes

Brain Arteriovenous Malformations (bAVMs) are rare but high-risk developmental anomalies of the vascular system. Microsurgery through craniotomy is believed to be the mainstay standard treatment for many grades of bAVMs. However, a significant challenge emerges in the existing body of clinical studies on open surgery for bAVMs: the lack of reproducibility and comparability. This study aims to assess the quality of studies reporting clinical and surgical outcomes for bAVMs treated by open surgery and develop a reporting guideline checklist focusing on essential elements to ensure comparability and reproducibility. This is a systematic literature review that followed the PRISMA guidelines with the search in Medline, Embase, and Web of Science databases, for studies published between January 1, 2018, and December 1, 2023. Included studies were scrutinized focusing on seven domains: (1) Assessment of How Studies Reported on the Baseline Characteristics of the Patient Sample; (2) Assessment and reporting on bAVMs grading, anatomical characteristics, and radiological aspects; (3) Angioarchitecture Assessment and Reporting; (4) Reporting on Pivotal Concepts Definitions; (5) Reporting on Neurosurgeon(s) and Staff Characteristics; (6) Reporting on Surgical Details; (7) Assessing and Reporting Clinical and Surgical Outcomes and AEs. A total of 47 studies comprising 5,884 patients were included. The scrutiny of the studies identified that the current literature in bAVM open surgery is deficient in many aspects, ranging from fundamental pieces of information of methodology to baseline characteristics of included patients and data reporting. Included studies demonstrated a lack of reproducibility that hinders building cumulative evidence. A bAVM Open Surgery Reporting Guideline with 65 items distributed across eight domains was developed and is proposed in this study aiming to address these shortcomings. This systematic review identified that the available literature regarding microsurgery for bAVM treatment, particularly in studies reporting clinical and surgical outcomes, lacks rigorous scientific methodology and quality in reporting. The proposed bAVM Open Surgery Reporting Guideline covers all essential aspects and is a potential solution to address these shortcomings and increase transparency, comparability, and reproducibility in this scenario. This proposal aims to advance the level of evidence and enhance knowledge regarding the Open Surgery treatment for bAVMs.

Enigmatic echoes: Exploring brainstem neurenteric cysts - A case series and literature review

INTRODUCTION AND IMPORTANCE

Neurenteric cysts (NCs) are rare congenital anomalies within the central nervous system, originating from the endodermal layer due to inappropriate embryonic notochordal plate and endoderm separation. Despite constituting a minute fraction of CNS tumors, their diverse clinical presentations and brainstem occurrence pose diagnostic challenges.

CASE PRESENTATION

This study presents a series of three brainstem NCs, detailing demographics, clinical presentations, radiological features, and operative findings. Patients aged 2-40 years exhibited varied symptoms including headaches, vomiting, cranial nerve deficits, and motor/sensory deficits. Literature review of 27 cases showed a mean age of 26.8 years, predominantly in females, with diverse cystic characteristics on MRI. Surgical intervention achieved mostly complete resection, with varying outcomes including recurrence and malignant transformation.

CLINICAL DISCUSSION

This study sheds light on the rare entity of brainstem NCs, emphasizing their diagnostic complexity. NCs, though constituting a minute fraction of CNS tumors, present a diagnostic challenge due to their diverse clinical presentations and rarity in the brainstem.

CONCLUSION

This study provides insights into brainstem NCs, emphasizing diagnostic complexity and the importance of MRI in accurate diagnosis and surgical intervention. Enhanced collaboration is needed to refine management strategies for these intriguing lesions.

Surgical outcomes for carotid body tumour resection without preoperative embolization: a 10-year experience

Background

Carotid body tumours (CBTs) are neoplasms originating from the paraganglionic cells of the carotid body. Excision is the main route of treatment. This study sought to assess the surgical outcomes of post-carotid body tumour resection without preoperative embolization and discern any underlying relationships between modified Shamblin classes (MSC) and related complications.

Methods

A retrospective medical record review of prospectively collected data is performed at Sulaymaniyah Teaching Hospital between 2008 and 2019, for 54 patients. Presurgical and postsurgical variables such as comorbidities and complications were noted, respectively.

Results

Patient ages ranged between 26 and 60 years (x̄=40.06) with a minimal female predominance (57.4%). Complications included one minor stroke. MSC and postoperative complications were significantly related (P≤0.001). Our analyses also suggested a significant relationship between intraoperative blood loss and the incidence of postoperative complications (P=0.001, χ²=25). The MSC III subtype was significantly associated with intraoperative blood loss (P=0.000), length of stay (P=0.000), and operating time (P=0.001).

Conclusions

Our study purports a strong relationship between greater MSC and complications of all types. As such, surgeons may benefit from preoperative strategies to minimize complications.

Unveiling the complexity of right middle lobe syndrome: a case series highlighting the association with asthma

Introduction and importance

Right middle lobe syndrome (MLS) is a rare lung disorder primarily affecting children with a history of asthma or atopy. It encompasses a range of pathological and clinical conditions, from recurrent collapses of the middle lobe to bronchiectasis. In this study, the authors present a case series featuring four individuals with MLS associated with asthma, aiming to deepen our understanding of this uncommon condition.

Case presentation

Four paediatric patients with right MLS exhibited symptoms of persistent cough, dyspnoea, and recurrent asthma exacerbations. Radiographic evaluations confirmed features consistent with right MLS, and bronchoscopy revealed mucus plugs and oedematous airways obstructing the right middle lobe bronchus. Treatment with bronchodilators, antibiotics, and corticosteroids led to symptom improvement and resolution of atelectasis.

Clinical discussion

MLS is a rare condition characterized by chronic collapse of the right middle lobe and bronchiectasis. It is challenging to diagnose MLS, but computed tomography (CT) scans provide detailed lung images for confirmation. Treatment focuses on addressing the underlying cause, such as infections or mucus obstruction. Lobectomy may be considered in severe cases. This case series emphasizes the need for further research on MLS, as its rarity and characteristics remain unclear.

Conclusion

These cases exhibited obstructive MLS with and without asthma. Accurate diagnosis is challenging, requiring imaging techniques. MLS has clinical implications, particularly in asthma patients. Future studies should focus on understanding the aetiology of non-obstructive MLS.

Clinical manifestations, diagnosis, and management of first branchial cleft fistula: Case series and review of the literature

INTRODUCTION AND IMPORTANCE

The first branchial cleft (FBC) is an extremely rare occurrence, manifesting as cysts, sinuses or fistula. Among all branchial anomalies, FBC represents 8-10 % of branchial clefts. It accounts for about 17 % of all cervical masses in childhood. FBC can be caused by inadequate removal or closure of the ectoderm. The location of the fistula can be adequately determined by magnetic resonance imaging (MRI).

CASE SERIES PRESENTATION

We report three cases from the first branchial cleft fistula (FBCF) in our ENT Department with a good response to surgical treatment. Patients had an average of 24 months of follow-up. The aim of our study is to study the clinical manifestations, the diagnosis and the surgical management of the FBCF.

DISCUSSION

An in-depth knowledge of the embryology of the neck and face will ensure early diagnosis and complete surgical resection of FBCFs, which will minimize the risk of severe complications including facial paralysis.

CONCLUSION

FBC is rare and may present as a cyst or fistula. It is managed by surgical excision, leaving the tract cyst of the fistula intact with preservation of the facial nerve.

Modified intermittent low negative pressure wound therapy for complex injuries: A case series

INTRODUCTION AND IMPORTANCE

Combat wounds can be difficult to manage and can lead to disfigurement and infection. The closure of these wounds is crucial, as delayed closure also increases the risk of further complications. Military medicine has introduced negative pressure wound therapy, which modulates wounds perfectly through the microscopic and macroscopic configurations of the wound environment. It is expensive and not available worldwide, and several modifications using low cast materials were mentioned in literature.

METHODS

We present a case series of four patients using the previously mentioned modified technique in combat wound management, and discuss the results, outcome, and justification for choosing this modality of treatment. All patients underwent a thorough debridement, followed by a modified negative pressure wound treatment for three weeks, employing readily available medical devices.

RESULTS

All wounds healed successfully without complication and a simple closure was used to cover the resultant wound.

CONCLUSION

Modified NPWT with limited resources is capable of promoting healing in conflict-related wounds through multifactorial properties and transforming reconstructive methods from complex to simple procedures in areas with a shortage of medical supplies and surgeons in addition to busy operating rooms.

Microsurgical treatment of posterior circulation aneurysms: an institutional experience from Nepal

Background

Management strategies and outcomes of patients with posterior circulation aneurysms are varied due to uncertainty in the optimal treatment modality and limited experience of neurosurgeons. Data are scarce regarding patients with posterior circulation aneurysms from developing countries. This study aims to describe the clinical characteristics, management strategies and outcome of patients with these aneurysms treated microsurgically in an academic institute in Nepal.

Methods

The clinical records of patients confirmed to have posterior circulation aneurysms treated microsurgically between July 2014 and July 2022 were retrospectively reviewed. Demographic and clinical characteristics, morphometric characteristics of aneurysms, management strategies, postoperative complications, and 1-year outcomes were described.

Results

Out of 220 aneurysms in 190 patients, 20 were posterior circulation aneurysms. The median age of the patients was 43 (15-60) years. All were ruptured aneurysms. The admission Hunt and Hess grades of 18 (90%) patients were less than or equal to III. The posterior inferior cerebellar artery (8) was the commonest location. The postoperative complications rate was 20%, with the overall mortality of 10%. 80% of patients had a favourable outcome at 1-year follow-up.

Conclusions

The patient characteristics and outcome are comparable with those described in the literature from other countries. With an individualized and careful selection strategy, our results are satisfactory despite fewer operations.

A case series of clinical characteristics and prognosis of congenital hepatoblastoma in a single center

INTRODUCTION AND IMPORTANCE

Congenital hepatoblastoma is an exceedingly rare neoplasm, predominantly documented as isolated instances, with contentious aspects surrounding its therapeutic approaches and prognostic implications. This study aims to comprehensively summarize and evaluate the management experience of congenital hepatoblastoma (CHB).

CASE PRESENTATION

This cohort comprised five infants diagnosed with hepatoblastoma, confirmed through pathological examination, and with an onset of symptoms before 28 days of age. They were enrolled between November 2019 and May 2022. The treatment course they underwent has been summarized, and their prognosis has been subject to analysis.

CLINICAL DISCUSSION

Distinguishing congenital hepatoblastoma from other medical conditions is typically necessary. Given the patient's tender age, the approach to treatment demands comprehensive assessment, particularly in cases involving unique tumor locations or substantial tumor sizes. The selection of treatment modalities, encompassing preoperative neoadjuvant chemotherapy and surgical techniques, becomes of paramount importance. Furthermore, determining the treatment's endpoint poses a notable challenge and often necessitates a comprehensive evaluation.

CONCLUSION

For pediatric patients afflicted with CHB, the application of preoperative neoadjuvant chemotherapy mitigates surgical risks, while the incorporation of surgical procedures followed by postoperative chemotherapy significantly enhances the overall prognosis. Additionally, AFP-L3% levels may serve as a valuable adjunctive marker signifying the conclusion of treatment.

Malignant degeneration of thyroglossal duct cysts: Clinical aspects, imaging findings and management: Case series

INTRODUCTION AND IMPORTANCE

Thyroglossal duct cysts (TDCs) are congenital anomalies that can rarely undergo malignant transformation, with approximately 1 % of operated TDCs demonstrating malignant degeneration. Therapeutic management and follow-up methods are still controversial subjects.

CASE SERIES PRESENTATION

We report 3 cases of a papillary carcinoma of thyroid occurring in a thyroglossal duct cyst. The diagnosis was suspected preoperatively in 2 patients, hence the indication of frozen section examination. All patients underwent Sistrunk procedure associated with total thyroidectomy and central neck dissection. Concomitant papillary thyroid carcinoma was found in 2 patients. A complementary treatment by radioactive iodine 131 with frenetic hormone therapy was undertaken in all the cases. The follow-up showed no recurrence.

CLINICAL DISCUSSION

The clinical presentation of thyroglossal duct cyst carcinoma is often nonspecific, posing challenges in early diagnosis. The chosen treatment strategy, involving the Sistrunk procedure, total thyroidectomy, and central neck dissection, along with adjuvant therapy using radioactive iodine 131 and frenetic hormone therapy, was effective in preventing recurrence.

CONCLUSION

The management of degenerated TDC is based on a multidisciplinary approach. Papillary carcinomas of TDC generally have a good prognosis.

Challenges and perspectives of abdominal pregnancy in a resource-limited setting: A case series

INTRODUCTION AND IMPORTANCE

Abdominal pregnancies, although rare, present unique challenges in both diagnosis and management. This case series reports on four cases of abdominal pregnancies diagnosed in a remote and underserved region of the Democratic Republic of Congo, highlighting the difficulties encountered in an under-equipped environment.

CASE PRESENTATION

The cases were documented in a remote village of DRC, which lacks specialized medical personnel and relies heavily on traditional healers. We report here 4 cases of abdominal pregnancies, their clinical presentations, diagnostic modalities, and surgical approaches. The cases varied in terms of clinical symptoms, gestational age, and placental implantation sites. Delayed diagnosis and presentation were common, resulting in significant hemoperitoneum and adverse fetal outcomes. All cases required laparotomy for both diagnosis and intervention.

CLINICAL DISCUSSION

Abdominal pregnancies can go undetected until advanced gestational age, with common physical findings including abdominal tenderness, abnormal fetal lie, fetal body parts readily palpable, and a displaced cervix. Laboratory tests may raise suspicion, but treatment options depend on intraoperative findings and gestational age. Advanced abdominal pregnancies are associated with high mortality rates for both the mother and the fetus. Laparotomy is typically required for diagnosis and intervention, with variations in placental implantation sites. Management of the placenta remains a debated topic, with partial or complete removal both viable options.

CONCLUSION

Abdominal pregnancies pose significant challenges in resource-poor settings, where limited healthcare resources and a shortage of specialized medical personnel can impede early diagnosis and appropriate management. Enhancing prenatal care, improving diagnostic capabilities, and increasing awareness among healthcare providers and communities are essential for optimizing outcomes in these complex obstetric cases.

Epidermoid cyst of central nervous system: A case series and review of literature

INTRODUCTION

Epidermoid cysts, originating from ectodermal cell remnants during embryogenesis, are rare, slow-growing tumours commonly found in the cerebellopontine angle, fourth ventricle, and sellar/parasellar regions. This retrospective study explores clinicopathological features, demographics, and radiological details of fifteen central nervous system epidermoid cyst cases over three years.

MATERIALS AND METHODS

Histologically confirmed cases undergoing surgical excision from July 2020 to July 2023 were retrospectively evaluated. Patient age, clinical presentations, radiological features, and histopathological findings were analyzed using descriptive statistics and aligned with the PROCESS criteria.

RESULTS

Fifteen cases, spanning various age groups and clinical presentations, were included. There were four cases each in the posterior fossa and cerebellopontine angle, three in temporal region, two in intraspinal region, and one each in the retromastoid intra-diploic and third intra-ventricular region. Lesions exhibited diverse distribution, gross findings, and microscopic features. Radiological imaging exhibited well-defined hypo-attenuated masses on computed tomography and contributed to the preoperative diagnosis in eight cases. Despite challenges in complete excision due to adherence, 13 cases underwent successful resection. Chemical meningitis, a common postoperative complication, underscores the importance of meticulous surgery.

CONCLUSION

This study highlights clinicopathological characteristics, challenges in surgical management, and postoperative complications of central nervous system epidermoid cysts. Comparative analysis with existing literature emphasizes the uniqueness of epidermoid cysts, differentiating them from craniopharyngiomas and dermoid cysts. Despite the retrospective design, valuable insights are provided, emphasizing the need for prospective studies. Effective management involves complete excision, ensuring long-term remission and emphasizing the distinctive nature of these intriguing intracranial lesions.