Thyroid abscess, an uncommon diagnosis: A case report and mini‑review of the literature

Thyroid abscess is a rare entity, commonly experienced by immunocompromised patients, or those who have anatomical abnormalities or a pre-existing thyroid disease. An early diagnosis continued by treatment with antibiotics and drainage of the abscess is the recommended therapeutic strategy for such cases. The present study describes a clinical case of this rare event, and also provides a brief literature review. The present study describes the case of a 48-year-old healthy male with no medical antecedents, apart from acute prostatitis treated with antibiotics for 6 days prior, who visited the Emergency Department of the authors' hospital with neck pain and progressive swelling of the mass. Diagnostic imaging confirmed the authors' suspicion of an abscess and revealed the lesion displacing the airway to the contralateral side. This restricted the mobility of the neck of the patient. As an emergency measure, the patient was then taken to the operating room for a neck examination. A hemithyroidectomy was finally performed. Following a prolonged hospital duration, he was discharged from the hospital and his recovery was uneventful without any voice alterations, hypocalcemia or recurrence.

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago

BACKGROUND

Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA.

METHODS

This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up.

RESULTS

564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections.

CONCLUSIONS

After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Single metachronous bone metastasis following rectal adenocarcinoma: A case report

Colorectal cancer (CRC) ranks as the third leading cause of cancer-related mortality in developed countries. While its incidence in early stages has increased due to screening programs, a significant number of patients experience the development of metastases either at the time of diagnosis or during follow-ups. Unlike certain other types of cancer, such as breast, prostate, or lung cancer, where bone tissue is a common site for secondary dissemination, CRC primarily spreads to the lymph nodes, liver and lungs. The occurrence of bone metastases from CRC is rare and usually coincides with tumor involvement in other locations. Risk factors for bone metastases include the location of the primary tumor, the age of the patients, KRAS mutations and the degree of tumor differentiation. Unlike metastases to the liver and lungs, bone metastases tend to be symptomatic, affecting the patient's quality of life and resulting in a poorer prognosis with shorter survival rates. The approach to patient management needs to be personalized. The present study describes the of a patient who underwent surgery for stage IV rectal adenocarcinoma and later developed a metastasis in the costal wall 79 months post-intervention, with no evidence of recurrence at other sites.

Spontaneous cervical hematoma caused by giant parathyroid adenoma in an elderly patient: A case report

Spontaneous cervical hematoma usually occurs as a consequence of extracapsular bleeding from a parathyroid gland, generally due to the presence of an adenoma (giant adenoma), glandular hyperplasia, cystic component, or, less frequently, due to the existence of a carcinoma. The hematoma can be confined to the cervical compartment or extend to the mediastinum, potentially causing airway compression. Despite this, the recommended management in hemodynamically stable patients consists of surveillance and hospital monitoring with delayed surgery after a few weeks. On the other hand, in those patients with airway compromise and instability, emergency surgery, consisting of cervicotomy and drainage, is mandatory. The present study describes the case of a 78-year-old patient with a medical history of high blood pressure, non-insulin-dependent diabetes mellitus, dyslipidemia, moderate aortic stenosis, chronic kidney disease and sarcoidosis under pharmacological treatment who attended the emergency department due to symptoms of neck pain, an increase in soft tissue, and dyspnea on moderate exertion with an evolution leading to respiratory failure. This was secondary to a diagnosis of spontaneous cervical hematoma that required urgent surgical intervention. The results of histopathological analysis revealed that a giant parathyroid adenoma was responsible for the bleeding. The patient had a complicated post-operative period with a prolonged admission to the intensive care unit.

Malignant Bowel Obstruction Due to Intraluminal Metastasis of Endometrial Adenocarcinoma Located in the Sigmoid Colon After Nine Years of Follow-Up

Endometrial adenocarcinoma is currently the most common malignant tumor of the female genital tract. In the early stages, surgical or radiotherapy treatment offers high survival rates and excellent prognosis, although late recurrences have been described. Recurrences of endometrial adenocarcinoma are more frequent in the vaginal vault; however, implants are sometimes detected in the serosa of the colon and rectum, resulting in extrinsic compression. Here, we present the case of a 77-year-old patient with a clinical history of hysterectomy, lymphadenectomy, and double adnexectomy for endometrial adenocarcinoma (International Federation of Gynecology and Obstetrics (FIGO) Ia). Nine years after the initial treatment, she presented an endoluminal recurrence in the sigmoid colon, which is exceptional. The patient underwent surgery by performing an oncological sigmoidectomy. The immunohistochemical study revealed the tumor origin as metastasis of endometrial adenocarcinoma. The patient had a favorable postoperative period, subsequently receiving adjuvant therapy and being disease-free after 18 months of follow-up.

Gallbladder Volvulus in an Elderly Patient: A Case Report and Review of Literature

Gallbladder volvulus is an uncommon cause of acute cholecystitis that results from the rotation of the gallbladder about its mesentery along the axis of the cystic pedicle. We present the case of an 87-year-old woman with acute abdominal pain in the right upper quadrant that began two days prior with no additional symptoms. The physical examination showed a large abdominal eventration on the right side and tenderness. A CT scan showed a distended gallbladder outside its liver bed and with a twist on its cystic pedicle, suggesting a gallbladder volvulus. Abdominal ultrasonography complementary revealed the gallbladder outside its vesicular fossa with incipient changes of acute cholecystitis but without evidence of gallstones. With the diagnosis of acute abdomen secondary to gallbladder volvulus, an emergency cholecystectomy was performed. The exact etiology of the gallbladder volvulus is unknown, although anatomical variants that predispose to its appearance have been described. The clinical presentation is similar to acute cholecystitis, so preoperative diagnosis can be challenging for both surgeons and radiologists and is often misdiagnosed. This is one of the few cases diagnosed with preoperative imaging techniques. Once diagnosed, the appropriate treatment is emergency cholecystectomy. Early diagnosis and surgical treatment are important before it progresses to necrosis, perforation, biliary peritonitis, and hemodynamic instability. Gallbladder volvulus is an uncommon condition. A high index of suspicion is required because the preoperative diagnosis is unusual. Once the diagnosis is established, the treatment is fundamentally surgical.

Malignant adipocytic tumours: A 20‑year single‑centre retrospective study

Adipocytic tumours are the most common soft tissue neoplasms. Among them, liposarcoma is the most frequent malignant neoplasm. However, to the best of our knowledge, no previously published study has assessed the evolution and oncological prognosis of the different subtypes of liposarcoma at the retroperitoneal level compared with at other locations. The present study is a retrospective observational study in which all patients were operated on between October 2000 and January 2020 with a histological diagnosis of liposarcoma. Variables, such as age, sex, location, histological type, recurrence, type of treatment and mortality, among others, were analysed. The patients were divided into two groups: Group A (retroperitoneal location) and group B (non-retroperitoneal location). A total of 52 patients with a diagnosis of liposarcoma (17 women and 35 men) and a mean age of 57.2±15.9 years were assessed. A total of 16 patients were classified into group A and 36 into group B. The OR of recurrence was 1.5 (P=0.02) for R1 vs. R0 resection in group A. The OR of recurrence in group B for R1 vs. R0 resection was 1.8 (P=0.77), whereas for R2 vs. R0 resection, the OR was 69 (P=0.011). In conclusion, 52 cases of malignant adipocytic tumours collected during 2000-2020 were analysed with the new World Health Organization classification (updated 2020). Although its recurrence potential and capacity for distant metastasis depended on each histological type, surgical treatment with unaffected margins was the main prognostic factor for survival. The present study identified differences in relation to the survival of each histological subtype and its location, finding greater survival in dedifferentiated liposarcoma, myxoid liposarcoma and pleomorphic liposarcoma located at the extraperitoneal level than in the retroperitoneal location. Resectability was not influenced by liposarcoma location.

Association of Age and Surgical Technique with the Quality of Life of Male Patients Treated for Abdominal Aorta Aneurysms: A Cross-Sectional Study

OBJECTIVES. The achievement of a good health-related quality of life (HRQoL) has become one of the primary objectives of medical–surgical interventions. The objective of this study is to determine the HRQoL of patients who underwent abdominal aortic aneurysm (AAA) surgery and to analyse the influence of age on HRQoL. MATERIALS AND METHODS. This is an observational cross-sectional study with 151 male patients who underwent an operation for AAAs between January 2013 and December 2020 in two hospital centres. HRQoL was assessed with the Spanish version of the 36-Item Short Form Survey (SF-36), starting in the month following the surgical intervention. Statistical analyses were performed using hypothesis tests and multivariate linear regression. RESULTS: The mean age of the patients was 73 years (SD: 7), and the mean interval between surgery and the interview was 37 months (SD: 27). The scores of the Physical Function (p = 0.001), Vitality (p = 0.016), Social Function (p = 0.014), and Mental Health (p = 0.007) dimensions of the SF-36 were significantly lower in the older age groups. In addition, the scores on the Physical Summary Component (p = 0.003) and the Mental Summary Component (p = 0.026) were significantly lower among individuals older than 70 years of age. The HRQoL in patients who underwent operations for AAAs was similar to that reported in the general population of Spain. Patients with an aorto-aortic shunt had better scores on the Physical Function (Beta: 10; p = 0.014) and Mental Health (Beta: 8.12; p = 0.040) dimensions than those who had an aorto-bi-iliac or bifemoral shunt, regardless of the age of the patients at operation. CONCLUSION: Among patients who underwent an operation for an AAA, there was a negative association between the age at operation and scores on the Physical Function, Vitality, Social Function, and Mental Health dimensions of the SF-36. The type of surgical technique influences the evolution of Physical Function and Mental Health scores, regardless of age.

Clostridium perfringens necrotizing pancreatitis: an unusual pathogen in pancreatic necrosis infection

Pancreatic necrosis infection (PNI) accounts for about 20–40 % of severe acute pancreatitis. PNI caused by anaerobic bacteria is unusual but when they present, Clostridium perfringens is the microorganism most commonly involved. We present a 60-year-old patient with a previous history of SARS-CoV-2, diagnosed with acute pancreatitis. During the hospitalisation he developed Clostridium perfringens bacteraemia. A CT-scan showed pancreatic gas gangrene and a surgical necrosectomy was performed. Clostridium perfringens was isolated in cultures of the pancreatic tissue and collections. The patient’s clinical status improved after surgery and the appropriate medical therapy. He was discharged 76 days after admission. Nowadays, the ‘step-up approach’ is an accepted therapeutic tool in treatment of pancreatic necrosis and peripancreatic fluid collections. However, most authors suggest that Clostridum perfringens infection requires a more aggressive approach due to the high mortality associated to clostridial infection.

Surgical Treatment of Gallstone Ileus: Less Is More

<b><i>Introduction:</i></b> The objective of this study was to evaluate the need for cholecystectomy in patients who underwent surgery for gallstone ileus. <b><i>Methods:</i></b> This was a retrospective review of the clinical history of patients who underwent surgery for gallstone ileus between December 1992 and December 2018 and follow-up until October 2020. Data regarding the surgical intervention, location of the obstruction, and surgical procedure performed were collected, as well as complications in relation to biliary pathology in the postoperative period. <b><i>Results:</i></b> Twenty-five patients underwent surgery for gallstone ileus. In all patients, except one, the site of the obstruction was identified. The mean age of the patients was 72 (standard deviation [SD] 13.3) years, with a female predominance (18: 7). The patients presented symptoms, on average, 2.9 (1–7) days before going to the emergency room; the primary symptoms were vomiting associated with abdominal pain and constipation (56%). Fifty-six percent of patients were diagnosed preoperatively by imaging tests. In 72% of patients, an enterolithotomy was performed alone without any other intervention on the gallbladder or bile duct. Eighty-three percent of the patients did not present any cholecystobiliary complications during the entire follow-up period, and urgent or delayed cholecystectomy was not performed after the acute episode. <b><i>Conclusions:</i></b> Gallstone ileus is a rare entity, and there are no randomized studies that support a preferred treatment. If surgical intervention is required, enterotomy for stone extraction is a safe and effective technique, and in our experience, urgent or delayed cholecystectomy is not necessary.

Prognostic factors of survival in stage IV colorectal cancer with synchronous liver metastasis: Negative effect of the KRAS mutation

The aim of the present study was to identify predictive parameters of survival in patients affected by stage IV colorectal cancer with synchronous and bilateral liver metastases. A retrospective cohort study was performed. Patients diagnosed between January 2013 and December 2018 were included in the present study. Data on the histopathological, clinical and treatment factors (chemotherapy as the first measure or resection of the primary tumor) were collected. The effect of each variable on survival was evaluated using Cox regression analysis. A total of 104 patients were included [43 women (41.3%) and 61 men (58.7%); mean age, 63 years]. The long-term survival rate at 36 months was 29% (median, 25 months). Kaplan-Meier analysis was used to estimate that survival was higher in patients with wild-type KRAS tumors (42%) than in patients with mutated KRAS tumors (9%; P=0.001). In the multivariate analysis, KRAS mutation (HR, 2.484; 95% CI, 1.472-4.192), T4 tumors (HR, 1.795; 95% CI, 1.045-3.084), resection/local treatment of hepatic metastases (HR, 0.447; 95% CI, 0.222-0.901), Eastern Cooperative Oncology Group performance status (HR, 1.632; 95% CI, 1.182-2.254), were revealed to have independent predictive value. The type of treatment (chemotherapy or resection of the primary tumor) did not influence the survival. The results indicated that mutation of the KRAS gene was an important prognostic factor and associated with survival.

Desmoid-type Fibromatosis of the Splenic Hilum: A Rare Tumor at an Unusual Location

Desmoid-type fibromatoses (DTFs), also known as desmoid tumors, are benign but infiltrative neoplasms that often appear next to previous surgical site. Intra-abdominal tumors usually involve the mesentery, but splenic hilum is an unusual localization. We present a case of a desmoid tumor of the splenic hilum laparoscopically resected in a 70-year-old male with a previous history of chromophobe renal cell carcinoma and ocular spindle melanoma. Although benign, desmoid tumors might be infiltrative and produce serious complications. Treatment remains controversial, ranging from surgery and medical therapies to observation. Management of DTF must be individualized, considering the risk of complications and recurrence.

Parasitic Myomas: Case Report and Literature Review

Parasitic myomas are an infrequent type of myomas that appear in abdominal cavity. The incidence of this pathology has increased over the past years. There has been many hypothesis about the pathogenesis. One of the most recent ones is in relation to the start of laparoscopic morcellation at myomectomy or hysterectomy to treat uterine myomas due to the small fragments that can be detached during the procedure and that implant themselves in the abdominal cavity. Parasitic myomas, in most cases, are asymptomatic, but it can cause an unspecific abdominal pain, menstrual disturbances, dyspareunia and other gynecological symptoms. Physical exploration in patients is often also normal. The correct identification of parasitic myoma by image tests, such as transvaginal ultrasound, CT or MRI, is still complicated because it is difficult to diagnose due to the unspecific radiological characteristics that show up. CT and MRI give information about the location that could be useful during the surgery. Usually the diagnosis is an accidental finding during an abdominal surgery done for another reason and the histology of the piece is what gives the definitive diagnosis. We present a case of a 32-year-old woman, asymptomatic, after a transvaginal ultrasound is diagnosed a retroperitoneal tumor. The tumor was removed by laparoscopic surgery and the patient had a favourable recovery. The histopathology of the tumor was a parasitic myoma.

Duodenal Rupture after Blunt Abdominal Trauma by Bicycle Handlebar: Case Report and Literature Review

Blunt abdominal trauma is most frequent in the pediatric population. Duodenal lesions after abdominal trauma in children are infrequent and tend to be secondary to traffic accidents. It is up to five times more frequent in males, with an average age between 16 and 30 years. Bicycle accidents continue to lead to morbidity and mortality in children, representing between 5% and 14% of total blunt abdominal injuries. The diagnosis of duodenal injuries after trauma is difficult and requires a high index of clinical suspicion. We present the case of a 17-year-old patient seen in the emergency room after falling off his bicycle and presented a blunt trauma in the epigastric region. On physical examination, there was a swelling in the upper right abdominal quadrant and epigastrium with tenderness on deep palpation. He presented with hematemesis without hemodynamic repercussion. A contrast abdominal computed tomography was performed and he was diagnosed with third-part duodenal rupture. A resection of the perforated third-part duodenal rupture was performed, and the transit was reconstructed using a Roux-Y duodenojejunostomy. The postoperative period was uneventful and the patient was discharged after 16 days of stay. Duodenal injury is very rare, produced by high-energy trauma. They rarely present as single lesions as other visceral lesions are usually associated. The early diagnosis is important to reduce the morbidity and mortality.

Analysis of the Increase in Bone Mineral Density After Surgical Treatment of Primary Hyperparathyroidism

AIM

To analyze the effect of the surgery in bone mineral density (BMD) and to study the value of preoperative clinical and analytical factors as predictors of bone increase.

MATERIAL AND METHODS

Prospective observational study. Postmenopausal women who were operated for primary hyperparathyroidism were included. A bone densitometry of the lumbar spine and femoral neck and analytical determinations (parathyroid hormone [PTH], alkaline phosphatase, albumin, phosphate, creatinine, 25-hydroxy-vitamin D3, creatinine clearance, and calciuria) were performed previous to the intervention and after 12 months from surgery.

RESULTS

Two hundred and twenty-eight patients were operated on for primary hyperparathyroidism were considered for study, 108 postmenopausal women entered in the final analysis. The mean age was 63 ± 7 yr. After the intervention, a significant increase in BMD was observed in the two locations analyzed, although this increase was significant greater at the level of the lumbar spine. In the lumbar spine, 68 patients (63%) recorded a significant postoperative increase in bone density. Median postoperative BMD was 0.860 g/cm² (interquartile range: 0.93). The observed average percentage of density increase was 6.63 ± 17.9. In femoral neck, 61 patients (56.6%) registered a significant increase in bone density. Median postoperative BMD value was 0.741 g/cm² (interquartile range: 0.76). The average percentage of density increase was 3.19 ± 17.9. In the lumbar spine, patients with osteoporosis before surgery increased postoperative BMD more frequently than those with osteopenia or normal density. Patients who increased BMD preoperatively presented lower bone density levels both in the lumbar spine (median: 0.775, interquartile range: 0.882) and in the hip (median: 0.655, interquartile range: 0.562) than patients in whom it was not observed postoperative increase. PTH preoperative serum was lower among patients who increased bone density in the femur (median: 141 pg/ml, interquartile range: 291) than among those who did not (median: 152 pg/ml, interquartile range: 342) (p = 0.01). In the multivariate analysis, the increase in BMD in the lumbar spine was related to preoperative BMD (odds ratio [OR] 0.084, 95% confidence interval [CI]: 0.007-0.961); in femoral neck it was related to preoperative BMD (OR 0.001; 95% CI: 0.0-0.028) and to the preoperative PTH serum concentration (OR 0.99; 95% CI: 0.98-0.99).

CONCLUSIONS

After surgery, a significant increase in BMD was observed in the lumbar spine and femoral neck. In the multivariate analysis, preoperative bone density was the factor that showed the highest predictive value of the increase in BMD after surgery.

Prognostic value of carcinoembryonic antigen, CA 19-9 and CA 72-4 in gastric carcinoma

The prognostic value of preoperative serum levels of carcinoembryonic antigen (CEA), CA 19-9 and CA 72-4 tumor markers was investigated in patients with gastric cancer. Eighty-two patients who underwent surgical resection of gastric cancer were entered in the study. Correlation analyses showed that CA 72-4 was more frequently positive in patients with advanced tumors (p = 0.04), lymph node invasion (p = 0.02), liver metastasis (p = 0.02) and peritoneal involvement (p = 0.03). CA 19-9 was more frequently positive in patients with advanced tumors (p = 0.01) and with serosal (p = 0.04), lymph node (p = 0.008) and peritoneal involvement (p = 0.02). CEA was more frequently positive in patients with liver metastasis (p = 0.03). Low 3-year cumulative survival was significantly associated with elevated serum levels of CA 72-4 (p = 0.004), CA 19-9 (p = 0.001) and CEA (p < 0.001). Age, tumor stage and CA 72-4 provided prognostic information in the multivariate analysis. Patients with elevated serum levels of CA 72-4 showed a 4.2 times higher risk of death than patients with low levels of the marker. Our results suggest that CA 72-4 has prognostic value in gastric cancer, and patients with a high preoperative serum level of CA 72-4 have a greater risk of death due to gastric cancer.