The Utilisation of Digital Applications for Measuring Patient Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis of Comparative Studies

In the context of escalating obesity rates, bariatric surgery holds a crucial role in managing severely obese patients. With a demonstrated effectiveness in weight loss and with the advent of ambulatory surgery, bariatric surgery allows for a streamlined care pathway, ideally suited for postoperative surveillance using digital health applications. The aim of this systematic review and meta-analysis is to evaluate the effect of eHealth-delivered health services or support for adults undergoing bariatric surgery. Five studies, encompassing 2210 patients, were analysed. The intervention group showed a 10% increase in total weight reduction and a 22% reduction in excess weight loss. ED visitation rates also trended towards reduction. Despite the absence of clear statistical superiority for DHA, the findings suggest potential benefits of DHA in postoperative monitoring.

Severe Candida infections in critically ill patients with COVID-19

The frequency of co-infections with bacterial or fungal pathogens has constantly increased among critically ill patients with coronavirus disease 2019 (COVID-19) during the pandemic. Candidemia was the most frequently reported invasive fungal co-infection. The onset of candidemia in COVID-19 patients was often delayed compared to non-COVID-19 patients. Additionally, Candida invasive infections in COVID-19 patients were more often linked to invasive procedures (e.g., invasive mechanical ventilation or renal replacement therapy) during the intensive care stay and the severity of illness rather than more "classic" risk factors present in patients without COVID-19 (e.g., underlying diseases and prior hospitalization). Moreover, apart from the increased incidence of candidemia during the pandemic, a worrying rise in fluconazole-resistant strains was reported, including a rise in the multidrug-resistant Candida auris. Regarding outcomes, the development of invasive Candida co-infection had a negative impact, increasing morbidity and mortality compared to non-co-infected COVID-19 patients. In this narrative review, we present and critically discuss information on the diagnosis and management of invasive fungal infections caused by Candida spp. in critically ill COVID-19 patients.

Is a giant incisional hernia a contraindication for laparoscopic cholecystectomy?

Laparoscopic cholecystectomy (LC) is one of the most commonly performed surgical procedures worldwide. A previous abdominal operation is not considered a significant risk factor for conversion to open cholecystectomy. We describe the case of an 80-year-old woman with a surgical history of a giant uncomplicated incisional midline hernia presenting at our department with choledocholithiasis and acute cholangitis. After an ERCP with extraction of common bile duct stones, a LC was planned. The first trocar was inserted in the right midclavicular line, using an open technique and a careful inspection of the abdominal cavity and the hernia sac content. An uncomplicated cholecystectomy was performed and the postoperative course was uneventful.

The Prognostic Role of GLIM Criteria in Postoperative Outcomes after Upper Gastrointestinal Cancer Surgery: A Meta-Analysis of Observational Studies

Oncologic patients often suffer from malnutrition, which might negatively affect treatment outcomes. Global Leadership Initiative on Malnutrition (GLIM)-based malnutrition is associated with short- and long-term outcomes in cancer patients. The aim of the current meta-analysis was to determine the impact of GLIM-defined malnutrition on postoperative complications and survival in esophageal and gastric cancer patients. A systematic search was conducted to identify studies published until February 2022 that assessed the association between GLIM criteria and short- and long-term outcomes in esophageal and gastric cancer patients. We included seven observational studies reporting on a total of 3662 patients with esophageal and gastric cancer. GLIM-defined malnutrition was associated with increased overall complications (pooled HR 2.58, 95% CI 1.45-4.59, p = 0.001). Malnutrition was significantly associated with decreased overall survival (pooled HR 1.63, 95% CI 1.18-1.84, p = 0.003) as well as with decreased disease-free survival (pooled HR 1.78, 95% CI 1.36-2.33, p < 0.0001). GLIM-based malnutrition was associated with an increased risk for developing postoperative complications and impaired survival of esophageal and gastric cancer patients. Our findings support the use of GLIM criteria in clinical practice as a relatively simple and reliable tool for assessing the nutritional status of oncologic patients.

Risk factors and consequences of post-esophagectomy delirium: a systematic review and meta-analysis

Post-operative delirium (POD) is a state of mental and neurocognitive impairment characterized by disorientation and fluctuating levels of consciousness. POD in the context of esophageal surgery may herald serious and potentially life-threatening post-operative complications, or conversely be a symptom of severe underlying pathophysiologic disturbances. The aim of the present systematic review and meta-analysis is to explore risk factors associated with the development of POD and assess its impact on post-operative outcomes. A systematic literature search of the MedLine, Web of Science, Embase and Cochrane CENTRAL databases and the clinicaltrials.gov registry was undertaken. A random-effects model was used for data synthesis with pooled outcomes expressed as Odds Ratios (OR), or standardized mean differences (WMD) with corresponding 95% Confidence Intervals. Seven studies incorporating 2449 patients (556 with POD and 1893 without POD) were identified. Patients experiencing POD were older (WMD 0.29 ± 0.13 years, P < 0.001), with higher Charlson's Comorbidity Index (CCI; WMD 0.31 ± 0.23, P = 0.007) and were significantly more likely to be smokers (OR 1.38, 95% CI 1.07-1.77, P = 0.01). Additionally, POD was associated with blood transfusions (OR 2.08, 95% CI 1.56-2.77, P < 0.001), and a significantly increased likelihood to develop anastomotic leak (OR 2.03, 95% CI 1.25-3.29, P = 0.004). Finally, POD was associated with increased mortality (OR 2.71, 95% CI 1.24-5.93, P = 0.01) and longer hospital stay (WMD 0.4 ± 0.24, P = 0.001). These findings highlight the clinical relevance and possible economic impact of POD after esophagectomy for malignant disease and emphasize the need of developing effective preventive strategies.

An extremely rare clinical manifestation of acute appendicitis in a nonagenarian patient: lessons still to be learned

Abstract.

A Rare Case of Cervical Vagus Nerve Schwannoma in an Adult Patient

Schwannomas of the head and neck are relatively rare benign tumors that derive from the Schwann cells. Schwannomas are usually asymptomatic; however, tumors of bigger size may produce unspecific symptoms due to compression of the adjacent anatomic structures. Vagus nerve schwannomas may present as solitary neck masses, produce hoarseness of voice, or induce paroxysmal cough on palpation, which is also pathognomonic. Preoperative diagnosis is challenging and imaging studies may play a vital role in the diagnosis. Surgical treatment with complete tumor removal is the treatment of choice. In this study, we present a case of vagus nerve schwannoma in an adult male patient.

Laparoscopic Management of Concomitant Sigmoid Colon Cancer and Type 2 Endoleak Following Endovascular Aneurysm Repair

The co-occurrence of abdominal aortic aneurysm (AAA) and colorectal malignancy creates a significant surgical dilemma over which entity should be addressed first. A 73-year-old male was referred to our hospital due to a painful pulsatile abdominal mass. Computed tomographic angiography revealed an infrarenal aortic aneurysm measuring 5.8 cm in diameter and incidentally, a synchronous mass lesion in the sigmoid colon. The patient underwent an emergency EVAR using a Gore Excluder endograft. Postoperative CT staging for colon cancer revealed a type 2 endoleak on the grounds of a patent wide inferior mesenteric artery. The patient underwent a standard laparoscopic left colectomy with high ligation of the inferior mesenteric artery in order to simultaneously address the ongoing type 2 endoleak. Follow-up examinations with computed tomographic angiography were performed confirming the resolution of the endoleak. Synchronous laparoscopic sigmoidectomy and high ligation of inferior mesenteric artery for type 2 endoleak treatment appears to be applicable with hopeful results.

Surgical Management of a Pancreaticopleural Fistula After Failed Endoscopic Therapy

Inflammatory diseases of the pancreas or pancreatic trauma result in ductal cell disruption, which in turn may lead to leakage of pancreatic fluid, mostly in the retroperitoneal space. Pancreatopleural fistulas are uncommonly encountered following pancreatic injury; however, they often prove a difficult problem to manage.

Herein, we present a rare case of a 68-year-old male suffering from a pancreaticopleural fistula (PF) between the pancreatic tail and the left pleural space one year following splenectomy for trauma. About three months after percutaneous drainage of a left pleural effusion and left upper quadrant abdominal collection and endoscopic pancreatic duct stent placement, surgical management was decided. Distal pancreatectomy and Roux-en-Y drainage of the pancreatic remnant were successfully performed.

Gallstone Ileus in Octogenarians: Is Cholecystectomy Really Needed?

Gallstone ileus is an uncommon complication of cholelithiasis and occurs when a gallstone migrates through a cholecystoenteric fistula and impacts within the gastrointestinal tract. Surgical intervention remains the treatment of choice, which consists of a full-thickness incision of the visceral wall and removal of the impacted gallstone. In this paper we present the treatment approach of 6 cases of gallstone ileus in octogenarians. In our cohort, intestinal obstruction was resolved through an enterotomy or gastrotomy and lithotomy/stone extraction in every patient. No cholecystectomies were undertaken. Despite the fact that gallstone ileus is diagnosed in small percent of patients suffering from gallstone disease, it accounts for a large proportion of intestine obstruction in patients older than 65 years old. Since accurate diagnosis and timely intervention are vital, providers should be familiar with the diagnostic approach and the treatment of this clinical entity.

Endoscopic versus surgical treatment for thoracopancreatic fistulas complicating chronic pancreatitis: A systematic review

BACKGROUND

Thoracopancreatic fistulae are a rare complication of chronic pancreatitis. The aim of the present study is to evaluate potential risk factors for endoscopic treatment failure and explore the safety of surgery when utilized either upfront or as a "bail-out" procedure after failed endoscopic treatment.

METHOD

A comprehensive literature search was conducted on the MedLine, Scopus, Embase, and Web of Knowledge databases for cases of thoracopancreatic fistulae. Data regarding patient demographics, fistula anatomy, and treatment interventions performed were extracted for further analysis.

RESULTS

The study pool consisted of 75 case reports and 19 case series published between the years 1972 and 2020. Duct disruption in the pancreatic body was most commonly encountered (41.1%), and a left pleural effusion was the most common manifestation (46%). Endoscopic treatment was attempted for 104 patients with an overall success rate of 42.3% (n = 44). Predictive factors for eventual success of endoscopic treatment were the ability of endoscopic retrograde cholangiopancreatography to diagnose the thoracopancreatic leak (odds ratio 9.76, 95% confidence interval 2.71-35.09, P < .001), the use of pancreatic duct stents (odds ratio 22.1, 95% confidence interval 7.92-61.61, P < .001), and the use of sphincterotomy (odds ratio 7.96, 95% confidence interval 2.1-30.1, P < .001). Conversely, the presence of pancreatic duct calculi was associated with endoscopic treatment failure (odds ratio 0.34, 95% confidence interval 0.12-0.94, P = .03). Pooled results suggest that surgical outcomes were comparable between the primary and salvage surgery groups.

CONCLUSION

A step-up approach from endoscopic management to salvage surgery may be effectively employed in cases of thoracopancreatic fistulae refractory to endoscopic treatment.

Epidemiology and Incidence of COVID-19-Associated Pulmonary Aspergillosis (CAPA) in a Greek Tertiary Care Academic Reference Hospital

INTRODUCTION

Invasive pulmonary aspergillosis is an emerging complication among intensive care unit (ICU) patients with COVID-19 (CAPA). In the present study, all CAPA cases during the first year of the pandemic were reviewed in critically ill patients at a 650-bed tertiary Greek COVID-19 reference hospital.

METHODS

Data regarding patients admitted to the ICU of Attikon Hospital in Athens, Greece, between 22 March 2020 and 28 February 2021 with a positive PCR for SARS-CoV-2 infection were reviewed. Clinical and microbiological records were analysed including demographic, clinical, laboratory and radiological features, treatment and outcomes. CAPA was determined according to the recent 2020 ECMM/ISHAM definitions.

RESULTS

A total of 179 patients were admitted in the ICU and 6 (3.3%) patients were diagnosed with CAPA (4 probable and 2 possible CAPA) with 5/6 with co-infection with multidrug-resistant (MDR) gram-negative pathogens. No patient had a history of immunosuppression. All suffered from acute respiratory distress syndrome. The median (range) time from intubation to diagnosis was 6 (1-14) days. Five patients had positive Aspergillus cultures in bronchial secretions (1 A. fumigatus, 1 A. flavus, 1 A. fumigatus + A. flavus, 1 A. fumigatus + A. terreus and 1 A. terreus) while culture was negative in one patient. All isolates were susceptible to antifungal drugs. Serum galactomannan (GM), pan-Aspergillus PCR and (1,3)-β-D-glucan (BDG) were positive in 4/6 (67%), 5/6 (83%, 3/5 in two consecutive samples) and 4/6 (67%, in consecutive samples) patients, respectively. GM and PCR positive bronchial secretions had GM indices > 9.95 and PCR Ct < 34. All were treated with antifungal drugs with 5 out of 6 receiving isavuconazole. Mortality was 67% (4/6) with 1/4 attributed to CAPA (two died as a result of bacterial septic shock and one as a result of multiorgan failure).

CONCLUSION

The incidence of CAPA in ICU patients was 3.3% and it was associated with approximately a 17% attributable mortality in the setting of MDR gram-negative pathogen co-infections.

The effect of the COVID pandemic lockdown measures on surgical emergencies: experience and lessons learned from a Greek tertiary hospital

Background

The COVID-19 pandemic caused a rise in healthcare demands leading to significant restructuring of hospital emergency departments worldwide. The aim of the present study is twofold: firstly, to discern any differences in regard to reason for surgical emergency department (SED) attendance and hospital admission during the pandemic and pre-pandemic eras in Greece, and secondly, to assess the impact of the lockdown measures implemented during the pandemic on SED patient attendance.

Methods

Since the beginning of the COVID-19 pandemic in Greece (1 March 2020) and up to 15 December 2020, the charts of all adult patients arriving at the SED of the third surgical department of the “Attikon” University Hospital (a tertiary referral center for surgical and COVID-19 cases) were retrospectively reviewed and broken down in four periods reflecting two nationwide lockdown (period A 1/3/2020 to 30/4/2020 and period D 16/10/2020 to 15/12/2020) and two interim (period B 1/5/2020 to 15/6/2020 and period C 15/9/2020 to 30/10/2020) periods. Demographic and clinical data were compared to those obtained from the same time periods of the year 2019.

Results

The total number of patients attending the SED decreased by 35.9% during the pandemic (from 2839 total patients in 2019 to 1819 in 2020). During the first lockdown, there was statistically significant reduction of motor vehicle accidents (p=0.04) and torso injuries (p=0.01). Contrarily, the rate of head injuries (p<0.001) and abdominal pain (p=0.04) were significantly increased. The same effect was observed regarding the rate of hospital admissions (p=0.002), although in terms of absolute numbers, admissions remained unchanged. During the second lockdown, there was a reduction in the number of perianal abscess cases (p=0.04) and hernia-related problems (p=0.001). An increase in the rate of fall injuries was also demonstrable (p=0.02). Overall, application of the lockdown led to a significant decrease in minor (p<0.001) and torso (p=0.001) injuries.

Conclusion

The burden of the new COVID-19 disease has left a noticeable imprint in the function of emergency departments worldwide. In Greece, SED attendance was significantly reduced during the pandemic, an effect that was even more pronounced during the lockdown implementation; nevertheless, the overall rate of hospital admissions remained the same, denoting that patient care was not altered.

Pneumothorax as a rare complication during laparoscopic total extra-peritoneal inguinal hernia repair: A case report and review of the literature

Totally extra-peritoneal (TEP) and trans-abdominal pre-peritoneal repair are the two most commonly performed types of laparoscopic hernia repair procedures. Herein, we present a rare case of pneumothorax and pneumomediastinum that ensued during a TEP inguinal hernia repair. A 73-year-old man presented for elective laparoscopic right-sided hernia repair. After intubation, a 10-mm and two 5-mm trocars were placed in the peri-umbilical and midline area, respectively. A balloon dissector was inserted from the 10-mm trocar to develop the retro-rectus space and carbon dioxide was insufflated up to a pressure of 14 mmHg. About 55 min after insufflation, the patient presented subcutaneous emphysema, oxygen saturation dropped from 100% to 96% and pCO₂ increased to 55 mmHg. Due to concerns for pulmonary embolism, he immediately underwent a chest computed tomography, which revealed pneumothorax, pneumomediastinum and subcutaneous emphysema extended throughout the neck, thorax and upper abdomen. The patient was successfully treated conservatively with oral analgesia and supplemental oxygen and was discharged on the 4^th post-operative day without any further complications.

An alternative management of a Littré hernia case: food for thought

AIM

We present a novel approach to a Littré hernia case.

CASE REPORT

A 62-year old male presented at our department with a painless mass in the inguinal area and was successfully treated for an inguinal Littré hernia. A Lichtenstein tension-free mesh repair was used without performing simultaneous diverticulectomy.

DISCUSSION

Resection of an asymptomatic Meckel's diverticulum remains a controversial issue. In adult population, leaving an accidentally found silent Meckel's diverticula in situ could reduce the risk of postoperative complications without increasing late complications. Mesh-based techniques provide lower recurrence rates compared to non-mesh techniques.

CONCLUSIONS

Management of asymptomatic Littré hernias presents a challenge for the operating surgeon. Treatment guidelines should be developed for the optimal management of these patients.

Management of Segmental Bile Duct Injuries After Cholecystectomy: a Systematic Review

BACKGROUND

Injuries to segmental or aberrant bile ducts are encountered less commonly than their major bile duct counterparts and present a unique diagnostic and therapeutic challenge, since the nature of this injury involves a transected bile duct that loses its communication with the main ductal system. In this systematic review, we aim to pool available data on this particular type of biliary injury in an effort to outline available diagnostic and therapeutic modalities and evaluate their efficacy.

MATERIALS AND METHODS

An extensive literature search was performed on MEDLINE, Scopus, and Web of Science to identify isolated segmental or aberrant bile duct injuries.

RESULTS

A total of 21 studies were included in this systematic report. Ten studies reported non-operative management of patients, while 12 reported operative management of included patients. Outcomes of interest were the choice of treatment interventions and their success. Overall, 23 patients were managed non-operatively with a 91% success rate and 30 patients were managed operatively with a 90% success rate.

CONCLUSION

Non-operative management might be a viable alternative to surgery. Hepatobiliary surgeons should be encouraged to publish their results in treating these rare injuries to further elucidate the role and efficacy of such an approach.

Endoscopic Retrograde Cholangiopancreatography for Ampullary Carcinomas: Friend or Foe?

The role of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in ampullary carcinomas is under debate due to potential associated complications. We report the case of a 59-year-old male diagnosed with ampullary cancer, who had undergone ERCP that was followed by bleeding and perforation. We conclude that interventions before surgical resection, including ERCP, may compromise patient outcome.

Diverticulitis of the transverse colon manifesting as colocutaneous fistula

The transverse colon is a particularly rare site for a diverticulum to develop, with only few reports of solitary diverticula described in the literature. Among the reported complications, colocutaneous fistulas appear relatively infrequently. We describe the case of an 80-year-old woman with a solitary diverticulum of the transverse colon presenting as acute diverticulitis with abscess formation in the epigastric region. A fistulous tract was found between the inflamed colon and the skin. A wedge resection of the inflamed colon together with the fistula and the solitary diverticulum was performed followed by primary suturing of the healthy colonic tissue. Despite the sufficient treatment and thorough clearance of the area, the patient died ten days later from ventilator associated pneumonia. Although rare, in patients presenting with a subcutaneous abscess in the abdominal region, there should be a high level of suspicion for active intraperitoneal inflammation derived from complicated diverticular disease given the continuously elevated prevalence of the condition in Western societies. The decision regarding proper management of this clinical state should be based on thorough clinical examination and imaging.

Management of ruptured liver segment IV hepatocellular carcinoma: is transarterial embolization (TAE) superior to chemoembolization (TACE)?-the jury is still out

HCC rupture is a potentially life-threatening complication owing to underlying vascular dysfunction and coagulopathy. There is still a debate in the literature concerning the best approach in patients presenting in the emergency setting with shock due to spontaneous HCC rupture. In the current report, we describe the case of a 66-year-old female patient with ruptured HCC who was treated successfully by emergency transarterial embolization (TAE) with complete response proved by gradual shrinkage of the tumor. This impressive complete response suggests that TAE followed by elective hepatectomy could be an efficient approach for patients with Child-Pugh class A liver function and adequate liver remnant. More studies are needed in order to construct specific guidelines for the treatment of rHCC that will be based on the disease severity and the patient status.

De Garengeot's Hernia: Report of a Rare Surgical Emergency and Review of the Literature

This is a report of a case who was admitted and operated on for a strangulated femoral hernia. The hernia sac contained a gangrenous appendix, which was excised and the hernia was repaired with sutures without complication. De Garengeot's hernia, although very rare, should be included in the differential diagnosis of cases with strangulated hernia and should receive the optimal treatment.

A step by step approach in differential diagnosing of adrenal incidentaloma (epinephroma), (with comments on the new Clinical Practice Guidelines of the European Society of Endocrinology)

Objectives. To present a step by step approach for the diagnosis of adrenal incidentaloma (AI).

Method. An extensive review of the literature was conducted, searching the Pub-Med and Google Scholar using the Mesh terms; Adrenal; Incidentaloma; Adrenal tumours; Radiology; Diagnosis. We also did a cross-referencing search of the literature. Comments on the new European guidelines are presented.

Results. The majority of the tumours are non-functioning benign adenomas. The most important radiological characteristic of an adrenal incidentaloma is the radiation attenuation coefficient. Wash out percentage and the imaging characteristics of the tumour may help in diagnosis.

Conclusion. Density less than 10 HU is in most cases characteristic of a lipid rich benign adenoma. More than 10 HU or/and history of malignancy raise the possibility for cancer. 1 mg dexamethasone test and plasma metanephrines should be done in all patients. If there is history of hypokalemia and/or resistant hypertension we test the plasma aldosterone to plasma renin ratio (ARR). Newer studies have shown that tumours even nonfunctioning and less than 4 cm may increase the metabolic risks so we may consider surgery at an earlier stage.

Non-Complicated Acute Appendicitis in Adults Treated Successfully by Conservative Treatment without Recurrences

Backround: Surgical treatment of appendicitis remains the standard treatment, but many cases respond conservatively. Our purpose was the clarification of the clinical, laboratory and imaging characteristics of uncomplicated cases undergoing successful conservative treatment without recurrence. Methods: 105 adult patients (66 female, 39 male) with non-complicated acute appendicitis. Symptom duration, clinical abdominal examination, body temperature, inflammatory markers, imaging studies results and in-hospital treatment were recorded. No patient had a previous episode of appendicitis. Results: Duration of symptoms was 2 hours-3 days. Abdominal examination was compatible with appendicitis and findings were localized in the lower right quadrat. The majority (85.7%) had no or low fever ( 37.4 C). All had leukocytosis (range: 10.000-22.900 WBC/L, mean 14.370'+-2.900 WBC/L), 3 patients 20.000 WBC/L. All had CRP 3.36 mg/L (mean 46.8'+-40.5 mg/L), and 3 150 mg/L. U/S was performed on 95 patients (combined with transvaginal U/S in 19 females) with positive findings of acute appendicitis in 91 (91/95, 95.7%). When faced with inconclusive findings, CT was performed (13 patients) and MRI on one pregnant. In-hospital conservative treatment lasted 1-10 days, overstay was 1-2 days following clinic-laboratory regression. Outpatient, antibiotic treatment followed discharge in 27 patients. Conclusions: Young patients with non-complicated acute appendicitis and short symptom duration, without rare etiologic pathologies, are candidates for conservative treatment. Diagnosis of non-complicated acute appendicitis is based on combining clinical signs, positive inflammatory markers and imaging studies, excluding complicated cases, generalized peritonitis and sepsis. The inflammation seems self-limited, while the role of anti-inflammatory drugs remains obscure.

ABBREVIATIONS

AA = Acute Appendicitis, un-AA = Uncomplicated AA, cAA = Complicated Acute Appendicitis, WBC = White Blood Cells, CRP = C-Reactive Protein, U/S = Ultrasound, CT = Computed Tomography, MRI = Magnetic Resonance Imaging, pts = Patients, NET = Neuroendocrine Tumor.

Inhibin B and anti-Müllerian hormone in spermatic vein of subfertile men with varicocele

INTRODUCTION

The pathophysiology of subfertility in men with varicocele remains unclear as well as the role of inhibin B (Inh-B) and anti-Müllerian hormone (AMH). The aim of this study was to evaluate Inh-B and AMH concentrations in the spermatic vein of subfertile men with varicocele.

PATIENTS AND METHODS

A total of 61 subfertile men with varicocele and 31 fertile controls underwent standard andrological evaluation. All subfertile men underwent varicocelectomy, during which blood samples were obtained from the spermatic vein to evaluate Inh-B and AMH concentrations.

RESULTS

Peripheral vein Inh-B concentrations in men with varicocele were lower as compared to controls (52.9 [8.3-136.0) vs 116±9.7 ng/dL, P = .001). There was no difference in AMH concentrations (10.2 [4.4-45.4]) vs 10.4±0.8 pg/dL, P = 0.9). Spermatic vein Inh-B concentrations in men with varicocele were higher compared to those of peripheral vein (87.6±4.4 vs 52.9 [8.3-136.0] ng/dL, P = .001). On the contrary, spermatic vein AMH concentrations were lower compared to those from peripheral vein (8.84 [3.9-47.7] vs 10.2 [4.4-45.4] pg/dL, P = .013).

CONCLUSIONS

Inh-B constitutes a reliable marker of Sertoli cell function as well as spermatogenesis. On the contrary, the clinical significance of AMH in men with varicocele remains to be elucidated.

Removal of a detached head of the Brooks dilator from the corpora cavernosa during penile prosthesis implantation

INTRODUCTION

Several complications during and after penile implantation have been reported. The most difficult part of the procedure seems to be the dilatation of the corpora, especially in fibrotic cases.

AIM

To report a rare intraoperative complication during dilatation of the corpora and its management.

METHODS

During dilation of the corpora cavernosa with Brooks dilators for the implantation of penile prosthesis, its head was detached and stuck at the tip of the corpus cavernosum. Several trials to remove the head of the dilator using different kinds of clamps were unsuccessful. Finally, an incision was performed to the distal lateral part of the corpora cavernosa and the head of the dilator was removed. Implantation was completed uneventfully.

RESULTS

The patient instructed to inflate the prosthesis and use it for sexual intercourse after 6 weeks. Follow-up was 14 months and the patient is using properly the prosthesis.

CONCLUSIONS

Although this is a very rare complication not previously described, we recommend examination of the dilators before use.