Interactive virtual 3D image reconstruction to assist renal surgery in patients with fusion anomalies of the kidney

Objective: Renal fusion anomalies are rare and usually present as horseshoe kidneys or crossed fusion ectopia. The complex renal anatomy seen in patients with these anomalies can present a challenge. Pre-operative planning is therefore paramount in the surgical management of these cases. Herein we report the use of interactive virtual three-dimensional (3D) reconstruction to aid renal surgery in patients with fusion anomalies of the kidney. Materials and Methods: A total of seven cases were performed between May 2016 and October 2020. 3D reconstruction was rendered by Innersight Labs using pre-operative computed tomography (CT) scans. Results: Five patients had malignant disease and two patients had benign pathology. Robotic and open operations were performed in four and three patients, respectively. Conclusion: The use of 3D reconstruction in the cases reported in this series allowed for the identification of variations in renal vasculature, and this informed the choice of operative approach. Oxford Centre for Evidence-Based Medicine Evidence Level: 4

Incidentally Discovered Papillary Thyroid Microcarcinoma in Patients Undergoing Thyroid Surgery for Benign Disease

IntroductionIncidence of thyroid carcinoma (TC) has grown significantly over the last few decades worldwide, partly due to the increase detection of small thyroid microcarcinoma (TMc). TMc are tumors with a maximal diameter ≤ 1 cm, identified during histopathology examination following a thyroidectomy performed for reasons not pertaining to malignancy. The aim of this study is to investigate the prevalence of papillary thyroid microcarcinoma (PTMc) according to the nature of benign pathology that submit patients to thyroid surgery and its trend evolution.MethodsRetrospective cohort analysis of 1815 patients who underwent total thyroidectomy for non-malignant disease from 2005 to 2020. ResultsThe mean age of subjects was 53.5 years, with a higher proportion of women (1481, 82.1%). A total of 167 PTMc (9.3%) were incidentally discovered. Multivariate logistic regression analysis shows no differences in prevalence according to sex or age in patients with PTMc compared to those with final benign histology. Multinodular goiter increases the risk of PTMc with an odds ratio of 2.2 (p=0.001) compared to Hashimoto's thyroiditis and Graves´ disease (GD). There is a statistically significant increase in the incidence of PTMc in the group operated between 2017-2020 vs. 2005-2008 (p=0.005)ConclusionOverall prevalence of PTMc in patients who underwent thyroid surgery for benign disease was 9.3%. Thyroid nodular hyperplasia was the most frequent benign pathology associated to this occult cancer as compared to Hashimoto or GD. Gender and age were not correlated with prevalence of TMc. Over the years, surgical findings of PTMc have grown, particularly in the 2017-2020 period.

Laparo-endoscopic Approach for Large Ovarian Cyst in the Morbidly Obese: Case Report

We report a successful case of laparo-endoscopic single site total hysterectomy and bilateral salpingo-oophorectomy (LESS THBSO) using conventional laparoscopic instruments for a large ovarian cyst in a morbidly obese woman. A 58-year-old female with a BMI of 46kg/m2 complaint of abdominal distension. A pelvic ultrasound revealed a left ovarian cyst measuring 21.3 x 15.2 x 20.8 cm. The IOTA score is 3.5% and the RMI score was 51, suggesting a benign pathology. LESS THBSO was performed and the final histology was a benign ovarian mucinous cystadenoma. The patient recovered well with no postoperative complications. This case demonstrates that LESS is feasible for large ovarian cysts even in morbidly obese patients when appropriate cases are selected and when the patient is managed in a multi-disciplinary team.

ELECTIVE REMOVAL OF A LARGE MESENTERIC CYST – LAPROSCOPIC EXCISION.

A mesentric cyst is a rare intra abdominal benign pathology. They are found in the mesentry of small bowel (66%) and large intestine (33%), usually in the right colon. Very few cases have been reported of tumours found in mesentry of descending colon, sigmoid or rectum. Mesentric cysts do not show classical clinical findings and are detected incidentally during imaging due to absent or non-specific clinical presentation or during management of one of their complications. Optimal surgical management requires complete excision of the lesions. Although they are invariably benign, a full laparotomy has been the conventional approach for resection, often via a large midline incision. The advantage of minimally invasive surgery has allowed resection of the cysts, without need for a full laparotomy, with the benefit of improved cosmetics, less postoperative pain, and shorter hospital stay. However, laparoscopy can be technically challenging with large intra abdominal cysts. This is mainly due to lack of intra abdominal space and poor ergonomics in relation to port placements with large cysts. We report the incident of a 44-year-old female. A USG and computed tomography scan followed to help diagnose the lesion as a cyst. She underwent laproscopic removal and the cyst was enucleated intact. Postoperative period was uneventful and pathological examination showed a benign mesentric cyst . Objectives of this study is to analyze our experience with emphasis on the presentation, management, and outcome. Laproscopy not only helps in diagnosing the site and origin of the mesentric cyst but also has a therapeutic role. Laproscopic treatment of mesentric cyst is a safe, preferred method of treatment and is a less-invasive surgical technique. Here, we present an unusual case of mesentric cyst arising from Ascending colon treated by laproscopic excision.

Troubleshooting Difficult Bile Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or EUS-Guided Rendezvous Technique?

Despite experienced hands and availability of various well-designed catheters and wires, selective bile duct cannulation may still fail in 10–20% of cases during endoscopic retrograde cholangiopancreatography (ERCP). In case standard ERCP cannulation technique fails, salvage options include advanced ERCP cannulation techniques such as double-guidewire technique (DGW) with or without pancreatic stenting and precut papillotomy, percutaneous biliary drainage (PBD), and endoscopic ultrasound-guided Rendezvous (EUS-RV) ERCP. If the pancreatic duct is inadvertently entered during cannulation attempts, DGW technique is a reasonable next step, which can be followed by pancreatic stenting to reduce risks of post-ERCP pancreatitis (PEP). Studies suggest that early precut papillotomy is not associated with a higher risk of PEP, while needle-knife fistulotomy is the preferred method. For patients with critical clinical condition who may not be fit for endoscopy, surgically altered anatomy in which endoscopic biliary drainage is not feasible, and non-communicating multisegmental biliary obstruction, PBD has a unique role to provide successful biliary drainage efficiently in this particular population. As endoscopic ultrasound (EUS)-guided biliary drainage techniques advance, EUS-RV ERCP has been increasingly employed to guide bile duct access and cannulation with satisfactory clinical outcomes and is especially valuable for benign pathology at centres where expertise is available. Endoscopists should become familiar with each technique’s advantages and limitations before deciding the most appropriate treatment that is tailored to patient’s anatomy and clinical needs.

Efficacy of Differential Diagnosis of Thyroid Nodules by Shear Wave Elastography, the Stiffness Map

Background Fine-needle aspiration is the gold standard, but malignancy rate of the indeterminate cytology is reported as 20-50 %. We aimed to evaluate the efficacy of shear wave elastography (SWE) added to ultrasonogram in the differential diagnosis of thyroid nodules. Methods We retrospectively reviewed the medical records of 258 consecutive patients. Thyroid nodules were divided in to 4 categoies according to maximum elasticity (EMax) and nodule depth/width (D/W) ratio; Category 1 (EMax ≥42.6 kPa & D/W<0.9), Category 2 (EMax <42.6 kPa & D/W<0.9 ), Category 3 (EMax ≥42.6 kPa & D/W≥ 0.9) and Category 4 (EMax<46.2 kPa & D/W≥ 0.9 ). The cutoff value of EMax was set using ROC curve analysis to predict nodular hyperplasia (NH) from follicular neoplasm (FN). Cutoff value ​​for nodule D/W ratio was set using ROC curve analysis for malignancy. Results NH was the most prevalent pathology group in category 1, FN in category 2 and PTC in category 3. The category 3 demonstrated the highest rate of malignancy (81.8%) and had 55.4% sensitivity and 90% specificity for predicting malignancy. When assessing the benign pathology of NH in follicular patterned lesion, category 1 demonstrated the highest NH prevalence of 88.9% (34/37) and had 73.9% sensitivity and 85.0% specificity. Conclusion The performance for malignancy was highest in category 3 and predictive ability for benign pathology of NH in follicular lesion was highest in category 1. So the information of EMax and nodule D/W ratio was useful to predict the pathology of thyroid nodules

SP1.2.4A Single Centre experience in Robot-assisted Colorectal Surgery: First 70 cases

Aim To analyse the short-term outcome of robot-assisted colorectal surgery (RACS) in a single centre. Methods All the patients who underwent RACS using the DaVinci Xi platform between June 2018 and December 2020 were included in our study. RACS was performed by two consultant team. Data was collected from a prospectively maintained database. Results Over the 31-month study period, 70 RACS were performed with no 30-day mortality. Male to female ratio was 4:3, with mean age was 66 years (SD 12). The mean body mass index was 28.7 (SD 5.1). Pre-operative American society of anaethesiology (ASA) score was reported as 1-2 in 65% of patients and 35% as 3. Indication for surgery was malignancy in 89% (62/70) of patients and the remainder benign pathology. Type of surgery performed was high anterior resection (AR) in 39% (27/70) patients, low AR 33% (23/70), right hemicolectomies 21% (15/70), Hartmann’s procedure 3% (2/70), abdominoperineal resections 3% (2/70), and left hemicolectomy 1% (1/70). The mean operating time was 295 minutes (SD 92), with only 1 reported case of conversion to open. Complete resection (R0) was achieved in 95% (59/62) of malignant resections. The mean lymph nodes harvested were 19 (range 7-36). Post-operative complications occurred in 23% (16/70) of patients, including 6% (4/66) anastomotic leaks. The mean length of stay was 8 days (range 1-53), with readmission rate of 14% (10/70). Conclusion The robotic minimally invasive technique can be safely introduced for major colorectal resections without excessive morbidity.

Struck by Lightning and Bitten by Snake

Introduction The simultaneous occurrence of a benign as well as malignant epithelial lesion, albeit incidental, is a rare occurrence. A multi stage procedure had to be adopted for the appropriate management of this patient. Case Report We report one such case of a 65 year old male who presented with a small black lesion on the left side of the nose and complains of left sided nasal obstruction on a much later date. Discussion The decision to address the benign pathology initially followed by the malignant pathology owing to its indolent course formed the cornerstone in the management of this patient.