A Severe Acute Pancreatitis Mouse Model Transited from Mild Symptoms Induced by a “Two-Hit” Strategy with L-Arginine

To develop a severe acute pancreatitis (SAP) model transited from mild symptoms, we investigated a “two-hit” strategy with L-arginine in mice. The mice were intraperitoneally injected with ice-cold L-arginine (4 g/kg) twice at an interval of 1 h on the first day and subjected to the repeated operation 72 h afterwards. The results showed the “two-hit” strategy resulted in the destructive damage and extensive necrosis of acinar cells in the pancreas compared with the “one-hit” model. Meanwhile, excessive levels of pro-inflammatory mediators, namely IL-6 and TNF-α, were released in the serum. Remarkably, additional deleterious effects on multiple organs were observed, including high intestinal permeability, kidney injury, and severe acute lung injury. Therefore, we confirmed that the SAP animal model triggered by a “two-hit” strategy with L-arginine was successfully established, providing a solid foundation for a deeper understanding of SAP initiation and therapy research to prevent worsening of the disease.

Extensive penile skin necrosis after surgery for Peyronie's disease

The clinical case represents the surgical correction of postoperative complications in a patient with Peyronie's disease. The patient underwent flap corporoplasty using an autovein. The late postoperative period in the patient was complicated by extensive necrosis of the penile skin, which required repeated surgery as follows. The first stage of surgical treatment was performed by excision of necrotic tissues of the penile skin. Within 10 days of the postoperative period, chymotrypsin with an ointment containing dioxomethyltetrahydropyrimidine with chloramphenicol was applied to the penile wound surface to prepare the wound for subsequent skin autotransplantation. Further, within 5 days, the polymeric drainage sorbent «Aseptisorb DT» was applied to the wound surface until the wound was cleansed and granulation tissue was formed. The second stage of the surgical treatment performed penile skin replacement plasty with a free perforated skin graft taken from the patient's femoral surface.

Extensive Abdominal Skin Necrosis Following Anterior Component Separation for a Large Ventral Hernia: A Case Report

Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality.Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy.Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.

Electron microscopic and pathological changes of lung cancer after intratumoral injection of sodium bicarbonate

Background: Lung cancer can be treated with surgery, chemotherapy, radiation therapy, targeted therapy and palliative care. Palliative therapy is applied for inoperable lung cancer as it induces tumour necrosis. PH of tumour tissue is acidic; application of sodium bicarbonate (SB) into lung cancer locally via bronchoscopy can change its core pH, which may lead to tumour destruction. We aimed to study the ultrastructural characteristics of lung cancer and to assess the destructive effects of sodium bicarbonate 8.4% local injection on tumour tissue integrity by light and electron microscopies. Methods: This study was conducted on 21 patients with central bronchial carcinoma diagnosed according to WHO classification 2015. Three bronchoscopic biopsies were taken; two biopsies before and one after injection of sodium bicarbonate 8.4% solution of 20 ml via transbronchial needle. All biopsies were examined by both light and electron microscopes. The first biopsy was examined to diagnose the tumour morphologically with and without immunostaining. Second and third biopsies were taken before and after SB 8.4% injection to compare pathological changes in tumour tissue integrity as well as cellular ultra-structures. Different lung cancer pathological types were included in the study. Results: Tumour tissue integrity and pathological changes were examined in biopsies before and after injection of sodium bicarbonate 8.4%. Extensive necrosis in all cell types of lung cancer was seen after injection of SB; this important finding was delineated by both light and electron microscopies. Conclusion: Preliminary ultrastructural study of small biopsy of lung tumor has a complementary role to both morphological and immunohistochemical studies. Local injection of sodium bicarbonate into lung cancer induces extensive necrosis that may reflect its important therapeutic role in lung cancer.

A Case of Stevens–Johnson Syndrome in Recurrent Late-Stage Ovarian Cancer Patient after Management of Chronic Pain with Elastomeric Pump

(1) Background. Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous reactions, characterized by extensive necrosis and detachment of the epidermis. (2) Case presentation. We present a case of a 46-year-old patient with late-stage high-grade serous ovarian cancer who was primarily treated with neoadjuvant chemotherapy and interval debulking, which was followed by adjuvant chemotherapy. At first recurrence, she was again treated with chemotherapy, and due to severe abdominal pain, an elastomeric pump containing analgesics, anti-inflammatories, and ondansetron was administered. In the same month, she was admitted to the hospital due to severe dysphagia, and in the following days she developed haemorrhagic vesiculobullous lesions on the facial skin and trunk. Stevens–Johnson syndrome was confirmed and ondansetron as a plausible leading cause was discontinued. Despite multimodal treatment, her condition deteriorated, and she died. (3) Discussion and conclusion. Although gynaecologists rarely encounter Stevens–Johnson syndrome, high mortality of the disease should ensure a low threshold for diagnosing and treating this disease.

Acute oesophageal necrosis in a patient with recent SARS-CoV-2

A 57-year-old Hispanic man with diabetes presented with dyspnoea. He had a positive SARS-CoV-2 PCR. He was intubated for severe hypoxia and treated with intermittent pressors, methylprednisolone and supportive care. He was extubated on hospital day (HD) 9 and discharged to a skilled nursing facility (SNF) on HD 18. Approximately 1 month later, he presented with melena. Endoscopy revealed two large 1.5–2 cm wide-based distal oesophageal ulcers without active bleeding. Histology showed ulcerated squamous mucosa with extensive necrosis extending to the muscularis propria and coccoid bacterial colonies with rare fungal forms suggestive of Candida. He was treated with fluconazole and pantoprazole and was discharged to a SNF. Approximately 3 weeks later, he was readmitted for complications. Repeat endoscopy demonstrated improvement and histology revealed chronic inflammation with reactive epithelial changes. Incidentally, SARS-CoV-2 PCR was positive during this visit without any respiratory symptoms.

Case Report: Immune Checkpoint Inhibitor-Induced Exuberant Tumor Inflammation With Accelerated Clinical Deterioration in Metastatic Renal Cell Carcinoma

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy. Nivolumab, an anti-PD-1 monoclonal antibody, markedly improved overall survival in advanced renal cell carcinoma (RCC). However, ICIs can rarely trigger massive inflammation, a phenomenon characterized by rapid acceleration in radiographic tumor growth, the mechanisms underlying which are largely unknown. We report three patients with metastatic RCC who experienced rapid radiographic progression and clinical deterioration following treatment with nivolumab. However, histological analysis revealed no viable cancer despite the evidence of radiological progression. Instead, extensive necrosis and lymphohistiocytic infiltration were noted, as described previously in patients with ICI-induced pseudoprogression. Based on these observations, we postulate that exuberant antitumor inflammatory responses may contribute to adverse clinical outcomes in some patients with ICI-induced radiographic progression. Prospective studies incorporating tumor biopsies may shed more light on this rare phenomenon.

Necrosis and perforation of the stomach in newborn babies and infants

The Objective of the study was to identify the clinical features of newborns and infants with perforation of the stomach, and to justify the possibility of organ-preserving operations even with extensive gastric necrosis.Methods and Materials. The results of treatment of 32 newborns with stomach perforation was analyzed: not only the risk factors that cause this condition, but diagnostic methods and variants of surgical treatment. All patients with extensive necrosis of the stomach wall underwent an atypical resection within healthy tissues, a gastric «tube» was formed on the drainage probe with a significant decrease of organ volume. In cases of the local damage of the gastric wall, the perforated area was sutured after the excision of the edges of the defect.Results. Mortality rate was 36.5 % (n = 12). The cause of death in 5 children (15 %), in 3 to 8 days after surgery, was multiple organ failure syndrome. In 7 patients (22 %), a fatal outcome occurred due to the severe post-intensive care syndrome at the age of 3 to 12 months of life.Conclusion. The mechanism of perforations of the stomach in newborns and infants is multifactorial. All children with stomach perforation need preoperative preparation. The operation of choice for the stomach perforation is an organpreserving surgery. The function of the stomach is restored in all children after extensive resection of the stomach.

Necrotizing fasciitis of the breast: case repor

Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressive diffuse necrosis of fascia and adjacent tissues, most reported in the abdominal wall, perineum, and extremities. Cases of idiopathic necrotizing fasciitis of the breast are rare and unrelated to risk factors. This study was conducted with a 19-year-old woman reporting mastalgia and phlogistic signs in her right breast, which evolved with serosanguineous blisters and extensive necrosis of the fascia and periareolar wall, characterizing the necrotizing fasciitis. Therefore, the authors aim to show the relevance of early diagnosis associated with prompt treatment and procedure for a better intervention outcome.