Boari flap urinary tract reconstruction for rectosigmoid cancer with ureteral invasion: Report of a case

Introduction: The Boari flap technique is a unique urinary tract reconstruction procedure performed after resection of the urinary tract. However, few previous reports have described the application of this technique to gastrointestinal cancer. Moreover, we have not found any papers describing the long-term prognosis. We report a case of right ureteral tract resection followed by Boari flap reconstruction for rectosigmoid carcinoma, with survival for 108 months without any urological complications. Case presentation: A woman in her 50s was diagnosed with rectosigmoid caner by local physician and referred to our institution. Computed tomography revealed right hydronephrosis due to rectosigmoid cancer invasion at the lower two-thirds of the right ureter. During laparotomy, massive lymphatic infiltration from the primary lesion to right ureter was observed. After primary tumor resection with lower ureter excision, the Boari flap procedure was performed to reconstruct the ureteral deficit. Postoperative course was uneventful, and she was discharged on postoperative day 20. The patient has been followed every 4 months for 9 years with no recurrence or unpleasant symptoms. Discussion: This technique is usually performed to manage specific conditions such as ureteral stenosis caused by ureteral calculi, retroperitoneal fibrosis, and gynecological disorders. This procedure should be reconsidered as a possible option for gastrointestinal malignant cases instead of nephrostomy or cutaneous ureterostomy, given the low rate of complications and high patient satisfaction. Conclusion: The Boari flap technique is particularly useful for bridging between the ureter and bladder in cases of colorectal malignancy with combined resection of the lower urinary tract.

The prognostic significance of a histological response to preoperative chemotherapy in patients with synchronous colorectal liver metastases

Objective: Preoperative chemotherapy (PC) for colorectal liver metastasis (CRLM) is widely used to improve prognosis, but its clinical benefit has not been fully established. This study aimed to assess the effectiveness of PC for synchronous CRLM and the correlation between the histological response to PC and survival. Summary of Background Data: We enrolled 69 patients who underwent initial hepatectomy for synchronous CRLM between 2004 and 2018 at Gifu University Hospital. Methods: We retrospectively analyzed the clinicopathological factors and outcomes of 69 patients who underwent hepatectomy after receiving PC (PC group: n = 43) or who underwent upfront hepatectomy (non-PC group: n = 26). In the PC group, the patients were divided into the Grade 1 (n = 27) and Grade 2/3 (n = 16) groups according to their histological responses to PC. Results: The median survival and 5-year overall survival (OS) rates were 80.9 months and 61.5%, respectively, in the PC group and 71.7 months and 61.5%, respectively, in the non-PC group ( P = 0.867). Regarding recurrence-free survival (RFS) and remnant liver-RFS, there were no significant differences between the two groups ( P = 0.087 and 0.291). However, in a subgroup analysis, the median 5-year OS, RFS, and remnant liver RFS were significantly longer in the Grade 2/3 than Grade 1 group ( P = 0.008, P = 0.002, and P < 0.001, respectively). Conclusions: Some patients benefit from PC, and the histological response to PC had prognostic significance for patients with synchronous CRLM.

Role of Craniectomy Versus Craniotomy via the Retrosigmoid Approach in Decreasing the Incidence of Postoperative Headache

Background: Postoperative headache is a major complaint after RS surgery. PH affected the patient’s quality of life. The role of craniotomy in the prevention of such headaches. We aimed to evaluate the role of craniectomy versus craniotomy via the retrosigmoid approach in reducing the incidence of postoperative headaches. Materials and methods: Patients who underwent surgery between January 2012 and December 2018 were retrospectively assessed and were classified into the craniectomy and craniotomy groups. Clinical data, such as those on age, sex, type of surgery, surgical repair technique, development of infection, postoperative cerebrospinal fluid leak, postoperative meningitis, size of the bone flap, and wound infection, were collected. The severity of headache in all patients was clinically assessed using the Catalano grading system. Results: Overall, 95 patients underwent microsurgery via the retrosigmoid approach. Of these, 48 were men and 47 were women. In total, 34 patients underwent craniectomy, and 61 patients underwent craniotomy. On discharge, postoperative headache was observed in 47% (16/34) and 21% (13/61) of patients who underwent craniectomy and craniotomy, respectively ( P =.01). The incidence of headache decreased at follow-up. At 12 months after surgery, 15% of patients in the craniectomy group (5/34) and 2% of patients in the craniotomy group (2/61) experienced headache ( P =.01). Of the 61 patients in the craniotomy group, 2 (2%) had less severe headache at 12 months of follow-up. Conclusion: The severity of headache after surgery and upon discharge significantly decreased in patients who underwent craniotomy than in those who underwent craniectomy.

The risk factors for complications after Crohn’s Disease surgery .

Background: Crohn’s disease needs a multidisciplinary approach and surgery will ultimately be necessary for most patients. Complications usually occur after surgery. Objective : This study aims to present complication rates in surgically treated Crohn's disease patients at a single institution and to determine possible risk factors. Methods: A retrospective analysis of 112 consecutive surgery performed on Crohn’s disease patients between 2003 and 2015. The demographic data, patient and disease characteristics, surgery type, and complications were analyzed. Results: Of 112 patients, 64 (57.1%) were male and 48 (42.9%) were female. The mean age was 34 (18-78) years. The mean follow-up was 114±32.4 (61-197) months. The most common early complications were intra-abdominal abscess formation (n=10, 8.9%) and wound infection (n=7, 6.26%). The incisional hernia was the most common late complication (n=4, 3.6%). Non-modifiable disease features associated with complications were colonic involvement of the disease (p=0.001), penetrating disease character (p=0.037), stoma formation (p=0.000), fistula (p=0.008) and concomitant fistula and intra-abdominal abscess (p=0.043) existence. Stoma formation was found to be an independent risk factor for complications (p=0.001). Conclusions: Colonic involvement, penetrating disease, fistula, concomitant abscess and fistula, and stoma formation were identified as non-modifiable risk factors for complications after surgery for Crohn’s disease.

Air pollutants-particular matter (PM)2.5 with antenatal exposure leading to Adverse Obstetrical Outcomes of Birth Weight and Preterm Birth: A Systematic Review and Meta-Analysis.

Introduction: PM 2.5 exposure impacts on prenatal health and birth outcomes including low birth weight and preterm delivery. Objective: To identify and explore PM 2.5 exposure on adverse obstetrical outcomes including preterm birth and low birth weight. Method: A total of 409 studies was identified by searching from PUBMED, EMBASE, SCOPUS, WEB OF SCIENCE, and SCIENCE DIRECT. Of the 409 articles from 1982 to 2020, 24 articles were identified qualitatively considered, and 7 articles were quantitively eligible included in this meta-analysis. The pooled effect of PM 2.5 exposure and LBW, PTD were calculated using a random effect model with significant heterogeneity.Totally, 7 studies conducted in meta-analysis, and the pooled effect of PM 2.5 exposure in LBW and entire pregnant were 1.033 (95%CI: 1.025, 1.041) with significant high heterogeneity (I 2 = 96.110, P=0.000). The pooled effect of PM 2.5 exposure PTD and entire pregnant were 1.024 (95%CI: 1.015, 1.033) with significant different low heterogeneity (I 2 = 60.036, P=0.082). Discussion: Although prenatal exposure of PM 2.5 during pregnancy is significantly associated with the risk of LBW, the risk of PTD is a significant differrent, but consistently associated with PM 2.5 . Conclusion: Globally, PM 2.5 exposure is significantly associated with serious outcomes of pregnancy and birth outcomes across the world. It appears in the prenatal health emerging risks that government is needed to influence the health policies to pursue on maternal and child health. Key words: “maternal”, “prenatal”, “air pollution”, “PM 2.5 ”, “Preterm Birth”, and ”Low Birth Weight.”

EFFECTIVE TREATMENT FOR PRIMARY LOCALLY AGGRESSIVE INTERMEDIATE AND MALIGNANT SOFT TISSUE TUMOURS OF THE BREAST

OBJECTIVE This study aimed to examine the rare locally aggressive intermediate tumours and malignant primary breast mesenchymal tumours in the patients receiving surgical treatment. SUMMARY OF BACKGROUND DATA Locally aggressive intermediate tumours were subdivided into non-metastasising and rarely metastasising, while malignant group was subdivided as a single subgroup called able to metastasise. A retrospective examination of surgical notes and clinical charts was carried out reviewing gender, age, symptoms, duration of symptoms, tumour size, clinical presentation, radiation history, kind of surgery undergone, adjuvant radiotherapy, adjuvant chemotherapy, local recurrences, systemic metastases and mortality. RESULTS Mitotic index and Ki-67 were statistically different between locally aggressive and malignant groups (p ˂ 0.001). One local recurrence occurred in only one patient diagnosed as dermatofibrosarcoma protuberans among all patients. None of the entities showed distant metastasis or mortality. In this result, clear margin of surgery in locally aggressive intermediate group and combination of surgery with radiation therapy in the malignant group was the most important determinant for the prospect of the patients with mean follow up 28 months. CONCLUSION The main treatment for localised mesenchymal breast tumours is surgery. When the disease is locally advanced or malignant with high mitotic index, radiotherapy with surgery is predominantly used.Targeted therapies are promising with the limited place of chemotherapy.

The importance of early management of severe biliary infection: current concepts

Background. The incidence of biliary infections is rising worldwide and has become one of the main reasons for emergency admissions. Methods. Narrative review of the literature emphasizing news concepts related to the early management of biliary diseases. Results. The bacteriology is frequently polymicrobial, with a progressive increase of multidrug resistant bacteria. The form of presentation is variable, and the mortality rate may reach 20%. When cholecystitis or cholangitis is suspected, ultrasound is the gold standard imaging test. Depending on the severity of presentation, local resistances and risk factors for multi-resistant organisms, the most appropriate empirical antibiotic treatment must be initiated. In acute cholecystitis, cholecystectomy plays the main therapeutic role. In patients not suitable for surgery, percutaneous cholecystostomy is a valid alternative for source control. Treatment of severe cholangitis is based on the drainage of the bile duct and antibiotic therapy. Conclusions. Biliary infections are serious conditions which can lead to sepsis and death. The introduction of new internationally accepted guidelines, based on clinical presentation, laboratory tests and imaging, provides a platform for their timely diagnosis and management. Early severity assessment, initiation of intravenous antibiotics and source control are fundamental to improving morbidity and mortality.

Knowledge Assessment among Surgeons about Energy Devices safe use: A Multicenter Cross Sectional Study

Objective: To assess General Surgery trainee’s knowledge about safe use of energy devices in two tertiary hospitals in Riyadh, Saudi Arabia Background: Electro surgery is the use of high-frequency electrical energy to achieve cutting, and coagulation. This method has become ubiquitous worldwide for the purpose of achieving rapid hemostasis and rapid dissection of tissues Methods: Participants completed a 35-item multiple choice question examination, testing critical knowledge of ES. The examination was developed according to the objectives and blueprints of SAGES’ Fundamental Use of Surgical Energy curriculum. Sections of the examination included: principles of ES, ES-related adverse events, monopolar and bipolar devices, and pediatric considerations and interference with implantable devices.’’ Scores were compared between juniors and seniors participants. Results: A total of 51 general surgical trainees from two academic hospitals completed the assessment. 15.69% of the participants correctly answered 30 questions out of 35 questions, 39.22% of the participants responded correctly to 20 questions out of 35 answers, and 45.09 who responded correctly to less than 20 questions. It was found that 52.2% of the individuals with a low level of understanding were junior residents as opposed to 87.5% of the participants with the highest level of understanding were senior residents with a significant P-value of 0.04. Conclusions: majority of general surgery residents enrolled in the Saudi Arabian board of surgery lack adequate knowledge about the safe and efficient use of surgical energy devices. The level of understanding is lower among the junior residents than seniors.

Impact of postoperative complications on long-term survival of hepatocellular carcinoma patients after liver resection

Objective The effect of postoperative complications including red blood transfusion (BT) on long-term survival for hepatocellular carcinoma (HCC) is unknown. The purpose of this study was to define the relationship between postoperative complications and long-term survival in patients with HCC. Methods Postoperative complications of 1251 patients who underwent curative liver resection for HCC were classified, and their recurrence-free survival (RFS) and cumulative overall survival (OS) were investigated. Results Any complications occurred in 503 patients (40%). Five-year RFS and 5-year OS in the complication group were 21% and 56%, respectively, significantly lower than the respective values of 32% ( p < 0.001) and 68% ( p < 0.001) in the no-complication group (n=748). Complications related to RFS were postoperative BT [Hazard ratio (HR): 1.726, 95% confidence interval (CI): 1.338–2.228, p < 0.001], pleural effusion [HR: 1.434, 95% CI: 1.200–1.713, p < 0.001] using Cox-proportional hazard model. Complications related to OS were postoperative BT [HR: 1.843, 95%CI: 1.380-2.462, p < 0.001], ascites [HR: 1.562, 95% CI: 1.066–2.290 p = 0.022], and pleural effusion [HR: 1.421, 95% CI: 1.150–1.755, p = 0.001). Conclusions Postoperative complications were factors associated with poor long-term survival. Postoperative BT and pleural effusion, were noticeable complications that were prognostic factors for both recurrence-free survival and overall survival.

Giant mucinous carcinoma originating from the appendix: A case report

Introduction Appendiceal mucinous neoplasms can involve peritoneal pseudomyxoma or invasion of adjacent organs. This report describes a rare case in which a giant appendiceal mucinous carcinoma expansively developed in the retroperitoneum without perforating the abdominal cavity. Case presentation The patient was a 55-year-old woman with no relevant history who was admitted to our hospital after imaging examinations revealed a retroperitoneal tumor. The clinical diagnosis was a retroperitoneal tumor involving the hedge mucin. The patient underwent right hemicolectomy and partial resection of the duodenum and right abdominal wall to ensure complete tumor resection. Histopathological findings suggested that the tumor was a mucinous carcinoma arising from the appendix. The postoperative course was uneventful. Although adjuvant chemotherapy was performed for 6 months, peritoneal recurrence developed 7 years and 4 months postoperatively. Nine years have passed after surgery and the patient is alive under receiving chemotherapy. Conclusion Detailed pathological examinations revealed that the tumor originated from the appendix. The characteristics of mucinous carcinoma contributed to the extensive growth of the tumor.