Synchronous solid pseudopapillary neoplasm of the pancreas with intrahepatic cholangiocarcinoma in a young male patient: An unusual deadly occurrence.

INTRODUCTION AND IMPORTANCE: Solid pseudopapillary neoplasm of the pancreas (SPN) is a tumour with low malignant potential, albeit with good prognosis. Intrahepatic cholangiocarcinoma (iCCA) is a malignant and aggressive tumour with poor prognosis. CLINICAL PRESENTATION: We report a case of a 38 years old African male patient with abdominal pain for 5 years that worsened in the preceding 5 months. Radiology showed pancreatic and liver lesions which were thought to be malignant and benign, respectively. However, intra-operative and histopathological assessment confirmed SPN and iCCA which were contrary to radiological findings. Whilst surgery was uneventful, the patient died after 15 days. CLINICAL DISCUSSION: Whilst SPN is commonly seen in young females, it is rare in males and has been associated with aggressive behaviour. The prognosis is good, albeit the presence of metastasis. iCCA is rare in younger population notwithstanding the presence of risk factor. Combination of iCCA and SPT has not been described. Both these tumours do not share risk factors, pathogenesis or molecular alterations. CONCLUSION: The concomitant occurrence of these two pathologies in young male patient is unusual and preoperative diagnosis may be very difficult.

The Use of Modified Snorkel Masks as Personal Protective Equipment During Aerosol-Generating Procedures: COVID-19 Necessity.

Background: The available personal protective equipment (PPE) is insufficient to provide adequate protection during high-risk aerosol-generating procedures, and their shortage was reported. The full-face snorkel masks were modified to be used as PPE. However, little is known about their use in medical practice. Methods: The available masks were assessed and compared in terms of safety, comfort, visual acuity, and communication with team members during the aerosol-generating surgical and endoscopic procedures. The masks were compared with a standard option (full-face shield and N95 mask). The score was assigned to each domain to compare the masks. The aim of the study was to assess the modified full-face snorkel masks as PPE during surgical and endoscopic aerosol-generating procedures. Results: Four modified snorkel masks were assessed and compared with the standard option. All masks provided a good seal, comfort, vision, and protection. Communication was the biggest problem and improved after modification. Suggestions for the mask's selection and on further improvements were made. Conclusion: The modified snorkel masks seem a good alternative to the standard PPE during aerosol-generating procedures. However, additional improvements are still needed. More studies are required to prove the benefits of the modified snorkel masks over the standard PPE.

Laparoscopic management of retroperitoneal injuries from penetrating abdominal trauma in haemodynamically stable patients.

BACKGROUND: Laparoscopy is increasingly utilised in the trauma setting. However, its safety and reliability in evaluating and managing retroperitoneal injuries are not known. AIM: The aim of this study was to analyse our experience with laparoscopic management of retroperitoneal injuries due to penetrating abdominal trauma (PAT) and to investigate its feasibility, safety and accuracy in haemodynamically stable patients. METHODS: Over a 4-year period, patients approached laparoscopically with retroperitoneal injuries were analysed. Mechanism, location and severity of injuries were recorded. Surgical procedures, conversion rate and reasons for conversion and outcomes were described. RESULTS: Of the 284 patients with PAT, 56 patients had involvement of retroperitoneum. Stab wounds accounted 62.5% of patients. The mean Injury Severity Score was 7.4 (4-20). Among retroperitoneal injuries, the colon (27%) was the most commonly involved hollow viscera followed by duodenum (5%). The kidney (5%) and the pancreas (4%) were the injured solid organs. The conversion rate was 19.6% and was mainly due to active bleeding (73%). Significantly more patients with gunshot wound were converted to laparotomy (38% vs. 9%). Therapeutic laparoscopy was performed in 36% of patients. There were no recorded missed injuries or mortality. Five (9%) patients developed the Clavien-Dindo Grade 3 complications, three were managed with reoperation, one with drainage/debridement and one with endovascular technique. CONCLUSION: Laparoscopic management of retroperitoneal injuries is safe and feasible in haemodynamically stable patients with PAT. However, a high conversion rate indicates difficulties in managing these injuries. The requirements are the dexterity in laparoscopy and readiness to convert in the event of bleeding.

Diagnostic laparoscopy or selective non-operative management for stable patients with penetrating abdominal trauma: What to choose?

Background: Selective non-operative management (NOM) and diagnostic laparoscopy (DL) are well-accepted approaches in the management of stable patients with penetrating abdominal trauma (PAT). The aim of this pilot study was to investigate the advantages and disadvantages of early DL in stable asymptomatic or minimally symptomatic patients with PAT as opposed to NOM, a standard of care in this scenario. The secondary aim was to suggest possible indications for DL. Methods: Patients managed with DL or NOM over a 12-month period were included in this study. The age, gender, mechanism and location of injuries, trauma scores, haemodynamic and metabolic parameters, intraoperative findings and length of hospital stay (LOS) were recorded and correlated with outcomes. Results: Thirty-six patients were in the NOM group and 35 in the DL group. Stab wounds were more common. The most common location of injury was the anterior abdominal wall in the NOM group and the lower chest in the DL group. Computed tomography (CT) scan was performed more often in the NOM group (75% vs. 17.1%). The injury severity score (ISS), New ISS and PAT Index were higher in the DL group. Nearly 23 (66%) patients in the DL group had a penetration of the peritoneum, but no significant abdominal injuries. LOS in the NOM group was 2 days versus 3.1 days in the DL group. There were no missed injuries, complications or mortality. Conclusion: NOM is a preferred modality for minimally symptomatic stable patients. However, there is a risk of missed injuries and delayed treatment. DL accurately visualizes injuries, decreases unnecessary CT scans and avoids nontherapeutic laparotomies.

Laparoscopic Common Bile Duct Exploration Use of a Rigid Ureteroscope: A Single Institute Experience.

BACKGROUND: Laparoscopic common bile duct exploration (LCBDE) is used to treat choledocholithiasis. Flexible choledochoscopy is usually performed; however, this instrument is fragile and liable to breakage. MATERIALS AND METHODS: Data were collected and reviewed retrospectively from a prospectively maintained database. All cases of attempted LCBDE with the rigid ureteroscope at the institution since January 2014 were included. Demographic characteristics, preoperative attempted endoscopic retrograde cholangiopancreatography (ERCP), size of the bile duct, findings at laparoscopy, use of drain or T-tube, conversions, and morbidity or mortality were documented. RESULTS: A total of 37 patients were identified. The median age was 51 years (32-71). The male to female ratio was 1:5. Twenty-eight patients had failed ductal clearance at ERCP (75.7%). The mean common bile duct (CBD) diameter was 11.4 mm (10-13.5). There were five conversions. Cirrhosis in 2 patients, bleeding in 1 patient, impacted stone in 1, and equipment failure in 1. T-tubes were placed in 5% of cases. N = 8 (21.6%) of the patients had a Mirizzi syndrome. Average hospital stay was 4 days (3-7). Two patients had complications postoperatively-bleeding and collections. CONCLUSIONS: LCBDE using the rigid ureteroscope is feasible. It can be performed with acceptable morbidity. Use of the rigid ureteroscope represents a good alternative to the flexible choledochoscope with high duct clearance rates. One disadvantage is cirrhosis where the scope may not be negotiated into the CBD due to a stiff liver. It is a viable option when preoperative ERCP has failed to clear the CBD.

Trauma laparoscopy: when to start and when to convert?

BACKGROUND: The use of laparoscopy for stable patients with abdominal trauma is increasing and its accuracy is nearly 100%. However, indications for laparoscopy and for conversion differ among centers. The aim of this study was to investigate indications for trauma laparoscopy and for conversion to laparotomy. METHODS: All trauma patients managed with laparoscopy over a 4-year period were retrospectively analyzed. Indications for laparoscopy, morbidity, and reasons for conversion were investigated and predictors of morbidity and conversion were sought. The management algorithm of trauma patients was reviewed and updated. RESULTS: Laparoscopy was used in 318 stable trauma patients. Thirty-five patients presented with blunt and 283 with penetrating abdominal injuries. The conversion rate was 11.7% for penetrating and 22.9% for blunt abdominal trauma patients. The most common reason for conversion was continuous intraabdominal bleeding that could not be controlled quickly. It was followed by multiple complex injuries, hemodynamic instability, and intraoperative visualization problems. Diagnostic laparoscopy was performed in 45%, and therapeutic laparoscopy in 55% of cases. There were no missed injuries. Complications occurred in 21.2% in the converted group and in 9.6% in the laparoscopic group. Among initial systolic blood pressure, pulse, hemoglobin, lactate, and base deficit levels, only lower pH was associated with conversion. CONCLUSION: The management of all stable trauma patients with laparoscopy appears to be a safe approach. The use of sound laparoscopic equipment by a well-coordinated trauma team with adequate expertise in laparoscopy, adherence to the algorithm, and strict compliance with predetermined procedural steps are fundamental to success. Continuous intraoperative bleeding, complexity of injuries, deterioration of the patient, poor visibility, and equipment failure are indications for conversion.