An inguinal hernia 'hard to stomach'.

Inguinal hernias containing the stomach are extremely rare, and have never been described in females. We are reporting the case of a 79 year old female who presented in septic shock with a left inguinal hernia containing the stomach, resulting in gastric perforation and loss of abdominal domain. She underwent emergency exploratory laparotomy with manual reduction of the hernia, wedge resection of the perforated gastric segment, abdominal washout, and closure of the abdominal fascia using biological mesh. She had a complicated but successful postoperative course, and was discharged to a rehabilitation center three weeks after hospital admission.

Medullary Thyroid Cancer in Patients Older than 45-Epidemiologic Trends and Predictors of Survival.

Sporadic medullary thyroid cancer (MTC) can occur anytime in life although they tend to present at a later age (≥45 years old) when the tumors are more easily discernible or become symptomatic. We aimed to identify the factors affecting the survival in patients ≥45 years of age diagnosed with MTC. We analyzed the Surveillance, Epidemiology, and End Results (SEER) registry from 1973-2016 focusing on patients ≥45 years of age with MTC as an isolated primary. A total of 2533 patients aged ≥45 years with MTC were identified. There has been a statistically significant increase of 1.19% per year in the incidence of MTC for this group of patients. The disease was more common in females and the Caucasian population. Most patients had localized disease on presentation (47.6%). Increasing age and advanced stage of presentation were associated with worse survival with HR 1.05 (p < 0.001) and HR 3.68 (p < 0.001), respectively. Female sex and surgical resection were associated with improved survival with HR 0.74 (p < 0.001) and 0.36 (p < 0.001), respectively. In conclusion, the incidence of MTC in patients ≥45 years of age is increasing. Patients should be offered surgical resection at an early stage to improve their outcomes.

Passive drainage to gravity and closed-suction drainage following pancreatoduodenectomy lead to similar grade B and C postoperative pancreatic fistula rates. A meta-analysis.

INTRODUCTION: There is no level 1a evidence regarding the impact of passive drainage to gravity (PDG) and closed-suction drainage (CSD) following pancreatoduodenectomy on clinical outcomes. The aim of this meta-analysis was to evaluate the impact of PDG versus CSD on surgical outcomes following pancreaticoduodenectomy in high risk patients who would benefit from pancreatic drainage. METHODS: The Pubmed, EMBASE, and Cochrane Library were systematically searched. Postoperative pancreatic fistula (POPF) rate was the primary endpoint. A subgroup meta-analysis of randomized controlled trials (RCT) was performed in addition to a meta-analysis of all eligible studies. Mantel-Haenszel method (random-effects model) with odds ratios and 95% confidence intervals (OR (95%CI)) as an effect measure was utilized. RESULTS: Six studies, whereof 3 RCTs, involving 1519 patients (806 PDG and 713 CSD) were included. In meta-analysis of all studies, overall [OR (95%CI) = 0.81 (0.42, 1.56); p = 0.53; I2 = 79%; Tau2 = 0.54]; grade A [OR (95%CI) = 0.71 (0.33, 1.53); p = 0.39; I2 = 65%; Tau2 = 0.47]; grade B [OR (95%CI) = 1.23 (0.74, 2.05); p = 0.42; I2 = 0%]; and grade C [OR (95%CI) = 1.08 (0.56, 2.09); p = 0.82; I2 = 5%] POPF rates did not differ. Subgroup analysis of RCTs confirmed the finding that grade B and C POPF rates did not significantly differ with low heterogeneity [OR (95%CI) = 1.55 (0.79, 3.04); p = 0.20; I2 = 0%]. No publication bias was found (t = 0.48; p = 0.64). CONCLUSION: This meta-analysis found no difference in short-term clinical outcomes including, clinically relevant, grade B and C POPF rates between PDG and CSD. Furthermore, postoperative complication rates were similar with the use of either drain.

Postoperative hypoxemia from clinically suspected pulmonary embolism complicated by patent foramen ovale.

Postoperative hypoxemia can be a challenging diagnostic and management dilemma for the clinician. We present here a case of postoperative hypoxemia following laparoscopic gastric bypass surgery secondary to presumed pulmonary embolism complicated with a patent foramen ovale. The diagnostic pitfalls associated with a negative spiral computed tomography scan and the impact of coexisting medical conditions aggravating the pulmonary dysfunction are reviewed.