Surgical margin status outcome of intraoperative indocyanine green fluorescence-guided laparoscopic hepatectomy in liver malignancy: a systematic review and meta-analysis.

BACKGROUND: Hepatectomy stands as a curative management for liver cancer. The critical factor for minimizing recurrence rate and enhancing overall survival of liver malignancy is to attain a negative margin hepatic resection. Recently, Indocyanine green (ICG) fluorescence imaging has been proven implemental in aiding laparoscopic liver resection, enabling real-time tumor identification and precise liver segmentation. The purpose of this study is to conduct a systematic review and meta-analysis to ascertain whether ICG-guided laparoscopic hepatectomy yields a higher incidence of complete tumor eradication (R0) resections. METHODS: The search encompassed databases such as PubMed, Cochrane Library database, Scopus, ScienceDirect, and Ovid in April 2024, in strict adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies involving patients with malignant liver lesions who underwent ICG-guided laparoscopic hepatectomy and reported R0 resection outcomes were eligible for inclusion in this review. RESULTS: In a total of seven studies, involving 598 patients, were included in the meta-analysis. The ICG demonstrated a significantly elevated R0 resection rate compared to the non-ICG group [98.6% (359/364) vs. 93.1% (339/364), odds ratio (OR) = 3.76, 95% confidence intervals (CI) 1.45-9.51, P = 0.005]. Notably, no heterogeneity was observed (I2 = 0%, P = 0.5). However, the subtype analysis focusing on hepatocellular carcinoma [98.2% (165/168) vs. 93.6% (161/172), OR = 3.34, 95% CI 0.94-11.91, P = 0.06) and the evaluation of margin distance (4.96 ± 2.41 vs. 2.79 ± 1.92 millimeters, weighted mean difference = 1.26, 95% CI -1.8-4.32, P = 0.42) revealed no apparent differences. Additionally, the incidence of overall postoperative complications was comparable between both groups, 27.6% (66/239) in the ICG group and 25.4% (75/295) in the non-ICG group (OR = 0.96, 95% CI 0.53-1.76, P = 0.9). No disparities were identified in operative time, intraoperative blood loss, postoperative blood transfusion, and length of hospital stay after the surgery. CONCLUSIONS: The implementation of ICG-guided laparoscopic hepatectomy can be undertaken with confidence, as it does not compromise either intraoperative or postoperative events. Furthermore, the ICG-guided approach is beneficial to achieving a complete eradication of the tumor during hepatic resection. TRIAL REGISTRATION: PROSPERO registration number CRD42023446440.

Axillary and elbow lymph node metastasis arising after complete excision of microcystic adnexal carcinoma of a hand: A rare presentation.

INTRODUCTION: Microcystic adnexal carcinoma (MAC), a malignant transformation of adnexal structures, constitutes a rare locally aggressive malignancy of skin. Generally, the disease is associated with local invasion and distant metastases are extremely rare. We presented a case of MAC with distant metastasis after adequate wide excision. PRESENTATION OF CASE: A 65-year-old man presented with a scar-like lesion at his left hand's middle finger. As pathologic result from incisional biopsy confirmed MAC, the patient was then treated with ray amputation. Eight years later, there was a presence of scar changes. There was a palpable node at medial epicondyle and presence of enlarged lymph nodes at axilla by imaging with Computed tomography (CT) scan. Following left hand amputation and node dissection at elbow and axillary region, pathologic examination confirmed recurrence and metastasis of MAC. He went through adjuvant radiation with a complete response. At present, two years after surgery, he remains in complete remission. DISCUSSION: The presence of a recurrent MAC with distant lymph node metastasis after primary surgery is rare. The metastatic route as presented with the positive nodes at elbow and axilla could be explained the spreading via lymphatic system. CONCLUSION: MAC arising at a hand may require wider excision in order to achieve best result. Although this malignancy is a slowly progressive disease, distant metastasis should always be concerned, especially when there are suspicious presentations. CT scan will render more details and make more precise diagnosis in the suspicious situation.

A challenge in diagnosis and management of ulcerative colitis in elderly patient with atypical presentation: A reported case.

INTRODUCTION: Recognition of elderly-onset ulcerative colitis (UC) remains poor as the differential diagnosis in older patients with acute abdominal pain and bloody diarrhea is extensive and UC is generally not the obvious cause. A typical presentation in an elderly patient with acute severe UC can mimic surgical abdomen. PRESENTATION OF CASE: An 80-year-old female had been presented with high grade fever, abdominal pain and diarrhoea. Physical examination showed sign of peritonitis and severe hypotension. A provisional diagnosis of perforated sigmoid diverticulitis was made. However, at the theater, there was only turbid yellowish ascites at cal-de-sac. Consequently, colonoscopy was performed and revealed continuous and circumferential erythematous with friable mucosa and multiple shallow ulcer along upper left side colon. Histologic examination of the colonic tissue was consistent with UC. DISCUSSION: As UC is uncommon in Thailand and clinical features of elderly-onset UC are much more non-specific; as a result, misdiagnosis at initial presentation is more common in elderly patients (60%) than that in younger population (15%). These might result in an unnecessary exploratory laparotomy; however, computed tomography scan can reduce the risk of that event. CONCLUSION: The diagnosis of severe acute UC in elderly patients with acute abdomen had been complicated by the distinctive physiology of this aged group with atypical presentation and markedly unreliable physical examination. Eventually, severe UC should always be kept in mind with a circumstance of abdominal pain in geriatric population.

Tuberculous peritonitis in a cerebral palsy patient: A challenge in diagnosis and management.

INTRODUCTION: Diagnosis of tuberculous peritonitis (TBP) in a normal person, although possible, is often difficult to make because of its non-specific symptoms and signs. However, establishing a diagnosis of TBP in a patient with cerebral palsy (CP) does not seem to be possible due to impaired mental development accompanied by communication problems. PRESENTATION OF CASE: A 19-year-old spastic man diagnosed with CP presented with fever and a nonverbal complaint of abdominal pain. The conditions were hard to evaluate due to his mental status. Abdominal radiography showed dilatation of both small and large bowels, and a subsequent computed tomography (CT) scan did not provide any additional information. With respect to a common suspected cause, a diagnosis of perforated appendicitis was established. However, at the theatre, there was only bowel dilatation with multiple small nodules at the serosa of small and large bowels. Postoperatively, polymerase chain reaction and culture revealed Mycobacterium tuberculosis, thereby leading to a diagnosis of TBP. DISCUSSION: Due to spasticity caused by CP, on examination, the patient presented with board-like rigidity, from which a diagnosis of a surgical condition was established. The misdiagnosis of an acute abdomen situation had let the patient to undergo an unnecessary exploration. To our knowledge, there has not been a report of TBP in a CP patient. CONCLUSION: The diagnosis of TBP had been complicated by the presence of CP in the reported case. The underlying CP not only preclude the diagnosis of TBP, but also produced symptoms that mimicked a condition requiring surgery.