Robotic excision of a retrocaval ancient schwannoma: a case report.

We report a case of a robotic-assisted excision of a retrocaval ancient schwannoma. A 40-year-old female presented with generalized weakness and abdominal pain that led to the diagnosis of a retroperitoneal mass adjacent to the pancreas and inferior vena cava. Because of the clinical, imaging, and needle biopsy findings, the patient underwent an elective robotic-assisted retroperitoneal exploration. We provide an overview of the pathology and highlight the significance of utilizing a minimally invasive approach for excision of retroperitoneal masses.

Synchronous colon cancer presenting as toxic megacolon in a patient with ulcerative colitis: A case report.

INTRODUCTION AND IMPORTANCE: The incidence of colorectal cancer in patients with inflammatory bowel disease is greater than the general population. Of those with inflammatory bowel disease, synchronous cancers are more common in ulcerative colitis than in Crohn's disease. It is rare for synchronous cancer to present as toxic megacolon in a patient with concomitant inflammatory bowel disease, specifically ulcerative colitis. CASE PRESENTATION: In this report, we describe the clinical presentation of a 22-year-old female, who presented with toxic megacolon ultimately requiring total abdominal colectomy with end-ileostomy and a final pathology of two synchronous colon cancers, despite normal colonoscopy one year prior. The postoperative period was unremarkable, and the patient was referred to medical oncology to pursue adjuvant treatment. CLINICAL DISCUSSION: Due to the increased incidence of colorectal cancer in patients with ulcerative colitis, screening colonoscopies are typically recommended at more frequent intervals than the general population. Toxic megacolon as the presentation for colon cancer in patients with underlying ulcerative colitis is exceedingly rare. To our knowledge, this is the first case reported of synchronous colon cancer presenting as toxic megacolon in a patient with ulcerative colitis and recent negative screening colonoscopy. CONCLUSION: Colorectal cancer should always be high in the differential diagnosis for patients with ulcerative colitis regardless of the age. The principles of oncologic resection for colorectal cancer should be followed during colonic resections in patients with ulcerative colitis, even in the acute setting.

Perforated pre-pyloric ulcer in the gastric remnant over a decade after Roux-en-Y gastric bypass: A case report.

INTRODUCTION AND IMPORTANCE: Roux-en-Y gastric bypass (RYGB) is one of the two most common weight loss surgeries. Surgical emergencies after gastric bypass can be complicated by devastating events that are often difficult to diagnose and manage. Perforated ulcers are a very rare complication after a RYGB. CASE PRESENTATION: In this report, the diagnosis and surgical management of a 59-year-old immunosuppressed male patient who presented with late perforation of a pre-pyloric ulcer in the gastric remnant after RYGB is presented. The perforation was repaired transversely in a running horizontal mattress fashion and patched with a piece of well-vascularized omentum. CLINICAL DISCUSSION: This case illustrates the potential for gastric remnant ulceration, even a decade after RYGB. A high degree of suspicion for the diagnosis of perforated remnant stomach is required, especially in the absence of pneumoperitoneum and free fluid. Patient-specific factors, such as immunosuppression in this case, may blunt normal physiologic response. CONCLUSION: Considering the location of the ulcer in the pre-pyloric area, we caution that the typical paradigm of marginal ulceration of the gastro-jejunal anastomosis does not always apply when evaluating gastric complications after RYGB.

Novel TEVAR technique for thoracic aortic aneurysm repair: A case report.

INTRODUCTION AND IMPORTANCE: A thoracic aortic aneurysm (TAA) is a life-threatening condition affecting 5-10 per 100,000 people per year. If not repaired, mortality rates are reported as high as 11.8 %, increasing to 97 %-100 % following a TAA rupture. Thoracic endovascular aortic repairs (TEVAR) are becoming more common, but currently face limitations due to complex vasculature. New techniques may provide a safer alternative. CASE PRESENTATION: 70-year-old male presenting with a history of hypertension, dyslipidemia, and previous replacement of ascending aorta and hemi arch with reimplantation of innominate artery done in 2020. A CT scan done during routine interval monitoring of previous TAA repair demonstrated a new aneurysm, which was confirmed with CT angiogram. A novel TEVAR technique was used for repair. The patient tolerated this procedure well and was discharged from the ICU after six days. CLINICAL DISCUSSION: Open procedures and hybrid techniques for TAA repair are not always suitable for high-risk patients. Alternative parallel grafting techniques have shown promising early results but still lack clinical support and long-term data. Several small-scale studies and case reports have demonstrated the use of in-situ laser fenestrations in various settings, but none have demonstrated the ability to extend the landing zone as far as zone 0 for repair of a Type B TAA. CONCLUSION: The use of this novel technique may be considered suitable in high-risk patients with various subtypes of TAAs not suitable for open repair. More cases and clinical trials are needed to compare risks and long-term results to more commonly performed procedures.

Robotic versus laparoscopic colectomy outcomes in colon adenocarcinoma in the elderly population: a propensity-score matched analysis of the National Cancer Database.

PURPOSE: While robotic surgery is more costly and involves longer intra-operative time, it has a technical advantage over laparoscopic surgery. With our aging population, patients are being diagnosed with colon cancer at older ages. The aim of this study is to compare laparoscopic versus robotic colectomy short- and long-term outcomes in elderly patients diagnosed with colon cancer at a national level. METHODS: This retrospective cohort study was conducted using the National Cancer Database. Subjects ≥ 80-years-old who were diagnosed with stage I to III colon adenocarcinoma and underwent a robotic or laparoscopic colectomy from 2010-2018 were included. The laparoscopic group was propensity-score matched in a 3:1 ratio to the robotic group with 9343 laparoscopic and 3116 robotic cases matched. The main outcomes evaluated were 30-day mortality, 30-day readmission rate, median survival, and length of stay. RESULTS: There was no significant difference in the 30-day readmission rate (OR = 1.1, CI = 0.94-1.29, p = 0.23) or 30-day mortality rate (OR = 1.05, CI = 0.86-1.28, p = 0.63) between both groups. Robotic surgery was associated with higher overall survival (42 vs 44.7 months, p < 0.001) using a Kaplan-Meier survival curve. Robotic surgery had a statistically significant shorter length of stay (6.4 vs. 5.9 days, p < 0.001). CONCLUSION: Robotic colectomies are associated with higher median survival rates and decrease in the length of hospital stay compared to laparoscopic colectomies in the elderly population.

Does race influence the attainment of the principles of oncologic surgical resection in colon adenocarcinoma? A retrospective cohort analysis from the national cancer database.

The standard operation for colon cancer resection should follow certain principles to ensure appropriate oncologic resection, such as retrieving 12 or more nodes with the specimen and adequate surgical margins. Although these principles are well documented, there is little evidence regarding the association of race and the attainment of an adequate oncologic resection. Methods: The authors performed a retrospective cohort study of all cases of resectable colon adenocarcinoma who underwent surgical resection in the National Cancer Database between 2004 and 2018. The postoperative lymph node count and margins were grouped as 'principles of oncologic surgical resection'. A multivariate logistic regression analysis was performed to assess race and other demographic variables as independent factors influencing the attainment of the principles of oncologic resection. Results: A total of 456 746 cases were included. From this cohort, 377 344 (82.6%) achieved an adequate oncologic resection and 79 402 (17.4%) did not. On logistic regression, African American and Native American patients were less likely to attain an adequate oncologic resection. Similarly, patients with an elevated Charlson-Deyo score (2 or above), stage I cancer, and patients who underwent extended resection were less likely to achieve adequate oncologic resection. Resections performed in metropolitan areas, patients with private insurance, high-income quartiles, and patients diagnosed in more recent years were more likely to achieve adequate oncologic resection. Conclusions: There are significant racial disparities regarding the attainment of the principles of oncologic resection in colon cancer, which could be explained by unconscious biases, social discrepancies, and inadequate healthcare access. Early introduction and conscientization of unconscious biases are required in surgical training.

Metastatic pancreatic adenocarcinoma presenting as large bowel obstruction: A case report.

INTRODUCTION AND IMPORTANCE: The incidence of pancreatic cancer has gradually increased over the past decades. Metastatic pancreatic cancer to the colon is rare with only seven cases reported. Symptomatic metastasis to the colon as the initial presentation of pancreatic adenocarcinoma has only been reported in two occasions prior to this report. CASE PRESENTATION: In this report, the diagnosis and operative management of a 78-year-old male who presented with three days of obstipation and computed tomography evidence of an annular obstructing mass in the sigmoid colon in addition to a pancreatic body and lesser sac mass involving the gastric antral region. The patient underwent a laparoscopic sigmoidectomy with end colostomy. Pathology revealed metastatic adenocarcinoma of pancreatic origin. The postoperative period was unremarkable, and the patient was referred to medical oncology to pursue further treatment. CLINICAL DISCUSSION: Symptomatic metastasis to the colon as the initial presentation of pancreatic adenocarcinoma is exceedingly rare. To our knowledge, this is the 3rd case to be reported and the second that was located in the sigmoid colon. CONCLUSION: The presentation of metastatic pancreatic cancer to the colon causing a colonic obstruction is rare but should be considered in cases of atypical synchronic masses in cross-sectional imaging. When metastatic disease is suspected in the sigmoid colon, it is advisable to perform a colostomy instead of an anastomosis to avoid the potential risk of anastomotic leak that could delay the immediate need for systemic therapy.

Robotic-assisted extraction of giant gastric trichobezoar: a case report.

Trichobezoar is a rare condition, almost exclusively seen in young females with certain psychiatric disorders. Trichobezoars are usually confined within the stomach and the complications include ulceration, perforation, intussusception and obstruction for which surgery is usually required. Most of the reported cases of giant gastric trichobezoar extraction underwent an exploratory laparotomy with only a few reported cases that underwent a successful laparoscopic approach. This case report details the surgical management of the first case of a giant obstructing gastric trichobezoar extraction using robotic-assisted surgery.

Phytobezoar causing small bowel obstruction in a patient with Crohn's disease: A case report.

INTRODUCTION AND IMPORTANCE: Bezoars form in any location in the gastrointestinal tract with the small bowel being uncommon. The presentation with a small bowel obstruction (SBO) is rare, representing less than 1 % of cases. Phytobezoar causing a SBO in the setting of Crohn's disease is exceedingly rare with only three cases reported in the literature. CASE PRESENTATION: This case details the presentation and operative management of a phytobezoar causing small bowel obstruction in a patient with Crohn's disease. The patient is a 69-year-old male presenting with nausea, emesis, and obstipation. Imaging performed indicated a SBO with an obstructing intraluminal foreign body. The patient required exploration and a large phytobezoar was identified at the point of obstruction. This was treated with a segmental resection. The postoperative course was complicated by an anastomotic leak with re-exploration and end ileostomy. CLINICAL DISCUSSION: Phytobezoars are formed from indigestible plant residue which can accumulate and form a foreign body causing an obstruction in the small bowel. This is a rare occurrence in the setting of Crohn's disease. Most of these cases are managed surgically with a strictureplasty and enterotomy or a small bowel resection. CONCLUSION: Phytobezoars in the setting of Crohn's disease is very unusual. The pathophysiology of the disease predisposes patients to strictures and the mass-like foreign body can cause a bowel obstruction. This is typically managed surgically with a strictureplasty and enterotomy or in our case with an enterectomy.

Right and left atrial metastasis of renal cell carcinoma: A case report.

INTRODUCTION AND IMPORTANCE: Cardiac tumors are uncommon with an estimated incidence of 0.002-0.3 % in autopsy series. Most cardiac tumors are metastatic in nature. Renal cell carcinoma (RCC) metastatic to the heart without inferior vena cava (IVC) contiguous involvement is extremely rare with about 31 cases reported in the literature and only one case with bilateral atrial metastases. CASE PRESENTATION: In this report, the surgical management of metachronous RCC involving the right and left atrium is described in a 41-year-old male patient three years after initial diagnosis who presented with worsening episodes of cough, dyspnea, chest pain and hemoptysis. Transesophageal echocardiogram revealed significant inflow obstruction. The patient underwent bilateral atrial mass excision via median sternotomy. The postoperative period was unremarkable, and the patient was referred to medical oncology to pursue further treatment. CLINICAL DISCUSSION: Among the reported cases of cardiac RCC metastases without contiguous IVC involvement, bilateral atrial metastases are exceedingly rare. To our knowledge, this is the first case with bilateral atrial involvement to undergo surgical resection reported in the literature. CONCLUSION: Isolated biatrial cardiac metastases from RCC can be successfully resected with good outcomes in selected patients.

Colocolonic intussusception of a colostomy after colonoscopy.

The incidence of complications after colonoscopy is low and has been reported to range of 0.01-0.9%. Of these complications, colocolonic intussusception after colonoscopy is exceedingly rare, with around 12 known cases described in the literature. This case report details the presentation and operative management of a patient who developed an ischemic stoma due to a colocolonic intussusception of an end colostomy after a colonoscopy. Intraoperative surgical exploration revealed a colocolonic intussusception involving the end colostomy. This is the first known documented occurrence of this phenomenon.

Internal herniation of the cecum through the foramen of Winslow-a case report.

Foramen of Winslow hernias are a rare, but dangerous form of internal hernia that can present in individuals with signs and symptoms of bowel obstruction. This case report details operative management of a cecal herniation through the foramen of Winslow in an elderly male with no prior history of intra-abdominal surgery. The patient presented with worsening abdominal pain, nausea, vomiting and obstipation. Due to the clinical picture of a complete bowel obstruction and subsequent imaging findings, an urgent abdominal exploration was performed. During the procedure, the cecum was found to be ischemic and strangulated in the lesser sac, herniated through the foramen of Winslow. Following operative reduction and right hemicolectomy, it was decided to close the foramen of Winslow to prevent recurrence and future complications. The patient had an uncomplicated postoperative course with resolution of symptoms.