Complicated Liver Cystic Echinococcosis-A Comprehensive Literature Review and a Tale of Two Extreme Cases.

Cystic echinococcosis is a zoonotic parasitic disease that affects the liver in more than 70% of cases, and there is still an underestimated incidence in endemic areas. With a peculiar clinical presentation that ranges from paucisymptomatic illness to severe and possibly fatal complications, quality imaging and serological studies are required for diagnosis. The mainstay of treatment to date is surgery combined with antiparasitic agents. The surgical armamentarium consists of open and laparoscopic procedures for selected cases with growing confidence in parenchyma-sparing interventions. Endoscopic retrograde cholangiopancreatography (ERCP) is extremely useful for the diagnosis and treatment of biliary fistulas. Recent relevant studies in the literature are reviewed, and two complex cases are presented. The first patient underwent open surgery to treat 11 liver cysts, and during the follow-up, a right pulmonary cyst was diagnosed that was treated by minimally invasive surgery. The second case is represented by the peritoneal rupture of a giant liver cyst in a young woman who underwent laparoscopic surgery. Both patients developed biliary fistulas that were managed by ERCP. Both patients exhibited a non-specific clinical presentation and underwent several surgical procedures combined with antiparasitic agents, highlighting the necessity of customized treatment in order to decrease complications and successfully cure the disease.

The Curious Case of the Choledochal Cyst-Revisiting the Todani Classification: Case Report and Review of the Literature.

Choledochal cysts (CCs) are rare occurrences presenting as dilatations of biliary structures, which can present as single or multiple dilatations and can appear as both intra- and extrahepatic anomalies. The most widespread classification of CCs is the Todani classification, but there have been numerous reports of cysts that do not fall into any of the types described. We present such a case-a male patient 36 years of age who underwent preoperative CT, MRCP, and ERCP, which mistakenly indicated a type II Todani CC, and intraoperatively was found to be located at the confluence of the hepatic ducts and encompassed the origin of the common bile duct. Complete resection of the cyst and the proximal segment of the common bile duct was performed, and reconstruction was carried out by Roux-en-Y double-tutorized hepaticojejunostomy. Considering the risk of malignant transformation, the frequent preoperative misdiagnosis, as well as the technically challenging surgery required in such cases, we advocate for a revision of the classification and raise awareness of the need for guidelines regarding the proper short-term and long-term management of this disease to ensure adequate quality of life and disease-free survival for patients.

Laparoscopic vs. open resection for colon cancer-quality of oncologic resection evaluation in a medium volume center.

Despite concerns regarding oncologic safety, laparoscopic surgery for colon cancer has been proven in several trials in the lasts decades to be superior to open surgery. In addition, the benefits of laparoscopic surgery can be offered to other patients with malignant disease. The aim of the present study was to compare the quality of oncologic resection for non-metastatic, resectable colon cancer between laparoscopic and open surgery in terms of specimen margins and retrieved lymph nodes in a medium volume center in Romania. A total of 219 patients underwent surgery for non-metastatic colon cancer between January 2017 and December 2020. Of these, 52 underwent laparoscopic resection, while 167 had open surgery. None of the patients in the laparoscopic group had positive circumferential margins (P=0.035) while 12 (7.19%) patients in the open group (OG) had positive margins. A total of three patients in the laparoscopic group (5.77%) and seven patients (4.19%) in the OG had invaded axial margins. While the number of retrieved lymph nodes was not correlated with the type of procedure [laparoscopic group 16.12 (14±6.56), OG 17.31 (15±8.42), P=0.448], the lymph node ratio was significantly higher in the OG (P=0.003). Given the results of the present study, it is safe to conclude that laparoscopic surgery is not inferior to open surgery for non-metastatic colon cancer in a medium volume center.

Look beyond the Mirror: Laparoscopic Cholecystectomy in Situs Inversus Totalis-A Systematic Review and Meta-Analysis (and Report of New Technique).

BACKGROUND: Laparoscopic cholecystectomy in situs inversus totalis (SIT) is a technically and physically demanding procedure for surgeons and there is still a lack of consensus regarding the best technical approach in such cases. We conducted a systematic review and meta-analysis to evaluate port placement, the dominant hand of the surgeon, preoperative imaging, morbidity, and mortality. METHODS: We searched MEDLINE, SCOPUS, Web of Science, and the Cochrane Library for studies of patients with SIT that underwent laparoscopic cholecystectomy. Of 387 identified records, 101 met our inclusion criteria, all of them case reports or case series of maximum of 6 patients. RESULTS: Out of the 121 patients included in the analysis, 94 were operated on using a "mirrored American" technique, 12 using the "Mirrored French", 9 employed single-port techniques, and 6 described novel port placements. Even though most surgeries were conducted by a right-handed surgeon (93 cases), surgeries performed by the seven left-handed surgeons yielded shorter intervention times (p = 0.024). Preoperative imaging (CT, MRI, MRCP, ERCP) also correlated with a lower duration of surgery (p = 0.038. Length of stay was associated with the type of disease, but not with other studied endpoints. Morbidity was less than 1%, and conversion rates and mortality were nil. CONCLUSIONS: Cholecystectomy in SIT is a safe but challenging procedure and surgeons should prepare in advance for the unfamiliar aspects of completing such a task. While preoperative imaging and a left-handed surgeon are beneficial in terms of surgery length, when these are not available surgeons should focus on achieving the most comfortable setting based on their experience and tailor their approach to the patient at hand. Further studies are needed in order to properly describe and evaluate intraoperative findings as well as surgeon-dependent factors that could improve future recommendations.

Treatment of Achalasia in the Evidence-Based Medicine Era - A Quest in Search for a Proper Attitude by Reviewing the Present Guidelines.

The best way to start a paper like this is with a citation from W. Edwards Deming: Without data, you're just another person with an opinion. In the era of Evidence-Based Medicine (EBM) every surgical procedure has to be backed up by solid statistical data to offer our patients the best treatment. But is EBM always the path to truth? We decided to analyze the literature for achalasia and see if the guidelines and the data are reliable enough to justify a certain attitude. Practically, we engaged in this endeavor not because we do not trust the statements of the guidelines, but to see if a surgeon can find by themselves the proper attitude in this disease. Achalasia is a motility disorder of the esophagus characterized by deficient relaxation of the inferior esophageal sphincter that results in dysphagia. There are several methods of treatment, with various statements in the guidelines. Currently, every treatment should be sustained by data and statistics, evidence-based medicine being mandatory when a method is preferred over another. This article reviews several studies and also the available guidelines in search for an answer to the question which procedure is the best.

Posterior Circular Stapled GastroJejunostomy After Duodenopancreatectomy.

Anastomotic fistulae are the most common and dreaded postoperative complications of pancreaticoduodenectomy. Delayed gastric emptying (DGE) and slow recovery of bowel function are contributing causes for postoperative pancreatic fistula (PoPF) that should be taken into consideration. The present study evaluates data from 17 consecutive cases that underwent pancreaticoduodenectomy for pancreatic adenocarcinoma with pancreaticojejunal anastomosis and circular stapled mechanical gastrojejunal anastomosis instead of the standard terminolateral technique. Three patients developed Grade A DGE (one also developed grade B PoPF) and one patient required reinsertion of the nasogastric tube due to Grade B PoPF. Overall, the incidence of DGE was 23.5%. Three patients developed Grade B pancreatic fistulae that were successfully managed conservatively. Twelve patients resumed early bowel movement within 4 days, two reinterventions were required for postoperative bleeding. Mean hospital stay was 11.5 days. Patients with DGE had a mean hospital stay of 14.5 days. No gastrojejunostomy leak was encountered. Mortality was nil. Therefore we consider the posterior circular stapled gastrojejunostomy a simple, reproducible, safe technical alternative for avoiding DGE and consequently help lower the risk of PoPF, increased costs associated with prolonged hospital stay and an improved postoperative quality of life.

The Tubercle of Zuckerkandl is Associated with Increased Rates of Transient Postoperative Hypocalcemia and Recurrent Laryngeal Nerve Palsy After Total Thyroidectomy.

The current concept of complete resection of thyroid parenchyma shifted the practice from subtotal thyroidectomy to total thyroidectomy for a wide range of benign and malignant thyroid affliction and brought the tubercle of Zuckerkandl once again into attention. This embryological remnant has been shown to have a constant relationship with the recurrent laryngeal nerve and the superior parathyroid gland and may be used as a landmark for safe dissection. In order to assess if the presence of the tubercle of Zukerkandl has an impact on the most important complications of thyroid surgery, we have prospectively studied 128 patients diagnosed with nodular goiter who underwent total thyroidectomy. Grade 0 or the absence of the tubercle of Zuckerkandl, according to Pellizo et al, was noted in 42 cases (32.8%). During surgery, we identified 38 grade 1 tubercles (29.7%), 31 grade 2 tubercles (24.2%) and 16 grade 3 tubercles (12.5%). Out of 11 bilateral tubercles, 4 were measured as grade 3.Of all 47 patients with grade 2 and 3 tubercles, 18 (38.3%) developed transient postoperative hypocalcemia (p 0.0001, r=0.47) and 10 (21.3%) transient postoperative nerve palsy (p=0.004, r=0.25). All patients fully recovered during follow-up. The tubercle of Zuckerkandl, when present and of significant macroscopic size is associated with increased rates of transient postoperative hypocalcemia and recurrent laryngeal nerve palsy.

Risk Assessment and Learning Curve in Laparoscopic Transperitoneal Adrenalectomy - Early and Late Experience of a Single Team.

Since its first description in 1992, laparoscopic adrenalectomy has become the standard of treatment for most benign and low grade small adrenal tumors but due to the low incidence of adrenal disease, it remains a rarely performed intervention outside referral or excellence centers. Although laparoscopic surgery had a positive impact on complications of adrenalectomy, surgical risk should be thoroughly assessed when it comes to secreting or large tumors. This is a retrospective analysis of laparoscopic adrenalectomies performed in the first 4 years of practice 2007-2010 - the early experience including the learning curve of the senior surgeon, and our late experience from 2016 to 2019. All interventions were performed by a single team led by a senior surgeon with extensive experience in advanced laparoscopic surgery, using the lateral transperitoneal approach. In total, 82 cases were included, out of 153 laparoscopic adrenalectomies performed between 2007 and 2019. Only one conversion was recorded during the early experience and two laparoscopic reinterventions were needed for hemostasis and drainage. Non-secreting adenoma was the most frequent indication for surgery (26 cases) followed by Cushing's Syndrome (22 cases) while adrenocortical carcinoma was diagnosed in 3 cases. Significant differences were found between the two periods regarding operative time and length of postoperative hospital stay (p 0.001). With growing experience in laparoscopic transperitoneal adrenalectomy, less complications and shorter operative time and postoperative hospital stay are to be expected.

Clostridium difficile Infection and Colorectal Surgery: Is There Any Risk?

Background and objectives: Clostridium difficile infection (CDI) is an important healthcare-associated infection, with important consequences both from a medical and financial point of view, but its correlation with anastomotic leaks after colorectal surgeries is scarcely reported in the literature. Materials and Methods: We conducted a retrospective study looking for patients who underwent open or laparoscopic surgery for colorectal cancers between January 2012 and December 2017, excluding emergency surgeries for complicated colorectal tumors. We also examined patient history for risk factors for CDI such as age, sex, comorbidities, and clinical findings at admission or during hospital stay as well as tumor characteristics. Results: A total of 360 patients were included in the study, out of which 320 underwent surgeries that included anastomoses. There were 19 cases of anastomotic leaks, out of which 13 patients were diagnosed with CDI, with a statistic significance for association between CDI and anastomotic leakage (p < 0.0001). Most patients who developed both CDI and anastomotic leaks had left-sided resections or a type of rectal resection, while none of the patients with right-sided resections had this association, but with no statistical significance possibly due to the limited number of cases. Conclusions: CDI is a relevant risk factor and should be taken into consideration when trying to prevent anastomotic leaks in patients undergoing gastrointestinal surgery for colon or rectal cancer. Thorough assessment of risk factors at admission should be mandatory in order to adequately prepare the patient and plan an optimal course of treatment. Further studies are needed to confirm our findings and a multidisciplinary approach, with a team which should always include the surgeon, is mandatory when it comes to CDI prevention.

Peritoneal Encapsulation - A Rare Cause of Small Bowel Obstruction.

Peritoneal encapsulation (PE) is a rare anatomic anomaly which occurs due to an accessory peritoneal sac covering the small bowel which can cause chronic recurrent abdominal pain and even small bowel obstruction, most often in children or patients with no previous surgical history. The diagnosis is usually made during surgery, but recently it has been suggested that mindful examination of the abdominal CT may be helpful in considering PE beforehand. We present the case of a 21-year old patient who was admitted due to intense abdominal pain, asymmetrical abdominal distension, air fluid levels on the abdominal X-ray, but no specific findings on the abdominal CT. He underwent emergency surgery and PE was found and the peritoneal sac was excised. The postoperative course was uneventful. Histopathologic examination of the specimen confirmed the diagnosis. PE is often misdiagnosed as abdominal cocoon or sclerosing encapsulating peritonitis, but it is a pathology with a much lower rate of recurrence and postoperative complications, which can be treated successfully if the surgeon is aware of this pathology when making the differential diagnosis.

The Surgical Management of Acute Esophageal Perforation by Accidentally Ingested Fish Bone.

Esophageal foreign bodies are a relatively frequent pathology which does not need any kind of treatment in up to 80% of cases. Ten to 20% of patients are treated endoscopically, while less than 1% need surgery either due to perforation or to treat complications. We address the case of a 50 year old male who presented with an impacted esophageal foreign body which had perforated the esophageal wall. Flexible endoscopy confirmed the diagnosis and identified a large fish bone that was stuck transversally in the distal cervical esophagus and could not be mobilized. Surgery was mandatory in this case, with the extraction of the bone and double-layer suture, which did not prevent the appearence of an esophageal leakage more than two weeks postoperatively, which was treated conservatively. Even if it is rarely employed in the treatment of gastrointestinal foreign bodies, surgical treatment is unavoidable in cases of irretrievable esophageal foreign bodies or esophageal perforation.