Robotic D3 Partial Duodenal Resection with Primary Side-to-Side Anastomosis.

Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or extrinsic, such as pancreatic pseudocyst, superior mesenteric artery syndrome, and foreign bodies. Current treatments range from endoscopic approaches, such as endoscopic resection and stent placement, to surgical approaches, including duodenal resection, pancreaticoduodenectomy, and gastrointestinal bypass. Minimally invasive robot-assisted surgery is gaining importance due to its potential to decrease surgical stress, intraoperative blood loss, and postoperative pain, while its instruments and 3D-vision facilitate fine dissection and intra-abdominal suturing, all leading to a reduced time to functional recovery and shorter hospital stay. We present a case of a 75-year-old female who underwent robotic D3 partial duodenal resection with primary side-to-side duodeno-jejunal anastomosis for a 5 cm adenoma with focal high-grade dysplasia.

Correction: Daskalaki et al. Early Postoperative Parathormone and Calcium as Prognostic Factors for Postoperative Hypocalcemia. J. Clin. Med. 2022, 11, 2389.

In the published article [...].

Early Postoperative Parathormone and Calcium as Prognostic Factors for Postoperative Hypocalcemia.

BACKGROUND: Postoperative hypocalcemia is one of the most common complications after total thyroidectomy. Parathormone (PTH) and calcium levels, measured several hours after surgery, have been suggested as valuable markers for detecting patients at risk for post-thyroidectomy hypocalcemia. We aimed to determine if early post-surgery PTH and calcium levels can be used for the early identification of patients at risk for symptomatic hypocalcemia. METHODS: PTH and calcium were measured before surgery and at 10 min and 4 h post-thyroidectomy, in 77 patients. Performance characteristics of PTH and calcium levels and their post/pre-surgery ratios were calculated. RESULTS: Four-hour calcium was a sensitive (93.75%) but not specific (67.61%) indicator of patients at risk for symptomatic hypocalcemia. The 4-h/pre-surgery PTH ratio was the most accurate (90.81%) and the most specific (94.37%) test to identify patients at risk. Serum calcium at 4-h, 4-h/pre-surgery PTH ratio, and PTH at 10 min post-surgery had the higher diagnostic odds ratios (50.86, 32.85, and 29.04, respectively). The 4-h/pre-surgery PTH ratio also had the highest (0.694) Youden's J statistic. CONCLUSIONS: Low serum calcium levels 4 h after thyroidectomy and the 4-h/pre-surgery PTH ratio could be valuable additions to everyday clinical practice in post-thyroidectomy patients.

A case of solitary rectal diverticulum presenting with a large retrorectal abscess.

Colonic diverticular disease is a common condition, affecting 50% of the population aged above 80. In contrast, rectal diverticular disease is a rare condition with very few cases reported, while symptomatic rectal diverticular disease is even rarer. We present a case of a symptomatic large rectal diverticulum presenting with a retrorectal abscess. A 49-year-old Caucasian female was brought to the emergency department complaining of abdominal pain and weakness in the lower limbs. She was found to have obstructive uropathy and unilateral sciatic neuropathy. She rapidly developed acute abdomen and emergency laparotomy revealed a giant purulent rectal diverticulum. The patient underwent exploratory laparotomy and a loop colostomy was made to decompress the colon.

Newly recognized extratumoral features of colorectal cancer challenge the current tumor-node-metastasis staging system.

One of the most common malignant tumors in humans, colorectal cancer has been extensively studied during the past few decades. Staging colorectal cancer allows clinicians to obtain precise prognostic information and apply specific treatment procedures. Apart from remote metastases, the depth of tumor infiltration and lymph node involvement have traditionally been recognized as the most important factors predicting outcome. Variations in the molecular signature of colorectal cancer have also revealed differences in phenotypic aggressiveness and therapeutic response rates. This article presents a review of the extratumoral environment in colorectal surgery.

A Comparison of Two Preoperative Frailty Models in Predicting Postoperative Outcomes in Geriatric General Surgical Patients.

BACKGROUND: Frailty in a surgical geriatric population may identify patients at increased risk of complications. However, the optimal method to diagnose it remains to be identified. This study aims to compare two common frailty models and assess their association with postoperative adverse outcomes in elderly patients undergoing general surgical procedures. METHODS: Prospective study including 298 patients age 65 years or older undergoing elective general surgical operations in a tertiary hospital. Frailty phenotype (FP) was classified using a validated scale which included weight loss, weakness, exhaustion, slowed walking speed and low physical activity. A preoperative comprehensive geriatric assessment (CGA) was performed including managing daily activities (ADL), instrumental ADL, cognitive status, comorbidities, polypharmacy and nutritional status. Main outcomes measures were postoperative complications and length of stay. RESULTS: There were 135 (46%), 114 (38%) and 46 (15%) minor/intermediate, major and major + procedures, respectively. The agreement between the FP and CGA was moderate (kappa index: 0.45). FP was significantly associated with postoperative complications with an odds ratio (OR) of 2.3, (95% confidence interval 1.4-3.8, p < 0.01). The association of CGA with postoperative complications did not reach statistical significance (p = 0.07). Postoperative hospital stay was significantly longer in both CGA frailty (p < 0.001) and FP (p = 0.001) groups compared to the fit population. In the multivariate analysis adjusted for ASA and POSSUM category, FP retained its significance as a predictor of postoperative complications (OR: 1.9, 95% CI 1.03-3.3, p = 0.038). CONCLUSIONS: FP was associated more consistently than CGA with adverse postoperative outcomes in elderly patients undergoing general surgical procedures.

Guiding Management in Severe Trauma: Reviewing Factors Predicting Outcome in Vastly Injured Patients.

Trauma is one of the leading causes of death worldwide, with road traffic collisions, suicides, and homicides accounting for the majority of injury-related deaths. Since trauma mainly affects young age groups, it is recognized as a serious social and economic threat, as annually, almost 16,000 posttrauma individuals are expected to lose their lives and many more to end up disabled. The purpose of this research is to summarize current knowledge on factors predicting outcome - specifically mortality risk - in severely injured patients. Development of this review was mainly based on the systematic search of PubMed medical library, Cochrane database, and advanced trauma life support Guiding Manuals. The research was based on publications between 1994 and 2016. Although hypovolemic, obstructive, cardiogenic, and septic shock can all be seen in multi-trauma patients, hemorrhage-induced shock is by far the most common cause of shock. In this review, we summarize current knowledge on factors predicting outcome - more specifically mortality risk - in severely injured patients. The main mortality-predicting factors in trauma patients are those associated with basic human physiology and tissue perfusion status, coagulation adequacy, and resuscitation requirements. On the contrary, advanced age and the presence of comorbidities predispose patients to a poor outcome because of the loss of physiological reserves. Trauma resuscitation teams considering mortality prediction factors can not only guide resuscitation but also identify patients with high mortality risk who were previously considered less severely injured.

Multiple magnet ingestion causing instestinal obstruction and entero-enteric fistula: Which imaging modality besides radiographs? A case report.

Ingested foreign bodies occur in children younger than 3 years and pass uneventfully through the gastrointestinal tract. However, multiple magnet ingestion are associated with serious complications. A 9-year old male with abdominal pain and vomiting 3 days prior to admission, underwent abdominal radiographs showing radiopaque foreign bodies. Ultrasonography (US) independently discovered one magnet floating in the jejunum. Preoperative Computed Tomography (CT) confirmed the presence of two neighbouring magnets causing obstruction and beaking of an adjacent jejunal loop. Laparotomy led to uneventful recovery of transmesenteric fistula formation following pressure necrosis in two jejunal loops. We present the first case of multiple magnet ingestion managed in our institution, where the prevalence of magnet ingestions is low due to unpopularity of magnet toys. CONCLUSION: Awareness of the potentially devastating effects of multiple magnets passing the pylorus and the contribution of different imaging modalities for the diagnosis are emphasized and discussed.

Anesthetic management of a pediatric patient with Electron Transfer Flavoprotein Dehydrogenase deficiency (ETFDH) and acute appendicitis: case report and review of the literature.

BACKGROUND: Mitochondria are the energy producing organelles practically in every human cell except erythrocytes. Indeed mitochondria are widespread in high energy requiring organs like brain, heart and muscles. Currently there are no clinical trials supporting with clear evidence which is the most suitable surgical or anesthetic management of a patient with known mitochondrial disease presenting with surgical disorders. This condition poses possible hazardous problems to the medical attention of those patients. CASE PRESENTATION: A case of an 8 year old child with known Electron Transfer Flavoprotein Dehydrogenase deficiency (ETFDH deficiency) requiring surgery for acute appendicitis is presented. Our approach for anesthesia revealed a combination of fentanyl, low dose propofol and nitrous oxide. CONCLUSION: The choice of the safest pharmacological anesthetic agents for patients with ETFDH deficiency is challenging given that most of the general anesthetic medications have multiple effects on mitochondria, fatty acids metabolism and striated muscles. Anesthetists are expected to individualize anesthetic care for the patient based on current publications for similar cases, medical history and knowledge of pharmacology and physiology.

A case of asystole from carotid sinus hypersensitivity during patient positioning for thyroidectomy.

BACKGROUND: We present a case of a patient with multinodular goiter disease who suffered asystole during head hyperextension for surgical positioning on the operational table. CASE PRESENTATION: Manipulation of carotid sinus may trigger bradycardia or even asystole even in patients without prior history of carotid sinus hypersensitivity. The time proximity between patient positioning and asystole, the late responsiveness to atropine, the immediate increase of heart rate after head elevation and the lack of any other trigger factor or prior history support the hypothesis of carotid sinus syndrome. CONCLUSIONS: Head hyperextension during surgical positioning is not only responsible for jeopardizing blood flow to spinal cord and brainstem but may trigger reflexes, as well, even in patients without prior neck pathology.

A Rare Case of Mixed Neuroendocrine Tumor and Adenocarcinoma of the Pancreas.

Introduction. Neuroendocrine carcinoma (NEC) of pancreas is a rare tumor with aggressive progression and poor prognosis. Its coexistence with adenocarcinoma poses significant clinical problems and has not been addressed in the literature. Methods. We describe a case of a 51-year-old male who underwent pancreatoduodenectomy due to pancreatic head tumor 1.5 × 1 × 1.4 cm. Histological examination of the specimen revealed a mixed neoplasm: (1) a well differentiated adenocarcinoma, neoplastic blasts of which are extended focally to the submucosa without invading the muscular layer, and (2) a low differentiated NEC consisting of solid clusters and pagetoid formations. All 18 lymph nodes of the specimen were free of neoplastic disease and the surgical margins of the specimen were tumor-free. No adjuvant treatment was administered and two months after the operation the patient developed liver metastasis. FNA cytology of the hepatic lesions revealed low grade carcinoma with neuroendocrine characteristics. Five lines of chemotherapy were administered: VP + CDDP, paclitaxel + ifosfamide + Mesna + CDDP, Folfox + Avastin, Folfiri + Avastin, and CAV. During his treatment he revealed PD and succumbed to his disease 13 months after the operation. Conclusion. Coexistence of NEC with adenocarcinoma of the pancreas is a very rare entity presenting significant challenges regarding its adjuvant treatment and the treatment of distant relapse.

Therapeutic abdominoplasty: Report of a case.

BACKGROUND: Abdominoplasty is a surgical procedure which is commonly used for cosmetic purposes. However, there are very few reports in the world literature describing the abdominoplasty procedure for therapeutic purposes rather than for cosmetic reasons. METHODS: A 58 year old female presented with an excessive drooping belly and a concomitant minor umbilical stoma hernia, who suffered from chronic back pain, urinary incontinence, nerve atrophy of the low extremes, central-type obesity, gastric disorders, and spinal osteophytes who underwent abdominoplasty and umbilical hernia repair. RESULT: On discharge from the hospital after 11 days, the patient mentioned satisfactory elimination of the back pain as well as amelioration of the urinary incontinence. Within 14 months after the operation, the patient noticed extreme improvement of ambulation and postural stability as well as complete disappearance of the neuro-myodystrophy. CONCLUSION: Wide abdominal rectus plication abdominoplasty should be considered to be performed for therapeutic purposes when major health problems occur.

Internal-mesocolic hernia after laparoscopic left colectomy report of case with late manifestation.

INTRODUCTION: In contrast to right colectomy, closure of the mesocolic gap after laparoscopic left colectomy is not practiced, and reports of small gut herniation through this gap are scarce. PRESENTATION OF CASE: A 73 year old male was admitted as an emergency with symptoms and clinical signs, suggesting obstruction of the small bowel. Abdominal imaging, including computed tomography confirmed the diagnosis. The patient had undergone laparoscopic left colectomy for cancer, three years ago. At laparotomy small bowel loops were found to herniate through the mesocolic defect at the level of the colonic anastomosis. The small bowel loops were reduced and their viability was ascertained. Because of an iatrogenic perforation of the colon at the anastomosis during small bowel loops mobilization, the colon was temporarily exteriorized in the form of a double barrel colostomy. The postoperative course was uneventful. DISCUSSION: Very few cases have been reported in the liteature indicating the need of sutuing the mesenterium. Despite the limited numbe of the reported cases, there is clearly a risk of intenal hernia after laparoscopic left colectomy. CONCLUSION: Although rare internal hernia after laparoscopic left colectomy may occur, and this brings forward the question of mesocolic gap closure.

Laparoscopic repair of posttraumatic diaphragmatic rupture. Report of three cases.

INTRODUCTION: Posttraumatic diaphragmatic rupture (PTDR) is a rare complication of thoracoabdominal injuries. In the emergency phase, it is generally treated via wide laparotomy. The laparoscopic approach is controversial and it is reserved for the chronic type of PTDR. Herein we present three cases of laparoscopic treatment of PTDR, one of which was conducted early after the injury. PRESENTATION OF CASE: The patients' age was 42, 66 and 53 years and the time from the injury until the operation 1 week, 2 months and 4 years, respectively. Hernia involved the left hemidiaphragm in two patients and the right hemidiaphragm in the second patient. Prolapsing viscera were the omentum/stomach/spleen, the small intestine and the omentum/large bowel, respectively. The PTDR was diagnosed right after the injury of the first patient but its treatment was postponed until the fourth day of hospitalization because of severe respiratory distress due to bilateral pneumothorax, flail chest and extended bilateral lung contusions. All patients underwent laparoscopic operation and correction of the hernia with the use of non-absorbable sutures or endoclips in two patients. There were no serious intra- or postoperative complications and the patients were discharged 30, 5, 6 days after the operation. After a period of 1, 8 and 9 years, respectively the patients remain without clinical evidence of recurrence. DISCUSSION: Trauma is the major cause of acquired diaphragmatic hernias. CONCLUSION: Laparoscopy is an attractive approach for the management of chronic PTDR. Moreover, it may offer the benefits of minimally invasive surgery during the acute phase of injury in highly selected patients.