An indocyanine green fluorescence-guided operation for diagnosing and treating pleuroperitoneal communication.

Pleuroperitoneal communication occurs when ascites moves from the abdominal cavity to the pleural cavity via a diaphragmatic fistula. Managing large pleural fluid volumes is challenging, often requiring an operation. Identifying small diaphragmatic fistulas during the operation can be problematic, but ensuring their detection improves outcomes. This video tutorial presents a recent empirical case in which we successfully identified and closed a pleuroperitoneal contact using a thoracoscopic surgical procedure aided by indocyanine green fluorescence imaging. The patient, a 66-year-old woman, was hospitalized due to acute dyspnoea from a right thoracic pleural effusion during hepatic ascites treatment for cirrhosis. Because ascites decreased with pleural fluid drainage, surgical intervention was considered due to suspicion of a pleuroperitoneal connection. During the operation, indocyanine green was injected intraperitoneally, and near-infrared fluorescence-guided thoracoscopy pinpointed the location of the diaphragmatic fistula. The fistula was sutured and reinforced with a polyglycolic acid sheet and fibrin glue. Detecting the fistula intraoperatively is crucial to prevent recurrence, and the indocyanine green fluorescence method is a safe and effective technique for detecting small fistulas.

Prediction of Intraperitoneal Adhesions in Repeated Cesarean Deliveries with Stria Gravidarum Scoring System: A Cross-sectional Study.

BACKGROUND: The preoperative prediction of intraperitoneal adhesion (IPA) before repeated cesarean deliveries (CD), which are becoming more prevalent, is crucial for maternal health. AIM: The aim of the study was to preoperatively predict IPA in repeated CD with the stria gravidarum (SG) scoring system. METHODS: A total of 167 patients with at least one previous CD at or beyond 37 weeks of gestation were analyzed. Preoperative SG was calculated according to the Davey scoring system: 0-2 score were defined as mild SG (Group 1; n: 94, 56.2%), and 3-8 score were defined as severe SG (Group 2; n = 73, 43.8%). Preoperative previous cesarean incision features were evaluated according to the Vancouver scar scale. IPA was evaluated according to the Nair's and modified Nair's scoring systems. RESULTS: Parity, younger age at first pregnancy, higher body mass index, number of previous CDs, rate of scar symptoms, Nair's and the modified Nair's scores were statistically significant in Group 2 (P = 0.01; P = 0.04; P = 0.007; P = 0.004; P < 0.001; P = 0.007; P = 0.02, respectively). Davey score ≥3 and Vancouver score ≥4.5 were determined as the cut-off value to predict IPA (P = 0.1 and 0.07, respectively). According to multivariate analysis, both Davey and Vancouver scores are independent factors in predicting IPA (P = 0.02 and 0.04, respectively). CONCLUSION: Evaluating the SG score through the Davey score in women with a history of previous CD may assist in predicting IPA status before the planning of a subsequent surgery.

Giant intraperitoneal non-pancreatic pseudocyst: a case report.

INTRODUCTION: Non-pancreatic pseudocysts are rare lesions that typically form from the omentum and mesentery. These cysts have a thick fibrotic wall made up of fibrous tissue and may show signs of calcifications and inflammatory changes. The fluid inside them can vary, ranging from hemorrhage and pus to serous or sometimes chylous content. In most cases, these cysts appear as a result of trauma, surgery, or infection. CASE PRESENTATION: A 35-year-old male patient from Ethiopia presented with swelling in his lower abdomen that had been present for 2 years. Initially, the swelling was small but gradually increased in size. The patient experienced frequent urination but no pain or difficulty during urination, urgency, intermittent urination, or blood in the urine. The swelling was initially painless but became painful 2 months prior to his presentation. Abdominal computed tomography scans revealed a well-defined, lobulated peritoneal lesion measuring 16 × 12 × 10 cm, consisting primarily of fluid-filled cysts with a thick, enhancing wall and septa. Additionally, there was a large, heterogeneous enhancing soft tissue component measuring 8 × 6 cm. As a result, the cystic mass was surgically removed in its entirety with partial removal of the bladder wall, and the patient was discharged in an improved condition. CONCLUSION: Primary non-pancreatic pseudocysts are extremely rare lesions that must be differentiated from other possible causes of cystic lesions within the peritoneal or retroperitoneal regions. Surgeons should be aware of the potential occurrence of these lesions, which may have an unknown origin.

Primary Omental Torsion in Children in the Laparoscopy Era: What Have we Learned so far?

BACKGROUND/AIM: Primary omental torsion is uncommon, mimicking appendicitis and other acute abdominal pathologies. It often escapes diagnosis on imaging investigation or conventional open laparotomy. This study aimed to evaluate the effect of laparoscopy on the various parameters of this entity, including incidence, diagnosis, and treatment. MATERIALS AND METHODS: A systematic review was performed, including PubMed and Scopus databases, without a time limit, following the PRISMA principles. A total of 16 articles from January 2000 to December 2023, corresponding to 56 children with primary omental torsion, complied with the research criteria. RESULTS: Primary omental torsion was associated with obesity. Symptoms were right abdomen oriented, often compared to those of acute appendicitis. Preoperative ultrasound displayed low diagnostic accuracy, whereas computerized tomography diagnosed only two thirds of cases. In all patients, the vermiform appendix was normal. CONCLUSION: Laparoscopy affected both diagnosis and treatment of primary omental torsion in children. Easy peritoneal cavity access rendered possible the diagnosis of cases previously discharged as abdominal pain of unknown etiology. Combined with the increased pediatric obesity, it also affected primary omental torsion incidence. The recent pathogenetic theories may be better supported today, as laparoscopy provides a detailed view in situ, and facilitates harvesting of fat tissue from the omentum for molecular investigation. The diagnostic efficiency of laparoscopy is superior to ultrasonography and computerized tomography. Finally, the removal of the ischemic omentum is technically easier compared to the open laparotomy alternative with all the technical difficulties of traction of a vulnerable hemorrhagic tissue through a small incision.

Saliva-based microRNA diagnostic signature for the superficial peritoneal endometriosis phenotype.

OBJECTIVE: Patients with superficial peritoneal endometriosis (SPE) present with symptoms suggestive of endometriosis but clinical and imaging exams are inconclusive. Consequently, laparoscopy is usually necessary to confirm diagnosis. The present study aimed to evaluate the accuracy of microRNAs (miRNAs) to diagnose patients with SPE from the ENDOmiARN cohort STUDY DESIGN: This prospective study (NCT04728152) included 200 saliva samples obtained between January and June 2021 from women with pelvic pain suggestive of endometriosis. All patients underwent either laparoscopy and/or MRI to confirm the presence of endometriosis. Among the patients with endometriosis, two groups were defined: an SPE phenotype group of patients with peritoneal lesions only, and a non-SPE control group of patients with other endometriosis phenotypes (endometrioma and/or deep endometriosis). Data analysis consisted of two parts: (i) identification of a set of miRNA biomarkers using next-generation sequencing (NGS), and (ii) development of a saliva-based miRNA signature for the SPE phenotype in patients with endometriosis based on a Random Forest (RF) model. RESULTS: Among the 153 patients with confirmed endometriosis, 10.5 % (n = 16) had an SPE phenotype. Of the 2633 known miRNAs, the feature selection method generated a signature of 89 miRNAs of the SPE phenotype. After validation, the best model, representing the most accurate signature had a 100 % sensitivity, specificity, and AUC. CONCLUSION: This signature could constitute a new diagnostic strategy to detect the SPE phenotype based on a simple biological test and render diagnostic laparoscopy obsolete. PRéCIS: We generated a saliva-based signature to identify patients with superficial peritoneal endometriosis which is the most challenging form of endometriosis to diagnose and which is often either misdiagnosed or requires invasive laparoscopy.

Giant peritoneal loose body and its protein composition: a case report.

Peritoneal loose body (PLB) is a kind of lesions located in the abdominal cavity or pelvic cavity, which is rare and difficult to diagnose. The diameter of PLB is mostly 0.5-2.5 cm. Most PLBS are asymptomatic. Here we reported a case of giant PLB in the pelvis and analyzed its structure and protein composition. Surgical exploration revealed a white oval mass (4.5*4*3 cm) in the pelvic cavity. After the mass was removed, the symptoms of hematuria disappeared and the patient was discharged on the second postoperative day. Histochemical staining showed that PLB was mainly composed of collagen and scattered calcification. The protein components of PLB were detected by proteome analysis, and a variety of proteins related to collagen deposition and calcification were identified in PLB.

Do women with suspected endometriosis benefit from pelvic examination to improve diagnostic and management strategy?

OBJECTIVE: To analyze the literature and expose best evidence available regarding the benefit of pelvic examination for women with suspected endometriosis METHODS: the AGREE II and GRADE systems for grading scientific evidence. RESULTS: Endometriosis is characterized by the heterogeneity in its clinical presentation with many different symptoms reported by patients. In the literature, questioning for each symptom has a high sensitivity, reaching 76-98 %, but lacks specificity (20 - 58 %). The symptom-based approach is limited by its low specificity, the absence of external validation for most of the models developed and the inability to characterize the extent of the disease, which could have major implications in the decision - making process. The latest systematic review and meta-analysis included a total of 30 studies with 4,565 participants, compared the diagnostic performance of several modalities for endometriosis. Physical examination had a pooled sensitivity of 71 % and a specificity of 69 %, with an average diagnostic accuracy of 0.76. Overall, the value of pelvic examination is conferred by its high positive likehood ratio and specificity. Besides its diagnostic value, pelvic examination improves patients' management by allowing the identification of a possible myofascial syndrome as a differential diagnosis. It also increases the quality of the preoperative workup and influences the quality of surgical excision and decreases the time to diagnosis. CONCLUSION: Despite the lack of studies in the primary care context, pelvic examination (vaginal speculum and digital vaginal examination) increases the diagnostic value for suspected endometriosis in association with questioning for symptoms.

Management of uroperitoneum through combination of conservative and surgical treatments in two colts.

Background: Ruptures of the urinary bladder and urachus are the most frequent cause of uroperitoneum in foals. Surgical correction is often the first treatment choice, however, nonsurgical methods, such as urine removal via urinary catheters and abdominal drains, have been successfully performed in foals. Case Description: Two foals were referred to the Equine Perinatology Unit for suspicion of uroperitoneum. The diagnosis was confirmed by hematobiochemical and ultrasound examinations, thus cystorrhaphy and cystoplasty were attempted. Surgeons found a lesion in the dorsocranial margin of the bladder (Case 1) and a tear in the pelvic urethra (Case 2); in the first case, the defect was routinely repaired, while the last lesion was impossible to repair due to its localization. A urinary catheter was left in place in both cases. Uroperitoneum recurred 72 hours after the surgery in both foals: a second surgical correction was not recommended due to the localization of the tears and conservative treatment, with the placement of a 32F chest tube in the most ventral part of the abdomen, was preferred. Abdominal drains were removed 5-7 days after surgery, while urinary catheters were left in place for up to 7-8 days. Colts' conditions improved during hospitalizations. Two months after bladder surgery, Case 1 was euthanized due to multiple adhesions between the small intestine and the abdominal wall. Case 2 was still alive one year postoperatively. Conclusion: Although it cannot be considered the first choice for the treatment of uroperitoneum in the foal, nonsurgical treatment was successful in both cases in the short-term follow-up. However, the prognosis should be cautious due to the risk of long-term complications. Conservative management may be used to manage bladder/urethral tears that cannot be solved by surgery.

Case Report: A Child With Omental Infarction.

BACKGROUND: Omental infarction (OI) is a rare cause of acute abdominal pain, which is benign and self-limited. It is diagnosed by imaging. The etiology of OI is either idiopathic or secondary and due to torsion, trauma, hypercoagulability, vasculitis, or pancreatitis. CASE REPORT: Here, we present a case of OI in a child with acute severe right upper quadrant pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Correct diagnosis of OI via imaging can prevent unnecessary surgery.

Rare causes of acute abdomen and review of literature: Primary/secondary omental torsion, isolated segmental omental necrosis, and epiploic appendagitis.

BACKGROUND: Primary/secondary omental torsion (POT/SOT), isolated segmental omental necrosis (ISON), and primary epiploic appendagitis (PEA) are rare causes of acute abdominal pain that often lead to misdiagnosis. Although the differential diagnosis may vary according to the localization and severity of the pain, and associated symptoms such as nausea-vomiting and fever, depending on the disease and site of involvement, the character of the pain is generally similar and in a continuous form. Depending on pain localization, it can mimic different clinical pictures such as acute appendicitis, acute diverticulitis, ovarian pathologies, urinary tract stones and acute cholecystitis, and patients are often diagnosed after surgical exploration. With the increased availability of computed tomography and awareness of these diseases, more patients can be diagnosed in the preoperative process and unnecessary operations can be avoided. In particular, PEA is a self-limiting local inflammatory disease and can often be managed conservatively. For all diagnoses, the surgical treatment option is local excision of the relevant epiploic appendix or omental segment, preferably laparoscopically. The most common surgical indication is diagnostic confusion and the second is persistent pain. METHODS: The data of patients followed up and treated for a diagnosis of POT, SOT, ISON or PEA between 2006 and 2021 were recorded in a specially prepared database. The demographic characteristics of the patients, and the data regarding the diagnosis and treatment process were evaluated retrospectively and discussed in the light of the relevant literature. RESULTS: The reason for hospitalization and treatment in 12 of the 42 patients included in the study was necrosis of a part of the omentum. Of these patients, 4 were followed up and treated with a diagnosis of POT, 3 with SOT, 5 with ISON and 30 with a diagnosis of PEA. Thirty-three of the patients were diagnosed preoperatively, and 9 intraoperatively, 22 patients were operated on, and 20 patients with PEA were treated conservatively. After surgical or medical treatment, all the patients were discharged without complications. In the comparisons between the patients, no significant difference was observed in terms of clinical and laboratory findings. CONCLUSION: POT, SOT, ISON and PEA should be considered in the differential diagnosis of patients with acute abdominal findings. In patients with PEA diagnosed in the preoperative period, a conservative approach should be considered first. In patients with a diagnosis of POT, SOT, and ISON, a surgical or conservative approach should be evaluated according to the patient's clinical condition.

Can serum tumor necrosis factor-alpha predict peritoneal adhesions prior to secondary laparoscopic procedures?

AIM OF THE STUDY: This study aimed to investigate the incidence and degree of postoperative intra-abdominal adhesions(POAs) in secondary laparoscopic procedures and assess the power of the preoperative levels of tumor necrosis factor-alpha(TNF-α) and interleukin-1 beta(IL-1ß) and selected peripheral inflammatory biomarkers(PIBs) in the prediction of the development and extent of POA. PATIENTS AND METHODS: This prospective study enrolled 103 patients who had previously undergone at least one or more laparoscopic abdominal or gynecological operations. We examined TNF-α, IL-1ß, and PIBs, namely C-reactive protein, white blood cell count, neutrophil-to-lymphocyte ratio(NLR), platelet-to-lymphocyte ratio, and systemic immune-inflammation index(SII) according to the presence, location, and score of adhesions determined during secondary laparoscopic procedures. RESULTS: Only age, postoperative adhesion index(PAI) score, NLR, SII, TNF-α, and IL-1ß resulted in a significant difference in the existence of adhesion(P<0.05). The correlation analysis of TNF-α with variables showed that the PAI score and IL 1ß levels had a significantly positive correlation. CONCLUSION: The presence and extent of POA could be predicted by examining the preoperative TNF-α level in patients who had laparoscopic abdominal surgery previously. We could overcome adverse events during secondary laparoscopic procedures by assessing high-risk patients and integrating a personalized surgical approach to managing selected patients.

Intra-Peritoneal Pseudocyst as a Rare Complication After Peritoneal Dialysis: The Use of a Staged Surgical Approach in Management.

Despite its numerous benefits, peritoneal dialysis (PD) can rarely result in dangerous and even life-threatening complications, including peritonitis, hernias, encapsulating peritoneal sclerosis (EPS), and rarely peritoneal pseudocysts. Herein, we present a rare case of a giant intra-peritoneal pseudocyst that presented four months following the discontinuation of a 5-year course of complicated PD. Despite the initially successful drainages, the patient's symptoms continued to recur, and the imaging findings were concerning for underlying neoplastic processes. As such, a staged surgical approach was performed, starting with a diagnostic laparoscopy and was subsequently followed with cyst excision and marsupialization to the peritoneal cavity. While previous reports of such rare pseudocyst have been documented in the literature as a complication of PD, to our knowledge, this is the second case of pseudocyst formation to occur months after the discontinuation of PD therapy. This case emphasizes the importance of close follow-up in PD patients and showcases how a staged surgical approach can be utilized to accurately diagnose and manage such complicated cases.

[Omental infarction, unusual cause of abdominal pain]. / Infarto omental, causa poco común de dolor adbominal.

INTRODUCTION: Omental infarction describes ischemic torsion of the distal portion of the omentum and constitutes an infrequent cause of acute abdominal pain in childhood of which few cases are known. Objec tive: To analyze through a clinical case the characteristics and management of this pathology, to consider this entity in the differential diagnosis of acute abdominal pain. CLINICAL CASE: An 11-year- old child consulted the emergency department due to a 48-hour history of continuous abdominal pain, which had progressively increased. On the physical examination, the patient presented pain in the right side of the abdomen and the epigastric area, with no signs of peritoneal irritation, and was overweight (BMI 91st percentile). Biochemical analysis showed a slight increase in c-reactive protein (CRP) 41.31 mg/L (reference value < 3.0 mg/L) without leukocytosis and normal ultrasound study, without visualization of the appendix. Due to persistent pain, increased CRP, and absence of appen dix visualization in the ultrasound, the study was completed with an abdomen and pelvis CT scan which showed trabeculation of the fat of the anterior right subhepatic space, thus diagnosing omental infarction. The patient was hospitalized for conservative management with analgesia, anti-inflamma tory drugs, and fluid therapy, presenting good evolution in the first 48 hours. CONCLUSION: Omental infarction is an infrequent cause of acute abdominal pain in childhood. Imaging studies play a funda mental role in the differential diagnosis of this entity with other clinical conditions of similar course, thus avoiding unnecessary surgical interventions.

Magnetic resonance imaging characteristics of polypoid endometriosis and review of the literature.

AIM: Polypoid endometriosis is a rare variant of endometriosis and may mimic malignancy. The purpose of this study is to evaluate magnetic resonance (MR) imaging characteristics of polypoid endometriosis for the differential diagnosis with malignancy. METHODS: MR imaging findings of four histologically proven polypoid endometriosis were retrospectively evaluated with the review of the literature. RESULTS: All polypoid endometriosis exhibited high signal intensity on T2-weighted images reflecting abundant dilated endometrial glands. Peritoneal lesions were surrounded by low signal intensity rim represented the "black rim sign" reflecting endometriotic fibrous adhesion. Two cases arising from endometriotic cysts showed transmural extension (peritoneal extension and myometrial infiltration). Endometriotic hemorrhagic foci were demonstrated in four lesions as high signal intensity on T1-weighted images and/or susceptibility-induced signal voids on susceptibility-weighted MR sequence. Diffusion-weighted images showed high signal intensity with relatively high apparent diffusion coefficient (ADC) due to T2 shine-through effect but no diffusion restriction, and dynamic contrast-enhanced (DCE) MR imaging showed gradually increasing contrast-enhancement pattern like benign pathologies. CONCLUSIONS: Polypoid endometriosis may mimic malignancy; however, black rim sign may be a characteristic MR imaging finding for the peritoneal lesions, and no diffusion restriction and gradually increasing contrast-enhancement pattern may reflect its benign nature.

The new method to make diagnosis and identify the location of leakage of pleuroperitoneal communication in peritoneal dialysis patients.

Pleuroperitoneal communication is a severe complication in peritoneal dialysis, and about half of the patients forced to discontinue peritoneal dialysis. The method of coloring dialysis solution by indocyanine green or CT peritoneography have been reported to make diagnosis of pleuroperitoneal communication, however sensitivity of these tests is not a satisfactory level. By repairing the pleural hole with thoracoscopic surgery, it is possible to resume peritoneal dialysis. However, the recurrence rate is very high unless precisely detecting the location of the pleural hole during surgery. We report three cases of pleuroperitoneal communication in peritoneal dialysis patients, in which we found the combination of contrast-enhanced ultrasonography and the indocyanine green fluorescence system are reliable method to make diagnosis and identify the location of leakage of pleuroperitoneal communication. By making definite diagnosis and precisely identifying the localization, we were able to close diaphragm holes by video-assisted thoracoscopic surgery.

Omental torsion at the time of COVID-19 in Northern Italy: a case report of conservative management with a review of the pertinent literature.

BACKGROUND AND AIM: In middle-aged men, omental torsion (OT) can be a cause of acute abdomen.The right side of the omentum is longer, heavier and more mobile than the left one and, as a consequence, it can twist more easily on its vascular axis. Consequently, OT localization in the lower right quadrant is more frequent, and therefore it can mimic acute appendicitis clinical onset.In most cases, OT is defined as "primary" in the absence of any other underlying pathologies, or,  rarely, "secondary", when caused by other intra-abdominal diseases such as inguinal hernia, tumors, cysts or post-surgical scarring. To date, clinical diagnosis of OT still remains a challenging one in a preoperative setting and most cases are diagnosed intraoperatively. If diagnosis is correctly achieved preoperatively by adequate imaging examinations, most patients presenting with OT do not undergo surgery anymore. Such considerations gain importance at the time of COVID 19 pandemic, where a conservative management and an early discharge may be preferred owing to in-hospital morbidity after abdominal surgery whenever surgery may be avoided. METHODS AND RESULTS: We present a case of an OT successfully treated in a non-operative manner during COVID-19 outbreak in Norhern Italy and offer a review of the literature that supports such a clinical attitude.  Conclusions:  OT preoperative diagnosis is challenging and is usually achieved by abdominal CT-scan. The suggested OT initial management is conservative, leaving a surgical approach, preferably by laparoscopy, for the 15% of cases not improving with a non-surgical approach.

Acute abdomen caused by torsion of the omentum: A pediatric case report.

RATIONALE: Torsion of the omentum and infarction are rare and unusual disorders that often present as acute abdominal pain in the population. The diagnosis of omental torsion is based on clinical and imaging examinations. PATIENT CONCERNS: A 7-year-old girl presented with acute right lower quadrant abdominal pain, with symptoms resembling acute appendicitis. DIAGNOSIS: The patient was diagnosed with omental torsion based on imaging and laparoscopy. INTERVENTIONS: Laparoscopic exploration was performed. OUTCOMES: The patient was discharged seven days after satisfactory postoperative recovery. LESSONS: Omental torsion should be included in the differential diagnosis of acute abdominal pain, particularly in patients with free hemorrhagic fluid in the abdominal cavity and pelvis.

A new technique to detect communication sites for pleuroperitoneal communication.

Pleuroperitoneal communication is one of the complications for continuous ambulatory peritoneal dialysis. Communication sites, such as defects or bleb-like lesions, are found in the diaphragm, but it is sometimes difficult to detect these sites. We combined the infrared thoracoscopy and negative pressure technique to detect communication sites. We think our new technique will become an alternative option for difficult and complex cases.

Omental Fat Torsion: A Rare Mimicker of a Common Condition.

Acute abdomen is a common emergency condition affecting young adults, and the first consideration is usually aimed to rule out acute appendicitis in this age group. Omental fat torsion has emerged as one of the rare etiologies of acute abdomen in the younger population. It warrants serious consideration as it closely mimics acute appendicitis in its clinical presentation. Herein we report a case of omental fat torsion in a 22-year-old male patient who presented with an acute right-sided lower abdominal pain which was highly suggestive of acute appendicitis. However, the diagnostic laparoscopy revealed a normally looking appendix and terminal ileum with an infarcted omental segment on the right side of the greater omentum. A laparoscopic omentectomy and an appendectomy were performed with an uneventful postoperative recovery. The pathology report confirmed omental fat infarction and a normal appendix. This case highlights omental fat infarction as a rare etiology of acute abdomen in a young male patient.