Analysis of deferral times in patients diagnosed with acute appendicitis.

INTRODUCTION: There are still controversies regarding the time of surgical management for acute appendicitis (AA). The main objective of this study was to recognize the surgical deferral time in patients with acute appendicitis and its relationship with the severity of presentation. MATERIALS AND METHODS: We performed a retrospective review of prospectively collected data of all patients with acute appendicitis undergoing appendectomy from August 2018 to August 2020 in an academic, public hospital. Elapsed time from arrival to the emergency room to skin incision was determined. Patients were divided into three groups based on the elapsed time: less than 6 h, between 6 and 12 h, and more than 12 h. RESULTS: A total of 782 patients were included. Of them, 443 (56.6%) patients had a surgical deferral time of less than 6 h, 238 (30.4%) patients between 6 and 12 h, and 101 (13%) patients of more than 12 h. Patients with more than 12 h of surgical deferral time had a more complicated clinical presentation (P = 0.013), a higher frequency of abscess formation (P = 0.022), higher requirement for the use of surgical drainage (P = 0.018), and longer length of hospital stay (P = <0.001). CONCLUSION: Surgical deferral >12 h was associated with a higher incidence of complicated appendicitis, intra-abdominal abscesses, and overall hospital stay. However, in the multivariate analysis, only total evolution time, from the first symptom to surgery, was a significant independent predictor of complicated appendicitis.

Ileocolonic intussusception due to severe endometriosis.

Endometriosis is the presence of normal endometrial tissue outside the uterus, which may appear in up to 15% of fertile female population. Bowel endometriosis is uncommon, and obstruction due to endometrial ileocolic intussusception is extremely rare. Herein, we report a case of a 27-year-old female who presented with bowel obstruction due to ileocolic intussusception secondary to endometriosis. A 27-year-old female, without pregnancies, and with a 1 year history of endometriosis presented to the emergency department referring severe abdominal pain in right lower quadrant, nausea and vomiting, she had medical history of prior episodes of mild abdominal pain due to endometriosis with OB/GYN follow-up. Physical examination revealed abdominal distension with decreased bowel movements to auscultation. A CT scan reported suspicion of intussusception. Colonoscopy was ordered, where an ileocolic intussusception was found. Diagnostic laparoscopy was performed, and the initial diagnosis was confirmed. A right hemicolectomy with extracorporeal anastomosis was achieved without any surgical complications. The patient was discharge on postoperative day 4 and continues doing well on a 12 month follow-up. Ileocolic intussusception due to endometriosis is a very rare condition, and it must be considered a differential diagnosis in female patients in reproductive age, when presenting with intestinal obstruction.

Giant intramuscular thigh lipoma: A case report and review of literature.

INTRODUCTION: Lipomas are the most common soft tissue tumor. Giant lipomas are defined by measuring at least 10 cm in diameter in one dimension or by a minimum of 1000 g. They often are asymptomatic; however, they can cause compression syndromes due to nerve damage and difficulties in walking. PRESENTATION OF CASE: We described the case of a 25-year-old female with no significant medical history who began her condition two years before her consultation. The patient referred to the appearance of a non-painful mass on her right thigh with progressive growth that hinders daily activities. A simple CT scan reported a 10.3 × 8.1 × 19.6 cm adipose mass with infiltration towards the semitendinosus muscle and the biceps femoris muscle. A free margin resection of the tumor was performed, and the involved muscles were preserved. The patient had a satisfactory postoperative outcome. DISCUSSION: Lipomas are common benign soft tissue tumors that arise from fatty tissue and may challenge surgical management due to their extension and dimensions; they often require delicate surgical intervention due to their potential risk of malignant transformation. We believe surgical pathologists and radiologists must draw attention to muscle involvement and the infiltrative pattern. CONCLUSION: Giant lipomas should always raise awareness of malignant transformation. Radiological guidance should provide enough evidence to decide whether to do a biopsy or not; hence, saving the patient an extra invasive procedure. We recommend taking at least 1 cm of border margin while removing these tumors to avoid local recurrence.

Non-sebaceous Lymphadenoma of the Parotid Gland Mimicking a Pleomorphic Adenoma.

Non-sebaceous lymphadenoma of the salivary glands is a rare benign lesion, first described in 1991. We present the case of a 54-year-old woman, with a right parotid mass. She underwent right superficial parotidectomy, and histopathology reported a non-sebaceous lymphadenoma due to an encapsulated lesion and multiple non-atypical epithelial inclusions without sebaceous differentiation. The etiology of non-sebaceous lymphadenoma is not yet understood, but it can arise predominantly from the parotid gland. Surgical excision is the treatment of choice.

Proximal intestinal obstruction syndrome (PIOS) in a patient with cystic fibrosis: A case report.

INTRODUCTION: Distal Intestinal Obstruction Syndrome is a rare complication in patients with cystic fibrosis, which characterized by the accumulation of viscid fecal material, combined with sticky mucous secretions located in the distal ileum adhere to the intestinal wall, causing complete bowel obstruction. PRESENTATION OF CASE: We report a case of a 45 years old patient with cystic fibrosis, who presented bowel obstruction secondary to accumulation of fecal material, combined with mucous secretions, in the mid-jejunum. A diagnostic laparoscopy was performed where a dilated jejunum was encountered with impaction of fecal content. Surgery was converted to open surgery, where a longitudinal enterotomy of 5 cm after the transition zone was created, evacuating manually the fecal material with mucous secretion. The patient evolved favorably, without complications. DISCUSSION: We present a case of a patient with cystic fibrosis presenting with bowel obstruction due to a proximal intestinal obstruction syndrome, which can be diagnosed with the DIOS definition, with the only distinction of a more proximal location in the gastrointestinal tract, such as the stomach, the duodenum, or the jejunum. CONCLUSION: It is important for the clinician to know the existence of this syndrome at its different locations in the small bowel to treat accordingly.

How to provide vascular control of splenic artery aneurysms? A case series.

BACKGROUND: Spleen artery aneurysm represents the most common visceral aneurysm and the third most common splanchnic aneurysm. Most patients have no symptoms and are diagnosed as a part of other diagnostic focuses and examinations. Greater prevalence and application of modern diagnostic and imaging procedures has resulted in greater detection of this disease. RESULTS: We present two patients with splenic artery aneurysms localized in the splenic hilum, who auspiciously underwent laparoscopic splenectomies with the use of hem-o-lock clips in the vascular hilum without complications. Both postoperative courses were uneventful. At six months follow up, both patients are asymptomatic. CONCLUSION: These two cases showed that in addition to the numerous advantages of minimally invasive approaches for treating splenic arterial aneurysms, there is a possibility to improve laparoscopic technique in terms of safety and economic reasons by using hem - o - lock clips as a hemostatic technique for the vascular elements of the spleen hilum.

Ileal bezoar causing bowel obstruction mimicking an internal hernia in a patient with Roux-en-Y gastric bypass.

We presented a case of a 64-year-old female patient with a history of gastric bypass that presented with bowel obstruction due to a bezoar. She arrived at the emergency department, referring to severe abdominal pain, nausea, and vomiting. Abdominal X-ray reported gastric distention and hydro-air levels. CT scan reported swirling of the mesentery vessels and a collapsed intestinal loop, mimicking an internal hernia. Laparotomy was accomplished, which shows obstruction at 60 cm from the ileocecal valve. An enterolithotomy was performed, and a 6 × 6 cm phytobezoar was extracted. The patient had a satisfactory postoperative outcome, discharging her home on the fourth postoperative day. On a 12 month-follow up, the patient is doing well with no further complications. Gastric bypass continues to be one of the most performed bariatric procedures with low complication rates. It is important to note that not all intestinal obstructions in postoperative bariatric surgeries are due to internal hernias or adhesions. The differential diagnosis of intestinal obstruction due to bezoar must be present in patients who underwent bariatric surgery. Nutritional counseling is essential for the follow-up of patients, emphasizing fluid intake and slow chewing, as well as the use of absorbable materials for suture during the surgery.