Accuracy of sentinel node mapping in Marjolin ulcer: Comparison of three different injection techniques.

BACKGROUND: Marjolin ulcer is a specific type of squamous cell cancer that can benefit from the use of lymphoscintigraphy.The purpose of this study was to evaluate 3 different injection techniques for sentinel node biopsy in patients with Marjolin ulcer. METHODS: Forty-eight patients with Marjolin ulcer (27 male and 21 female) ranging in age from 24 to 85 years were included in our study. Intratumoral (IT), peritumoral (PT) and periscar (PS) tissue injections of radiotracer were done in 9, 10, and 29 patients respectively. Injections were done 2-4 h before surgery. Lymphoscintigraphy was done for mapping the lymphatic drainage. During surgery, lymphatic mapping and sentinel node biopsy was performed using a handheld gamma probe. After harvesting sentinel nodes, regional lymph node dissection was done. RESULT: Sentinel node detection rate was higher in the PS group as compared to the IT and PT groups (89.6% vs. 50% and 22.2%) respectively. False negative rate was 0%. Pathologically involved sentinel nodes were detected in 16% of the included patients of our study which led to management change. None of the patients with pathologically non-involved sentinel nodes developed regional lymph node recurrence. CONCLUSION: Lymphatic mapping and sentinel node biopsy is feasible in Marjolin ulcer with high detection rate and low false negative cases which by detection of regional lymph node involvement can potentially change the management of patients. Injection site may be an important factor influencing the success of the procedure and injection of the mapping material in the peri-scar normal skin proximal to the lesion is the best technique.

Using meta-learning to recommend an appropriate time-series forecasting model.

BACKGROUND: There are various forecasting algorithms available for univariate time series, ranging from simple to sophisticated and computational. In practice, selecting the most appropriate algorithm can be difficult, because there are too many algorithms. Although expert knowledge is required to make an informed decision, sometimes it is not feasible due to the lack of such resources as time, money, and manpower. METHODS: In this study, we used coronavirus disease 2019 (COVID-19) data, including the absolute numbers of confirmed, death and recovered cases per day in 187 countries from February 20, 2020, to May 25, 2021. Two popular forecasting models, including Auto-Regressive Integrated Moving Average (ARIMA) and exponential smoothing state-space model with Trigonometric seasonality, Box-Cox transformation, ARMA errors, Trend, and Seasonal components (TBATS) were used to forecast the data. Moreover, the data were evaluated by the root mean squared error (RMSE), mean absolute error (MAE), mean absolute percentage error (MAPE), and symmetric mean absolute percentage error (SMAPE) criteria to label time series. The various characteristics of each time series based on the univariate time series structure were extracted as meta-features. After that, three machine-learning classification algorithms, including support vector machine (SVM), decision tree (DT), random forest (RF), and artificial neural network (ANN) were used as meta-learners to recommend an appropriate forecasting model. RESULTS: The finding of the study showed that the DT model had a better performance in the classification of time series. The accuracy of DT in the training and testing phases was 87.50% and 82.50%, respectively. The sensitivity of the DT algorithm in the training phase was 86.58% and its specificity was 88.46%. Moreover, the sensitivity and specificity of the DT algorithm in the testing phase were 73.33% and 88%, respectively. CONCLUSION: In general, the meta-learning approach was able to predict the appropriate forecasting model (ARIMA and TBATS) based on some time series features. Considering some characteristics of the desired COVID-19 time series, the ARIMA or TBATS forecasting model might be recommended to forecast the death, confirmed, and recovered trend cases of COVID-19 by the DT model.

Incidental Synchronous 99mTc-HYNIC-TOC Avid Lesion of the Neck in a Patient with Metastatic Melanoma: A Metastatic Lymph Node or a Carotid Body Tumor Masquerading As a Lymph Node?

A 53-year-old woman with a plantar malignant melanoma lesion was referred to our tertiary clinic for sentinel lymph node mapping. Lymphoscintigraphy with 99mTc-Phytate detected ipsilateral inguinal and popliteal sentinel nodes. After total resection of nodes, the pathology report confirmed that all specimens were involved by the tumor. As part of an institutional study evaluating somatostatin receptor avidity of melanoma by 99mTc-HYNIC-TOC scan, she also underwent a whole-body octreotide scan, which surprisingly showed intense tracer uptake in the right cervical region, confining in SPECT/CT images to a mass at the C2 spinal level, adjacent to the right carotid bifurcation. Neck surgery with gamma probe after injection of another dose of 99mTc-HYNIC-TOC was performed successfully, and the pathology report was consistent with a carotid body tumor. To best our knowledge, our case is the first one in the literature, which reports an incidental paraganglioma with 99mTc-HYNIC-TOC scan which resected via radio-guided surgery, again with 99mTc-HYNIC-TOC tracer.

Transhiatal versus transthoracic esophagectomy for esophageal SCC: outcomes and complications.

BACKGROUND: Transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are both accepted procedures for esophageal cancer but still the most effective surgical approach continues to be controversial. This study aimed to determine post-operative complications and outcomes of TTE compared with THE. METHODS: A retrospective analysis was performed on data of 243 adult patients with resectable esophageal cancer who underwent THE or TTE between December 2016 and October 2018. Demographic data, consisting of preoperative co-morbidities, disease stage, and perioperative morbidity and mortality were collected. RESULTS: Among the patients, 99 individuals (40.7%) had a transhiatal resection and 144 (59.3%) had a transthoracic resection. Most patients (83.1%) were above 50 years old with no significant difference between groups (p = 0.297). The frequency distribution of comorbidities was similar in both groups. The most common site of the tumor in TTE group was middle esophagus and in THE group was lower esophagus. The most common complication was recurrence of dysphagia which was more common in THE group without significant difference. The other complications including pulmonary and cardiac events, tracheal and recurrent laryngeal nerve injury, chylothorax and anastomosis stricture did not differ between the groups. The operative mortality within 30 days after the operation was 2.8% with significant difference favored the THE group (THE 0%, TTE 5.2%, p = 0.033). CONCLUSION: Because of the controversies, the decision on the type of surgical technique in esophageal cancer treatment hinges on patient's co-morbidities, cancer stage, tumor location and surgeon's experience.

Which common test should be used to assess spleen autotransplant effect?

BACKGROUND: Historically, total splenectomy was the only choice of treatment for traumatic splenic injuries. However, nonoperative management and spleen-preserving surgical techniques are preferred in modern medicine. In some situations in which the surgeon has to perform splenectomy, spleen autotransplant may preserve the splenic function. Selecting the best method for evaluating the splenic autotransplant effect has been debated for several years. In this study, we compared three common tests in evaluating the implanted spleen function. METHODS: Participants included 10 patients who were candidates for laparotomy and splenectomy. After performing splenectomy, we implanted five pieces of the spleen in the greater omentum of each patient. After 3 months, the implanted spleen function was evaluated by nuclear red blood cell (RBC) scan, serum immunoglobulin (Ig) M level, and presence of Howell-Jolly (HJ) bodies in the peripheral blood smear. RESULTS: All patients had normal peripheral blood smear. The IgM level was lower than normal in one patient, and scintigraphy did not demonstrate the transplanted spleen in another patient. CONCLUSION: All these tests may have comparable results, but because of availability and low cost of peripheral blood smear, which is also easily performed, it can be considered as the first option to evaluate the implanted spleen function.

The Comparison of the Advantages of Neoadjuvant Chemoradiotherapy versus Postoperative Chemoradiotherapy: Outcomes in Esophageal Cancer Patients.

BACKGROUND AND OBJECTIVES: Esophageal cancer is the eighth most common type of cancer worldwide. For the treatment of which, surgical intervention alone or with neoadjuvant chemoradiotherapy or chemotherapy is recommended. In this study, we aimed to compare the benefits of neoadjuvant chemoradiotherapy versus postoperative chemoradiotherapy. PATIENTS AND METHODS: We collected data regarding 325 patients admitted for esophageal cancer to Qaem Hospital, Mashhad, Iran, during 2006-2016. The participants were divided into two groups of neoadjuvant and postoperative adjuvant therapies. Chi-square, McNemar, Kaplan-Mayer, and multivariate regression tests were performed using SPSS. RESULTS: Gender, age, stage of the disease, tumor grade and location, disease histopathology, and the recurrence showed no significant differences between the two groups (P Ëƒ 0.05), but there was a significant association between the two types of treatment in terms of postoperative complications (P = 0.03). We followed up 147 patients postoperatively and found no significant differences between the groups (P Ëƒ 0.05). CONCLUSION: No conclusion can be drawn on whether there are any advantages in adjuvant chemoradiotherapy over neoadjuvant approaches. Further confirmatory trials, particularly randomized trials, are necessary before any recommendations can be made.

Using of Ileucecal Interposition as a Neo-stomach in Dogs with Total Gastrectomy (Presentation of a Novel Technique).

Total gastrectomy and R&Y reconstruction is the standard treatment of gastric cancer except distal form one. Malnutrition is a common adverse effect of this technique, and in this study, we preset a novel technique in order to help to reduce the rate of it. We use seven dogs as participants and after total gastrectomy; we used the 10 cm of the ileum and its concomitant cecum as a neo-stomach in them. For 3 months, the dogs were evaluated in nutrition status. Three of the dogs died-one due to endocarditis and two due to internal hernia. No anastomosis leakage or stricture was seen and there were no unusual neo-stomach dilation or food stasis. This technique can help the nutrition status of total gastrectomy patients but needs more comparative human studies.

Delayed esophageal pseudodiverticulum after anterior cervical spine fixation: report of 2 cases.

INTRODUCTION: Although perforation of the esophagus, in the anterior cervical spine fixation, is well established, cases with delayed onset, especially cases that present pseudodiverticulum, are not common. In addition, management of the perforation in this situation is debated. CASE REPORT: Delayed esophageal pseudodiverticulum was managed in two patients with a history of anterior spine fixation. Patients were operated on, the loose plate and screws were extracted, the wall of the diverticulum was excised, the perforation on the nasogastric tube was suboptimally repaired, and a closed suction drain was placed there. The NGT was removed on the 7th day and barium swallow demonstrated no leakage at the operation site; therefore, oral feeding was started without any problem. CONCLUSION: In cases with delayed perforation, fistula, or diverticulum removal of anterior fixation instruments, gentle repair of the esophageal wall without persistence on definitive and optimal perforation closure, wide local drainage, early enteral nutrition via NGT, and antibiotic prescription is suggested.

Prevention of Biliary Leakage after Removal of T-tube in Immunocompromised Patients.

Biliary leakage after T-tube removal is an important complication which can be lethal especially in patients who received immunosuppressant agents. The purpose of the study is to determine a method which can evaluate the completion of tract formation in high-risk patients. Participants include 46 patients who were candidates for open cholecystectomy and common bile duct (CBD) exploration and T-tube insertion. Twelve of patients received corticosteroids and were divided into two groups. In the first group, T-tube was removed conventionally, but in the other group, we performed a "fistulography" 1 month postoperative to evaluate maturity of tract between CBD and the skin. Biliary peritonitis was seen in half of patients who are managed conventionally, but no complication was detected in patients who underwent fistulography. Fistulography is suggested to be done before T-Tube removal in immunocompromised patients in order to detect tract formation, which is effective in reduction of postremoval complications.

Effect of preoperative rectal indomethacin on postoperative pain reduction after open appendectomy.

BACKGROUND: One of the major challenges faced by the treatment planning teams is how to manage postoperative pain. Previous studies agreed upon the effects of preoperative administration of nonsteroidal anti-inflammatory drugs on postoperative pain, but all have focused on patients with surgical noninflammatory diseases (ie, inguinal hernia or breast biopsy). The aim of this study was to evaluate the effects of rectal indomethacin on reducing postoperative pain in patients with acute appendicitis. METHODS: It is a simple randomized, clinical trial including 200 patients with acute appendicitis who were divided into two groups (A1 and A2). The case group (A1) received 100 mg rectal indomethacin during 2 hours before the operation. Pain intensity was assessed in all patients using a visual analog scale (VAS). Similarly, total dosage of meperidine analgesic medication and postoperative time to use of rescue analgesia were evaluated. RESULTS: Patients who received preoperative rectal indomethacin (A1) showed a significant reduction in the VAS score. Also, a reduction in total dose of meperidine and longer time to use of rescue analgesic medication were observed in A1 group. CONCLUSION: Preoperative administration of rectal indomethacin in acute appendicitis reduces postoperative pain.

Effect of preoperative rectal indomethacin on postoperative pain reduction after open cholecystectomy.

The preoperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs) has been shown to have a positive impact on postoperative pain, but there is little research regarding the use of rectal NSAIDs given before surgery. The purpose of this study was to evaluate the effects of rectally administered indomethacin on postoperative pain in patients undergoing open cholecystectomy. A randomized controlled design was used to compare rectally administered indomethacin with placebo. Pain intensity, total opioid dose, and postoperative time to first request for analgesic were evaluated. The indomethacin group experienced significantly less postoperative pain and required less total opioid dose compared with the placebo group. Preoperative rectal administration of indomethacin reduces postoperative pain in open cholecystectomy when compared with placebo.

Serum Lipid Changes after Short Term SIPC Therapy for Lower Limb Lymphedema.

Lymphedema is a ubiquitous chronic disease with various suggested treatment options, but no definite treatment. Using (Sequential) Intermittent Pneumatic Compression (SIPC) is one of the most appropriate non-surgical treatments without any noticeable complications. In this study, we evaluated the serum lipids changes following SIPC. Participants included 40 lower limb lymphedema patients who underwent High Pressure SIPC for a period of 48 hrs. Pre and Post SIPC serum lipids changes were evaluated. Though, there was some increase in the serum level of cholesterol and triglyceride, none of the patients had the values above the normal range. We concluded that, the fluid entering the serum during SIPC, contain large molecules such as lipids, which increases serum lipid levels. However this phenomenon does not have any significant complication for the patients.

A newly designed SIPC device for management of lymphoedema.

PURPOSE: Using (Sequential) intermittent pneumatic compression (SIPC) is one of the most appropriate nonsurgical treatments for lymphoedema. In this study, we introduce a new mode for SIPC and evaluate its clinical results with higher pressures. METHODS: Participants included 43 lower limb lymphoedema patients who underwent high pressure SIPC. Limb circumference pre- and post-SIPC were evaluated. RESULTS: The mean reduction of the affected limb oedema was approximately 75%, which is regarded as a good response to the short-term treatment. Patients with disease duration more than 20 years didn't show a good or excellent response. Also the foot area had the least degree of reduction of oedema. CONCLUSION: We concluded that, the suggested mode may provide more acceptable results compared with the other This mode allows unidirectional forward lymph flow and associated high pressure usage well tolerated in chronic cases of the disease.

A rare case of lumbar vertebral lymphangioma presenting as chylothorax.

BACKGROUND CONTEXT: The lumbar lymphangioma occurs rarely. Several studies have presented cases with the involvement of multiple vertebrae in presence or absence of the other bones and/or adjacent soft tissue. We elucidate a rare case of lumbar lymphangioma which presents as chylothorax. PURPOSE: To report a rare case of lumbar lymphangioma presenting as chylothorax. STUDY DESIGN: A case report. METHODS: A 32-year-old man was admitted with lumbar and chest pain. Lumbar plain radiography, computed tomography (CT) scan and magnetic resonance imaging revealed L2 vertebra's sclerosis and destruction with canal compression leading up to vertebral lymph/hemangioma impression. Chest radiograph revealed a left-sided pleural effusion that further examination confirmed the chylothorax. Because of medical treatment failure in managing the chylothorax, surgical exploration was performed on. The involved vertebra was resected and stabilized with a mass ligation of its adjacent soft tissues. Histopathologic study of the resected material confirmed the diagnosis of lymphangioma. Serial plain radiography and CT scan were performed at postoperative follow-up. RESULTS: Following up assessments showed that the chylothorax resolved. Also, the pain significantly relieved. CONCLUSION: To the authors' knowledge, this is a unique reported case of lymphangioma affecting lumbar vertebral body presenting as chylothorax. Further observation is recommended because of the possibility of local recurrence.