Surgery Insights

Successful Treatment of a Major Leakage of an Esophagojejunal Anastomosis after Open Total Gastrectomy: A Case Report

Hesam Eghlimi — 2022-04-03

Esophagojejunal leakage is one of the most serious complications in total gastrectomy surgery for proximal gastric cancer anastomotic leakage after this procedure occurs despite improvements in surgical techniques. Although many cases of dehiscence due to the medical condition of the patient can be managed non-operatively, major leakage requires second or more surgery. It can seriously lead to death or major complications.
Case presentation
This report describes a 64-year-old man with a known case of proximal gastric adenocarcinoma, which underwent open total gastrectomy and esophagojejunal anastomosis. After the surgery, due to a major leak of anastomosis, which was diagnosed with oral gastrografin radiography pictures with patients fever and leukocytosis, the patient went to the operation room which at the second surgery esophagostomy and the jejunostomy feeding tube was inserted after six months esophagojejunotomy done and the patient tolerated the liquid and regular meals and was discharged.
Conclusion
Major leakage of an esophagojejunal anastomosis is a severe complication of total gastrectomy. Although if the patient s condition tolerates the morbidity of this complication, re-anastomosis after six months of leakage is possible. Therefore, aggressive and urgent reoperation and effective drainage are useful once it is diagnosed.

Trapdoor Orbital Fracture in a Pediatric Patient. Case Report and 57-years of Literature Review

Samuel Macedo Costa — 2022-02-21

The blowout trapdoor fracture is a rare condition with more prevalence in pediatric patients. Surgeons and clinicians should be aware of this condition due to its severity, which can cause ophthalmoplegia, blindness, and even death. The present study reports a unique case of the surgical correction of trapdoor fracture with the incarceration of the inferior rectus muscle in the maxillary sinus associated with a severe oculocardiac reflex, unimproved nausea, and ophthalmoplegia. Together with that, a 57-years literature review is provided. The TF is linked with assaults and playing activities, in a 12,73 years-old mean age. The oculocardiac reflex is not a common association, 29,2%, being one of the most alarming symptoms. It is fundamental to the correct and early diagnosis, together with the forehand surgery, related to success in the first 72 hours.

Calcium Rim Sign in Plain Abdominal Radiograph: An Underrated Alert for Unstable Abdominal Aortic Aneurysm

May Honey Ohn — 2022-09-09

Abdominal pain is a common presentation in the emergency department, and constipation is one of the commonest causes in elderly patients. We report a patient with a ruptured abdominal aortic aneurysm (AAA) who presented with features mimicking acute bowel obstruction. The abdominal radiograph, which showed a calcium rim sign, raised the suspicion of AAA. It was confirmed with contrast-enhanced computed tomography, which showed a large ruptured AAA. The patient was transferred immediately to a vascular center for urgent endovascular repair of AAA and made a complete recovery. This case highlighted the usefulness of plain abdominal radiography in diagnosing abdominal pain, which should not be taken for granted as it can aid in raising concerns of AAA. This case sends an important message, particularly to junior doctors, that symptoms of abdominal pain, vomiting, and total constipation can mask the possibility of AAA. Immediate treatment of a ruptured aortic aneurysm requires a high index of clinical suspicion.

Idiopathic Localized Dilation of Ileum

Alberto Robles Méndez Hernández — 2022-06-27

Idiopathic localized dilation of the ileum (ILDI) is rare in adults, debuting with nonspecific symptomatology.
We report one case of a 36-year-old male patient who suffered intense abdominal pain and bowel obstruction symptoms, with signs of acute abdomen upon physical examination and CT imaging evidence of intestinal occlusion in the right lower quadrant. During laparoscopic approach, a 30 cm terminal ileum mass with multiple inflammatory mesenteric nodes was found, resected and posteriorly analyzed. Post-surgically, further laboratory evaluations failed to justify any other diagnosis rather than ILDI, excluding histopathologic and laboratory compatible with abdominal cocoon syndrome. The patient was discharged without complications and, until today, no recurrence of the disease has been identified.

Trend Analysis for the Treatment of Incompetent GSV

Akos Farics — 2022-04-23

Purpose: Chronic venous disease (CVD) has an excellent socioeconomic impact. Treatment modalities of CVD are evolving fields that could be derived from the disease's progressive nature.
Materials and methods: After a wide literature search in Google Scholar (Publish and Perish software), extracted data was analyzed by VOSviewer software, creating network and overlay visualizations.
Results: CVD has been investigated intensively in the literature from the beginning of the 21st century. Studies aimed to understand the mechanism of CVD in the early 2000s. Later, the focus of scientific interest was moved to novel procedures. Researchers were motivated to explore the reasons for technical failures and recurrences of endovenous thermal ablation (EVTA) procedures and open surgery to treat saphenous incompetence. Less invasive procedures replaced invasive open surgery. The search for novel tissue sealants showed a thin centralized network. Papers were dated from 2010. Therefore, this is a very recent source of evidence. There were meeting points for some components of tissue sealants. Biomaterials for novel tissue adhesion are under development and investigation. The efficacy and safe application in humans is the focus of research.
Conclusion: Researchers widely investigate CVD. An evolution from invasive open surgery (stripping) through EVTA to non-thermal ablation procedures could be discovered in the literature. There could be some versatile options for replacing cyanoacrylate in the future, but there are no clear paths to reach that point in scientific literature yet.

Management of Breast Reconstruction Salvage in the COVID-19 Pandemic Era: Is there still Room for Plastic Surgery?

Glenda Giorgia Caputo — 2022-03-23

Implant infection after breast reconstruction is always disastrous and often leads to the need to remove the prosthesis and delayed reconstruction. In those cases when conservative treatments fail (i.e., oral or i.v. antibiotics), a surgical approach is necessary. Removing the implant and debridement are always required, but which are the following reconstructive steps? In the literature, different solutions chosen based on the severity of the infection are described. In the pandemic Covid-19 era, the healthcare system has to deal with a significant restriction in the delivery of surgical services due to the recruitment of hospital staff members to the “Covid-19 frontline”. Although implant removal for infection represents an urgent deferred procedure, the reconstruction is not considered as such. Here we report on a case of breast reconstruction with Deep Inferior Epigastric Perforator (DIEP) flap in a patient having a severe implant infection during the Italian second wave of the pandemic (February- March 2021). Initially, she was locally treated with the removal of the implant and the simultaneous application of negative wound pressure therapy with irrigation in the pocket site, which led us to an “immediate” reconstruction (10 days after implant removal) with a DIEP flap.

Laparoscopic Hepatectomy is a Feasible and Safe Choice for Primary Hepatocellular Carcinoma

Yi-Hsuan Lee — 2022-09-08

Introduction: Laparoscopic hepatectomy (LH) for hepatocellular carcinoma (HCC) is well-known for its advantages but its specific long-term outcomes are unknown. This study aimed to analyze the perioperative, short-term, and long-term outcomes between LH and open hepatectomy (OH) for primary HCC who underwent LH during the developing period of LH in a single center.
Methods: This retrospective study included patients diagnosed with primary HCC who underwent hepatectomy between January 2013 and December 2019. The patients were divided into the LH (n=63) and OH (n=96) groups. Demographic and perioperative data were collected.
Results: A higher percentage of patients in the OH group underwent major resection (38.5% vs. 11.1%, p < 0.001). The operative time was 47 minutes shorter and the intraoperative blood loss was 105 mL less in the LH group. The major postoperative complication rate (33.3% vs. 50.0%, p = 0.05) and the 90-day readmission rate (3.2% vs. 12.5%, p = 0.048) were lower in the LH group. The overall survival and disease-free survival were similar between the two groups.
Conclusions: LH is a feasible and safe alternative for primary HCC, with less blood loss, fewer major complications, and shorter postoperative hospital stay. LH does not worsen short- or long-term outcomes.

Thromboembolic Events among Multiple Trauma Victims with Pelvic Fractures with Injury Severity Score Greater Than 16 with and without Deep Vein Thrombosis Prophylactic Doses of Enoxaparin

Arsalan Ostovari — 2022-09-08

Introduction: Venous thromboembolism (VTE) is a common life-threatening complication in patients affected by severe trauma. The clinical manifestations of VTE are deep venous thrombosis (DVT) and pulmonary embolism (PE). Various prophylactic pharmacological strategies are used. We studied the efficacy of enoxaparin in preventing VTE in our level 1 trauma center. Materials and Methods: This cross-sectional study included patients with polytrauma with an Injury Severity Score (ISS) of greater than 16 units and a pelvis fracture diagnosis. Clinical features, laboratory data, and images were reviewed from medical documents. Moreover, the prophylactic medication regimens were recorded. Development of VTE was identified in patients, and a p-value <0.05 was considered statistically significant. Results: A total of 327 patients were examined, of which 18 had developed VTE (5.5%). The frequency was relatively higher in males, cases with fractures, and cases with a history of VTE. Patients with two or more pelvic fracture sites and those with a history of VTE manifested are statistically more likely to develop VTE than those with fewer than two pelvic fracture sites and no history of VTE (p-value = 0.02 and 0.006, respectively). Moreover, the administration of prophylactic doses of enoxaparin n had no statistically significant effect on VTE prevention (p-value = 0.08). Conclusion: In conclusion, we found no significant correlation between the prophylactic doses of enoxaparin and VTE probability. Furthermore, a history of VTE and more fracture sites would increase the probability of VTE.

Priapism in the Context of Sickle Cell Disease: State of the Art and Perspectives

Zakaria Bakkali Aissaoui — 2024-06-15

Priapism is a frequent complication in patients with sickle cell disease, putting their sexual and reproductive health at risk. This systematic review aims to analyze existing studies on priapism in this context comprehensively. The results show that priapism, particularly the ischaemic type, is prevalent in men with sickle cell disease, especially those carrying HbSS genotypes. Risk factors include vaso-occlusive crises, severe anemia, infections, and dehydration. Pathophysiological mechanisms involve endothelial dysfunction, vasoconstriction, local hypoxia, and inflammation. Diagnosis is based on clinical assessment and investigations such as penile Doppler ultrasound. Treatments include conservative measures, aspiration of the corpora cavernosa, intracavernous injections of vasoconstrictors, and surgical shunts. Prevention involves specific management of sickle cell anemia, with regular monitoring and raising awareness among the general public. This review highlights the clinical challenges of priapism in sickle cell disease and underlines the importance of a multidisciplinary approach to improve care and quality of life for affected patients.

Condyle Dislocation to Medial Cranial Fossa: A Systematic Review

Samuel Macedo Costa — 2022-04-18

Purpose: To investigate the clinical, immaginological, complications and its relations of each one of the treatment approaches for the traumatic dislocation of the mandibular condyle to the medial cranial fossa.
Methods: An electronic literature search was undertaken in June/2019. Eligibility criteria included publications having enough clinical, radiological, treatment protocols and post-operative outcomes information.
Results: 46 publications ( 50 patients) were included. Most of the patients were women ( 70%), the most common age range in the pediatric population from 0 to 15 years old ( 34%). The mean age is 25,66 years old ( +- 15,19). The most common causes are automotive accidents ( 60%), Falls ( 8%), Assaults ( 8%), followed by one case of industrial accident. Otorrhagia was present in 10% of the patients, loss of conciseness in 10% of the patients, followed by 6% of the patients presenting intracranial hematoma. Open treatment was the preferred with 44%, followed by the closed treatment ( 26%), condylectomy( 16%) and conservative treatment (14%). None complications were observed in 60% of the patients, however complications related to the TMJ were observed in 38% of the cases, followed by 2% of complications related to the medial cranial fossa. Comparative statistical analyzes did not show differences between the treatment modalities as the complications, except when compared with closed treatment in relation with complications related to the medial cranial fossa ( p = 0,035).
Conclusions: The traumatic dislocation of the mandibular condyle to the medial cranial fossa is a rare complication related to facial trauma, with only fifty cases described in the literature. The treatment modalities did have not influence into the development of complications, excepts when the chosen treatment is the closed one, when the odds for complications related to the medial cranial fossa are slightly higher.

Importance of Critical View of Safety, Rouviere’s Sulcus, and Minimal Energy Device Usage in Reducing Biliary Injury in Laparoscopic Cholecystectomy

Md Yusuf Afaque — 2022-04-11

Introduction: Major bile duct injury in laparoscopic cholecystectomy results in morbidity and needs further management, which adds to the increased cost of treatment. However, some studies have shown that by defining critical view of safety and seeing the relationship of Rouviere's sulcus with other structures, and minimal use of diathermy in Calot's triangle, we can bring down complications further close to zero percent. We wanted to see that such a low bile duct injury rate is achievable at every center by routinely following these steps. We retrospectively reviewed the database of patients who had undergone elective laparoscopic cholecystectomy (LC) in three years and evaluated the rate of bile duct injury and other complications.
Methods: We reviewed our database for patients and did a retrospective analysis on patients who were diagnosed with symptomatic cholelithiasis or chronic cholecystitis, and have undergone LC in our centre from January 2017 to December 2019. Patients less than 15 years of age, acute cholecystitis, and laparoscopic cholecystectomy combined with common bile duct exploration were excluded. We calculated the incidence of biliary injury. The secondary outcomes looked at were Veress needle or pneumoperitoneum-related complications, port site bleeding, intra-abdominal bleeding, bowel injury, liver injury, wound infection, and early port site hernia.
Results: LC was performed in 642 patients. In this study, there was no bile duct injury. Two patients (0.31%) had minor bile leak which resolved without any intervention within a week. Three (0.46%) patients developed port site infection, which responded to regular dressing and oral antibiotic therapy.
Conclusion: The effectiveness of these steps should make their use mandatory in every center to reduce bile duct injury.