A Survey on the Management of Patients with Severe Traumatic Brain Injury During Pregnancy: The MAMA Study.

BACKGROUND: Trauma, including traumatic brain injury (TBI), is the leading cause of nonobstetric maternal mortality during pregnancy. Few data are available regarding the optimal management of pregnant patients with TBI, leading to a lack of dedicated guidelines. We performed an international survey to examine the management of severe TBI in pregnant patients, focusing on monitoring, therapy, and intensive care practices. METHODS: This survey, endorsed by the World Society of Emergency Surgery, was composed of a questionnaire with 79 items divided into four sections: (1) general information (items 1-7), (2) management of the maternal-fetal unit (items 8-43), (3) management of intracranial hypertension (items 44-76), and (4) specific considerations (items 77-79). RESULTS: One hundred and twenty-two physicians from 110 centers in 35 countries responded. The main findings related to TBI care in pregnant patients included the following: (1) a lack of availability of a specific TBI protocol in pregnancy; (2) an increase in the utilization of magnetic resonance imaging as the primary neuroimaging tool; (3) higher hemoglobin thresholds for transfusion; and (4) a lower utilization of therapeutic hypothermia, neuromuscular blocking agents, and barbiturate coma. We also report large variability in the timing of cesarean section in pregnant patients with TBI (≥ 23 weeks of gestation) needing an emergency craniotomy (simultaneously 23% vs. later cesarean section 50.8%). CONCLUSIONS: Great variability in the management of pregnant patients with severe TBI was identified worldwide from the results of our survey. These findings, highlighting the lack of robust evidence on this topic, will be helpful to stimulate future investigations and to promote educational efforts on this difficult scenario.

The short form endometriosis health profile questionnaire (EHP-5): psychometric validity assessment of a Croatian version.

PURPOSE: To translate, adapt and validate the Endometriosis Health Profile-5 (EHP-5) in Croatian population. METHODS: This validation study is a part of a prospective, observational study (EHP-5 CRO) with aim of implementation of EHP-5 and to provide better insight in quality of life consideration of women with endometriosis in Croatian clinical practice. A 150 consecutive patients with surgically proven endometriosis were enrolled. The translation to Croatian followed standardized procedure. Cronbach's Alpha was calculated to calculate internal consistency reliability of EHP-5. The test-retest reliability was calculated using intraclass correlation coefficient (ICC). The t test for independent samples was used to assess known-groups validity. RESULTS: Both EHP-5 core and EHP-5 modular parts of the questionnaire had good internal consistency, assessed by the Cronbach's Alpha coefficient (α = 0.793 and α = 0.842, respectively). Obtained results indicate very good reliability for core as well as for modular part of EHP-5 questionnaire (ICC = 0.896 and 0.936, respectively). The independent t test showed that women who reported their pain with VAS scale 7 or more had significantly higher results (p < 0.001) on EHP-5 (M = 50.63) compared with women who reported their pain 6 or less (M = 26.91). Furthermore, we found statistically significant difference between women who are infertile with women who are fertile (p < 0.001), whereby infertile women had higher average result on EHP-5 (M = 49.55) compared with fertile women (M = 34.36). CONCLUSIONS: The Croatian version of the EHP-5 have very good psychometric characteristics and can be used as a reliable tool for assessing patients with endometriosis in everyday clinical practice.

Laser treatment of pilonidal disease: a systematic review.

Pilonidal disease (PD) is a common condition, and there is still an ongoing debate on ideal management that should be minimally invasive, safe, and efficient. The use of radially emitting laser in the treatment of chronic PD is a novel minimally invasive technique, and initial studies with a small number of patients showed promising results. This study aimed to assess the efficacy and safety of chronic PD treatment with a laser using a systematic review of the published literature. A systematic review was conducted after PubMed, Scopus, Embase, Web of Science, and the Cochrane database search for studies reporting laser treatment of chronic PD. Also, our unpublished prospective single-center study was included in this review. Ten of 87 studies were eligible for the review, including 971 patients. The median age of the patients was 26 (range 13-68), and the median operative time was 26 (range 6-65) min. With a median follow-up of 12 (range 7-25) months, 917 (94.4%) patients achieved primary healing with a weighted mean recurrence rate of 3.8%. The weighted mean complication rate was 10% (95% CI 5.7-14.3%, I2 = 82.28, p < 0.001), and all were minor. The published literature demonstrates that laser treatment is a promising procedure in the management of chronic PD. Furthermore, the review showed that standardized operative techniques and perioperative steps were used. The results were limited to the mild chronic PD. Classification of PD severity and standardized outcome reporting is required to define indications and contraindications for laser PD treatment. Randomized controlled trials are needed to determine the long-term effectiveness and superiority of laser treatment over other methods.

In correspondence to "Spontaneous common bile duct perforation in full term pregnancy: a rare case report and review of literature".

AIM: The correspondence letter aims to correct the historical perspective on common bile duct perforations (CBD) during pregnancy and complete the number of published cases. FINDINGS: Instead of declared article by Piotrowski et al., from 1990, and according to available English language literature, the first two descriptions of maternal spontaneous CBD perforation in pregnancy were by JT Hogan Jr in 1957 and then Maurice Abitbol in 1958. Additional six cases of this condition were found, which is an increase of 50% of published cases. PURPOSE: The purpose of this correspondence letter is to correct the historical perspective on CBD perforation during pregnancy. Also, only all published cases in English language literature can shed new light on incidence, diagnosis, treatment, and maternal and fetal prognosis from maternal CBD perforation in pregnancy.

Conservative treatment of partial testicular artery injury during transabdominal preperitoneal hernioplasty (TAPP).

Inguinal hernias are common conditions in general surgery. Laparoscopic approach, whether transabdominal preperitoneal (TAPP) or totally extraperitoneal (TEP), is favored for its lower rate of surgical site infection, shorter hospital stay, and faster return to daily activities. Complications still occur, albeit in a small percentage, but can prolong hospital stay or be fatal. We present a case of a 55-year-old male patient who underwent TAPP procedure with proposed iatrogenic testicular artery injury resulting in a bilateral retroperitoneal hematoma. The treatment was conservative, and the patient was discharged in good general condition after 13 days. Six months postoperatively, no signs of hernia recurrence were observed. According to available literature, this is the first conservatively treated occult testicular artery injury during TAPP inguinal hernioplasty.

Discordant outcomes of laparoscopic versus open appendectomy for suspected appendicitis during pregnancy in published meta-analyses: an overview of systematic reviews.

OBJECTIVES: Our study aimed to explore the discrepancy of results between overlapping systematic reviews (SRs) of laparoscopic appendectomy (LA) versus open appendectomy (OA) for suspected appendicitis during pregnancy. METHODS: MEDLINE, Embase, and Cochrane Database of Systematic Reviews (CDSR) were searched for SRs published from January 1, 2017 to September 10, 2019. SRs and meta-analyses (MA) that compared outcomes of LA versus OA during pregnancy were used. Data regarding the methodology of SR/MA, included studies, efficacy and safety outcomes were extracted. SR quality was analysed with AMSTAR 2. RESULTS: Four SRs were found, published between April 2018 and April 2019. These reviews included a variety of primary studies, ranging from 17 to 22, and number of included patients varied from 4694 to 6276. A total of 13 outcomes were analyzed. Nine outcomes were included in more than one review; among them, discrepancies between summary effect sizes in meta-analyses were found in four outcomes: preterm birth, Apgar score at 5 min, length of stay in hospital, and wound infection rates. One primary study, which included more than half of the total number of patients in analyzed reviews, showed a predominant effect on the outcome for fetal loss. All four SRs had critically low methodological quality. CONCLUSIONS: The outcomes of LA versus OA for suspected appendicitis in pregnancy represented in four recent SRs do not provide consistent results. Such uncertainties require new, high-quality primary and secondary evidence on this topic.

Chilaiditi Sign and Chilaiditi Syndrome in Pregnancy.

BACKGROUND: Chilaiditi syndrome is a rare condition characterized by impaired fixation of the colon resulting in symptoms secondary to colonic interposition. It commonly presents with nonspecific abdominal pain and constipation, making clinical diagnosis difficult, especially in pregnancy. CASE REPORT: A 29-year-old afebrile woman in the week 28 of pregnancy presented with right-sided abdominal pain and constipation. With an Alvarado score of 6, the working diagnoses were acute appendicitis and intestinal obstruction. After a normal transabdominal ultrasound, emergent abdominal magnetic resonance imaging showed abnormal fixation of hepatic flexure wedged between the falciform ligament and liver. Without clinical, laboratory, and radiologic signs of complete obstruction or colonic perforation, conservative therapy was introduced and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Symptoms associated with Chilaiditi syndrome in pregnancy include nonspecific abdominal pain, and the correct preoperative diagnosis is difficult. The most common differential diagnoses are intestinal obstruction and acute appendicitis. It is important to diagnose Chilaiditi syndrome early because it can lead to severe complications, including intestinal obstruction, perforation, and ischemia. Therefore, in patients with right-sided abdominal pain with inconclusive transabdominal ultrasound, emergent magnetic resonance imaging leads to early diagnosis and treatment, minimizes maternal and fetal complications, avoids unnecessary explorations, and shortens the hospitalization.

Ruptured renal artery aneurysm in pregnancy and puerperium: literature review of 53 cases.

PURPOSE: To summarize and define the most appropriate diagnostic methods and therapeutic options for ruptured renal artery aneurysms in pregnancy based on rarely published data. METHODS: Literature searches of English-, German-, Spanish-, and Italian-language articles were performed in PubMed (1946-2018), PubMed Central (1900-2018) and Google Scholar. The search terms included renal artery aneurysm, renal artery rupture, pregnancy, puerperium, nierenarterienaneurysma, schwangerschaft, wochenbett, aneurisma de la arteria renal, el embarazo, puerperio, aneurisma dell'arteria renale and gravidanza. Additional studies were identified by reviewing reference lists of retrieved studies. RESULTS: Fifty-three cases were collected. The average maternal age was 31 ± 6 years; 71.4% were multiparous and significantly older than primiparas. The majority presented in the third trimester (62.3%), followed by second (20.7%) and the first (5.7%), while 11.3% presented postpartum. All postpartum patients presented during the first week postpartum and 50% during the first 24 h postpartum. Parity was not associated with the trimester of presentation. The left renal artery was affected slightly more frequently (58.5% vs. 41.5%). There were no differences in the affected side according to trimester of presentation, including postpartum. 25 out of 53 cases underwent ipsilateral nephrectomy (47.1%) and 18 underwent aneurysm repair or coil embolization (34.0%). There was no difference in maternal (25.8%) vs. 4 (18.1%) and fetal mortality according to the side of rupture. There were no differences in the distribution of maternal or fetal mortality frequency according to the trimester of presentation. CONCLUSIONS: The clinical presentation is easily confused with more common conditions and time to diagnosis is often delayed. Diagnostic delay is associated with high maternal and fetal mortality. Ruptured renal artery aneurysm should be included in the differential diagnosis for pregnant or peripartum patients presenting with acute and severe flank pain, especially if followed by a drop in blood pressure. Early diagnosis and immediate intervention are important for achieving better maternal and fetal outcomes. There are several methods of managing asymptomatic or ruptured renal artery aneurysm during pregnancy although no established guidelines exist.

Specific small bowel injuries due to prolapse through vaginal introitus after transvaginal instrumental gravid uterus perforation: a review.

A small bowel prolapse through the vaginal introitus after a transvaginal instrumental gravid uterus perforation is a surgical emergency. To define the mechanisms of an irreversible, small bowel ischaemia due to small bowel prolapse through a vaginal introitus, ClinicalTrials.gov, PubMed, PubMed Central, and Google Scholar were searched. Out of the 81 articles screened, 28 cases of a small bowel evisceration through vaginal introitus were included. A small bowel obstruction severity grading was defined with risk factors; potential mechanisms of different severity grades after a transvaginal instrumental gravid uterine perforation with a vaginal evisceration. The duration of symptoms or a delay in the diagnosis did not change the incidence of the two most severe grades-mesenteric stripping and a small bowel degloving. Both obstruction types develop immediately during an instrumental abortion. The severity of obstruction does not influence the maternal outcome.

A Single Small Bowel Hemangioma Detected by Video Capsule Endoscopy in a Patient Presenting with Iron-deficiency Anemia - Two Case Reports.

Hemangioma of the small intestine is a rare vascular malformation which mostly presents as occult gastrointestinal bleeding and iron-deficiency anemia. Patients are often asymptomatic except of fatigue due to anemia. Hemangiomas can arise anywhere in the luminal gastrointestinal tract, with jejunum as the most commonly involved site. They are very hard to recognize mostly due to their localization. Video capsule endoscopy and balloon-assisted enteroscopy have very much improved preoperative diagnostics and made major contribution to establishing the diagnosis - which was very difficult in the past and almost all cases were diagnosed during or after the operation. Surgical resection is still the conventional treatment modality, although with the improvement of endoscopic therapeutic interventions (endoscopic mucosal resection, argon-plasma coagulation) there are more therapeutic possibilities.

Pilot study: Internally cooled orthopedic drills - standard sterilization is not enough?

Bone drilling causes focal temperature rise due to metal-to-bone contact, which may result in thermal osteonecrosis. Newly constructed internally cooled medical drill of an open type decreases temperature rise at a point of metal-to-bone contact although standard sterilization of such a drill could be inadequate due to bacteria retention within the drill lumen. The aim of this pilot study was to examine the effectiveness of sterilization and to propose sterilization recommendations for internally cooled open type bone drills. Unused internally cooled medical steel bone drills were tested. Drills were contaminated with Pseudomonas aeruginosa, Bacillus sp., beta-hemolytic Streptococcus sp., Enterobacter sp. and methicillin-resistant Staphylococcus pseudintermedius and then incubated for 24 hours at 37 °C. Afterwards, drills were autoclaved for 15, 20 and 30 minutes at 132 °C and 2.6 bar. When 15-minute sterilization was used, one out of 16 drills was contaminated with Pseudomonas aeruginosa, while the other 15 drills were sterile. Extended cycle sterilization in autoclave lasting for 20 and 30 minutes resulted in 100% sterility of all drills tested. In conclusion, lumened drills should be exposed to extended sterilization times in autoclave. Minimal recommended time for sterilization of lumened drills is 20 minutes.

LAPAROSCOPIC APPENDECTOMY DOES NOT INCREASE THE RATE OF NEGATIVE APPENDECTOMY along with a lower rate of perforated appendicitis - RESULTS IN 1899 PATIENTS at Zagreb UHC.

- Laparoscopic appendectomy is the method of choice of many professional societies owing to its many advantages. The question arises whether surgeons urge more easily to laparoscopic exploration due to its less invasiveness, faster recovery and adequate exploration of the entire abdominal cavity than to observation in unequivocal cases. This retrospective analysis (2009-2016) included 1899 patients undergoing laparoscopic (lap) or gridiron intra-abdominal approach treated at Zagreb University Hospital Centre. The analysis included total negative appendectomy, negative-negative appendectomy (normal appendix and no other pathology found), and negative-positive appendectomy (normal appendix but another pathology found) in children (≤16 years) and adults. There was no statistically significant difference in the rates of negative appendectomy (children) - lap vs. open (p=0.24); negative appendectomy (adults) - lap vs. open (p=0.15); negative-negative appendectomy (children) - lap vs. open (p=0.36); negative-negative appendectomy (adults) - lap vs. open (p=0.21); negative-positive appendectomy (children) - lap vs. open (p=0.53); negative-positive appendectomy (adults) - lap vs. open (p=0.56); and laparoscopy group negative appendectomy in children vs. adults (p=0.56). There was a statistically significantly higher perforation rate with the open approach in total (p<0.0001), in children (p<0.0001) and in adults (p=0.02). There was no statistically significant difference between adults and children in the perforation rate with laparoscopic approach (p=0.24) and perforation rate with open approach (p=0.29). Results confirmed that there was no statistically significant difference in the rate of negative appendectomy in all subgroups. It is concluded that laparoscopic appendectomy should be offered as the method of choice in any patient population with suspicion of acute appendicitis.

Immunohistochemical expression of 8-oxo-7,8-dihydro-2'-deoxyguanosine in cytoplasm of tumour and adjacent normal mucosa cells in patients with colorectal cancer.

BACKGROUND: The aim of this research was to study the levels of 8-oxo-7,8-dihydro-2'-deoxyguanosine (8-oxodG) in tumour tissue samples of colorectal carcinoma based upon immunohistochemical detection and compare those results with patients' outcome. METHODS: Tumour blocks of patients surgically treated for colorectal cancer were evaluated by 8-oxodG immunohistochemical staining. The expression was analysed in 500 tumour cells. The percentage of positive cells, as well as staining intensity, was recorded, and Allred score was calculated. For each patient, data of age, gender, tumour size and location, margin status, histologic grade, tumour stage, lymph node status, vascular invasion, overall survival, and therapy protocols were collected. Tumour grade was divided into two groups as low and high grade. RESULTS: In this study, 146 consecutive patients with primary colorectal carcinoma were included. All data were available for 138 patients, and they were included in this research. There were 83 male and 55 female patients; the median age was 64 years (range 35-87 years). The results showed shorter 5- and 10-year survival in patients with 8-oxodG positive tumour cells (5-year survival, n=138, Mantel-Cox, chi-square 4.116, degree of freedom (df)=1, p<0.05; 10-year survival, n=134, Mantel-Cox, chi-square 4.374, df=1, p<0.05). The results showed a positive correlation between Allred score and high tumour grade (two-tailed Spearman's ρ 0.184; p<0.05), as well as with non-polypoid tumour growth (two-tailed Spearman's ρ 0.198; p<0.05). There was no significant difference of 8-oxodG expression related to age, sex, blood group, size and tumour site, distance from the edge of the resected tumour margin, lymph nodes involvement, and vascular invasion. CONCLUSIONS: In this study, the positive correlation between 8-oxodG presence in the tumour cells, worse clinical outcome, higher tumour grade, and flat morphology was found.

[First synchronous liver resection as a part of cytoreductive surgery, peritonectomy and HIPEC in Croatia--case report]. / Prva sjnkrona resekcija jetre u sklopu citoreduktivne kirurgije, peritonektomije i HIPEC-a u hrvatskoj--prikaz bolesnice.

We present a case of a 37-year-old female, with large adenocarcinoma of transverse colon, and metastases in spleen, liver, peritoneum, greater omentum, gall bladder and right adnexa. She was transferred to our Hospital, and extensive elective cytoreductive surgery with intraabdominal hyperthermal chemotherapy (HIPEC) was performed. Couple of months later, she was operated on for a newly evidenced secondary nodus in liver segment VII, and metastasectomy was performed. Throughout entire postoperative period she was receiving cyclic chemotherapy. At this point, 2 years from the first operation, she was without evidenced recurrence of the disease. Aggressive cytoreductive surgery with multiorgan resection, peritonectomy, HIPEC and adjuvant chemotherapy which was proved to be a feasible option in some patients, with synchronous liver resection (LR) proved to be feasible and beneficial for patients with three or fewer liver metastases. This is the first liver resection included in usually performed cytoreductive surgery and HIPEC in Croatia.

Correlation between the liver transection line localization and future liver remnant hypertrophy in associating liver partition and portal vein ligation for staged hepatectomy.

Background and aims: Colorectal liver metastases (CRLMs) represent the most prevalent form of secondary liver tumors, and insufficient future liver remnant (FLR) often leads to unresectability. To tackle this challenge, various methods for stimulating liver hypertrophy have been developed including portal vein embolization (PVE), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and the newest one, liver venous deprivation (LVD). ALPPS was thoroughly studied over the last decade and it has been shown to induce rapid and intensive FLR hypertrophy. The objective of this study was to assess whether the localization of the liver transection line during the initial stage of ALPPS correlates with the degree of FLR hypertrophy. Methods: A retrospective, multicentric study was conducted, and we analyzed all consecutive patients with CRLMs who underwent ALPPS over the eight-year period. Patients were categorized into two groups based on the type of resection-right trisectionectomy (ERH) or right hemihepatectomy (RH) respectively. The degree of hypertrophy (DH), its correlation with FLR and postoperative outcomes were assessed. Results: The cohort consisted of 136 patients (72 in the ERH group and 64 in the RH group). Baseline characteristics, hypertrophy interval, and total liver volume showed no significant differences between the groups. DH was greater in the ERH group (83.2% vs. 62.5%, p = 0.025). A strong negative correlation was observed between FLR volume and DH in both groups. Postoperative outcomes and one-year survival were comparable between the groups. Conclusions: FLR hypertrophy is influenced by the localization of the liver transection line in ALPPS. Furthermore, correlation analysis indicated that a smaller estimated FLR is associated with greater DH. No statistical difference in outcomes was noted between the groups.

Comparison of Clinical, Pathological, and Procedural Characteristics of Adult and Pediatric Acute Appendicitis before and during the COVID-19 Pandemic.

BACKGROUND: This study aims to analyze the impact of the COVID-19 pandemic on the clinical, pathological, and surgical characteristics of acute appendicitis (AA) at the University Hospital Centre (UHC) Zagreb. METHODS: This retrospective study analyzed demographic, clinical, and surgical data from consecutive AA patients. Data were collected from an electronic database for two periods: 1 January to 31 December 2019 (pre-COVID-19), and 11 March 2020, to 11 March 2021 (COVID-19 pandemic). RESULTS: During the two study periods, 855 appendectomies were performed, 427 in the pre-pandemic, and 428 during the pandemic. Demographic data were comparable between groups. There was statistically no significant difference in the type of appendectomy (p = 0.33) and the median hospital length of stay (3; (2-5) days, p = 0.08). There was an increase in the conversion rate during the pandemic period (4.2% vs. 7.7%, p = 0.03). The negative appendectomy rate and the incidence of perforated AA did not differ significantly (p = 0.34 for both). CONCLUSIONS: We did not observe a significant increase in the rate of AA complications during the COVID-19 pandemic at the UHC Zagreb. This may be attributed to two factors: (1) AA was diagnosed and treated as an emergency, which remained available during the pandemic, and (2) diagnostic and therapeutic protocols remained unaltered. We recommend a laparoscopic approach even during the COVID-19 pandemic.

Primary hyperparathyroidism-induced acute pancreatitis in pregnancy: A systematic review with a diagnostic-treatment algorithm.

BACKGROUND: Primary hyperparathyroidism (PHPT)-induced acute pancreatitis (AP) during pregnancy has rarely been described. Due to this rarity, there are no diagnostic or treatment algorithms for pregnant patients. AIM: To determine appropriate diagnostic methods, therapeutic options, and factors related to maternal and fetal outcomes for PHPT-induced AP in pregnancy. METHODS: A literature search of articles in English, Japanese, German, Spanish, and Italian was performed using PubMed (1946-2023), PubMed Central (1900-2023), and Google Scholar. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) protocol was followed. The search terms included "pancreatite acuta," "iperparatiroidismo primario," "gravidanza," "travaglio," "puerperio," "postpartum," "akute pankreatitis," "primärer hyperparathyreoidismus," "Schwangerschaft," "Wehen," "Wochenbett," "pancreatitis aguda," "hiperparatiroidismo primario," "embarazo," "parto," "puerperio," "posparto," "acute pancreatitis," "primary hyperparathyroidism," "pregnancy," "labor," "puerperium," and "postpartum." Additional studies were identified by reviewing the reference lists of retrieved studies. Demographic, imaging, surgical, obstetric, and outcome data were obtained. RESULTS: Fifty-four cases were collected from the 51 studies. The median maternal age was 29 years. PHPT-induced AP starts at the 20th gestational week; higher gestational weeks were seen in mothers who died (mean gestational week 28). Median values of amylase (1399, Q1-Q3 = 519-2072), lipase (2072, Q1-Q3 = 893-2804), serum calcium (3.5, Q1-Q3 = 3.1-3.9), and parathormone (PTH) (384, Q1-Q3 = 123-910) were reported. In 46 cases, adenoma was the cause of PHPT, followed by 2 cases of carcinoma and 1 case of hyperplasia. In the remaining 5 cases, the diagnosis was not reported. Neck ultrasound was positive in 34 cases, whereas sestamibi was performed in 3 cases, and neck computed tomography or magnetic resonance imaging was performed in 9 cases (the enlarged parathyroid gland was not localized in 3 cases). Surgery was the preferred treatment during pregnancy in 33 cases (median week of gestation 25, Q1-Q3 = 20-30) and postpartum in 12 cases. The timing was not reported in the remaining 9 cases, or surgery was not performed. AP was managed surgically in 11 cases and conservatively in 43 (79.6%) cases. Maternal and fetal mortality was 9.3% (5 cases). Surgery was more common in deceased mothers (60.0% vs 16.3%; P = 0.052), and PTH values tended to be higher in this group (910 pg/mL vs 302 pg/mL; P = 0.059). Maternal mortality was higher with higher serum lipase levels and earlier delivery week. Higher calcium (4.1 mmol/L vs 3.3 mmol/L; P = 0.009) and PTH (1914 pg/mL vs 302 pg/mL; P = 0.003) values increased fetal/child mortality, as well as abortions (40.0% vs 0.0%; P = 0.007) and complex deliveries (60.0% vs 8.2%; P = 0.01). CONCLUSION: If serum calcium is not tested during admission, definitive diagnosis of PHPT-induced AP in pregnancy is delayed, while early diagnosis and immediate intervention lead to excellent maternal and fetal outcomes.

Can small bowel obstruction during pregnancy be treated with conservative management? A review.

BACKGROUND: Small bowel obstruction can occur during pregnancy, which, if missed, can lead to dire consequences for both the mother and foetus. Management of this condition usually requires surgical intervention. However, only a small number of patients are treated conservatively. OBJECTIVE: The objective was to review the literature to determine the feasibility of conservative management for small bowel obstruction. METHODS: A systematic search of the PubMed and Embase databases was performed using the keywords [small bowel obstruction AND pregnancy]. All original articles were then reviewed and included in this review if deemed suitable. CONCLUSION: Conservative management of small bowel obstruction in pregnant women is feasible if the patient is clinically stable and after ruling out bowel ischaemia and closed-loop obstruction.

Spontaneous Sigmoid Colon Perforation and Ruptured Subserosal ("Zebra" Pattern) Small-Bowel Hematomas in Type IV Ehlers-Danlos Syndrome: A Case Report and a Short Review.

Background and Objectives: Spontaneous colonic perforations (SCPs) in teenagers and young adults are extremely rare. Common underlying conditions, such as colonic tumors and diverticulitis, are absent at that age. The vascular type of Ehlers-Danlos Syndrome (vEDS) is one cause of SCP. Methods: A 23-year-old male presented with an acute abdomen. The abdominal CT showed pneumoperitoneum with a large amount of fluid in the pelvis and abdomen, indicating hollow viscus rupture. At the level of the sigmoid colon, a defect in the intestinal wall and gas bubbles were seen. Results: Exploratory laparotomy confirmed sigmoid colon perforation without underlying pathology. Loop sigmoid colostomy was performed. Revisional surgery was undertaken due to clinical deterioration and intra-abdominal free fluid with small-bowel distension and air-liquid levels on abdominal CT 6 days later. Ileal subserosal hematomas were found, and many had ruptured, leaving a "zebra" pattern with lines of residual hematomas on the borders of subserosal hematomas. Genetic analysis confirmed vEDS. Conclusions: SCP in young adults or teenagers, in the absence of colonic disease, with clinical manifestations of connective tissue disorders should trigger genetic investigations for vEDS. SCP with a known vEDS could be treated with total colectomy to prevent further SCPs in the remaining colon. If segmental resections are performed, further SCP should be immediately excluded with any significant abdominal pain.

Evaluation of PD-L1 Expression in Colorectal Carcinomas by Comparing Scoring Methods and Their Significance in Relation to Clinicopathologic Parameters.

BACKGROUND: This study aims to evaluate PD-L1 expression in colorectal carcinomas (CRCs) by using the tumor proportion score (TPS) and the combined positive score (CPS), and to investigate whether there is a correlation with clinicopathologic features. METHODS: A cross-sectional study was conducted that included samples from patients with colorectal adenocarcinoma treated with colon resection and rectal resection after neoadjuvant radio- and chemotherapy at the Department of Abdominal Surgery at Pozega Hospital in the period from 2017 to 2022. The study included 102 tumor tissue samples from patients after resection and the pathohistological diagnosis of adenocarcinoma. RESULTS: In our study, the PD-L1 positivity rate after the TPS was 42 (41%) samples, and after the CPS, 97 (95%) of them (p < 0.001). The positive expression of PD-L1 in tumor cells using the TPS method showed a statistically significant association with adenocarcinoma (TPS ≥ 10-50% and ≥50%). There were significantly more that were moderately differentiated, with TPS ≥ 50%, and those poorly differentiated had values ≥ 10-50%. There were significantly more patients with a status of more than one positive lymph node with TPS values ≥ 10-50%. Patients without metastases in the lymph nodes are significantly more likely to have CPS values > 50%, compared with other lymph node statuses. CONCLUSIONS: These results suggest that the total number of PD-L1-expressing cells, including tumor and immune cells, is a more sensitive biomarker than the number of PD-L1-expressing tumor cells alone in CRC.