Anterior Resection Syndrome and Quality of Life With Long-term Follow-up After Rectal Cancer Resection.

BACKGROUND: Surgical and systemic therapies continue to advance, enabling restorative resections for distal rectal cancer. These operations are associated with low anterior resection syndrome. Recent studies with methodological and size limitations have investigated the incidence of low anterior resection syndrome after anterior resection. However, the long-term trajectory of low anterior resection syndrome and its effect on health-related quality of life remain unclear. OBJECTIVE: The purpose of this study was to assess the impact of anterior resection and reversal of ileostomy on long-term health-related quality of life and low anterior resection syndrome. DESIGN: Patient demographics were analyzed alongside low anterior resection syndrome and health-related quality-of-life qualitative scores (EORTC-QLQ-C30) obtained through cross-sectional postal questionnaires. SETTING: Patients who underwent anterior resection of the rectum for cancer with defunctioning ileostomy between 2003 and 2016 at 2 high-volume centers in the United Kingdom were identified, excluding those experiencing anastomotic leakage. PATIENTS: Among 478 eligible patients, 311 (65.1%) participated at a mean of 6.5 ± 0.2 years after anterior resection. Demographics and neoadjuvant chemoradiotherapy rates were similar ( p > 0.05) between participants and nonparticipants. RESULTS: The percentage of patients who experienced major low anterior resection syndrome was 53.4% (166/311). Health-related quality-of-life functional domain scores improved in the years after reversal of ileostomy, with significant changes in constipation ( p = 0.01), social function ( p = 0.03), and emotional scores ( p = 0.02), as well as a reduction in the prevalence of major low anterior resection syndrome ( p = 0.003). LIMITATIONS: The main limitation of this study was that the data collected were cross-sectional rather than longitudinal, and that nonresponders may have had worse cancer symptoms. CONCLUSIONS: In this first large-scale study assessing long-term function after anterior resection and reversal of ileostomy, there is a linear improvement in major low anterior resection syndrome beyond 6 years, alongside improvements in key quality-of-life measures. See Video Abstract at http://links.lww.com/DCR/B825 . SEGUIMIENTO A LARGO PLAZO DEL SNDROME DE RESECCIN ANTERIOR BAJA Y LA CALIDAD DE VIDA POR CNCER DE RECTO: ANTECEDENTES:Los tratamientos tanto quirúrgicos como sistémicos continúan evolucionando día a día, así éstos permiten resecciones restaurativas por cáncer de recto distal. Estas operaciones están asociadas con el síndrome de resección anterior baja. Estudios recientes con limitaciones tanto metodológicas como de talla han estudiado la incidencia del síndrome de resección anterior bajo post-quirúrgico. Sin embargo, la evolución a largo plazo del síndrome de resección anterior baja y su acción sobre la calidad de vida relacionadas con la salud siguen sin estar claros.OBJETIVO:Evaluar el impacto de la resección anterior baja y el cierre de la ileostomía en la calidad de vida relacionadas con la salud a largo plazo y el síndrome post-resección anterior.AJUSTE:Se incluyeron todos los pacientes sometidos a una reseccción anterior baja de recto por cáncer asociada a una ileostomía de protección entre 2003 y 2016 en dos centros de gran volumen en el Reino Unido, se excluyeron los pacientes que presentaron fuga anastomótica.DISEÑO:Se revisaron los datos demográficos de todos los pacientes que presentaban el síndrome de resección anterior baja, se revisaron las puntuaciones de la calidad de vida relacionadas con el estado general de salud (EORTC-QLQ-C30) obtenidas a través de cuestionarios transversales enviados por correo.PACIENTES:478 pacientes fueron escogidos, 311 (65,1%) participaron del estudio en una media de 6,5 ± 0,2 años después de la resección anterior. Las tasas demográficas y de radio-quimioterapia neoadyuvante fueron similares (p > 0,05) entre los participantes y los no participantes.RESULTADOS:El porcentaje de pacientes que experimentaron síndrome de resección anterior baja mayor fue del 53,4% (166/311).PRINCIPALES MEDIDAS DE RESULTADO:Las puntuaciones funcionales en la calidad de vida relacionadas con estado general de salud mejoraron en los años posteriores al cierre de la ileostomía de protección, los cambios fueron significativos con relación al estreñimiento (p = 0,01), con relación a la actividad social (p = 0,03) y con las puntuaciones emocionales (p = 0,02), así como con la reducción de la prevalencia del síndrome de resección anterior baja mayor (p = 0,003).LIMITACIONES:La principal limitación del presente estudio mostró que los datos recopilados fueron transversales y no longitudinales, y que los pacientes no respondedores pueden haber tenido peores síntomas relacionados con el cáncer.CONCLUSIONES:Este primer estudio a gran escala, evalúa la función a largo plazo después de la resección anterior baja y el cierre de la ileostomía, demuestra una mejoría lineal en el síndrome de resección anterior baja de grado importante, más allá de los 6 años, asociado con la mejoría en las medidas clave de calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B825 . (Traducción-Dr. Xavier Delgadillo ).

Combined epidural-general anaesthesia vs general anaesthesia in neonatal gastrointestinal surgery: A randomized controlled trial.

BACKGROUND: Post-operative ileus is a frequent complication of gastrointestinal surgery under general anaesthesia. The aim of this study was to investigate whether combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery in neonates undergoing elective gastrointestinal surgery. METHODS: A randomized controlled trial including 60 neonates who underwent gastrointestinal surgery at a university hospital was performed. Thirty neonates received combined epidural-general anaesthesia (CEGA), and 30 neonates received general anaesthesia (GA) alone. The primary outcome was the post-operative time to tolerance of full enteral nutrition. The secondary outcomes were the post-operative time defaecation, the duration of nasogastric drainage, and infections. RESULTS: After excluding two neonates from the CEGA group, where repeated attempts at epidural catheterization were unsuccessful, a total of 58 patients completed the study (CEGA: 28; GA: 30). Full enteral nutrition was tolerated earlier in CEGA vs the GA group (4.0 vs 8.0 days; P = .0001). Time to defaecation was shorter in the CEGA group (3.5 vs 5.0 days; P = .0001). Duration of nasogastric drainage was similar between groups (7.0 vs 7.0 days; P = .9502). Fewer patients in the CEGA group experienced post-operative infection (35.7% vs 60.0%; P = .038). CONCLUSION: Combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery and a lower infection risk after gastrointestinal surgery in neonates.

Effectiveness and Safety of Nitrous Oxide as a Sedative Agent at 60% and 70% Compared to 50% Concentration in Pediatric Dentistry Setting.

Objective: Sedation using 50% nitrous oxide (N2O) concentration is common in pediatric dentistry. The aim to assess sedation and cooperation levels following sedation with 60% and 70% N2O concentrations in children whose dental treatment failed using 50% N2O concentration. Study design: Children (n=51) aged 5-10 years were included. Sedation started with N2O concentration of 50%; when appropriate cooperation and sedation were not achieved, N2O concentration was increased to 60%, and subsequently to 70% during the same session. Sedation and cooperation levels were the primary outcomes. Adverse events were defined as secondary outcomes. Results: At 50% N2O concentration, five children reached adequate sedation and cooperation and completed their dental treatment, where 32 children completed the treatment at 60% N2O concentration. Fourteen children required a concentration of 70% to complete treatment. For ten of the latter, treatment was successfully completed, while for four, treatment failed, despite the achievement of adequate sedation. Adverse events were observed in 9%, 22%, of the children who received 60%, 70% N2O concentrations, respectively. Conclusions: When sedation with 50% N2O concentration does not achieve satisfactory cooperation to complete pediatric dental treatment, 60% N2O concentration appears to be more effective than 50% and safer than 70%.

Defining Benchmark Outcomes for ALPPS.

OBJECTIVE: The aim of this study was to use the concept of benchmarking to establish robust and standardized outcome references after the procedure ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged hepatectomy). BACKGROUND AND AIMS: The recently developed ALPPS procedure, aiming at removing primarily unresectable liver tumors, has been criticized for safety issues with high variations in the reported morbidity/mortality rates depending on patient, disease, technical characteristics, and center experience. No reference values for relevant outcome parameters are available. METHODS: Among 1036 patients registered in the international ALPPS registry, 120 (12%) were benchmark cases fulfilling 4 criteria: patients ≤67 years of age, with colorectal metastases, without simultaneous abdominal procedures, and centers having performed ≥30 cases. Benchmark values, defined as the 75th percentile of the median outcome parameters of the centers, were established for 10 clinically relevant domains. RESULTS: The benchmark values were completion of stage 2: ≥96%, postoperative liver failure (ISGLS-criteria) after stage 2: ≤5%, ICU stay after ALPPS stages 1 and 2: ≤1 and ≤2 days, respectively, interstage interval: ≤16 days, hospital stay after ALPPS stage 2: ≤10 days, rates of overall morbidity in combining both stage 1 and 2: ≤65% and for major complications (grade ≥3a): ≤38%, 90-day comprehensive complication index was ≤22, the 30-, 90-day, and 6-month mortality was ≤4%, ≤5%, and 6%, respectively, the overall 1-year, recurrence-free, liver-tumor-free, and extrahepatic disease-free survival was ≥86%, ≥50%, ≥57%, and ≥65%, respectively. CONCLUSIONS: This benchmark analysis sets key reference values for ALPPS, indicating similar outcome as other types of major hepatectomies. Benchmark cutoffs offer valid tools not only for comparisons with other procedures, but also to assess higher risk groups of patients or different indications than colorectal metastases.

Protective multimodal analgesia with etoricoxib and spinal anesthesia in inguinal hernia repair: a randomized controlled trial.

BACKGROUND: Inguinal hernia repair is a common procedure, and can be performed under spinal anesthesia. Although adequate analgesia is crucial to postoperative recovery, the optimal protective analgesic regimen remains to be established. PURPOSE: To investigate the effects of preoperative etoricoxib within a protective multimodal analgesic regimen with respect to pain control following open inguinal hernia repair. METHODS: Sixty adult patients undergoing open inguinal hernia repair participated in a single-center, randomized, double-blinded, placebo-controlled trial in a general academic medical center. The intervention group (n = 30) received 120 mg of oral etoricoxib 1 h preoperatively, and 10-12 mg bupivacaine with 25 µg fentanyl as spinal anesthesia. The control group (n = 30) received oral placebo 1 h preoperatively, and spinal anesthesia as above. Postoperative Visual Analog Scale pain scores at rest and on active straight leg raise were recorded and analyzed. RESULTS: Resting pain scores were significantly lower in the intervention than the control group at 16 h, 24 h, and on discharge (3.00 vs. 4.35; 1.57 vs. 4.00; 1.24 vs. 3.76, respectively; p < 0.05). Pain scores on active straight leg raise were significantly lower in the intervention than the control group at 16 h, 24 h, and on discharge (3.85 vs. 5.59, p < 0.01; 2.84 vs. 4.90, p < 0.05; 3.55 vs. 5.32, p < 0.05, respectively). CONCLUSION: The addition of etoricoxib to spinal anesthesia as a multimodal protective regimen can improve pain control after inguinal hernia repair. The optimal dose and applicability to other operations remains to be established.

Detection of Respiratory Adverse Events in Pediatric Dental Patients Sedated With 0.75mg/Kg of Midazolam and Oxygen by Continuous Pretracheal Auscultation: A Prospective Randomized Controlled Trial.

PURPOSE: Sedation is becoming more commonplace for pediatric patients undergoing minor procedures. Fortunately, electronic monitors have contributed to a reduction in the associated respiratory adverse events (RAEs). To test the hypothesis that adding the pretracheal stethoscope (PTS) to standard monitoring methods (SMMs) may improve RAE detection in sedated pediatric dental patients, the frequency of RAEs detected by SMMs (i.e. visual observation, capnography, and pulse oximetry) was compared to that detected by SMMs alongside continuous PTS auscultation. STUDY DESIGN: A prospective, randomised, controlled trial was performed with 100 pediatric patient participants of ASA≤2, who were scheduled to receive dental treatment under 0.75 mg/kg and oxygen. Patients were randomised into Groups A (n=50; SMMs) and B (n=50; SMMs+PTS). Inclusion criteria were behavioral management problems and intolerance to dental treatment despite behavioral management techniques or nitrous oxide administration. Exclusion criteria were high-risk conditions for RAEs, altered mental status, gastrointestinal disorders, parental refusal of conscious sedation and failure of previous conscious sedation. An anesthesist was present throughout the dental treatments. RESULTS: RAEs were detected in 10 (20%) and 22(44%) Group A and B patients respectively (p=0.01). The majority of RAEs within Group B were detected by PTS auscultation (n=19). Capnography produced 13 and 15 false-positive results in Groups A and B respectively, whereas the PTS produced 4(8%) false-positive results in Group B (p=0.009). CONCLUSIONS: PTS was found to be useful for detecting RAEs during pediatric dental sedation with 0.75mg/kg midazolam and oxygen, in the presence of an anesthesist.

Dietary supplementation with vitamin D stimulates intestinal epithelial cell turnover after massive small bowel resection in rats.

PURPOSE: While the endocrine action of the active metabolite 1,25-dihydroxyvitamin D (VtD) has been well characterized in relation to the maintenance of plasma calcium and phosphate homeostasis through regulation of intestinal absorption, recent research has focused on its autocrine and/or paracrine activities. Such activities have been best characterized in intestine, where VtD regulates cell differentiation and maturation. The purpose of this study was to evaluate the effect of VtD on enterocyte turnover in a rat model of short bowel syndrome (SBS). METHODS: Male rats were divided into four groups: sham rats underwent bowel transection, sham-VtD rats underwent bowel transection and were treated oral VtD, SBS rats underwent a 75 % bowel resection, and SBS-VtD rats underwent bowel resection and were treated with VtD. Parameters of intestinal adaptation, enterocyte proliferation and apoptosis were determined at sacrifice. Illumina's digital gene expression (DGE) analysis was used to determine VtD pathway-related gene expression profiling. VtD receptor (VDR) and its promoter, Bax and Bcl-2 mRNA expression were determined using real-time PCR. Western blotting was used to determine p-ERK, Bax and ß-catenin protein levels. RESULTS: From the total of 20,000 probes, 11 genes related to VtD signaling were investigated. Of these genes, five were found to be up-regulated in SBS versus sham animals with a relative change in gene expression level of 20 %, five remained unchanged, and one was down-regulated. VtD treatment in sham and SBS rats resulted in significant up-regulation of the VDR gene and its promoter's expression. SBS-VtD rats demonstrated a significant increase in all intestinal mucosal parameters compared to SBS animals. A significant increase in cell proliferation in SBS-VtD rats was accompanied by increased ß-catenin protein levels. A significant decrease in cell apoptosis in this group was correlated with lower Bax/Bcl-2 mRNA and protein levels. CONCLUSION: In a rat model of SBS, dietary supplementation with VtD stimulates enterocyte turnover, which correlates with up-regulated VtD receptor expression in the remaining small intestine.

Computed tomographic colonography for symptomatic patients: the diminutive polyp dilemma.

BACKGROUND: Computed tomographic colonography (CTC) is sensitive to polyp detection but is considered inaccurate for measuring diminutive polyps (<6 mm), with divergence between CTC and either colonoscopic or histopathological polyp measurements. Reporting diminutive polyps remains debatable. This study aims to compare outcomes of symptomatic patients with diminutive versus borderline polyps on CTC and to thereby examine the potential implication of reporting diminutive polyps. METHODS: A single-centre retrospective study of symptomatic patients who underwent CTC from October 2016 through September 2018 was performed. After excluding CTC demonstrating cancer, no polyps, or polyps >6 mm, cases were categorized as either 'diminutive' (largest polyp <6 mm), or 'borderline' (largest polyp = 6 mm). The outcome measures were progression to endoscopy, surgery, procedure-related morbidity, dysplasia and malignancy. RESULTS: A total of 308 cases (211 diminutive and 97 borderline) were analysed. The groups were similar (P > 0.05) in mean age (73 vs. 74 years), female proportion (57% vs. 49%), endoscopy-related morbidity (6% vs. 7%) and CTC-related morbidity (0 vs. 1%). Most patients (64%) underwent endoscopy, which was more common in the borderline vs. the diminutive group (76% vs. 59%; P = 0.003). Dysplasia was more common in the borderline vs. the diminutive group (69% vs. 48%; P = 0.003). No malignancies were diagnosed, and no patients proceeded to surgery. CONCLUSION: Reporting diminutive polyps on CTC for symptomatic patients frequently leads to endoscopy, which often reveals dysplasia but rarely malignancy. This raises the question of how referring clinicians can best counsel and manage symptomatic patients with diminutive polyps on CTC, by considering the balance between utilitarianism and deontology.

Improved outcomes in paediatric anaesthesia: contributing factors.

PURPOSE: To discuss developments in paediatric anaesthesia and explore the factors which have contributed to improved anaesthetic-related patient outcomes. METHODS: Narrative review of findings in the literature retrieved from MEDLINE/Pubmed and manual search. RESULTS: Adverse perioperative outcomes related to anaesthesia have been extensively debated over the past few decades, with studies implicating factors such as major human error and equipment failure. Case series and event registries have enlightened physicians on sources of error and patient risk factors such as extremes of age, comorbidity and emergent circumstances. Anaesthetic-related deaths in children fell from 6.4 per 10,000 anaesthetics in the early 1950s to as low as 0.1 per 10,000 anaesthetics by the end of the century. Advances in anaesthetic agents, techniques, monitoring technologies and training programmes in paediatric anaesthesia play a vital role in driving this downward trend. CONCLUSION: Despite substantial progress, there is still much room for improvement in areas such as adverse-event reporting, anaesthetic-related risk and late neurocognitive outcomes. Systematic reviews comparing paediatric patient outcomes after neuroaxial block versus general anaesthesia are currently unavailable. The future of paediatric anaesthesia will most likely be influenced by much-needed large prospective studies, which can provide further insight into patient safety and service delivery.

Simple oncoplastic breast defect closure improves long-term cosmetic outcome of breast conserving surgery for breast cancer: A randomised controlled trial.

INTRODUCTION: Breast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure. METHODS: A randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the "reshaping" group (closure of excision defect with mobilised breast tissue; n = 124) and to the "control" group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ). RESULTS: There were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of "good" or "excellent" by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001). CONCLUSIONS: Simple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes.

Liver regeneration biology: Implications for liver tumour therapies.

The liver has remarkable regenerative potential, with the capacity to regenerate after 75% hepatectomy in humans and up to 90% hepatectomy in some rodent models, enabling it to meet the challenge of diverse injury types, including physical trauma, infection, inflammatory processes, direct toxicity, and immunological insults. Current understanding of liver regeneration is based largely on animal research, historically in large animals, and more recently in rodents and zebrafish, which provide powerful genetic manipulation experimental tools. Whilst immensely valuable, these models have limitations in extrapolation to the human situation. In vitro models have evolved from 2-dimensional culture to complex 3 dimensional organoids, but also have shortcomings in replicating the complex hepatic micro-anatomical and physiological milieu. The process of liver regeneration is only partially understood and characterized by layers of complexity. Liver regeneration is triggered and controlled by a multitude of mitogens acting in autocrine, paracrine, and endocrine ways, with much redundancy and cross-talk between biochemical pathways. The regenerative response is variable, involving both hypertrophy and true proliferative hyperplasia, which is itself variable, including both cellular phenotypic fidelity and cellular trans-differentiation, according to the type of injury. Complex interactions occur between parenchymal and non-parenchymal cells, and regeneration is affected by the status of the liver parenchyma, with differences between healthy and diseased liver. Finally, the process of termination of liver regeneration is even less well understood than its triggers. The complexity of liver regeneration biology combined with limited understanding has restricted specific clinical interventions to enhance liver regeneration. Moreover, manipulating the fundamental biochemical pathways involved would require cautious assessment, for fear of unintended consequences. Nevertheless, current knowledge provides guiding principles for strategies to optimise liver regeneration potential.

Management of anastomotic leaks after elective colorectal resections: The East of England experience. A retrospective cohort.

INTRODUCTION: Colorectal anastomotic leaks (AL) are associated with high morbidity and mortality. Management of AL and its intra-operative decision making is often difficult. The aim of this multi-centre study is to explore different management strategies, including different surgical options, and analyse rates and patterns of failure of initial management. METHODS: All consecutive patients who had a confirmed AL after elective colorectal resections from 1st January 2014 to 31st December 2019 were included at seven hospitals across the East of England Region. Morbidity (length of stay, and failures) and mortality were compared across the different management strategies, and survival analyses were performed (Clinicaltrials.gov ID: NCT05000580). RESULTS: Across all seven hospitals, a total of 3391 elective resection were done during the study period. 201 (5.9%) consecutive patients with confirmed AL were included. The initial treatment was conservative in 102(50.7%). 19 patients (9.5%) had a radiological procedure, 80 (39.8%) of patients required surgery as an initial treatment post AL. Of those who initially did not have a surgical intervention (n = 121), 10% (n = 12/121) eventually required laparotomy, 2 additional patients required transanal drainage. Ultimately 45.8% (n = 92/201) of the whole population eventually required a laparotomy. Patients managed conservatively had a shorter LOS when compared to either radiological drainage or surgical patients. Patients with a defunctioning stoma are more likely to have a successful conservative management and shorter LOS. 90-day mortality across the entire population was 8.1%. There were no significant differences in mortality or long-terms survival between the different initial treatment modalities or whether the leak was right or left sided. CONCLUSION: Despite initial conservative, antibiotic and radiological intervention being successful in the majority of patients, two out of five patients will still require a laparotomy and over a quarter of patients will have an end stoma.

External aortic clamping versus endoaortic balloon occlusion in minimally invasive cardiac surgery: a systematic review and meta-analysis.

OBJECTIVES: Minimally invasive cardiac valve surgery is safe, effective and increasingly popular. It is performed worldwide with the use of either external aortic clamping or endoaortic balloon occlusion. METHODS: We conducted a literature search using MEDLINE, EMBASE, Scopus and Web of Science. Primary outcomes included aortic dissection, conversion to sternotomy, mortality, stroke and cross-clamp time. Secondary outcomes included atrial fibrillation, acute kidney injury, reoperation for bleeding, cardiopulmonary bypass times, myocardial infarction, use of intra-aortic balloon pump and length of hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data. RESULTS: Thirty retrospective studies were included in the meta-analysis. The incidence of aortic dissection (pooled odds ratio = 3.88, 95% confidence interval = 1.06-14.18; P =0.04) and conversion to sternotomy (pooled odds ratio = 3.07, 95% confidence interval = 1.33-7.10; P = 0.009) was higher in the endoaortic balloon occlusion group than in the external aortic clamping group, in whom a direct comparison was possible. The remaining observational studies did not show any significant differences in either group. There was no significant difference in 30-day mortality (P = 0.37), stroke (P = 0.26), cross-clamp time (P = 0.20), atrial fibrillation (P = 0.18), acute kidney injury (P = 0.49), reoperation for bleeding (P = 0.24), cardiopulmonary bypass time (P = 0.06), myocardial infarction (P = 0.74), use of intra-aortic balloon pump (P = 0.11) or length of hospital stay (P = 0.47). CONCLUSIONS: External aortic clamping may be safer than endoaortic balloon occlusion with respect to aortic dissection and conversion to sternotomy. However, mortality, length of stay, stroke, cross-clamp time and other cardiovascular complication rates were similar between the 2 techniques.

A rare case of a chest wall abscess caused by a migrating oesophageal stent. An iatrogenic gastrocutaneous fistula.

We report the case of a 65-year-old male, who presented with septicaemia and a chest wall mass on a background of oesophageal carcinoma. This chest wall mass measured 10 cm by 10 cm, was fluctuant, and was situated on the anterior chest wall. Owing to local erythema and surgical emphysema, necrotising fasciitis was suspected and thus intravenous antibiotic and fluid therapy were instituted. Following a chest radiograph, which confirmed the presence of subcutaneous gas, the patient underwent thoraco-abdomino-pelvic CT, which demonstrated oesophageal stent migration through the gastric fundus to the chest wall, between the 10th and 11th left ribs. Through this migration tract, the chest wall was contaminated with gastric contents, accounting for the mass and sepsis. The patient underwent endoscopic stent removal, and incision and drainage to create a gastrocutaneous fistula. Additionally, a nasojejunal tube and intravenous line were sited for jejunal and total parenteral nutrition, respectively, in order to promote healing of the fistula.

Laparoscopic Finney pyloroplasty in the emergency setting: first case report in the literature and technical challenges.

Pyloroplasty is currently reserved for emergencies (perforation, bleeding), but may occasionally be performed to treat benign gastric outlet obstruction (GOO). Historically, two techniques are available: the Mikulicz pyloroplasty, by which the pylorus is incised longitudinally and sutured vertically, and the Finney pyloroplasty, by which a U-shaped inverted incision is made in the second part of duodenum (D1-D2), followed by a side-to-side gastroduodenostomy. We report our experience in this single case of laparoscopic Finney pyloroplasty (LFP) performed in the emergency setting for a woman with a perforated duodenal ulcer and severe loss of tissue in D1-D2. Due to the presence of severely inflamed perforation edges and the risk of duodenal narrowing with subsequent GOO, Finney technique was favored over direct ulcer repair. The patient achieved a full postoperative recovery free of complications, with a dynamic oral contrast study demonstrating good gastric evacuation. Review of the current literature revealed no similar cases, as LFP has only been performed in the canine model. Although LFP requires a specific surgical skill-set, we believe it can be effective and feasible in cases of duodenal perforation with significant loss of mural substance.

Long-term survival with repeated resections of recurrent hepatocellular carcinoma in a non-cirrhotic liver: case report and brief review of the literature.

A healthy and asymptomatic 55-year-old woman underwent a complete (R0) non-anatomical resection of an incidentally detected solitary hepatocellular carcinoma (HCC) in a non-cirrhotic liver. Six years following the initial R0 non-anatomical resection, intrahepatic recurrence was diagnosed and the patient underwent a second R0 non-anatomical resection. At 12.5 years following the initial resection, a further intrahepatic recurrence was diagnosed, which was once again completely resected by left lateral hepatectomy. This represents one of the longest reported periods between initial resection and HCC recurrence, following repeated R0 resections in the absence of cirrhosis. The appropriate surveillance period and genetic testing protocol for such cases remains to be established.

Primary small bowel melanomas: fact or myth?

Small bowel melanoma (SBM) is a rare entity, which often evades diagnosis and therefore presents late. Its origin, whether arising primarily or metastatically from an unidentified or regressed primary cutaneous melanoma, remains debatable. In this report, we present a rare case of primary SBM and review the current literature. A 60-year-old man presented with melena and microcytic anemia. A series of investigations including abdominal ultrasonography (US), esophago-gastro-duodenoscopy (EGD) and colonoscopy were normal. Abdominal computed tomography revealed no specific pathology. Subsequent capsule endoscopy identified a jejunal mass, which was confirmed on laparotomy, was resected, and histologically diagnosed as melanoma. Extensive postoperative clinical examination revealed no cutaneous lesions. This report discusses gastrointestinal (GI) malignant melanoma, and examines the evidence both for and against the existence of true primary vs. metastatic disease. Furthermore, this case highlights the capabilities of capsule endoscopy in identifying an extremely rare GI tumor, which evaded other diagnostic modalities. Finally, the origins and pathophysiology of this rare cancer are evaluated, with the aim of promoting early diagnosis and treatment, and therefore improving current poor outcomes.

Successful Outflow Reconstruction to Salvage Traumatic Hepatic Vein-Caval Avulsion of a Normothermic Machine Ex-Situ Perfused Liver Graft: Case Report and Management of Organ Pool Challenges.

Donor organ shortage continues to limit the availability of liver transplantation, a successful and established therapy of end-stage liver diseases. Strategies to mitigate graft shortage include the utilization of marginal livers and recently ex-situ normothermic machine perfusion devices. A 59-year-old woman with cirrhosis due to primary sclerosing cholangitis was offered an ex-situ machine perfused graft with unnoticed severe injury of the suprahepatic vasculature due to road traffic accident. Following a complex avulsion, repair and reconstruction of all donor hepatic veins as well as the suprahepatic inferior vena cava, the patient underwent a face-to-face piggy-back orthotopic liver transplantation and was discharged on the 11th postoperative day after an uncomplicated recovery. This report illustrates the operative technique to utilize an otherwise unusable organ, in the current environment of donor shortage and declining graft quality. Normothermic machine perfusion can definitely play a role in increasing the graft pool, without compromising the quality of livers who had vascular or other damage before being ex-situ perfused. Furthermore, it emphasizes the importance of promptly and thoroughly communicating organ injuries, as well as considering all reconstructive options within the level of expertise at the recipient center.

Postsplenectomy thrombocytosis with pseudohyperkalaemia.

A 52-year old man developed hyperkalaemia on the 11th postoperative day following an extensive open retroperitoneal liposarcoma resection that included splenectomy. Despite thorough investigations, no aetiology for the hyperkalaemia was identified and standard empirical treatment was ineffective. On reconsideration, in view of the patient's concurrent thrombocytosis, a pseudofactual or artefactual hyperkalaemia was suspected. This was confirmed by contemporaneous testing of serum and plasma potassium levels, with the latter value lying within the normal range. Treatment for hyperkalaemia was discontinued, thus averting an iatrogenic and potentially dangerous hypokalaemia. This case highlights pseudohyperkalaemia as an often-neglected cause of elevated serum potassium levels and discusses its association with thrombocytosis following splenectomy.

Synchronous Hepatic Epithelioid Hemangioendothelioma and Hepatocellular Carcinoma: First Case Report in the Literature and Challenges.

We would like to report the first case in English literature, to the best of our knowledge, of a synchronous hepatic epithelioid hemangioendothelioma (HEHE) and hepatocellular carcinoma (HCC), as well as to address the current trends and challenges in the management of HEHE.An otherwise well 58-year-old man was referred to his local hepatology service with elevated serum γ-GT levels. Imaging revealed bilobar liver lesions consistent with HEHE, a discrete left lobe lesion suspected as HCC, and multiple pulmonary nodules. Biopsies confirmed HEHE with pulmonary metastases. After multidisciplinary team discussions, the patient was admitted under our team and underwent an uneventful laparoscopic left lateral hepatectomy for suspected HCC, which was confirmed histologically.As part of a watch-and-wait approach to metastatic HEHE, in the first follow-up (3 months postoperatively) the patient was clinically fine and the surveillance CT scan did not show recurrent disease.By presenting this case, we aim to raise awareness that this rare entity can coexist with others, potentially complicating their management.