Unusual presentation of intramuscular hemangioma in abdominal oblique muscles.

Intramuscular hemangiomas are rare benign tumors that are difficult to diagnose. We report a successful case of intramuscular hemangioma excision involving the external oblique muscles. The mass was excised successfully, and histopathology confirmed the diagnosis of intramuscular hemangioma with a negative margin and no malignancy.

Left paraduodenal hernia: a rare cause of recurrent abdominal pain: case report.

Internal hernias are quite rare, accounting for fewer than 1% of all abdominal hernias. Moreover, the most frequent cause of internal herniation is paraduodenal hernia (PDH). Diagnosing paraduodenal hernias can be difficult due to the wide range of symptoms that can occur. It is a case report of paraduodenal hernia that was diagnosed and managed in a tertiary center. We describe the case of a 55-year-old male patient who had been experiencing nonspecific abdominal discomfort for the last 5 years and had several comorbidities and positive serology. An abdominal computed tomography (CT) revealed that he had a left PDH, which was effectively treated with laparoscopic surgical repair. The study's strength is that it was correctly identified by CT and subsequently laparoscopically corrected. A gastrografin swallow study was also performed postoperatively to ensure there was no leak. The study's flaw is that the patient was misdiagnosed for five years in other medical facilities. Because paraduodenal hernia is an uncommon diagnosis, it's important to keep it in mind as one of the differential diagnoses for persistent discomfort. It also needs accurate imaging in order to identify and successfully manage it. To demonstrate the relevance of this uncommon condition, future research is needed to report on any misdiagnosis or treatment. To conclude, nowadays the best option for paraduodenal hernia repair is laparoscopic surgery. However, because it can present with a wide variety of symptoms and diagnosis might be challenging, it demands a high index of suspicion. The gold standard for identifying paraduodenal hernia is still a CT scan of the abdomen. Patients who are stable and have no signs of intestinal obstruction might decide to have their hernia repaired to avoid future problems. To demonstrate the relevance of this uncommon condition, future research is needed to report on any misdiagnosis or treatment.

Elevation of CA 19-9 in Mirizzi Syndrome in the Absence of Malignancy: A Case Report.

BACKGROUND Mirizzi syndrome (MS) is relatively a rare condition; incidence rates may increment with age. It is characterized as an obstruction of the common hepatic duct (CHD) auxiliary to outward compression of an infected stone in the cystic duct. Carbohydrate antigen (CA) 19-9 is a tumor marker that is usually related to upper-gastrointestinal malignancies. However, a few case reports have shown high levels of CA19-9 in the absence of malignancy. In this case, we report a case of a patient with MS, elevated CA19-9, and radiological findings suggesting gallbladder cancer, which shows the challenges of diagnosis and therapeutic procedures. CASE REPORT We report the case of a 71-year-old Saudi man who presented to the emergency department with signs of obstructive jaundice. Magnetic resonance cholangiopancreatography (MRCP) revealed cholelithiasis, with a huge cystic duct stone compressing the CHD, resulting in mild intra-/extrahepatic biliary dilatation and positive MRCP pearl necklace sign for adenomyomatosis of the gallbladder. Serum tumor markers revealed raised levels of CA19-9 to 21 068 u/ml. The patient underwent laparoscopic cholecystectomy. Biopsy results confirmed the diagnosis of acute calcular cholecystitis and adenomyosis with no malignancy. CONCLUSIONS We report what can be considered a rare case of Mirizzi syndrome with a very high CA19-9 marker, in an elderly patient, in the absence of malignancy. This illustrates that Mirizzi syndrome and cholangiocarcinoma are difficult to distinguish, and the diagnosis is considered challenging. Thus, a high index of suspension must be kept in mind, especially in elderly patients, to rule out the cause of malignancy and thus to create an appropriate management plan.

Robotic cholecystectomy: first experience with the new Senhance robotic system.

This retrospective study was performed to evaluate the safety and feasibility of the new Senhance robotic system (Transenterix) for robotic cholecystectomy. Our series is the first experience with cholecystectomies utilizing this new platform. From May 2017 to August 2017, 20 robotic cholecystectomies were performed using the Senhance robotic system. Patients were between 23 years and 78 years of age, eligible for a laparoscopic procedure with general anesthesia, with no life-threatening co-morbidities that limited the subjects' life-expectancy to fewer than 12 months. A retrospective chart review was performed for a variety of pre-, peri- and postoperative data including, but not limited to patient demographics, intraoperative complications and postoperative complications. 9 male and 11 female patients were included in this study. Median age was 39.5 years (range 23-78); median BMI was 27.35 kg/m2 (range 22.8-48.3). Median docking time was 10 min (range 2-26), and median operative time was 71.5 min (range 34-197). Conversion to standard laparoscopy occurred in one case for lysis of extensive adhesions. There were no conversions to open technique. There were no intra- or post-operative complications noted. We report the first series of robotic cholecystectomies using the new Senhance system. Docking time and total operative time decreased significantly over the course of this series and did not plateau; console time did not change significantly. This study demonstrates the feasibility of utilizing this platform in performing minimally invasive cholecystectomies.

Robotic low anterior resection versus transanal total mesorectal excision in rectal cancer: A comparison of 115 cases.

BACKGROUND: Robotic low anterior resection (RLAR) and transanal total mesorectal excision (TaTME) are novel surgical techniques for resection of rectal cancer. To our knowledge, no data exist on direct comparison of these procedures in terms of oncological or functional parameters. METHODS: 60 RLAR and 55 TaTME for rectal cancer were compared in respect to patient characteristics, clinicopathological parameters, intraoperative and perioperative results and anatomopathological outcome. RESULTS: 62 surgeries addressed tumors of the lower third (53.9%). No intergroup differences in terms of patient characteristics and clinicopathological parameters were observed. Operating time did not differ between groups (p = 0.312), nor did the perioperative complication rate (p = 0.176). Circumferential resection margin was wider in the RLAR than in the TaTME group (p < 0.001), while no differences were found in the remaining oncological parameters. CONCLUSION: Our study shows comparable results for RLAR and TaTME in rectal cancer treatment. Both procedures should be considered equally feasible for low rectal cancer cases and as an alternative to conventional anterior resections (open or laparoscopic). Furthermore, both techniques allow excellent oncological outcome especially in patients with anatomical limitations.

Upper Gastrointestinal Endoscopy prior to Bariatric Surgery-Mandatory or Expendable? An Analysis of 801 Cases.

BACKGROUND: Upper gastrointestinal pathologies are common in bariatric patients. Preoperative esophagogastroduodenal endoscopy (EGD) should detect and treat pathologies that might alter the type of bariatric surgery. However, clinical consequences of these findings are often insignificant. The aim of this study was to assess the influence of preoperative endoscopy in our cohort and its clinical consequences. METHODS: We conducted a retrospective analysis of endoscopic findings in patients under evaluation for bariatric surgery. Endoscopic findings were compared to preoperative risk factors as well as postoperative complications, and its clinical consequences were analyzed. RESULTS: Data was available for 801 patients. Abnormal endoscopic findings were found in 65.7% of all patients. The most common conditions were gastritis (32.1%) and gastroesophageal reflux (24.8%). Malignancies were observed in 0.5% of all patients. We observed early-stage adenocarcinoma of the esophagus in two patients through our routine preoperative evaluation. Helicobacter pylori infections were detected in preoperative biopsies in only 3.7% of all patients. Patients who reported reflux symptoms had a higher rate of pathological EGDs (74.2 vs. 64.9%, p .019). We did not find any other risk factors for a pathological endoscopy. The postoperative complication rate was 11.2%. Leakage rate was 1.1%. Mortality rate was 0.4%. We did not find any correlation between the incidence of postoperative complications and preoperative endoscopic findings. CONCLUSIONS: Relevant findings in routine preoperative endoscopy are rare but have significant influence on decision-making in bariatric patients and should be assessed as a necessary diagnostic tool.

HSP90 is a promising target in gemcitabine and 5-fluorouracil resistant pancreatic cancer.

Chemotherapy (CT) options in pancreatic cancer (PC) are limited to gemcitabine and 5-fluorouracil (5-FU). Several identified molecular targets in PC represent client proteins of HSP90. HSP90 is a promising target since it interferes with many oncogenic signaling pathways simultaneously. The aim of this study was to evaluate the efficacy of different HSP90 inhibitors in gemcitabine and 5-FU resistant PC. PC cell lines 5061, 5072 and 5156 were isolated and brought in to culture from patients being operated at our institution. L3.6pl cell line served as a control. Anti-proliferative efficacy of three different HSP90 inhibitors (17-AAG, 17-DMAG and 17-AEPGA) was evaluated by the MTT assay. Alterations in signaling pathway effectors and apoptosis upon HSP90 inhibition were determined by western blot analysis and annexin V/PI staining. The cell lines 5061, 5072 and 5156 were resistant to gemcitabine and 5-FU. In contrast 17-AAG and the water-soluble derivates 17-DMAG and 17-AEPGA displayed high anti-proliferative activity in all tested cell lines. The calculated IC50 was below 1 µM. Highly significant down regulation of epidermal-growth-factor-receptor, insulin-like-growth-factor-receptor-1, AKT and MAPK reflected the intracellular molecular signaling-network disruption. Furthermore, besides HSP70 also HSP27 was upregulated in all cell lines. Apoptosis occurred early under HSP90 inhibition and was determined by annexin V/PI staining and CASPASE-3 and PARP assay. In contrast, gemcitabine treated cells did not show any apoptosis. HSP90 inhibition disrupts multiple signaling cascades in gemcitabine and 5-FU resistant PC simultaneously and promotes cancer cell apoptosis. Watersoluble 17-DMAG is equally effective as 17-AAG. HSP27, besides HSP70, may represent an effective response marker of successful HSP90 inhibition.

Evaluation of the germline single nucleotide polymorphism rs583522 in the TNFAIP3 gene as a prognostic marker in esophageal cancer.

Most esophageal cancer patients die because of disease relapse, hence an accurate prognosis of disease relapse and survival is essential. Genetic variations in cancer patients may serve as important indicators. Three genotypes (GG, AG, and AA) are displayed by the single nucleotide polymorphism (SNP) rs583522, which maps to the TNFAIP3 gene on chromosome 6. Evaluation of the potential prognostic value of the TNFAIP3-SNP in esophageal cancer (EC) was the aim of this study. A total of 158 patients underwent complete surgical resection of the esophagus for EC. None of them received any neoadjuvant or adjuvant treatment. Peripheral blood was sampled, and genomic DNA was extracted from leukocytes before each operation. Clinicopathologic parameters, tumor cell dissemination in bone marrow, and clinical outcome were correlated with the TNFAIP3-SNP. A-allele carriers showed advanced tumor stages compared with those of homozygous G-allele carriers (P<0.001). Patients with an A-allele genotype (AA or AG) were significantly more likely to experience a relapse (P=0.003). Survival analysis (log-rank test) revealed a significant difference in overall survival between the three groups (P=0.039); however, none of the genotypes was identified as a disease stage-independent prognostic marker. In conclusion, TNFAIP3-SNP stratifies patients into different risk groups; however, it could not be identified as an independent prognostic marker.

Laparoscopic duodenojejunostomy omega loop with braun anastomosis as a treatment for superior mesenteric artery syndrome.

Superior mesenteric artery (SMA) syndrome is a rare clinical phenomenon caused by compression of the third portion of the duodenum by the overlying SMA, and can be easily misdiagnosed. We report a case of SMA syndrome treated with laparoscopic duodenojejunostomy omega loop with Braun anastomosis. A 24-year-old women with body mass index of 14.9 presented with a 4-year history of vague abdominal pain mainly at the epigastric region, radiating to the back associated with heartburn, repeated vomiting, and significant loss of weight during the previous 6 months. The case was misdiagnosed as acute pancreatitis. The SMA syndrome was diagnosed using CT-scan and fluoroscopy. Laparoscopic omega loop with Braun anastomosis was preformed. She did well postoperatively, and Gastrografin study showed no leak and a patent anastomosis. She was subsequently discharged on regular diet.