Incidence and outcomes of post-hepatectomy diaphragmatic hernia: a systematic review.

BACKGROUND: Post-hepatectomy diaphragmatic hernia is the second most common cause of acquired diaphragmatic hernia. This study aims to review the literature on this complication's incidence, treatment and prognosis. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we systematically searched PubMed for all studies related to acquired diaphragmatic hernias after hepatectomy. RESULTS: We included 28 studies in our final analysis, comprising 11,368 hepatectomies. The incidence of post-hepatectomy diaphragmatic hernia was 0.75% (n = 86). The most frequent type of hepatectomy performed was right hepatectomy (79%, n = 68), and the indications for liver resection were a liver donation for living donor transplantation (n = 40), malignant liver tumors (n = 13), and benign tumors (n = 11). The mean onset between liver resection and the diagnosis of diaphragmatic hernia was 25.7 months (range, 1-72 months), and the hernia was located on the right diaphragm in 77 patients (89.5%). Pain was the most common presenting symptom (n = 52, 60.4%), while six patients were asymptomatic (6.9%). Primary repair by direct suture was the most frequently performed technique (88.3%, n = 76). Six patients experienced recurrence (6.9%), and three died before diaphragmatic hernia repair (3.5%). CONCLUSION: Diaphragmatic hernia is a rare complication occurring mainly after right liver resection. Repair should be performed once detected, given the not-negligible associated mortality in the emergency setting.

Different laparoscopic treatment modalities for splenic artery aneurysms: about 3 cases with review of the literature.

INTRODUCTION: The first laparoscopic treatment of splenic artery aneurysm (SAA) was performed in 1993. Since then, many papers have been published mentioning different laparoscopic treatment modalities, including splenectomy, aneurysmectomy, ligation or even occlusion. PATIENTS AND METHODS: An updated literature review of the English medical literature using the following MeSH, 'Lapaorscopic splenic artery aneurysm', 'laparoscopic aneurysectomy', 'Laparoscopic Splenic artery Aneurysm Ligation' and 'Laparoscopic Splenic artery aneurysm excision' was done. Also three cases performed at our institutions are discussed, in terms of techniques, morbidity, mortality and postoperative outcomes. RESULTS: About eight case series and 16 case reports were retrieved from the literature. Different techniques were described by the authors, including splenectomy, aneurysmectomy, splenic aneurysm ligation or even occlusion. Few morbidity cases were reported and none of the authors has mentioned a single mortality case. In our three cases, the postoperative course was uneventful, with good long-term results. CONCLUSIONS: Despite the variations in the adopted operative techniques, the laparoscopic approach seems to be harmless. However, no treatment algorithm or consensus has been published.

Symptomatic Gallbladder Adenomyomatosis: A rare clinical presentation.

INTRODUCTION AND IMPORTANCE: Gallbladder Adenomyomatosis (GA) is a benign rare condition that is mostly asymptomatic but can present as abdominal pain. GA usually occurs in the middle-aged population with an equal sex distribution. CASE PRESENTATION: A case of a 49-years-old female who sought medical care several times due to abrupt abdominal pain. She underwent echography, Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) before performing laparoscopic cholecystectomy for symptomatic GA. The pathology report confirmed acalculous cholecystitis in the presence of GA. CLINICAL DISCUSSION: In fact, echography can reveal the "comet- tail" sign, the CT can show the "rosary sign"; and MRI shows the "pearl necklace" sign. These signs, in the absence of gallstones, can justify the abdominal pain hence the diagnosis of symptomatic GA. CONCLUSION: GA is being increasingly reported; however, symptomatic cases remain the exception. We believe that awareness to this entity should be raised so that healthcare professionals can establish the diagnosis efficiently.

Hepatic round ligament necrosis: A report of two cases managed differently.

INTRODUCTION AND IMPORTANCE: Hepatic round ligament necrosis is a rare condition that has atypical clinical presentation. Its diagnosis; however, being a combination of clinical and biological signs, is very dependent on the computed topography scan. CASE PRESENTATION: This report demonstrates 2 cases that had different presentations. Case 1 was an elderly female with multiple comorbidities presenting with signs of sepsis, perturbation of liver enzymes and presence of thrombosis of portal vein as well as dilatation of bile ducts. On the other hand, case 2 was a younger male patient presenting with inflammatory syndrome, no other biological abnormalities and only an evident fatty stranding in his radiological workup. CLINICAL DISCUSSION: Our 2 cases had different presentations in severity and were thus treated differently. The first patient had clinical, biological and radiological signs of severity; thus, he was treated surgically. On the other hand, the other patient with benign presentation was treated medically with antibiotics. CONCLUSION: In the absence of recommendations concerning the management of hepatic round ligament necrosis, we suggest that treatment choice be based on the severity signs being: clinical, biological or radiological.

Minimally invasive resection of gastric GIST tumor by trans-gastric approach: A case report of a novel technique.

INTRODUCTION AND IMPORTANCE: GIST (Gastro Intestinal Stromal Tumor) treatment is surgical however surgical resection, especially for gGIST (gastric GIST), may be challenging due to location of tumor and the possible sequelae post resection. CASE PRESENTATION: We present a case of 66-year-old female presented for the management of gGIST. We opted for transgastric resection assisted by robot. The resection was with free surgical margins for a 4 cm GIST tumor low in grade. CLINICAL DISCUSSION: Classical wedge resection of gastric tumors poses post-operative complications especially if the tumor is located near the cardia or pylorus. Various minimally invasive techniques were described aiming to avoid post-operative complications as in stenosis and gastric reflux. CONCLUSION: Minimally invasive transgastric resection of gGIST tumor seems to be worth of attention for it can prevent stenosis, hemorrhage and can preserve gastric tissue. Further studies need to be involved to endorse this technique.

Intestinal presentation of non-Hodgkin lymphoma: Case report.

BACKGROUND: MEITL (monomorphic epitheliotropic intestinal T-cell lymphoma) is a rare primary intestinal T-cell lymphoma associated with high mortality rate. Being intestinal this implies difficult diagnostic workup and management. CASE: We present a case of 59-year-old male presented with abdominal pain and found to have 15 × 11 cm mass in the right iliac fossa. Decision for surgical excision was retained and the Pathological examination determined monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) with CD30 positive immune-histochemical profile. CONCLUSION: MEITL is a rare entity which retains challenging diagnosis and management as well as variable immune-histochemical profile. In the absence of clear guidelines for the management of intestinal manifestation of lymphoma, surgical approach may have its indications.

A report of an unexpected complication of PORT-A-CATH insertion.

INTRODUCTION: Vascular access is essential in the management of patients, and sometimes poses a problem, especially in patients requiring chronic treatment. Surgical insertion of the port-a-cath solved this problem by providing easy access, but unfortunately, it's associated with some complications. CASE PRESENTATION: We present a case of 32 year-old woman, diagnosed with advanced breast cancer, admitted for insertion of a port-a-cath for neoadjuvant chemotherapy. A few hours after the operation, the patient developed hoarseness and a cough. A flexible laryngoscope showed the left vocal cord which was fixed in the middle position and did not move, while the other maintained normal motility. The patient was treated conservatively. CONCLUSION: This case demonstrated a rare and unexpected complication of the insertion of a port-a-cath, which is the result of an injury to the recurrent laryngeal nerve. We are reporting this case to encourage physicians to take note of this complication and know how to manage it.

Colo-colic intussusception secondary to colon lipoma: A case report.

INTRODUCTION AND IMPORTANCE: Intestinal intussusception is rare in adults and it is associated with lead points affecting the colon in around 17% of patients. Lipomas are very rare benign tumors which may act as lead points for intestinal intussusception. Indeed, the incidence of intestinal intussusception is much rare when caused by lipomas. CASE PRESENTATION: Our patient is a 29-year-old male, previously healthy and admitted for severe right lower quadrant abdominal pain of 2-day duration. Computed tomography (CT) scan of the abdomen and pelvis showed large mass of fat consistency containing colon structure. CLINICAL DISCUSSION: Urgent laparotomy was opted during which colo-colic intussusception was diagnosed and right hemicolectomy with primary ileocolic anastomosis was performed. Pathology report showed that intussusception was induced by a colon lipoma. Patient had an uneventful hospital stay and was discharged on post-operative day 5. CONCLUSION: Thus we recommend that colo-colic intussusception caused by lipoma be considered in the differential when diagnosing adults with right lower quadrant pain.

A Novel Technique for the Treatment of a Case of Verneuil's Disease of Perineum and Axillary Regions.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving apocrine glands of the skin. It carries out an important burden on the daily life of the patient. Unfortunately, it presents a major concern for medical care management in the absence of clear guidelines for proper medical and surgical treatment. Hence, we report a case of concomitant axillary and perianal HS. We opted for surgical management using a novel technique, which proved efficacy for a year of follow-up recurrence free.

Left gastric artery pseudo-aneurysm post sleeve gastrectomy: A case report.

INTRODUCTION: Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases however pseudo-aneurysm is an overlooked complication. CASE: For instance, we present case of a 25 year-old Lebanese woman that undergone sleeve gastrectomy and presented 3 weeks later with a bleeding left gastric artery pseudo-aneurysm. CONCLUSION: Angiography followed by embolization is best for diagnosing and treating the pseudo-aneurysm by coiling. Serious outcomes could arise from such a complication. Hence, accurate diagnosis and treatment using the appropriate methods is essential to avoid life-threatening events.

Incidental Finding of Ectopic Liver during Laparoscopic Cholecystectomy.

BACKGROUND Incidental finding of ectopic liver is gaining more attention especially during laparoscopic cholecystectomy. It is reported to be found in different locations as gallbladder, stomach, spleen, umbilical ligament and other intra-peritoneal and intra-thoracic sites. CASE REPORT We present 2 cases of ectopic liver found on gallbladder during elective laparoscopic cholecystectomy for 2 Lebanese females. Our findings were consistent with previous reports. The ectopic liver tissues measured 0.9 cm and 0.5 cm respectively, which were smaller than other reports. The liver tissue lacked a biliary system, which was similar to what has been previously reported in the literature. However, no malignant histological signs were seen when excised. CONCLUSIONS These 2 cases highlight the fact that ectopic liver tissue may be encountered on the gallbladder during laparoscopic cholecystectomy. Awareness of this potential entity is beneficial to widen the differential diagnosis when identified on imaging studies pre-operatively or when found incidentally during surgery as in this case.

Breast adenomyoepithelioma, a case report.

BACKGROUND: Adenomyoepithelioma is a rare tumor of the breast characterized by a dual/biphasic proliferation of two cell populations: the epithelial cells and the myoepithelial cells. The first case was reported in 1970. The majority of the cases are benign, but few malignant cases were reported in literature. CASE PRESENTATION: A case of a 66-year-old lady presenting with an asymptomatic breast mass, of 18 × 17 × 15 mm size with irregular borders and negative metastatic workup. The patient was operated for wide local excision of the tumor, with a confirmed negative margins intraoperatively. The final pathology was Adenomyoepithelioma. CONCLUSION: We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of breast mass.

Prepyloric gastric inflammatory fibroid polyp presenting as chronic epigastric discomfort in a 5th decade aged female: A case report.

INTRODUCTION: Inflammatory fibroid polyps is a rare entity that mostly occur in the stomach. Gastric type is usually asymptomatic or may show nonspecific symptoms. Diagnosis is mainly postoperative with limited roles of usual diagnostic techniques. PRESENTATION OF CASE: A 42 years old healthy female presenting with chronic symptoms for epigastric discomfort and mild nausea. Labs showed mild anemia. A gastric lesion was detected by Endoscopy and being studied by echo-endoscopy and needle aspirate. Gastric Inflammatory fibroid polyp was diagnosed after distal gastrectomy by histopathology and immunohistochemistry. CONCLUSION: Gastric inflammatory fibroid polyp is a preoperative diagnostic challenge of unclear pathogenesis. Histopathology and immunohistochemistry are the gold standard. Studies around this exact pathology are required for better management and prevention.

Adrenal hemangioma: A rare presentation of bleeding incidentaloma: Case report.

INTRODUCTION: Adrenal incidentalomas are tumors found accidentally by imaging. Among the incidentalomas, hemangiomas are quite rare and in certain cases their surgical intervention should never be overlooked. PRESENTATION OF CASE: We present a case of 70 years old Lebanese female with an adrenal tumor presented as syncope found to have anemia on presentation and a bleeding 17 cm adrenal tumor on imaging. Patient had workup to rule out functioning adrenal tumors and decision to excise the tumor was taken after failure of embolization. Pathology report denied malignancy despite of the huge size and was in favor of hemangioma. CONCLUSION: Adrenal hemangiomas are rare and they rarely present as syncope. Attention to such a life-threatening condition should be sustained. Embolization is primarily implied but one should never neglect the failure rate and the need for surgical intervention.

Surgical approach for duodenal diverticulum perforation: A case report.

INTRODUCTION: Duodenal Diverticula is not uncommon and it is mostly found in the 2nd part of the duodenum. Despite the fact that it is mostly found incidentally, it can complicate however it rarely complicates by perforation. Treatment is indicated only in complicated cases and it is divided into conservative and surgical arms. PRESENTATION OF CASE: It is a case of 78 years old Lebanese female that was diagnosed intra-operatively with a perforated duodenal diverticulum after presenting with post prandial abdominal pain, distention and pneumoperitoneum on imaging. Our case was consistent with previous reports where the diverticulum occurred in the second part of the duodenum. We opted for primary resection of the diverticulum and over-sewing. Moreover, patient had an uneventful post-operative course and progressed gradually to be discharged on day 10. CONCLUSION: Our case aims to draw attention to a rare complication of duodenal diverticula and to widen the differential diagnosis of pneumoperitoneum thus concluding about the better treatment option. Previous reports show that proper management is still a controversial topic; however surgical approach is indicated in case of systemic signs.

Choledochoduodenal Fistula Secondary to Peptic Ulcer Disease: A Case Report.

BACKGROUND Choledochoduodenal fistula is an uncommon complication secondary to peptic ulcer disease. Determining this diagnosis is challenging especially when confronted with unspecific physical and radiological findings. CASE REPORT Here we report a case of a 29-year-old Ethiopian female who presented to Geitaoui University Hospital in Beirut, Lebanon with epigastric pain and was diagnosed to have of choledochoduodenal fistula. CONCLUSIONS Choledochoduodenal fistula is a rare complication of duodenal ulcer and this case report may help clinicians to identify suspected cases of this entity with similar presentations.

The impact of gender matching between donor and recipient on the outcome of kidney transplant patients: A retrospective study.

The influence of donor and recipient gender on patients postkidney transplant (KT) is still controversial, and literature data do not present unanimous conclusions. We were concerned with the gender impact on the outcome of kidney transplantation at the level of acute rejection (AR), graft function represented by serum creatinine level, delayed graft function (DGF), graft survival, and infection rate. The impact of gender matching between donors and recipients was studied in 299 KT recipients performed in the Transplantation Unit, Middle East Institute of Health, Bsalim, Lebanon, between November 1998 and September 2014. The patients were divided into the following groups: Group I (131 patients, male donor to male recipient), Group II (55 patients, male donor to female recipient), Group III (88 patients, female donor to male recipient), and Group IV (25 patients, female donor to female recipient). AR and DGF were not statistically different among the four groups. Moreover, all groups showed excellent graft survival with no statistical difference. Interestingly, human leukocyte antigen AB-DR matching (P < 0.001) and sensitization were statistically different among the four groups (P = 0.05). The number of patients with infections was statistically significantly lower in Group I (35.4%) and Group III (37.5%) (P = 0.35). Most importantly, graft function, represented by serum creatinine, showed a statistically significant difference among the four groups (P <0.004), with Group II (male to female) and Group IV (female to female) showing the best improvement in five-year survival. However, Group III (female to male) had the worst posttransplant graft function. These results revealed that gender impacts graft function, and Group II, male donor to female recipient, had the best 5-year graft function. This emphasizes that gender should be regarded as a determinant for the success of kidney transplantation.

Prevalence of Depression in Medical Students at the Lebanese University and Exploring its Correlation With Facebook Relevance: A Questionnaire Study.

BACKGROUND: The prevalence of major depression is particularly high in medical students, affecting around one-third of this population. Moreover, online social media, in particular Facebook, is becoming an intrinsic part in the life of a growing proportion of individuals worldwide. OBJECTIVE: Our primary objective is to identify the prevalence of depression in medical students at the Lebanese University Faculty of Medicine, a unique state university in Lebanon, its correlation with the utilization of the interactive features of Facebook, and the way students may resort to these features. METHODS: Students of the Lebanese University Faculty of Medicine were assessed for (1) depression and (2) Facebook activity. To screen for major depression, we used the Patient Health Questionnaire-9 (PHQ-9) scale. To test for Facebook activity, we developed the Facebook Resorting Questionnaire (FbRQ), which measures the degree to which students resort to Facebook. RESULTS: A total of 365 out of 480 students (76.0%) participated in the survey. A total of 25 students were excluded, hence 340 students were included in the final analysis. Current depression was reported in 117 students out of 340 (34.4%) and t tests showed female predominance. Moreover, PHQ-9 score multiple regression analysis showed that feeling depressed is explained 63.5% of the time by specific independent variables studied from the PHQ-9 and the FbRQ. Depression varied significantly among the different academic years (P<.001) and it peaked in the third-year students. One-way analysis of variance (ANOVA) showed that depression and resorting to Facebook had a positive and significant relationship (P=.003) and the different FbRQ categories had significant differences in resorting-to-Facebook power. The like, add friend, and check-in features students used when resorting to Facebook were significantly associated with depression. CONCLUSIONS: This study showed that depression was highly prevalent among students of the Faculty of Medicine at the Lebanese University. Moreover, Facebook may be a promising, helpful, psychological tool for optimizing the management of depression. Our study brought to bear further questions that now prompt further observation and scrutiny to know more about the high rates of depression in this student population, more so in the part of the world studied, and to the growing role of social media.