Enteroenteric intussusception caused by a small bowel metastatic cutaneous melanoma.

Unlike in children, intussusception is very rare in adults and accounts for only 1% of ileus in that population. While intussusception in children is most often idiopathic, in adults the cause of intussusception in most cases is tumor and most often metastatic adenocarcinoma. It is an extremely rare phenomenon for intestinal melanoma metastasis to be the cause of intussusception and has been described in the literature so far only in a limited number of case reports. 41-year-old female patient was admitted to the emergency department with a clinical picture of ileus. The patient had a melanoma excision on her back five years ago, for which chemotherapy and radiotherapy were carried out. An MSCT of the abdomen was performed, which indicated an obstructive ileus of the small intestine with a typical sign of intussusception (target sign). Upon explorative laparotomy enteroenteric intussusception was found with an invaginated segment of the ileum in a length of about 20 cm. When the intussuscepted segment was reduced, a black tumor the size of a plum was verified as a leading point. Histological analysis indicated metastatic cutaneous melanoma with foci of melanocytes underneath normal intestinal epithelium.

An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer.

BACKGROUND: Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method. METHODS: A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α. RESULTS: Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance. CONCLUSIONS: The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

Is non-mentored initiation of laparoscopic colorectal surgery safe? Single surgeon initial experience with the first 40 cases.

Introduction: Although laparoscopic colorectal surgery is now accepted as a standard procedure in treating colorectal cancer, the proportion of laparoscopically operated patients with colorectal cancer is still generally quite low. The aim of this study is to assess feasibility, safety, and outcomes of a non-mentored initiation of laparoscopic colorectal resections by a young surgeon without previous experience in laparoscopic colorectal surgery. Materials and methods: We analyzed the characteristics of the first 40 elective cases of laparoscopic colorectal resections performed by a single surgeon during the period between June 2019 and March 2022. All of the operations were performed without the attendance or supervision of an experienced surgeon in laparoscopic colorectal surgery. The patients were divided into three groups (the early, intermediate, and late group). Results: The conversion rate, complications rate, and postoperative recovery were similar among groups. The mean overall operative time was 219.5 min (range 130-420 min) and had reduced significantly during the learning curve (p = 0.047). The overall conversion rate was 12.5%. In two cases (5%), the oncological principles were violated (incomplete total mesorectal excision). In three patients (7.5%), intraoperative complications had occurred (small bowel injury, splenic injury, and significant bleeding from the minor peripancreatic artery). Three cases of major postoperative complications (Clavien-Dindo grade III) were recorded, two of which required reoperation (anastomotic bleeding and fascial dehiscence). There was no 90-day mortality reported. The overall mean number of lymph nodes retrieved was 12.45, which did not differ significantly among groups (p = 0.678). The average follow-up was 13.75 months (range 1-31 months). Cancer recurrence was recorded in four patients (10%). Port-site metastasis was not detected in any of the cases. Conclusion: A safe and non-mentored initiation of laparoscopic colorectal surgery with an acceptable rate of complications and acceptable oncological results can be achieved. Still, when compared with a structured initiation in a controlled environment with the supervision of an experienced surgeon in laparoscopic colorectal surgery, the results of a non-mentored initiation are worse in most of the fields, including operative time, conversion rate, complications rate, and duration of hospital stay. Therefore, I strongly recommend engaging young surgeons in fellowship programs on structured laparoscopic colorectal surgery whenever possible before starting performing these procedures on their own.

Are religious patients less afraid of surgery? A cross-sectional study on the relationship between dimensions of religiousness and surgical fear.

INTRODUCTION: Surgical fear is common and has a negative impact on surgery and its outcome. Recent research has identified individual religiousness as an important factor among patients with associations to mental health, particularly anxiety. OBJECTIVE: This study aimed to examine associations between religiousness and surgical fear in a representative sample of adult surgical patients in Croatia. DESIGN: Cross-sectional study among elective surgery patients at different departments of a single hospital. SETTING: University Hospital Sveti Duh, a tertiary health care facility in Croatia. MEASUREMENTS: Religiousness and surgical fear were the variables of interest and assessed through self-report instruments. The Croatian version of the Duke Religiosity Index questionnaire (DUREL) assessed organizational religious activity (ORA), non-organizational religious activity (NORA), and intrinsic religiousness (IR). The Croatian version of the Surgical Fear Questionnaire (SFQ) measured surgical fear and its subscales the fear of the short-term and long-term consequences of surgery. Additionally, sociodemographic characteristics and medical history were assessed. Analyses were carried out using descriptive and linear regression analyses. RESULTS: 178 subjects were included for data analysis. Univariate linear regression found two dimensions of religiousness (non-organizational religious activity, intrinsic religiousness) to be weak, but significant predictors of greater surgical fear (adj. R2 = 0.02 and 0.03 respectively). In the multiple linear regression model together with age, gender, education and type of surgery, all three dimensions of religiousness were found to be significant independent predictors of greater surgical fear. LIMITATIONS: The study was single-center and cross-sectional and did not assess patients' specific religious identity. CONCLUSIONS: This study demonstrated significant positive associations between dimensions of religiousness and surgical fear, potentially suggesting that surgical patients experience increased religiousness to cope with heightened anxiety. Assessment and intervention to address patient religiousness is warranted in the context of surgical fear among religious patients, and the importance of religiousness in the context of surgical fear needs to be further addressed in research.

Colorectal adenocarcinoma presenting with a pathological fracture due to a solitary bone metastasis to the tibia: a case report and literature review.

Introduction: Solitary bone metastasis of colorectal carcinoma (CRC) without other metastasis sites is extremely rare and can be found in less than 1% of patients with CRC. Aim: In the present study, we report the first case of a solitary tibia metastasis and its pathologic fracture as the first presenting feature of a colorectal adenocarcinoma. Material and methods: A 78-year-old female patient presented to our emergency department due to atraumatic pretibial swelling. Plain radiography did not detect any pathology. The swelling was incised and serous-bloody collection was evacuated, and the patient was discharged. On the 17th postoperative day, during a regular walk, the patient fell down and broke her leg, which transpired to be a pathologic fracture of the proximal tibial diaphysis, confirmed by X-ray. A biopsy of the altered bone tissue from the fracture site revealed metastatic colorectal adenocarcinoma. On colonoscopy, a circular mass in the upper rectum was found. Conclusions: Solitary bone metastases are most commonly found in bones that are related to venous drainage via the paravertebral plexus of Batson - the pelvis, vertebrae, and sacrum. Long bones are extremely rare localizations of solitary CRC metastases, with only few cases published so far in medical literature. In our case, the patient`s first symptom was related to the osseous tibial metastasis - leg swelling. No tumour was suspected until the pathologic fracture occurred. It is important to consider osseous metastasis in every patient with unexplained swelling, haematoma, or pain of the extremities and make a bone scan to recognize the metastasis early.

VALIDATION OF THE CROATIAN VERSION OF THE SURGICAL FEAR QUESTIONNAIRE (SFQ) IN ADULT PATIENTS WAITING FOR ELECTIVE SURGERY.

The Surgical Fear Questionnaire (SFQ) is an instrument for self-assessment of surgical fear and consists of two subscales, one assessing the fear of short-term consequences (SFQ-s) and another one of long-term consequences (SFQ-l) of surgery. The aim of this study was to test the Croatian version of the SFQ with regard to its psychometric properties. This prospective cohort study included patients who presented to the Department of Surgery for elective surgery in the inpatient setting at a tertiary health care facility in Croatia between April 1 and May 31, 2019. Data on 144 patients were suitable for data analysis. Data collection was performed in the afternoon before surgery using the Personal Information Form, Numerical Rating Scale self-report instruments (NRS), SFQ and Hospital Anxiety and Depression Scale (HADS) assessing sociodemographic factors, surgical fear via NRS and SFQ, expected pain and emotional state. The Cronbach alpha value as a statistical measure for reliability of psychometric tests for the SFQ-s subscale was 0.79, for SFQ-L subscale 0.84, and for total SFQ 0.81. The exploratory factor analysis (EFA) showed a two-factor structure. Significant correlations of the SFQ with the NRS and HADS-anxiety subscale were demonstrated. Our study demonstrated the Croatian version of the SFQ to have a high level of reliability and hence can be used as a self-report instrument for surgical fear with two subscales. Convergent validity of the SFQ with other self-report instruments is shown.

Mucinous Adenocarcinoma of the Colon with Clear Cell Component: A Case Report and Literature Review.

Clear cell adenocarcinomas of the colon are defined as a subtype of colorectal adenocarcinoma with clear cell morphology. A 65-year old man was admitted to a Gastroenterology Department for diagnostic evaluation of a tumor in the sigmoid colon found on CT. There, the patient developed complete bowel obstruction and was operated urgently, where intraoperatively, a large tumor in the sigmoid fixated to the lateral abdominal wall was revealed. A subtotal colectomy was performed. Histopathological analysis of the surgical specimen was conducted. The immunohistochemistry staining was positive for CEA, CDX2, and CD20 and negative for CK7, CD10, MUC2, AFP, and PAS staining. Mismatch repair protein testing was negative. The pathological diagnosis was mucinous carcinoma with a clear cell component which bears an extremely low incidence that has been scarcely reported in literature. This stresses the need for more case reports like ours to be published.

A case of an inverted appendiceal stump with dysplastic mucosa mimicking cecal polyp managed by a combined endoscopic laparoscopic approach.

Endoscopic finding of invaginated appendiceal stump mimicking polyp is very rare. We present a case of patient with appendiceal stump mimicking cecal polyp covered with dysplastic mucosa which makes it even more rare. Polypoid lesions involving the appendiceal area represent a specific diagnostic-therapeutic dilemma. In these situations simple colonoscopic polypectomy poses increased risk for perforation. In our case biopsy of the polypoid cecal lesion revealed dysplastic mucosa. Due to the non-lifting sign and increased risk of perforation from simple polypectomy, polyp was removed by cecal wedge resection using combined endoscopic laparoscopic approach. Histopathology of the specimen confirmed medium dysplastic epithelium covering lymphoid follicles specific for appendix. In our case, decision on the need to remove the polyp, based on biopsy histology, was quite clear; however, the question is what should we have done if the biopsy finding was negative? In such a situation, conservative approach with endoscopic follow-up of the polyp and regular biopsy specimen analysis, or a more active approach of polyp removal should be considered. This issue can be discussed, however, we do believe that decision on approaching such patients should be made individually, based on the patient's age, comorbidities, general condition and operative risk.

Jejunal Lipoma Causing Intussusception in an Adult.

First described by Barbette in 1674, intestinal intussusception represents a telescoping of proximal bowel segment into the lumen of the adjacent aboral segment. Adult intussusception comprises only about 5% of all intussusceptions. We present a case of 28-year male patient who complained of colicky, intermittent epigastric pain for the last one month. Imaging detected specific signs of intussusception. Laparotomy revealed enteric intussusception of the jejunum caused by an intraluminal tumour, confirmed to be a benign lipoma on histology. Small bowel obstruction caused by jejunal lipoma in adults is a rare clinical entity and must be kept in mind when evaluating adult patients with abdominal pain. Key Words: Intussusception, Lipoma, Ileus, Jejunum.

Duodenal diverticulum causing obstructive jaundice - Lemmel's syndrome.

The duodenum is the second most common location of intestinal diverticula. Periampullary duodenal diverticulum rarely causes obstructive jaundice and this condition was first described by German surgeon Gerhard Lemmel in 1934. Lemmel's syndrome is defined as obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledocholithiasis or a neoplasm.

Extensive Abdominal Skin Necrosis Following Anterior Component Separation for a Large Ventral Hernia: A Case Report.

Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality. Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy. Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.

Intramural Stomach Gas with Hepatic Portal Venous Gas Indicating Spontaneous Stomach Necrosis.

Intramural gas in the stomach associated with hepatic portal venous gas is a rare entity, which suggests ischemic or infectious pathology of the stomach. We report a case of a 73-year-old man who presented with epigastric pain and nausea of 6 hours duration followed by hematemesis. The patient had pale skin, anemia, and a diffusively tender and distended abdomen. Abdominal radiography and computed tomography (CT) revealed gas in thickened gastric wall and gas in intrahepatic portal vein branches. Surgery was indicated, which consisted of partial gastrectomy with Roux en esophago-jejunal anastomosis. Postoperative course was uneventful, and pathohistological analysis indicated stomach wall necrosis with emphysametous gastritis (EG). The patient was free of symptoms at 2 years follow-up. Intramural gas in the stomach should always be meticulously investigated to differentiate between emphysematous gastritis and gastric emphysema, as this would direct the therapeutic approach to be adopted.

CORRELATION BETWEEN THE LEVEL OF COLORECTAL ANASTOMOSIS AND ANORECTAL FUNCTION.

Anterior rectal resection is a standard surgical procedure for treating carcinomas of rectum and distal sigmoid colon. In many cases of anterior rectal resection, postoperatively some level of fecal incontinence may occur. The aim of our study was to evaluate the impact of the colorectal anastomosis level on anorectal functional disorder. In our prospective study, the participants were patients diagnosed with carcinoma of rectum or distal sigmoid colon. All patients underwent standard open or laparoscopic anterior rectal resection. Six months after the surgery, the function of anorectum was evaluated in all participants. Finally, 38 patients were analyzed, including 13/38 (34.2%) patients with high rectal anastomosis, 11/38 (28.9%) with mid rectal anastomosis and 14/38 (36.8%) with low rectal anastomosis. Patients with a lower level of anastomosis had a statistically significantly greater number of stools, higher urgency and discrimination impairment, more pronounced solid, liquid and gas incontinence, and greater need for diapers (p<0.05 all). Therefore, patients with lower anastomosis had a statistically significant impairment of their quality of life and higher Wexner score (p<0.001 for both analyses). Our study results suggested reduced neorectal capacity to be the main pathophysiological factor for the development of postoperative anorectal function impairment.

Common Bile Duct Stricture After Laparoscopic Cholecystectomy: Case Report

Despite progress in laparoscopic surgery and increasing surgical experience, the incidence of bile duct injury during laparoscopic cholecystectomy fails to fall below 0.3%-0.6% and it is still higher than those recorded in the era of open cholecystectomy. Bile duct injuries belong to the most serious complications of abdominal surgery in general and often end up with liver transplantation as the only hope for cure. We present a case of a 78-year-old jaundiced male patient who sustained common hepatic duct injury during laparoscopic cholecystectomy eight months earlier. Exploratory laparotomy, ERCP and MRCP revealed a metal clip placed just below hepatic duct confluence and causing stricture of bile duct with dilatation of bile ducts proximal to the level of stenosis (Strasberg classification type E3 injury). Repair of the injury was performed by creating termino-lateral hepaticojejunostomy between the right and left hepatic ducts and retrocolic Roux en-Y jejunal limb. By presenting this case, we wish to emphasize the importance of timely conversion and execution of intraoperative cholangiography in all cases when identification of the structures of Calot's triangle is not clear enough. Successful treatment of bile duct injury is only possible with joint approach of radiologist, gastroenterologist and experienced hepatobiliary surgeon.

Laparoscopic Treatment of Morgagni Hernia: Report of Three Cases.

We report on three cases of diaphragmatic (Morgagni) hernia with different clinical presentation. It is important to consider the possibility of this rare but potentially very dangerous condition in patients with respiratory problems and pain in the upper abdomen. Before laparoscopy, two different approaches were used in diaphragmatic hernia operations (abdominal and thoracic approach). Laparoscopy has brought significant changes in the treatment of diaphragmatic hernia. It is important to stress that laparoscopic diaphragmatic surgical therapy uses stronger mesh than the mesh used to repair an inguinal hernia.

War surgical care--experience from Franciscan Hospital "dr. fra Mato Nikolic" in Nova Bila during conflict in Central Bosnia (1993-1994).

This report presents experience in treatment of war injuries in Franciscan hospital "dr. fra Mato Nikolic" in Nova Bila, during the war in Central Bosnia from 1993 to 1994, in conditions of encirclement and typhoid fever outbreak. Descriptive-retrospective analysis of organization, implementation and outcomes of surgical care for patients treated from January 1, 1993 till August 20, 1994. In this period, the hospital took care of 2500 wounded persons, 2286 (91.4%) of them male and 214 (8.6%) female, their the average age being 31.5 +/- 12.8. There were 1412 gunshot injuries (56.5%), 1022 explosive injuries (40.9%), and 66 blunt injuries (2.6%). There were 1250 injuries to extremities (50.0%), 349 injuries to head and neck (14%), 233 chest injuries (9.3%) and 193 injuries to abdomen (7.7%). There were also 475 multiple injuries (19%). Surgical operations were performed in 1498 patients (60%), with surgical mortality rate of 4.5%. Total hospital mortality rate was 11.4 percent (n = 286). Despite extremely difficult conditions of work and lack of doctors, we achieved a low hospital mortality rate. The hospital continued to work after the war. Today, it is a modern health institution in Lasva Valley, Central Bosnia.