Reasons for Delayed Diagnosis of Pediatric Acute Appendicitis during the COVID-19 Era: A Narrative Review.

Global pandemics cause health system disruptions. The inadvertent disruption in surgical emergency care during the Coronavirus Disease 2019 (COVID-19) pandemic has been the topic of several published studies. Our aim was to summarize the reasons that led to the delayed diagnosis of pediatric appendicitis during the COVID-19 era. This systematic literature search evaluated studies containing pediatric appendicitis patient data regarding outcomes, times to hospital admission or times from symptom onset to emergency department visit. Studies elucidating reasons for delays in the management of pediatric appendicitis were also reviewed. Ultimately, 42 studies were included. Several reasons for delayed diagnosis are analyzed such as changes to public health measures, fear of exposure to COVID-19, increased use of telemedicine, COVID-19 infection with concurrent acute appendicitis, recurrence of appendicitis after non-operative management and increased time to intraoperative diagnosis. Time to hospital admission in conjunction with patient outcomes was extracted and analyzed as an indicative measure of delayed management. Delayed diagnosis of acute appendicitis has been documented in many studies with various effects on outcomes. Suspicion of pediatric acute appendicitis must always lead to prompt medical examination, regardless of pandemic status. Telemedicine can be valuable if properly applied. Data from this era can guide future health system policies.

Record and Appraisal of Endophytic Tumor Localization Techniques in Minimally Invasive Kidney-Sparing Procedures. A Systematic Review.

PURPOSE: Review and efficacy assessment of techniques used for intraprocedural endophytic renal mass localization. MATERIALS AND METHODS: Advanced search was carried out on PubMed, Cochrane Library, Web of Science and Google Scholar databases up to August 2020. Eligibility criteria were set, according to PRISMA statement. OR (95 % CI) for identification or technical success, positive margins and recurrence, were calculated for completely endophytic tumors. Risk of Bias was evaluated using ROBVIS tool. RESULTS: 77 studies used for result synthesis, including 1,317 endophytic tumors, with 758 of them completely endophytic. 356 endophytic tumors treated laparoscopically and 598 robotically, using ultrasound-based methods, transarterial embolization, dual-source CT, invasive signage, 3D printing, and augmented reality variations. Identification success was 97.8-100%, positive margins 0-12.5 %  (completely endophytic: 95 % CI; 0.255-1.971, OR 0.709 in laparoscopic, 95 % CI ; 0.379-3.109, OR 0.086 in robotic partial nephrectomy), recurrences 0-3.9 % (completely endophytic: 0 recurrences in laparoscopic, 95 % CI ; 0.0917-2.25, OR 0.454, in robotic partial nephrectomy), and complications 0-60 % . 363 were treated with ablation techniques using CT-based methods, thermal monitoring, transarterial embolization, ultrasound guidance and invasive signage. Technical success was 33.4-100 % (completely endophytic: 95 % CI ; 0.00157-2.060, OR 0.0569 for invasive and 95 % CI ; 0.598-13.152, OR 2.804 for non-invasive localization techniques) and recurrences were 0-20%. CONCLUSION: Ultrasound-based techniques showed acceptable identification success and oncologic outcomes in laparoscopic or robotic setting. Augmented reality, showed no superiority over conventional techniques. Near infrared fluoroscopy with intravenous indocyanine green, was incapable of endophytic tumor tracking, although when administered angiographic, results were promising, along with other embolization techniques. Percutaneous hook-wire or embolization coil signage, aided in safe and successful tracking of parenchymal isoechoic masses, but data are inadequate to assess efficacy.  CT-guidance, combined with ultrasound or thermal monitoring, showed increased technical success during thermal ablation, unlike ultrasound guidance that showed poor outcomes.

Experimental Intestinal Stenosis Alters Crohn's Disease-Like Intestinal Inflammation in Ileitis-Prone Mice.

BACKGROUND: Clinical observations indicate that mechanical factors contribute to the expression or recurrence of Crohn's disease. We investigated whether the creation of an intestinal stenosis could alter the severity of the expected Crohn-like ileitis, in a Crohn's disease animal model, the TNFΔare/+ mouse. METHODS: Thirty-six, 6-weeks-old TNFΔare/+ mice, were divided into 3 intervention groups: triple suture, single suture and sham. In the terminal ileum, in the first group, a triple suture stenosis was created, whereas, in the second, a loose suture was placed. Same triple-suture stenosis was performed on twelve wild type mice. All animals were sacrificed at 6 weeks post-operatively and the ileum parts were evaluated histopathologically. A summative total ileitis score was applied in each sample using a bespoke semiquantitative histological scoring system for the Crohn-like changes. RESULTS: The triple suture stenosis induced significant muscular hypertrophy proximal to interventional site which was more prominent in TNFΔare/+ than wild type mice. In triple suture group, the total ileitis score was significantly increased proximal to the intervention as compared to the single suture (P: 0.004) and the sham groups (P: 0.013). The total ileitis score distally, was unaffected, regardless of the experimental intervention. Intestinal stenosis did not induce intestinal inflammation in wild type mice. CONCLUSION: The creation of a stenosis in the terminal ileum of TNFΔare/+ mice alters Crohn-like inflammation. We assume that mechanical forces, such as intraluminal pressure, may contribute as important co-factors to the pathophysiology of Crohn's disease in genetically predisposed subjects.

Synchronous nephrectomy and cavoatrial tumor thrombectomy under normothermic extracorporeal circulation and beating heart.

Formation of tumor thrombus is an occasional manifestation of renal cell carcinoma (RCC). Intravascular invasion of the renal vein and thereafter the inferior vena cava (IVC) might in very rare cases extend into the cardiac chambers. The subtle course and symptoms of such cases alongside with the engagement of vital anatomical structures marks them as a diagnostic and therapeutic challenge. Aggressive surgical intervention has proven to be critical for survival rates in such cases; however total synchronous resection remains a challenge for the surgical team and a debate for the medical community. Following we report the case of a 66-year-old male who was diagnosed with a RCC of the right kidney accompanied by a tumor thrombus extending into the right atrium, after he suffered a presyncope episode. The patient underwent a radical en bloc nephrectomy and tumor thrombectomy under extracorporeal circulation with beating heart.