Large Cell Neuroendocrine Carcinoma of the Gallbladder: Where Survival Is a Rare Entity - Case Report and Review of the Literature.

Introduction: Carcinoma of the gallbladder is extremely rare, papillary adenocarcinoma comprises 90% of these cases. Although neuroendocrine neoplasms (NENs) comprise 0.5% of the cases of gallbladder cancer, the incidence is rising. NEN is classified into a well-differentiated neuroendocrine tumor and poorly differentiated neuroendocrine cancer (NEC). Histologically, NEC is small-cell or large-cell carcinoma. We present the extremely rare case, 15th in the literature to be precise, of large cell neuroendocrine carcinoma of the gallbladder. Case Presentation: A 72-year-old male presented to the emergency department with constipation and right upper quadrant pain for 3 months. Computed tomography scan of the abdomen demonstrated an ill-defined 7.2 × 4.9 cm hypodense lesion in the gallbladder fossa with extension into the liver. Histopathological and immunohistochemical analysis of the biopsy specimen confirmed the diagnosis of large cell neuroendocrine carcinoma of the gallbladder. He was started on palliative chemotherapy. Conclusion: The plethora of tumors present in the gallbladder necessitates a search for risk factors for gallbladder neoplasia, and underscores the need to more carefully examine the nature of "asymptomatic gallstones." Further studies may reveal subclasses of cholelithiasis, gallbladder morphology, or imaging to define which patients should be followed more carefully, and may clarify additional risk factors for cancer of the gallbladder.

Preexisting anticoagulation is an independent predictor of mortality in geriatric trauma patients - a retrospective cohort study.

Introduction: Preexisting anticoagulation is common among geriatric trauma patients. Geriatric trauma patients have a higher risk of mortality compared to younger patients. We sought to evaluate the association of preexisting anticoagulation with mortality in a group of geriatric trauma patients. Methods: A retrospective review of geriatric trauma patients was conducted for those admitted to a Level 1 trauma center from January 2018 to December 2020. Vital signs, demographics, injury characteristics, laboratory data, and mortality were all collected. Multivariable logistic regression analysis was performed for the association of preexisting anticoagulation and a primary endpoint of all-cause mortality. These groups were controlled for preexisting comorbidities, injury severity scores, and systolic blood pressure in the emergency department. Results: Four thousand four hundred thirty-two geriatric patients were admitted during the study period. This cohort was made up of 36.9% men and 63.1% women. Three thousand eight hundred fifty-nine (87.2%) were white; the average age was 81±8.5 years, and the median injury severity score (ISS) was 5. The mean systolic blood pressure was 150±32 mmHg, mean heart rate was 81±16 bpm, mean lactate was 2.3±1.3, mean hematocrit was 37.3±8.8, and mean international normalized ratio (INR) was 1.7±10.3. One thousand five hundred ninety-two (35.9%) patients were on anticoagulation (AC) upon presentation. One hundred and sixty-five (3.7%) mortalities were recorded. Multivariable logistic regression analysis results show that preexisting anticoagulation [ odds ratio (OR) 1.92, 95% CI 1.36-2.72] was independently predictive of death. The analysis was adjusted for systolic BP in the emergency department less than90 mmHg (OR 5.55, 95% CI 2.83-10.9), having more than 1 comorbidity (OR 2.30, 95% CI 1.57-3.38) and ISS (OR 1.13, 95% CI 1.10-1.15). Conclusion: Our study indicates that preexisting anticoagulation is associated with mortality among geriatric trauma patients.

Laser ablation: a unique and beneficial therapeutic option for pilonidal sinus? And the potential for further innovation-a review.

Laser has revolutionized the medical field, broadening the diagnostic and therapeutic spectrum, with diode (630-980 nm) and Nd:YAG (1064 nm) lasers being the common choices in ablation procedures. Laser ablation in pilonidal sinus disease is a new minimally invasive technique with good treatment efficacy, low post-op morbidity, and shorter recovery periods following employment. This review study aimed to provide information on the use of lasers in pilonidal sinus disease and their effectiveness compared to other conventional methods. The articles considered were obtained by performing a literature search in PubMed, Cochrane, and Google Scholar, and 44 articles were included in this study. Techniques like sinus laser-assisted closure (SiLaC), sinus laser therapy (SiLaT), pilonidal sinus laser treatment (PiLaT), and laser-assisted endoscopic pilonidal sinus treatment (LEPSiT) were included and reviewed. Diode laser was most commonly used, with local anesthesia preferred over spinal or general anesthesia. The highest healing rate was observed with Nd:YAG laser and the SiLaT technique. Recurrence was low, particularly in patients who underwent multiple procedures. On reviewing the published literature, laser ablation procedures showed lower morbidity and post-op complications. Patient satisfaction was higher, and the overall cost was found to be lower with minimally invasive techniques. Long-term prospective studies comparing lasers with other surgical techniques would help us ascertain the future treatment modality of pilonidal sinus disease.

A Repeat Case of Cefotetan-Induced Hemolytic Anemia in a Surgical Patient.

Drug-induced hemolytic anemia is a rare hematologic condition in which the immune system creates antibodies against red blood cell antigens in response to a medication exposure. This condition is commonly triggered by antibiotics, nonsteroidal anti-inflammatory drugs, and certain chemotherapies. Here, we describe a patient who experienced a repeat episode of drug-induced hemolytic anemia related to prophylactic cefotetan given before surgery. This case is important for increasing awareness of cephalosporin-induced hemolytic anemia, illustrating the significance of early detection and treatment of the condition, and highlighting the need for careful review of medication history in the surgical setting.

Robotic-assisted left adrenal cystic mass excision in a pregnant patient.

A symptomatic adrenal mass diagnosed during pregnancy is a rare clinical scenario. Two primary considerations are the timing of intervention and determining the appropriate surgical approach. Here, we present the case of a young female patient with flank pain, whom on diagnostic imaging, was found to have a large cystic adrenal mass. She was taken for a robotic-assisted resection of her left-sided adrenal mass during the second trimester of pregnancy. Preoperative and postoperative assessment demonstrated a viable intrauterine pregnancy. She tolerated the procedure well and was discharged 5 days later with resolution of her symptoms on follow-up. As one of only three reported cases of robotic adrenal surgery during pregnancy, we demonstrate that a robotic-assisted surgical approach is a viable and durable surgical option under the given clinical circumstances.

Operative Management of Perforated Jejunal Diverticulitis.

Small jejunal diverticulitis is very rare, presenting in 0.06% to 1.3% of the population. Many patients remain asymptomatic or have nonspecific symptoms such as malabsorption and abdominal pain, making diagnosis complicated. Up to 6% of patients present with acute perforation. Here, we present such a case involving a 69-year-old female who presented with altered mental status due to sepsis and generalized peritonitis from a perforated jejunal diverticulum that was successfully managed with definitive surgery. We highlight the importance of maintaining a broad differential, early resuscitation, and prompt surgical management in complicated jejunal diverticulitis. Although adjunctive studies such as computed tomography may be helpful in stable patients, definitive surgery was both diagnostic and therapeutic in this case.

Recurrent aseptic liver abscesses in a patient with Crohn's disease: True infection or a Crohn's flare?

A liver abscess is identified as a rare extraintestinal manifestation of Crohn's disease, with an incidence of approximately 150 in 100,000 patients with this condition. In many of these patients, infectious causes are identified, and the patient's condition is often noted to improve with antibiotics. An aseptic abscess (AA) is an increasingly recognized entity, especially in patients with inflammatory bowel disease, where repetitive evaluations to identify the infectious cause are futile. The average age of diagnosis for an AA is 29 years. The most common site is the spleen, followed by the lymph nodes and then the liver. In this study, we present a unique case of extensive aseptic liver abscesses extending into the pleural cavity in a young patient with Crohn's disease.

STROCSS 2021: Strengthening the reporting of cohort, cross-sectional and case-control studies in surgery.

INTRODUCTION: Strengthening The Reporting Of Cohort Studies in Surgery (STROCSS) guidelines were developed in 2017 in order to improve the reporting quality of observational studies in surgery and updated in 2019. In order to maintain relevance and continue upholding good reporting quality among observational studies in surgery, we aimed to update STROCSS 2019 guidelines. METHODS: A STROCSS 2021 steering group was formed to come up with proposals to update STROCSS 2019 guidelines. An expert panel of researchers assessed these proposals and judged whether they should become part of STROCSS 2021 guidelines or not, through a Delphi consensus exercise. RESULTS: 42 people (89%) completed the DELPHI survey and hence participated in the development of STROCSS 2021 guidelines. All items received a score between 7 and 9 by greater than 70% of the participants, indicating a high level of agreement among the DELPHI group members with the proposed changes to all the items. CONCLUSION: We present updated STROCSS 2021 guidelines to ensure ongoing good reporting quality among observational studies in surgery.

Rare Presentation of Incarcerated Incisional Richter's Hernia of the Cecum.

Richter's hernia, also called a partial enterocele, involves a protrusion of peritoneum with subsequent strangulation or incarceration of only part of the lumen of the anti-mesenteric portion of the small bowel through a fascial defect. We report a rare presentation of incarcerated incisional Richter's hernia of the cecum in a 39-year-old female. The patient presented with acute abdominal pain that gradually improved. Physical examination revealed right lower quadrant tenderness and nodularity just above an abdominoplasty scar. Subsequent computed tomography scan demonstrated a 1 cm by 1 cm hypovascular pocket arising from the cecum with protrusion into the anterior abdominal wall. The hernia was successfully repaired surgically with resolution of symptoms. It is essential for clinicians to be mindful of the diagnosis of Richter's hernia on the differential for abdominal pain as the risk of detrimental outcomes increases with delayed surgical intervention.

Submucosal Lipoma Causing Small Bowel Intussusception.

Intussusception involves telescoping of one segment of the intestine into an adjacent segment. Although this diagnosis is common in the pediatric population, it is much less common in adults. One of the main reasons it may occur in adults is due to a mass. Intestinal masses can be malignant, such as gastrointestinal stromal tumors, lymphomas, or adenocarcinomas; or they can be benign. One benign lead point in intussusception is a lipoma. A lipoma usually presents on the trunk, neck, or forearm, but can rarely be seen in the gastrointestinal tract. When it presents in the intestine, it can be either asymptomatic or it can be symptomatic and causes abdominal pain, nausea, vomiting, and gastrointestinal bleeding. Furthermore, it may act as a lead point and causes intussusception. We present an adult patient with two rare findings: small bowel obstruction from intussusception caused by a benign intestinal lipoma as its lead point. The patient was promptly taken to the operating room, where the intussuscepted bowel was resected along with the lipoma, and the patient had an uncomplicated recovery. The pathology report confirmed the specimen to be a submucosal lipoma with mature adipose tissue without atypia. Although intussusception and intestinal lipomas are both rare in adults, it is important to be aware of them on the list of differential diagnoses in adult patients with abdominal pain. This is because it can cause a wide array of complications including, ischemia, bowel perforation, sepsis, shock, and peritonitis. The lead point in intussusception has the possibility of being malignant. Careful consideration of these diagnoses with prompt imaging and appropriate intraoperative management is vital for good patient outcomes.

Neuromuscular and Vascular Hamartoma: Starting Point in Crohn's Disease?

Neuromuscular and vascular hamartoma (NMVH) is a benign and rare lesion comprising abnormal proliferation of cellular elements in the mucosa of the small intestine. NMVH shares certain histological features with inflammatory conditions like Crohn's disease, radiation and ischemic enteritis, and has been a part of ongoing debate since it was first described in 1982. We intend to describe an interesting case of small bowel obstruction caused by NMVH and emphasize the importance of keeping it as an important differential diagnosis in cases of small bowel obstructions for general practitioners and gastroenterologists. After detailed analysis of the 28 cases of the NMVH in the literature we are also suggesting NMVH as a starting point in Crohn's disease, and if proven it will change the management strategies for Crohn's disease.

Solid Pseudopapillary Neoplasm of the Uncinate Process of the Pancreas: A Case Report and Review of the Literature.

Solid pseudopapillary neoplasm (SPN) is a rare pancreatic neoplasm that accounts for 1-3% of all pancreatic tumors. SPNs are most commonly found in females in their third and fourth decades of life. Even though the majority of the tumors are benign, malignant tumors have also been reported. Given its rare occurrence, it remains a clinical dilemma in gastroenterology, oncology, and pathology. It is critical to diagnose it early and differentiate it from other similar pancreatic tumors or cysts to ensure favorable patient outcomes. Advanced imaging techniques, characteristic histologic findings, and immunohistochemical analysis can help in diagnosing solid pseudopapillary tumors. Early diagnosis and surgical resection can result in a cure in most cases, and tumor recurrence is extremely rare. In this report, we present a case of a 40-year-old female patient who presented to the emergency room and was diagnosed with SPN of the pancreas.

Haemobilia Secondary to Spontaneous Cystic Artery-Gallbladder Fistula: A Unique Gastrointestinal Anomaly.

Spontaneous cystic artery-gallbladder fistula is an extremely rare condition described in the medical literature. We have found two articles in the literature describing fistula formation between the cystic artery and gall bladder. In this report, we present a unique case of a cystic artery-gall bladder fistula that resulted in massive gastrointestinal bleeding through cystic artery erosion and was adequately managed with coil embolization.

Perforated Jejunal Diverticulitis.

Small intestinal diverticula are very rare; their incidence ranges from 0.06 to 1.3%, with a higher prevalence after the 6th decade of life. Among these small intestinal diverticula, duodenal diverticula are more frequent, followed by diverticula of the jejunum and ileum. A jejunal diverticulum is usually asymptomatic; sometimes patients complain of vague chronic symptoms like malabsorption, pain, or nausea that easily lead to misdiagnosis. Complications are rarely reported, only in 10% of patients. We report a unique case of a 70-year-old female who presented with confusion due to sepsis from perforated jejunal diverticulitis, which was successfully managed with initial resuscitation and definitive surgery.

Scoping Renal Cell Carcinoma in the Rectal and Anal Canal: A Literature Review.

Renal cell carcinoma (RCC) is a common tumor of the kidneys that can often metastasize to other organs, including the lungs, brain, bones, and adrenal glands. However, colon involvement is less common, with metastasis to the rectum and anal canal being an extremely rare phenomenon. The present study describes patients with renal cell carcinoma metastasizing to this unusual location in the gastrointestinal tract (GI).

Available technologies and clinical applications of targeted chemotherapy in pancreatic cancer.

The incidence of pancreatic cancer, the fourth leading cause of cancer death in United States, is increasing worldwide. Even though the cure rate has doubled in 40 years, it is abysmally poor at 6-7%. As surgical resection remains the only curative treatment and less than 20% of the newly diagnosed cancers are resectable, the major burden of disease management lies in early diagnosis, good prognostication, and proper neo-adjuvant and/or adjuvant therapy. With advancing technologies and their ease of availability, researchers have better tools to understand pancreatic cancer. In the post-genetic era, proteomic, phosphoproteomic, metabolomic, and more have brought us to a multi-omics era. These newer avenues bring promises of better screening modalities, less invasive diagnostics and monitoring, subtyping of pancreatic cancer, and fine tuning the treatment modalities not only to the right stage of tumor but also to the right tumor biology. As the multitudes of technologies are generating extensive amounts of incongruous data, they are giving clinicians a lot of non-actionable information. In this paper, we wish to encompass the newer technologies, sub-classifications, and future treatment modalities in personalized care of patients with pancreatic cancer.

Continuous intraarterial thrombolysis for early hepatic artery thrombosis following liver transplantation: case report.

Hepatic artery thrombosis remains one of the major causes of graft failure and mortality in liver transplant recipients. Urgent re-transplantation has been considered as mainstay therapy; however, even with re-transplantation mortality of more than 50% has been reported by many series. Early detection on Doppler ultrasonography and subsequent revascularization in asymptomatic patients can avoid graft loss. Endovascular therapy including intra-arterial thrombolysis, percutaneous transluminal angioplasty, and stent placement have shown encouraging results in recent years; nevertheless, their use remains controversial due to potential risk of bleeding. We present a case of early hepatic artery thrombosis following liver transplantation treated successfully with continuous transcatheter intra-arterial thrombolysis using tissue plasminogen activator (t-PA).