Outcomes after laser interstitial thermal ablation for temporal lobe epilepsy: a systematic review and meta-analysis.

Epilepsy is a common condition that affects approximately 1% of the world's population, with about one-third being refractory epilepsy. Temporal lobe epilepsy is the most common type of drug-resistant epilepsy, and laser interstitial thermal therapy (LITT) is an innovative treatment. In this systematic review and meta-analysis, we aimed to summarize the current evidence on outcomes after LITT, including seizure freedom rate, complication rate, and neurocognitive outcome. PubMed and OVID Medline search engines were systematically searched for all indexed publications in the English language up to July15, 2023. The search was limited to human studies. Proportions and 95% confidence interval (CI) values were calculated for seizure, neurocognitive outcome, and complication rate. A total of 836 patients were included. Overall seizure outcomes, regardless of the pathology, included Engel I outcome in 56% (95% CI, 52.4-59.5%), Engel II outcome in 19.2% (95% CI, 15.4-23.6%), Engel III outcome in 17.3% (95% CI, 13.5-21.8%), and Engel IV outcome in 10.5% (95% CI 6.3-17%) of the patients. The overall decline in verbal and visual memory regardless of laterality was 24.2 (95% CI 8.6-52%) and 25.2% (8.3-55.8%). For naming, the decline was 13.4% (6.6-25.4%). The results of the pooled analysis in comparison with available data in the literature showed that seizure outcomes after LITT were slightly inferior to published data after temporal lobectomy. Data on cognitive outcomes after LITT are scarce and heterogeneous.

Successful clinical management of mesenteric ischemia caused by superior mesenteric artery obstruction and celiac artery stenosis: a case report.

Acute mesenteric ischemia (AMI) is a rare, yet deadly thromboembolic accident that requires urgent surgery and or revascularization. We report the case of a 67-year-old male patient, who presented with severe abdominal pain and reduced oral intake, causing dehydration and impaired kidney function. The imaging evaluation including arterial Doppler and computed tomography (CT) scan showed AMI caused by superior mesenteric artery (SMA) obstruction and celiac artery stenosis, besides multiple atherosclerotic segments. Given the absence of guidelines in such an uncommon combination, a multidisciplinary management was initiated involving general medicine, general surgery, vascular surgery, and radiology. The agreed plan consisted of anticoagulation, exploratory laparotomy with necrosis resection and anastomosis, followed by percutaneous thrombectomy and angioplasty with stenting. The patient was discharged on day 7 postop with a highly satisfactory outcome and follow up. This case highlights the value of an early multidisciplinary approach in tailoring the management to the specific case of AMI.

Prostate Cancer Metastasis to Stomach: A Case Report and Review of Literature.

Metastatic prostate cancer is a common diagnosis with a protracted but terminal course. Gastrointestinal (GI) tract involvement is extremely rare, and reportedly portends a poor prognosis. It can present years after the initial prostate cancer diagnosis. Only fifteen cases of prostate cancer metastasis to the stomach have been reported in the literature. We report a case of a 72-year-old man with metastatic castration-resistant prostate cancer and extensive bony involvement. He presented a decade after the diagnosis of prostate cancer with signs of heartburn; a gastric biopsy was initially believed to represent primary gastric carcinoma, but subsequently a diagnosis of prostate cancer metastatic to the stomach was confirmed. This case highlights the importance of the provision of a pertinent clinical history and clinical differential diagnosis at the time of submission of surgical pathology specimens, as well as highlighting the need to have a low index of suspicion to pursue additional pathologic markers whenever a presumed second adenocarcinoma is noted in the context of a patient having a history of current or prior advanced-stage adenocarcinoma of another site. The correct diagnosis can shield the patient from the morbidity of inappropriate surgical or medical management.

Complicated appendicitis increases the hospital length of stay.

Background: There are insufficient data from Saudi Arabia regarding appendectomy outcomes and hospital length of stay. Further, there is a need to compare the length of stay of Saudi patients and the literature. The purpose is to evaluate the surgical outcomes and hospital length of stay for complicated appendicitis and simple appendicitis. Method: This is a single-center retrospective review of patients who had undergone an appendectomy between 2016 and 2018. The patients were divided into 2 groups: complicated appendicitis versus simple appendicitis. Results: Of 449 patients who underwent appendectomy, 60 (13.4%) had complicated appendicitis. The complicated appendicitis was significantly associated with increased age, pain duration, neutrophilia, high C-reactive protein, fecalith presence, and free fluid. The incidence rate of surgical site infection was 5.8% (identified in 26 patients). Compared to simple appendicitis, complicated appendicitis was associated more with wound infection (1.8% vs 10%, respectively, P = .001), postoperative collection (1.2% vs 11.6%, respectively, P = .001), and readmission within 30 days (2.3% vs 13.4%, respectively, P = .001). By multivariate analysis, factors associated more with increased hospitalization were pain duration (hazard ratio = 2.37, 95% confidence interval = 1.09-5.16, P = .029), operative time (hazard ratio = 2.09, 95% confidence interval = 1.04-4.21, P = .038), and complicated appendicitis (hazard ratio = 6.61, 95% confidence interval = 2.67-14.21, P = .001). Conclusion: Complicated appendicitis correlates with significant morbidity, readmission rate, and 6 times more hospital LOS than simple appendicitis. This review might help in appreciating the burden of complicated appendicitis on hospital length of stay, which needs allocating patients and planning the discharge day for hospitals with limited beds.

Pancreatic Carcinoid Tumor in a Pediatric Patient.

BACKGROUND Carcinoid tumors are well-differentiated tumors that develop from neuroendocrine cells. They are rare tumors and occur most commonly in the gastrointestinal tract, followed by the pulmonary system. They usually present with abdominal pain or cough or persistent pneumonia. They are usually diagnosed with computed tomography (CT) or magnetic resonance imaging (MRI) of the chest or abdomen. The cornerstone of treatment is surgical resection. There are rare reported cases of carcinoid tumor presenting in the pancreas as gastrinoma or insulinoma and are associated with multiple endocrine neoplasia type 1 (MEN1). CASE REPORT We report a case of an otherwise healthy 9-year-old girl who presented with manifestations of Cushing syndrome (easy fatigability, weakness, back pain, easy bruising, hirsutism, acne, skin discoloration [pigmentation], and blurred vision). She was diagnosed with incidental carcinoid tumor in the pancreas based on hypertension and typical stigmata. She underwent distal pancreatectomy and splenectomy. The histopathology showed a well-differentiated neuroendocrine tumor with G2. The diagnosis of concurrent Cushing syndrome and carcinoid syndrome can be challenging, as it is rare. It is important to screen for MEN syndrome when Cushing syndrome occurs in a child, as there is a high rate of transition to malignancy. They are usually diagnosed with ACTH, cortisol, and imaging. CONCLUSIONS Incidental hypertension in children is not common and mandates further investigation and clinical work-up to look for endocrinopathies such as Cushing syndrome and carcinoid syndrome. As the literature on such cases is scant, further reporting of cases is needed.

A Successful En Bloc Excision of a Giant Retroperitoneal Liposarcoma With Distal Splenopancreatectomy.

Retroperitoneal sarcomas are considered a rare type of malignant tumors, accounting for fewer than one-fifth of all cases. Among all malignancies, the incidence of soft tissue sarcomas is approximately 1%. It constitutes 38% of soft tissue sarcomas in liposarcomas. Putting it that way may better indicate that liposarcomas are a rare tumor. They are frequently asymptomatic until they become large enough to compress the adjacent organs. As a result, it must be validated using appropriate imaging modalities, for example, computed tomography (CT) abdomen or magnetic resonance imaging (MRI) abdomen with contrast. The preferred treatment is complete surgical resection. The patient presented with vague symptoms. She had a CT abdomen with contrast, as well as an MRI abdomen. Both images revealed the presence of a giant sarcoma displacing the pancreas and left kidney posteriorly and the transverse colon inferomedially. The patient underwent en bloc resection of the mass with distal splenopancreatectomy. The patient tolerated the procedure well and was discharged on day 6 postoperatively in a stable state. Giant liposarcoma is a rare and aggressive form of sarcoma. Because of the unique presentation, it is difficult to diagnose clinically. CT scans with MRIs are viable imaging modalities for determining tumor extent and ruling out any vascular invasion. Complete surgical resection of liposarcoma is a treatment of choice. En bloc resection of retroperitoneal sarcoma with distal splenopancreatectomy can be performed successfully and safely.

A Large Lipoma of the Labia Majora.

A 40-year-old woman presented with a huge right labial swelling that had been enlarging gradually for the last four years. A 10-cm labial swelling was revealed on clinical examination. Preoperative magnetic resonance imaging (MRI) was used to rule out other possible diagnoses, such as hernias, vulvar cysts and tumours. When it came to assessing and diagnosing soft tissue swelling, MRI was the method of choice. It determined that the swelling had a bright T1 and T2 signal intensity similar to that of subcutaneous fat, with a decline in signal in fat-saturated sequences, indicating a diagnosis of vulvar lipoma. The mass was surgically excised, and histopathology confirmed the diagnosis of a benign lipoma. Lipomas are considered the most common soft tissue tumours accounting for a prevalence of 1% in the population. Their occurrence in the vulva in premenopausal women is considered rare and only a few cases of vulvar lipomas have been reported in the literature. Herein, we report a rare case of a patient with vulvar lipoma and review the available literature.

A rare presentation of hydatid cyst in abdominal wall: case report.

Echinococcus species cause hydatidosis, which is a verminosis. Echinococcus vogeli results in polycystic hydatid disease, and wild dogs are the definitive hosts. In fact, wild dogs and rats are the most common hosts. The transit of Echinococcus eggs through the liver and lungs is hypothesized to result in hydatid cyst formation in the subcutaneous tissue. In 1.5 percent of patients with hydatidosis, hydatid cysts of the subcutaneous tissue have been documented. They ranged from 0.6 percent to 2.6 percent. We here report a case of hydatid cyst of the abdominal wall which was surgically treated. A 30-year-old lady had been experiencing pain associated with lump in her right lower abdomen for three months. On clinical examination, an enlargement in the left side measuring 4 x 3 cm was discovered. Imaging was performed preoperatively to rule out other differential diagnoses. Ultrasound was performed, followed by computed tomography and magnetic resonance imaging, which revealed multilocular cystic mass measuring 9 x 8.5 x 4.7 cm along the right lower anterior abdominal wall muscles (with cysts inside cysts), which suggested hydatid cyst. Histopathology confirmed the diagnosis of hydatid cyst, after the mass was surgically removed. Treatment with albendazole was continued. Hydatid cyst of the subcutaneous tissue is uncommon, with only a few occurrences recorded in the literature. This study describes a case of hydatid cyst in an uncommon place. Imaging confirmed the diagnosis, and the tumour was surgically removed. It ruptured during surgery and was successfully treated with hypertonic saline and albendazole. Then it was adequately managed. Given that subcutaneous hydatid cyst is rare, it's vital to keep in mind that it can be a possible cause of abdominal wall mass. Specific imaging test is essential to correctly locate and remove it. It must be treated with anthelmintic before surgery, in order to reduce the risk of contamination due to cyst rupture during surgery. Subcutaneous hydatid cyst should be considered one of the differential diagnoses for soft tissue masses, in particular in patients living in endemic areas. To rule out alternative possibilities, proper imaging test is essential. The treatment of choice is complete excision.

Case Report: Ectopic Liver (Choristoma) Discovered During Laparoscopic Cholecystectomy.

BACKGROUND Ectopic liver (EL) is liver tissue that is not attached to the mother liver, and is also known as choristoma and hepar succenturiatum. According to Watanabe's 1060-patient series, it has an incidence rate of less than 1% (0.47%). The absence of an anatomical attachment to the hepatic proper is a rare congenital departure from the norm, known as EL. EL is thought to be caused by abnormal hepatic tissue growth from the foregut diverticulum, particularly at cystic structures. CASE REPORT We report the successful management of a 47-year-old male patient, not known to have any medical illness, who was referred to the surgical team with a clinical picture of biliary colic. An ultrasound (US) abdomen was performed, and cholecystitis was confirmed. During a laparoscopic cholecystectomy, ET was identified by chance. He tolerated the operation well. Gallbladder histological examination revealed significant mucosal and wall ulcers, chronic inflammation, many black stones, no dysplasia or malignancy, and connected liver tissue measuring 12×5 mm. As a result, chronic calcular cholecystitis was confirmed, as was normal EL architecture and no evidence of malignancy. CONCLUSIONS We conclude that EL is a rare condition, but there have been cases reported in the literature. Imaging modalities such as US and computed tomography scans are recommended to rule out other underlying diagnoses and should be tailored to each individual when necessary. Because the presence of EL attached to the vesicle is a rare occurrence in the literature, a histological examination is required due to the elevated risk of hepatocellular carcinoma. Keeping such an abnormality in mind can help surgeons demarcate the embryological plane of dissection during cholecystitis to avoid tumor cell spillages if present.

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.

Perception, Academic Performance, Gender Judgment and Barriers among Surgeons' Career Progression in Jeddah, Saudi Arabia: A Cross-Sectional Study.

INTRODUCTION: Gender discrimination continues to be an issue in different surgical subspecialties, especially in Saudi Arabia, where no studies have been conducted so far on female surgeons in academia, on gender discrimination, and on job satisfaction. Considering the increasing number of women enrolling for surgery programs in Jeddah, Saudi Arabia, this study aims to examine their perceptions about and equity in working as surgeons. METHODS: Following the STROCSS criteria, cross-sectional analyses were conducted of survey data from a multicentric online questionnaire in 2019/2020. A representative sample of medical interns and surgeons (n = 100) from Saudi Arabia responded out of 400 from the 4th iteration. RESULTS: Females were 53%; most participants were less than 40 years. Women ranked assistant professors were fewer than men (2% vs. 11%). The number of publications by females vs. males was 2.58 +/- 2.68 vs. 11.37 +/- 20.53 (p = 0.002). Surgery was not considered a profession conducive to family life according to more than half the women citing lack of flexible/part-time training or work (26/53, or 49%). However, only 1/5, or 9/47 (19.1%), of men thought there was gender attitude/bias; men also had more variety in surgical career choices. Further, most patients preferred male surgeons ( p = 0.026). Both females (30/53 or 56.6%) and males (25/47 or 53.2%) agreed that the best response to an offensive question was to ignore it. Decision in choosing their specialty was influenced mostly by career and promotion prospects, enthusiasm, and commitment (females: 31/53 or 58.5% and males: 17/47 or 36.2%) with p = 0.026. CONCLUSIONS: The findings reveal the persisting discrepancies based on gender in the surgical field in Saudi Arabia. A nationwide movement limiting working hours, encouraging medical students to enter surgery, and upholding women in leadership positions can help in overcoming this situation.

Analysis of 190 Female Patients after Appendectomy.

This study is a retrospective cohort review carried out at a single, private tertiary center. We included 190 female patients who underwent surgery for acute appendicitis between January 2016 and December 2018. Two groups of patients were analyzed based on the pregnancy. The main outcome measures were complication rate and risk of abortion during or after surgery. Out of 190 female patients, eight of them were pregnant (4.2%). The pregnant group more significantly underwent ultrasound investigation compared to the nonpregnant group. Complicated appendicitis present in two pregnant patients at advanced gestational age was not statistically significant from nonpregnant. Laparoscopic appendectomy was performed in 6/8 (75%) of pregnant compared to 158/182 (87%) in nonpregnant (p = 0.415). Compared to the nonpregnant, the pregnant group has a more fecolith, positive peritoneal fluid culture, and wound infection, with E. coli more frequently isolated in 25%. None of the pregnant patients had an abortion, preterm labor, or mortality during or after surgery. In conclusion, laparoscopic appendectomy is a low-risk operation for pregnant with acute appendicitis.

Substance P/ Neurokinin-1 Receptor, Trigeminal Ganglion, Latency, and Coronavirus Infection-Is There Any Link?

Novel Severe Acute Respiratory Syndrome-Corona Virus-2 infection (SARS-CoV-2) is an acute respiratory and infectious disease. This perspective aims to provide a basic understanding of the inflammation caused by SARS-CoV-2 and its relation to the trigeminal ganglion (TG). The virus enters through the mucous membranes of the orofacial region and reaches the TG, where it resides and takes control of its peptides including Substance P (SP). SP is the main neuropeptide, neuromodulator, and neuro-hormone of TG, associated with nociception and inflammation under noxious stimulus. SP release is triggered and, consequently, affects the immune cells and blood vessels to release the mediators for inflammation. Hence, cytokine storm is initiated and causes respiratory distress, bronchoconstriction, and death in complicated cases. Neurokinin-1 Receptor (NK-1R) is the receptor for SP and its antagonists, along with glucocorticoids, may be used to alleviate the symptoms and treat this infection by blocking this nociceptive pathway. SP seems to be the main culprit involved in the triggering of inflammatory pathways in SARS-CoV-2 infection. It may have a direct association with cardio-respiratory rhythm, sleep-wake cycle, nociception, and ventilatory responses and regulates many important physiological and pathological functions. Its over-secretion should be blocked by NK-1R antagonist. However, experimental work leading to clinical trials are mandatory for further confirmation. Here, it is further proposed that there is a possibility of latency in SARS-CoV-2 virus infection if it is acting through TG, which is the main site for other viruses that become latent.

Pain Management in Breast Cancer Patients: A Multidisciplinary Approach.

Pain is a significant problem and is one of the most invalidating symptoms in breast cancer (BC) patients that would negatively affect the functional status and the Quality of Life (QoL). Pain management in BC patients requires thorough patient evaluation and critical assessment of pain. The actual cause for the pain must be recognized, so management can be tailored to each patient. This review aims to discuss various treatment modalities employed for effectively managing pain in BC patients. Pharmacotherapy makes up the cornerstone of the management of pain in BC patients. Both opioid and non-opioid analgesics are utilized. The WHO recommends a method called "by the ladder" for managing pain in BC patients where analgesics are used in ascending order. In comprehensive pain management (CPM), non-pharmacologic therapies are gaining wide acceptance and popularity, including complementary and alternative medicine (CAM), procedural and psychosocial interventions. Procedural interventions are usually used in case of severe pain refractory to pharmacological therapy. Techniques, such as radiotherapy, neurectomy, and nerve blocks, are effective in managing cancer pain. However, CAM therapies in BC pain management need to be guided by enough scientific evidence, decision-making, and medical judgment of regulatory bodies. BC pain management is based on careful routine pain assessments and appropriate patient evaluation both physically and psychologically. Pain control is one of the methods to improve the QoL of BC patients. Both pharmacological and non-pharmacological therapies are accessible to patients today, but they should be used with caution to minimize toxicity and increase effectiveness. The use of any pain management intervention should be based on proper scientific evidence and collective medical judgment.

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.

Knowledge and attitudes towards Zika virus among medical students in King Abdulaziz University, Jeddah, Saudi Arabia.

Zika Virus (ZIKV) and its associated consequences remain vital public health challenge of international concerns. The current study was done to assess knowledge and attitudes towards ZIKV and the factors associated with good knowledge among medical students in King Abdulaziz University, Jeddah. A cross-sectional study was conducted among 426 students. They were selected through multistage stratified random sample method, 2016. A validated, confidential, interviewing questionnaire contained 25 knowledge and 10 attitude items was used. Descriptive and inferential statistics were done. Results revealed that Facebook was the commonest source of ZIKV information. About half of the participants correctly identified mosquito bites and vertical route as ZIKV transmission modes. However, smaller percentages recognized the sexual and blood transmission modes. Calculations of knowledge score revealed that 77.5%, 15.0%, and 7.5% of the participants obtained poor, fair, and satisfactory scores, respectively. Age, educational year and attending ZIKV training were significantly associated with good knowledge (p<0.05). Concerning attitudes, about half of the participants agreed that ZIKV could add new burden on healthcare system of the affected countries. Most of participants were interested in learning more about ZIKV, emerging diseases and travel epidemiology. In conclusion, medical students had limited knowledge about ZIKV, and good attitudes towards learning about it. Conduction of ZIKV educational programs, and development of courses about emerging disease epidemiology are required.