The Beirut Port Explosion Injuries and Lessons Learned: Results of the Beirut Blast Assessment for Surgical Services (BASS) Multicenter Study.

OBJECTIVE: This multicenter study aims to describe the injury patterns, emergency management and outcomes of the blast victims, recognize the gaps in hospital disaster preparedness, and identify lessons to be learned. SUMMARY BACKGROUND DATA: On August 4th, 2020, the city of Beirut, Lebanon suffered the largest urban explosion since Hiroshima and Nagasaki, resulting in hundreds of deaths and thousands of injuries. METHODS: All injured patients admitted to four of the largest Beirut hospitals within 72 hours of the blast, including those who died on arrival or in the emergency department (ED), were included. Medical records were systematically reviewed for: patient demographics and comorbidities; injury severity and characteristics; prehospital, ED, operative, and inpatient interventions; and outcomes at hospital discharge. Lessons learned are also shared. RESULTS: An estimated total of 1818 patients were included, of which 30 died on arrival or in the ED and 315 were admitted to the hospital. Among admitted patients, the mean age was 44.7 years (range: 1 week-93 years), 44.4% were female, and the median injury severity score (ISS) was 10 (5, 17). ISS was inversely related to the distance from the blast epicenter (r = --0.18, P = 0.035). Most injuries involved the upper extremities (53.7%), face (42.2%), and head (40.3%). Mildly injured (ISS <9) patients overwhelmed the ED in the first 2 hours; from hour 2 to hour 8 post-injury, the number of moderately, severely, and profoundly injured patients increased by 127%, 25% and 17%, respectively. A total of 475 operative procedures were performed in 239 patients, most commonly soft tissue debridement or repair (119 patients, 49.8%), limb fracture fixation (107, 44.8%), and tendon repair (56, 23.4%). A total of 11 patients (3.5%) died during the hospitalization, 56 (17.8%) developed at least 1 complication, and 51 (16.2%) were discharged with documented long-term disability. Main lessons learned included: the importance of having key hospital functions (eg, laboratory, operating room) underground; the nonadaptability of electronic medical records to disasters; the ED overwhelming with mild injuries, delay in arrival of the severely injured; and the need for realistic disaster drills. CONCLUSIONS: We, therefore, describe the injury patterns, emergency flow and trauma outcome of patients injured in the Beirut port explosion. The clinical and system-level lessons learned can help prepare for the next disaster.

Global Survey of Demand-Side Factors and Incentives that Influence Advanced Trauma Life Support (ATLS) Promulgation.

BACKGROUND: We aimed to identify and describe demand-side factors that have been used to support ATLS global promulgation, as well as current gaps in demand-side incentives. METHODS: We performed a cross-sectional survey about demand-side factors that influence the uptake and promulgation of ATLS and other trauma-related CME courses. The survey was sent to each of the four global ATLS region chiefs and 80 ATLS country directors. Responses were described and qualitative data were analyzed using a content analysis framework. RESULTS: Representatives from 30 countries and each region chief responded to the survey (40% response rate). Twenty of 30 country directors (66%) reported that there were some form of ATLS verification requirements. ATLS completion, not current verification, was often the benchmark. Individual healthcare systems were the most common agency to require ATLS verification (37% of countries) followed by medical/surgical accreditation boards (33%), governments (23%), training programs (27%), and professional societies (17%). Multiple credentialing frameworks were reported including making ATLS verification a requirement for: emergency unit or trauma center designation (40%), contract renewal or promotion (37%); professional licensing (37%); training program graduation (37%); and increases in remuneration (3%). Unique demand-side incentives were reported including expansion of ATLS to non-physician cadre credentialing and use of subsidies. CONCLUSION: ATLS region chiefs and country directors reported a variety of demand-side incentives that may facilitate the promulgation of ATLS. Actionable steps include: (i) shift incentivization from ATLS course completion to maintenance of verification; (ii) develop an incentive toolkit of best practices to support implementation; and (iii) engage leadership stakeholders to use demand-side incentives to improve the training and capabilities of the providers they oversee to care for the injured.

Postoperative outcomes after laparoscopic splenectomy compared with open splenectomy.

OBJECTIVE: To evaluate 30-day postoperative outcomes in laparoscopic (LS) versus open splenectomy (OS). SUMMARY BACKGROUND DATA: LS has generally been associated with lower rates of postoperative complications than OS. However, evidence mainly comes from small studies that failed to adjust for the confounding effects of the underlying indication or clinical condition that may have favored the use of one technique over the other. METHODS: A retrospective cohort study of patients undergoing splenectomy in 2008 and 2009 using data from the American College of Surgeons National Surgical Quality Improvement Program database (n = 1781). Retrieved data included 30-day mortality and morbidity (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thromboembolism, and major bleeding outcomes), demographics, indication, and preoperative risk factors. We used multivariate logistic regression to assess the adjusted effect of the splenectomy technique on outcomes. RESULTS: A total of 874 (49.1%) cases had LS and 907 (50.9%) had OS. After adjusting for all potential confounders including the indication and preoperative risk factors, LS was associated with decreased 30-day mortality [OR (odds ratio): 0.39, 95% CI: 0.18-0.84] and postoperative respiratory occurrences (OR: 0.46, 95% CI: 0.27-0.76), wound occurrences (OR: 0.37, 95% CI: 0.11-0.79), and sepsis (OR: 0.52, 95% CI: 0.26-0.89) when compared with OS. Patients who underwent LS also had a significantly shorter total length of hospital stay and were less likely to receive intraoperative transfusions compared with patients who underwent OS. CONCLUSIONS: LS is associated with more favorable postoperative outcomes than OS, irrespective of the indication for splenectomy or the patient's clinical status.

Retroperitoneal desmoid-type fibromatosis: a case report.

Desmoid-type fibromatosis (DF) is a rare subtype of soft tissue sarcomas that most commonly occurs in the anterior abdominal wall. When occurring in the retroperitoneum, DF is usually part of familial syndromes while only rarely sporadic. This makes it imperative to report any instance of experience with DF and the oncological outcomes of the different approaches to management. We report two cases of sporadic and severe DF occurring in the retroperitoneum at our institution. Case presentation: The first case is a male that presented with urinary obstruction symptoms and underwent surgical resection of the tumor that extended into the left kidney. The second case is a female with a history of recurrent desmoid tumors of the thigh and was incidentally diagnosed with retroperitoneal DF on imaging. She underwent tumor resection and radiotherapy; however, the tumor recurred with urinary obstruction symptoms that required another surgical resection. Histopathological characteristics and radiological imaging of both cases are described below. Clinical discussion: Desmoid tumors often recur, thus significantly influencing the quality of life which is reflected in one of our cases. Surgery remains a mainstay treatment, and both cases presented in this report required surgical resection of the tumors as symptomatic and curative measures. Conclusion: Retroperitoneal DF is a rare entity, and our cases add to the scarce literature available on the topic, which may well contribute to the formulation of practice-changing recommendations and guidelines focused on this rare variant of DF.

Robotic versus laparoscopic revisional bariatric surgeries: a systematic review and meta-analysis.

Purpose: In recent years, the need for revisional bariatric surgery (RBS) procedures has experienced a noteworthy surge to confront complexities and weight recidivism. Despite being a subject of controversy for many, the utilization of the Da Vinci robotic platform (Intuitive Surgical, Inc.) may present benefits in RBS. This study aimed to evaluate the outcomes of robotic RBS in comparison to Laparoscopic RBS. Methods: A meticulous and thorough analysis was ensured through a comprehensive exploration of the literature, which included PubMed, Medline, Scopus, and Cochrane. This exploration was conducted in adherence to the directives outlined in the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The Newcastle-Ottawa scale was used for quality assessment. Results: A total of 11 studies were included in this meta-analysis, comprising 55,889 in the laparoscopic group and 5,809 in the robotic group. No significant differences were observed in the leak, bleeding, operative time, or length of stay across both groups. However, the robotic group showed higher rates of conversion to open surgery (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.53-0.79; p < 0.0001; I2 = 0%), reoperation (OR, 0.70; 95% CI, 0.57-0.87; p = 0.0009; I2 = 6%), and readmission (higher rate of readmission in the robotic group; OR, 0.76; 95% CI, 0.62-0.92; p = 0.005; I2 = 30%). Conclusion: Robotic-assisted bariatric surgery has no significant advantage over conventional laparoscopic surgery. Further research is warranted to explore and evaluate surgeons' methodology and proficiency differences.

Roux-en-Y Gastric Bypass Versus One Anastomosis Gastric Bypass as Revisional Surgery After Failed Sleeve Gastrectomy: A Systematic Review and Meta-analysis.

Purpose: This study aimed to assess the outcomes of revisional procedures, namely Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) following unsuccessful laparoscopic sleeve gastrectomy. Materials and Methods: This systematic review and meta-analysis included 817 patients (404 in OAGB group, 413 in RYGB group) from seven retrospective comparative studies. Data on sample size, demographics, perioperative complications, operative time, pre- and post-revisional body mass index, total weight loss, and global weight loss over follow-up were extracted. Results: The mean operative time was 98.2-201 minutes for RYGB versus 78.7-168 minutes for OAGB. Despite classical RYGB gastric bypass taking longer, mini gastric bypass resulted in greater weight loss than RYGB, with a mean difference of -5.84 (95% confidence interval [CI], -6.74 to -4.94; P<0.00001; I2=0%), greater total weight loss, and a higher diabetes remission rate (odds ratio [OR], 0.32; 95% CI, 0.14 to 0.71). However, OAGB was associated with a significantly higher incidence of postoperative gastroesophageal reflux than RYGB (52 vs. 31: OR, 0.40; 95% CI, 0.24 to 0.67; P=0.0005; I2=0%). Conclusion: OAGB was performed more quickly and boasted greater total weight loss and higher diabetes remission rates compared to RYGB after failed sleeve gastrectomy. However, OAGB also demonstrated a higher incidence of postoperative gastroesophageal reflux disease. Thus, careful patient selection is essential when considering OAGB. Trial Registration: PROSPERO Identifier: CRD42023474966.

Single Anastomosis Duodeno-Ileal Bypass (SADI) as a Second Step After Failed Sleeve Gastrectomy: Systematic Review and Meta-analysis.

Purpose: Our aim in this study is to assess single anastomosis duodeno-ileal bypass (SADI) as a salvage procedure following sleeve gastrectomy (SG), examining its technical feasibility, outcomes, and potential complications. Materials and Methods: A systematic review and meta-analysis were conducted, drawing data from PubMed, Medline, and the Cochrane library. The analysis encompassed 14 studies, involving 1,066 patients. We evaluated operative time, comorbidity resolution (hypertension, dyslipidemia, diabetes), post-operative diarrhea incidence, excess weight loss (EWL) at six, twelve, and twenty-four months, and post-operative leak rates. Results: SADI as a salvage procedure following SG yielded positive outcomes. Mean operative time was 125.98 minutes (95% CI 102.50-149.46, I2=99%). Importantly, SADI led to comorbidity resolution in a notable proportion of cases: hypertension in 48% (95% CI 38-57%, I2=44%), dyslipidemia in 55% (95% CI 40-69%, I2=30%), and diabetes in 63% (95% CI 53-72%, I2=30%) of patients. Post-operative diarrhea incidence was relatively low at 2% (95% CI 1-9%, I2=75%). In terms of weight loss, SADI patients exhibited substantial EWL: 47.73% (95% CI 37.86-57.61, I2=95%) at six months, 59.39% (95% CI 51.18-67.61, I2=95%) at twelve months, and 23.84% (95% CI 5.76-41.92, I2=100%). At twenty-four months. Furthermore, post-operative leak rate was relatively low, reported in only 1% (95% CI 0-5%, I2=80%) of cases. Conclusion: SADI as a salvage procedure post-SG demonstrates technical feasibility and marked effectiveness. It offers substantial comorbidity resolution, significant weight loss, and low post-operative complication rates, notably post-operative leaks. Further research should investigate the long-term impact of SADI on patient nutritional status to facilitate its broader adoption.

Clinicopathologic and immunohistochemical characteristics of male breast cancer: a single center experience.

Male breast cancer (MaleBC) is a rare tumor that has been insufficiently described in the Middle East. The purpose of this study is to report the first MaleBC series in Lebanon, describing its clinicopathologic and immunohistochemical phenotype, and how it compares with MaleBC in the West and with female breast cancer in Lebanon and the Middle East. Forty-seven cases of MaleBC were reviewed. Results showed younger ages at presentation (62 years versus 67 years), higher incidence of lobular carcinoma (6% versus 1%), and more frequent p53 positivity and axillary node metastases in our series than in those reported about MaleBC. Other results such as higher estrogen receptor (ER) positivity and lower HER-2/neu over-expression were comparable to the literature. These findings suggest that MaleBC in our region may represent a biologically different tumor with potentially distinct prognostic and therapeutic implications.

Isolated splenic metastasis from colorectal cancer.

Splenic metastases are unusual, arising in less than 1% of all metastases. Isolated solitary splenic metastasis from colorectal carcinoma is considered exceptional. This rarity has been explained by several hypotheses relating to the anatomical, histological, and immunological features of the spleen. We review the reported cases of isolated solitary splenic metastasis from colorectal carcinoma and discuss the diagnostic and therapeutic options for this entity. We searched the English-language medical literature, using the Medline and Pubmed databases from January 1966 through July 2010, for articles reporting isolated splenic metastasis from colorectal carcinoma. Only 26 cases have been reported; four cases had synchronous splenic metastasis. Fifteen patients had regional lymph node involvement on diagnosis of primary carcinoma. The primary tumor was located in the left colon or in the rectum in 18 cases. Carcinoembryonic antigen (CEA) level was elevated in 73% of cases. All patients underwent curative splenectomy; only one patient had laparoscopic resection of the spleen. Mean reported survival interval was 19.5 months; only three patients were deceased at last follow-up. Solitary splenic metastasis from colorectal carcinoma is very rare; clinicians are advised to pay close attention when routinely evaluating patients with serial CEA levels and abdominal scans. Splenectomy seems to be the preferred treatment modality with improvement of long-term survival. However, definitive conclusions cannot be drawn from the small number of case reports available.

Metastasis of colorectal carcinoma to the testes: clinical presentation and possible pathways.

Distant metastasis from colorectal carcinoma most often occurs in the liver and lungs. Metastasis to bones, adrenals, lymph nodes, brain, and skin has also been reported. Metastatic colorectal carcinoma to the testes is very uncommon. Even more uncommon is testicular metastasis from rectal carcinoma. Researchers throughout the last few decades have not acquired a clear understanding of the lymphatic pathways involved in reported cases of testicular metastasis from primary colorectal carcinoma. These cases may present with testicular complaints after or even before the diagnosis of colorectal cancer; this is why it is crucial to differentiate between primary testicular tumor and a secondary one from a colorectal primary. We searched the English medical literature using the MEDLINE/PUBMED database from 1950 through January 2010. Our search yielded 33 cases of testicular metastasis from rectal or colonic carcinoma. These cases are reviewed and summarized. This paper reviews the literature for all cases of testicular metastasis from colonic and rectal adenocarcinomas shedding light on the possible pathways of metastasis. We recommend that physicians be aware of the risk of metastasis from the colorectal region to the testis in their evaluation of patients with testicular symptoms in the setting of colorectal carcinoma.

A large bi-lobed classic renal angiomyolipoma with vena caval extension.

Renal angiomyolipomas (AMLs) are the most common benign renal tumors encountered, and composed of 3 components: mature adipose tissues, smooth muscles, and blood vessels. Mostly asymptomatic and discovered incidentally, the classic type of AMLs rarely extend to involve great vessels. Radiological confirmation of such lesions is paramount for diagnosis and planned intervention. Management of AMLs is based on clinical presentation and varies from active surveillance to invasive surgical interventions. A case of sizeable classic AML with extension to inferior vena cava is presented here, with successful tumor resection performed after complete liver mobilization. A literature review and a summary of similar cases are also presented. A multidisciplinary approach is required for proper and precise radiological diagnosis to achieve an adequate surgical resection, which might sometimes be complicated and complex, as in this current case.

Metabolic and respiratory variables during pressure support versus synchronized intermittent mandatory ventilation.

BACKGROUND: Mechanically ventilated patients interact and respond differently to different modes of ventilatory support. OBJECTIVES: To assess changes in metabolic and respiratory variables during equivalent changes with either pressure support ventilation (PSV) or volume-cycled synchronized intermittent mandatory ventilation (SIMV) in non-tracheostomized patients without known obstructive pulmonary disease receiving short-term mechanical ventilation in the intensive care unit. METHODS: Fourteen patients receiving volume-cycled SIMV at 12 breaths/min (SIMV(100%)) were included in the study. The PSV level (PSV(100%)) resulting in a minute volume and respiratory rate equivalent to that during SIMV(100%) was determined for each patient. Then each patient underwent trials at 66% and 33% of initial ventilator support with volume-cycled SIMV (SIMV(66%) and SIMV(33%)) and PSV (PSV(66%) and PSV(33%)) in random order. At the end of each trial, oxygen consumption ((.)VO2), carbon dioxide production ((.)VCO2), measured energy expenditures (MEE), peak inspiratory flow, total respiratory frequency, tidal volume, minute ventilation, occlusion pressure (P(0.1)) and inspiratory duty cycle (T(i)/T(tot)) were measured. RESULTS: There were smaller changes in (.)VO2, (.)VCO2 and MEE when equivalent changes were applied with PSV (15.7 +/- 4.4; 12.5 +/- 2.2 and 15 +/- 3.5%) compared with volume-cycled SIMV (32.7 +/- 7.7; 23 +/- 5.2 and 30.7 +/- 6.8%; p < 0.05). P(0.1) and T(i)/T(tot) were significantly smaller during PSV (2.64 +/- 0.28 and 0.38 +/- 0.03 cm H(2)O) than volume-cycled SIMV (4.01 +/- 0.21 and 0.43 +/- 0.02 cm H2O; p < 0.05). CONCLUSIONS: Changes in the level of PSV resulted in smaller changes in metabolic and respiratory variables compared with equivalent changes in the level of volume-cycled SIMV support. PSV may be more suitable for progressive respiratory muscle reloading.

Life threatening presentation of thoracic duct injury post thyroid surgery; a case report.

BACKGROUND: Injury to thoracic duct is a rare potential complication of time-honored conventional thyroidectomy. Nevertheless, it can be a cause of significant morbidity, and sometimes life-threatening. PATIENT FINDINGS: A 78-year-old female patient with a previous surgical history of thyroid lobectomy for nodular disease presented with primary hyperparathyroidism, and a nodule in the remaining thyroid lobe. The patient underwent completion thyroidectomy and parathyroidectomy. Less than 24h post operatively, the patient developed progressive shortness of breath and neck swelling requiring immediate intubation and re-exploration. A large amount of chyle was drained and an injured thoracic duct was identified and ligated. SUMMARY: In experienced hands thyroid surgery is safe. Nevertheless, factors such as the type of pathology and its extent, the level of surgery, and re-operative surgery increase the risk of postoperative complications. Immediate surgical exploration is necessary when patients present with neck swelling and respiratory distress. In our case, a high output chyle leak in a confined space was life threatening. CONCLUSION: Timely re-exploration following thyroid surgery and thorough knowledge of the anatomy of neck structures is crucial in sparing patients potential morbidity and/or mortality.

Complex rectal and anal canal injuries secondary to unusual blunt perineal trauma.

A 27-year-old woman sustained a trauma to her perineal area when she was ejected from a jet ski while riding on water at high speed. The patient presented to the emergency department with blood streaking from her anal canal. Imaging revealed pneumoperitoneum. Surgical intervention showed complex anal canal and rectal injuries. Primary repair of the injuries was performed. Postoperatively the patient did well and was followed up with no evidence of residual symptoms and with a continent anal sphincter.

Abdominal Wall Desmoid during Pregnancy: Diagnostic Challenges.

Background. Desmoids are benign tumors, with local invasive features and no metastatic potential, which have rarely been described to be pregnancy associated. Case. We described the rapid growth of an anterior abdominal wall mass in a 40-year-old pregnant woman. Due to its close proximity to the enlarged uterus, it was misdiagnosed to be a uterine leiomyoma by ultrasound examination. Final tissue diagnosis and radical resection were done at the time of abdominal delivery. Conclusion. Due to the diagnostic limitations of imaging techniques, desmoids should always be considered when the following manifestations are observed in combination: progressive growth of a solitary abdominal wall mass during pregnancy and well-delineated smooth tumor margins demonstrated by imaging techniques. This case emphasizes the importance of entertaining uncommon medical conditions in the differential diagnosis of seemingly common clinical manifestations.

Laparoscopic repair of a left paraduodenal hernia presenting with acute bowel obstruction: report of a case.

An internal hernia is any protrusion of a solid organ or a hollow viscus through a defect within the abdominal cavity. Paraduodenal hernias (PDHs) are rare; however, they are the most common form of internal hernias. We present a case of a left PDH in a 59-year-old healthy woman who presented with acute bowel obstruction. The PDH was diagnosed preoperatively using computed tomography scan. Laparoscopic exploration of the abdomen was then performed for reduction of the hernia. Using this approach, we managed to close the defect with intracorporeal continuous suturing with the aim of avoiding future incarceration. The patient was discharged 60 hours postoperation in a good condition, compared with 3 to 28 days postoperation reported in most of the literature. Our search of the english language literature revealed only 16 reported cases of laparoscopic repair of PDH. We believe that laparoscopic treatment of PDH in experienced hands is recommended in selected cases as it decreases the morbidity and significantly shortens the hospital stay.

Solitary hydatid cyst of the thigh: a challenging diagnosis.

A 53-year-old woman presented with an enlarging mass in the medial aspect of her right thigh. Magnetic resonance imaging suggested an intramuscular hydatid cyst. The cyst was surgically excised. Although muscular hydatidinosis is rare, its resemblance to soft tissue tumors warrants careful diagnosis since any invasive diagnostic measures may lead to fatal complications.