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This is a case series of three patients who presented with complex anorectal fistulas. Each patient underwent repair of complex anorectal fistulas with biologic mesh. We will discuss each case and our institution's experience with this relatively new technique. This case series demonstrates the use of biologic mesh for the repair of complex anorectal fistulas. Three patients are discussed who underwent repair of perianal fistulas using ACell mesh by two separate surgeons. We will discuss the rationale for offering this treatment, as well as the advantages and disadvantages. The use of biologic mesh in perianal fistulas is a relatively new topic that needs further investigation. Perianal fistulas can be difficult to manage for both patients and surgeons. There are many options for repair, ranging from simple to complex. Biologic mesh for complex fistulas may be a useful option to avoid the morbidity of more complex repairs, such as flaps.
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Anatomical airway labeling is crucial for precisely identifying airways displaying symptoms such as constriction, increased wall thickness, and modified branching patterns, facilitating the diagnosis and treatment of pulmonary ailments. This study introduces an innovative airway labeling methodology, BranchLabelNet, which accounts for the fractal nature of airways and inherent hierarchical branch nomenclature. In developing this methodology, branch-related parameters, including position vectors, generation levels, branch lengths, areas, perimeters, and more, are extracted from a dataset of 1000 chest computed tomography (CT) images. To effectively manage this intricate branch data, we employ an n-ary tree structure that captures the complicated relationships within the airway tree. Subsequently, we employ a divide-and-group deep learning approach for multi-label classification, streamlining the anatomical airway branch labeling process. Additionally, we address the challenge of class imbalance in the dataset by incorporating the Tomek Links algorithm to maintain model reliability and accuracy. Our proposed airway labeling method provides robust branch designations and achieves an impressive average classification accuracy of 95.94% across fivefold cross-validation. This approach is adaptable for addressing similar complexities in general multi-label classification problems within biomedical systems.
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Anastomotic leaks are one of the most feared and morbid complications after colorectal anastomosis. Management of leaks depends on the severity of the leak and focuses on controlling sepsis and saving the anastomosis. The lower the anastomosis, the more amenable it is to transanal approaches for salvage. However, when a complication exists higher up in the rectum, the surgeon is more limited in the ability to visualize and intervene. With the advent of transanal minimally invasive surgery (TAMIS) and the advancement of endoscopic procedures, there are now more options for surgeons to visualize and intervene in anastomotic colorectal leaks. Prior reports have described the use of TAMIS for the management of anastomotic leaks in the acute phase. However, this same approach can be useful in the management of chronic leaks. This report highlights the benefit of TAMIS to allow visualization and marsupialization of a chronic abscess cavity following an anastomotic leak.
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Endoluminal vacuum-assisted devices have become increasingly popular solutions for low-colorectal injuries and anastomotic defects in recent years. We present a case of a 23-year-old male who underwent salvage of an ileal pouch-anal anastomosis (IPAA) anastomotic leak with a customized endoluminal vacuum sponge and cavity marsupialization. This case highlights the easy-to-follow steps to create a customized endoluminal vacuum (endo-vac) sponge with readily available materials for the treatment of low colorectal anastomotic leaks. Included are step-by-step photos and instructions for successful endoluminal vacuum device construction.
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Splenic flexure cancer is relatively rare among colon cancers. We present a case of a 76-year-old female with a partially obstructing tumor in the proximal descending colon and pulmonary metastasis who underwent a laparoscopic resection of the splenic flexure with end transverse colostomy due to clinical symptoms of obstruction. This case highlights several important technical considerations in safely performing the laparoscopic resection of the splenic flexure through the medial-to-lateral approach starting at the plane below the inferior mesenteric vein (IMV), taking care to preserve the tail of the pancreas. We present a narrated video demonstrating our approach, taking care to highlight important anatomic landmarks.
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We present a case of a chronic perineal sinus following abdominoperineal resection with management via endoscopic electrocauterization. This patient presented with 1 year of bloody, mucus drainage from a perineal wound following abdominoperineal resection for anastomotic leak and stricture from a remote low anterior resection for T2N1 rectal cancer. We describe a novel use of endoscopic electrocautery to debride, de-epithelialize and ultimately eliminate the sinus cavity. The patient's postoperative course was uncomplicated and reported decreased drainage at 2- and 4-week postoperative follow-up. Long-term plans include sequential drain downsizing to facilitate cavity closure. Our findings suggest that endoscopic electrocauterization can safely and effectively reduce chronic perineal sinus drainage to facilitate cavity elimination, while avoiding morbidity associated with more invasive operative interventions.
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Introduction: Carcinosarcoma, also known as malignant mixed Mullerian tumor (MMMT) is a malignant biphasic neoplasm consisting of carcinomatous and malignant non-epithelial components of mesenchymal origin. MMMTs typically arise from the female genital tract in patients over 40 years old. Primary extragenital MMMTs are extremely rare with published literature totaling 40 reported cases. The primary peritoneal carcinosarcoma is an aggressive tumor as patients with this tumor have an average survival of 7.6 months. Surgical debulking is the mainstay of treatment for these tumors and systemic chemotherapy is advised in all cases. Case: A 48-year-old Amish female presented with 5 day history of bloating and abdominal pain superimposed on a 1 year history of worsening fatigue and intermittent bloody bowel movements. She was found to have a pelvic mass on physical exam. Computed tomography scan of the abdomen and pelvis that demonstrated stricturing of the sigmoid colon, and a large multi-cystic mass in the midline pelvis measuring 12.5 × 9.9 × 11.7 cm. Colonoscopy showed stenosis due to external compression without intraluminal lesion. CEA and CA 125 levels were elevated and CA 19-9 was normal. Exploratory laparotomy was performed with en-bloc resection of a 15 cm mass originating from the sigmoid colon mesentery with several other small tumor deposits throughout the mesentery. Pathology diagnosed primary peritoneal carcinosarcoma Mullerian-type with three positive lymph nodes. Conclusion: Malignant mixed Mullerian tumor (carcinosarcoma) caries a universally grim prognosis. Herein, we report a unique case of primary peritoneal carcinosarcoma and discuss the work-up and surgical management of this rare tumor.
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We present a rare case of recurrent primary midgut volvulus in an elderly female with an interesting intraoperative finding of an abnormally elongated small bowel mesentery. This patient presented with symptoms of obstruction, including nausea, vomiting and obstipation, similar to previous episodes of volvulus for which she underwent exploratory laparotomies and reduction of the volvulus. We describe a novel use for enteropexy in which we effectively shortened the small bowel mesentery in an effort to eliminate the source of recurrent volvulus. The patient's post-operative course was complicated by prolonged ileus requiring total parenteral nutrition. However, she had not developed signs or symptoms of bowel ischemia or recurrent volvulus at the time of this writing. Our findings suggest that enteropexy is an effective technique for preventing recurrent midgut volvulus primarily caused by abnormally elongated mesentery.
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A rectoperineal fistula (RPF) is a relatively rare, non-life-threatening form of anorectal malformation that nevertheless causes significant physical discomfort, and remains technically challenging for surgeons to treat. We present a case of a 72-year-old female with a history of a recurrent perianal fistula with multiple approaches including endorectal advancement flap previously attempted. Our procedure involved laparoscopic loop ileostomy with transversus abdominis plane (TAP) block, and RPF repair through the perineal approach with primary repair involving Martius flap and house advancement flaps. The patient tolerated the procedure well with no known peri-operative complications and resolution of stool incontinence at subsequent post-operative visits, the first within a month of the procedure. This case was used to demonstrate and highlight the surgical technique of the RPF repair by Martius flap. Informed consent was obtained from the patient for video recording for educational purposes.
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Venous aneurysms often present as painful masses. They can present either in the deep or superficial venous system. Deep venous system aneurysms have a greater risk of thromboembolism. Though rare, there have been case reports of superficial aneurysms and thrombus causing significant morbidity such as pulmonary embolism. We present a case of an anomalous greater saphenous vein connection with an aneurysm and thrombus resulting in a pulmonary embolism. This is the only reported case of an anomalous greater saphenous vein connection with aneurysm and thrombus, which eventually led to a pulmonary embolism. Recognition of the morbidity and mortality associated with superficial venous aneurysms can help prevent catastrophic outcomes such as pulmonary embolism. Surgical intervention on large symptomatic superficial venous aneurysms may be the optimal treatment in preventing unwanted complications compared to anticoagulation alone.
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Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder characterized by the appearance of cafe au lait spots, neurofibromas and Lisch nodules. There is an established link between NF1 and the development of breast cancer in women; however, due to the rarity of both NF1 and male breast cancer, the same link has yet to be elucidated in men. The concurrent presentation of NF1 and male breast cancer is a very rare phenomenon with only a handful of case descriptions in the literature. To the best of our knowledge, there have only been four other reported cases of NF1 and male breast cancer before ours. We present one such case of a 56-year-old male with a four generation history of NF1 and a personal history of NF1 who presented with invasive ductal carcinoma of the right breast.
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Successful treatment of traumatic hemothoraces is imperative to reduce morbidity and mortality among patients. Treatment modalities range from more conservative to invasive measures, including antibiotic therapy, thoracostomy tube placement, video-assisted thoracoscopic surgery, or thoracotomy. Various studies have documented success in using fibrinolytics such as tissue plasminogen activator (tPA) in conjunction with deoxyribonuclease administered through a chest tube to resolve a hemothorax. The optimal dose and frequency of fibrinolytic therapy have not yet been determined although most studies report administering therapy two times a day for 3 days. We report a successful case of a one-time dose of fibrinolytic therapy through thoracostomy tube which could support that a single dose may be ideal and sufficient enough to resolve a hemothorax. We also performed this in the acute postoperative period, which has not been well studied, and believe fibrinolytic therapy can be safe to use in this setting.