An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer.

BACKGROUND: Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method. METHODS: A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α. RESULTS: Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance. CONCLUSIONS: The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

Freedom of choice adds value to public goods.

Public goods, ranging from judiciary to sanitation to parkland, permeate daily life. They have been a subject of intense interdisciplinary study, with a traditional focus being on participation levels in isolated public goods games (PGGs) as opposed to a more recent focus on participation in PGGs embedded into complex social networks. We merged the two perspectives by arranging voluntary participants into one of three network configurations, upon which volunteers played a number of iterated PGGs within their network neighborhood. The purpose was to test whether the topology of social networks or a freedom to express preferences for some local public goods over others affect participation. The results show that changes in social networks are of little consequence, yet volunteers significantly increase participation when they freely express preferences. Surprisingly, the increase in participation happens from the very beginning of the game experiment, before any information about how others play can be gathered. Such information does get used later in the game as volunteers seek to correlate contributions with higher returns, thus adding significant value to public goods overall. These results are ascribable to a small number of behavioral phenotypes, and suggest that societies may be better off with bottom-up schemes for public goods provision.

Laser treatment of pilonidal disease: a systematic review.

Pilonidal disease (PD) is a common condition, and there is still an ongoing debate on ideal management that should be minimally invasive, safe, and efficient. The use of radially emitting laser in the treatment of chronic PD is a novel minimally invasive technique, and initial studies with a small number of patients showed promising results. This study aimed to assess the efficacy and safety of chronic PD treatment with a laser using a systematic review of the published literature. A systematic review was conducted after PubMed, Scopus, Embase, Web of Science, and the Cochrane database search for studies reporting laser treatment of chronic PD. Also, our unpublished prospective single-center study was included in this review. Ten of 87 studies were eligible for the review, including 971 patients. The median age of the patients was 26 (range 13-68), and the median operative time was 26 (range 6-65) min. With a median follow-up of 12 (range 7-25) months, 917 (94.4%) patients achieved primary healing with a weighted mean recurrence rate of 3.8%. The weighted mean complication rate was 10% (95% CI 5.7-14.3%, I2 = 82.28, p < 0.001), and all were minor. The published literature demonstrates that laser treatment is a promising procedure in the management of chronic PD. Furthermore, the review showed that standardized operative techniques and perioperative steps were used. The results were limited to the mild chronic PD. Classification of PD severity and standardized outcome reporting is required to define indications and contraindications for laser PD treatment. Randomized controlled trials are needed to determine the long-term effectiveness and superiority of laser treatment over other methods.

Duodenal diverticulum causing obstructive jaundice - Lemmel's syndrome.

The duodenum is the second most common location of intestinal diverticula. Periampullary duodenal diverticulum rarely causes obstructive jaundice and this condition was first described by German surgeon Gerhard Lemmel in 1934. Lemmel's syndrome is defined as obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledocholithiasis or a neoplasm.

Psychological Effects of "Double Crisis" (COVID-19 Pandemic and Earthquakes) on Croatian Medical Students.

INTRODUCTION: In 2020. the COVID-19 pandemic presented an additional source of stress and anxiety not just to the general population but also to medical students who are, even under normal circumstances, constantly under pressure due to demanding student duties. In addition, they experienced a series of devastating earthquakes in and around the Zagreb region which altogether could have had compromised their psychological well-being. The aim of this review was to evaluate the psychological effects of these two natural disasters on the mental health of Croatian medical students. RESULTS: According to standardized questionnaires for depression and anxiety evaluation, 75.3% of students were anxious and 65.2% were depressive during the "double crisis". No significant difference of these two outcomes was observed regarding genders, but it was found that first year students had a significantly higher anxiety score than older ones. CONCLUSION: In such stressful situations, we should emphasize the importance of mental health not just of healthcare workers, but also of medical students in order to prevent serious psychological consequences and to alleviate the negative effects on students' motivation and their educational process.

A Single Small Bowel Hemangioma Detected by Video Capsule Endoscopy in a Patient Presenting with Iron-deficiency Anemia - Two Case Reports.

Hemangioma of the small intestine is a rare vascular malformation which mostly presents as occult gastrointestinal bleeding and iron-deficiency anemia. Patients are often asymptomatic except of fatigue due to anemia. Hemangiomas can arise anywhere in the luminal gastrointestinal tract, with jejunum as the most commonly involved site. They are very hard to recognize mostly due to their localization. Video capsule endoscopy and balloon-assisted enteroscopy have very much improved preoperative diagnostics and made major contribution to establishing the diagnosis - which was very difficult in the past and almost all cases were diagnosed during or after the operation. Surgical resection is still the conventional treatment modality, although with the improvement of endoscopic therapeutic interventions (endoscopic mucosal resection, argon-plasma coagulation) there are more therapeutic possibilities.

[FEMUR FRACTURES IN CHILDREN ­ CAUSES AND MECHANISMS OF INJURY].

Children are often exposed to injuries due to their hyperactivity. Femur fractures can however leave permanent consequences despite adequate treatment. The high prevalence and possible invalidity justify research in the field of prevention of this injury. But prevention is possible only by knowing the causes and circumstances of the fractures. The aim of this research is to analyze the circumstances and places of occurrence in femur fractures according to children age groups. This retrospective study includes 103 children up to the age of 18 years treated at the University Hospital Center of Medicine Zagreb, or at the Clinic for children diseases Zagreb in the period from 2012 to 2016. The study includes 35 (33 %) girls and 71 (67 %) boys, a total of 106 children with femur fractures. The average age was five years. The majority of the injured children, 52 children (55,2 %), belonged to the youngest age group from 0 to 4 years of age. Diaphysis fractures were the most common with 66 fractures (62 %), and the rarest were fractures of the distal metaphysis with 15 fractures (13 %). The fractures occurred at home in 41 cases (38 %), in the street in 38 cases (36 %), at recreation in 22 cases (21 5), and at school or kindergarten in 3 cases (3 %). The most common causes of femur fractures were falls in 38 cases (57,5 %), motor vehicle accidents in 35 cases (33 %), and crashes and blows in 10 cases (9,5 %). One third of the children with femur fractures had associated injuries, and four fifths of them were caused by motor vehicle accidents. The results of this study show that femur fractures are most frequent in the youngest age groups, and are generally a consequence of accidents at home (mostly falls), seldom in the streets or recreational places. Parents of preschool children should be educated about prevention of falling at their homes, and parents of school children should be educated about the dangers of fractures at recreational places and traffic.

FRACTURE OF THE HUMERUS IN CHILDREN ­ CAUSES AND MECHANISMS OF INJURY. / PRIJELOMI NADLAKTICNE KOSTI U DJECE ­ OKOLNOSTI I UZROCI NASTANKA.

Due to hyperactivity, children are often exposed to injuries of the upper arm and fractures of the humerus can leave permanent damage even after the surgical treatment. The high incidence of fractures justifi es questioning the possible prevention of this injury. Preventive actions are possible only with the knowledge of the causes and circumstances of the fracture. Aim is to analyze the circumstances of the injury, critical places and activities engaged in at the time of the humeral fracture by age groups. The paper analyzed 102 children that were treated at the University Hospital Centre in Zagreb due to fractures of the humerus in the period from 2010 to 2014. In this study, we analyzed 45 girls (44%) and 57 boys (56%). The average age of children was 8.3 years. Fractures of the distal third of the humerus accounted for 4/5 of all analyzed fractures. The right hand was affected more frequently. Nearly 80% of fractures were unstable, which generally require surgical treatment. The injury occurred most often among the 5-9 year-olds. Most injuries took place at the recreational facilities (47%), followed by injuries at home (31%), on streets or roads (15%) and at school or kindergarten (7%). Mechanism of the injury was mainly a fall onto the arm (94%) and the rest of the injuries were due to a direct blow. Almost half of the children got injured in sports or recreational activities. Due to close physical contact and engagement in games, children in preschool and early school age are by far the most susceptible to injuries. To reduce the incidence of such injuries, preventive actions should be taken during daily activities under the supervision of parents towards the most vulnerable age group (5-9 years), along with increasing the supervision in preschools and schools. Of all the activities, the most dangerous to cause fractures of the humerus occur in sports grounds and recreational facilities of preschool children and children in the lower grades of elementary school.

[FRONTAL, AXILLARY AND TYMPANIC TEMPERATURE MEASUREMENTS IN CHILDREN]. / TIMPANICNA, FRONTALNA I AKSILARNA TEMPERATURA U DJECE.

The purpose of this study was to compare the results of body temperature measurements obtained by standard axillary thermometers with the results of infrared tympanic and frontal skin thermometry in afebrile children. This study comprises a single-center, prospective comparison trial. A total of 345 afebrile children aged 4 to 16 years hospitalized in the pediatric surgery department for elective surgery were included. One thousand axillary, tympanic and frontal measurements were obtained and compared. We used two different infrared thermometers in this study; one type measured the tympanic temperature, the other the temperature on the forehead. The axillary temperature measured with the glass thermometer was set as the standard. Each patient was exposed to a constant environmental temperature for a minimum of 10 min before simultaneous temperature measurements. The mean-frontal temperature 36.9 ± 0.38 °C was equal to the axillary temperature 36.9 ± 0.16 °C. The mean tympanic temperature was 36.3 ± 0.98 °C. The mean difference between the tympanic and axillary temperatures was -0.4 °C. The tympanic temperature had a threefold greater dispersion than frontal and a fivefold greater dispersion than axillary temperature. The results of this study suggest that the axillary temperature measured with glass thermometer has the least dispersion. Somewhat less reliable is the frontal temperature measured with infrared thermometer. The least reliable is tympanic temperature measurement.

A Synchronous Occurrence of Hepatocellular Carcinoma and Echinoccocal Liver Cyst - Can Parasite Promote Carcinogenesis? Literature Review and Classification Proposal.

Concomitant presence of hydatid cyst and hepatocellular carcinoma is a very rare clinical scenario especially in a previously non-diseased liver. Including our case here reported, there are 12 cases of synchronous HCC and hydatid cyst found in the scientific literature and 3 of them were found in a patient with non-diseased liver. We provide detailed review of all reported cases with additional highlights on etiology, pathogenesis, diagnosis, treatment and outcomes of both HCC and echinococcal disease. Although there is a small number of patients, possible relation between these 2 liver lesions should be investigated and standardized classification should be established. This will help us to understand the nature of HCC carcinogenesis, identify diagnostic features of liver lesions and choose the most appropriate type of treatment.

[HAND FRACTURES IN CHILDREN - CAUSES AND MECHANISMS OF INJURY]. / PRIJELOMI KOSTIJU SAKE U DJECE - OKOLNOSTI I UZROCI NASTANKA.

Hand is extremely exposed to various loads and traumas of everyday tasks and activities, resulting in fist fractures being fairly common injuries. The most common mechanism of injury is a direct blow. This retrospective study analyzed the data on 274 children admitted for hand fractures at Clinical Hospital Center Zagreb in the period from 2006 to 2014. The study included 76 girls (28%) and 198 boys (72%). The average patient age was 11.9 years and most were between 10 and 13 years of age. Phalangeal fractures accounted for 80%, metacarpal fractures for 17%, and carpal fractures for 3% of all injuries. Most commonly injuries occurred during recreation (4 1%), at home (37%), at school (18%) and in the street (4%). Direct blow was the major cause of injury (76%), and 24% were caused by fall. Injuries during sport activities are the most common cause of the hand fractures in pediatric population and direct blow is the main mechanism of injury. The peak incidence is at the age of 10-13 years in boys and girls, so prevention should be aimed at this age group. Preventive actions should be focused on injuries that tend to occur in parks, schools and during sport activities.

[Radius fractures in children--causes and mechanisms of injury]. / Prijelom palcane kosti u djece--okolnosti i uzroci nastanka.

Radius fractures are the most common fractures in childhood. The main mechanism of injury is fall onto an outstretched hand. This retrospective study analyzed the data on 201 children admitted for radius fractures at KBC-Zagreb in the period 2011-2013. The study included 85 girls (42.3%) and 116 boys (57.7%) . The average age of the children was 9.6 years. Radius was injured in the distal segment in 79.1% of children. The sites of injuries were: park, campi and beach (24.9% of all children), playground, skate park and swimming pool (23.9%), kindergarten or school (20.9%), at home and around the house (17.9%), in the street (11.4%) and in the store or at a hotel (0.9%). The boys were mostly injured at playgrounds, during skating and at swimming pools (37.1% of all boys), while girls were mostly injured in parks, camps and at beach (42.4% girls). Fall was the major cause of the injury (49.3%), and children usually fell during ice skating and skating (32.3% of all falls). In 20.4% the injury was caused by pushing and hitting. The smallest percentage (9.5%) of children were injured in traffic accidents while riding a bike (only one child was hit by a car). Sport related activities caused injuries in 53.7% of the cases. Sport activities are the most important cause of the radial fractures in the pediatric population and falls during sports are the main mechanism of injury. The peak incidence is at 12 years for boys and at 10 years for girls, so intervention and/or prevention should be aimed at the age groups. Preventive actions should be focused on injuries that tend to occur in parks, schools and during sport activities.

[CLAVICLE FRACTURES IN CHILDREN--CIRCUMSTANCES AND CAUSES OF INJURY]. / PRIJELOM KLAVIKULE U DJECE--OKOLNOSTI I UZROCI NASTANKA.

Clavicle fractures in children occur twice as often as in adults. During a child's growth period they account for 10-15% of all fractures sustained. The questions which should be asked are how these fractures are sustained and under which circumstances are the children injured. In the study 256 children with clavicle fractures treated during the period 2008-2013 were analyzed. The underlying cause and place of injuries were classified using the ICD-10 classification system, using environmental causes of injury. The circumstances were in each case accidental injury. Environmental causes were traffic accidents (V01-V99) or mishaps/accidents (W00-X59). Fracture injuries were caused in traffic accidents in 24 (9.4%), and in mishaps/accidents in 232 (90.6%) children. Of the injuries caused by mishaps/accidents, in 204 children these were caused by falls (W00-W19). In 123 of them the injuries were caused by falls from a ground level, and in 81 were from a greater height. Direct blow injuries, caused by another person or a blunt instrument, weere the causes of fractures seen in 28 children. Place of fracture sustainment was dominantly at home. This was followed by injuries sustained outside in recreational areas, while least were suffered at school or kindergarden facilities. Bicycle riding was the cause of clavicle fractures in 48 children, which was 18.7% of all fractures seen. Sports related injuries and fractures were seen in 47 (18.4%) out of 256 children: 30 in football, 10 in defensive sports (wrestling, judo, karate), three in hockey, while basketball and gymnastics accounted for two each. Preschool children were injured more often while in the care of their parents while school aged children were adaquately protected, but in after-school activities they were often injured. The most common injuries after school were those suffered in traffic accidents and recreational sports activities. In the adolescent period, the most common injuries seen were again those in traffic accidents, bicycle riding, recreational sports activities and injuries sustained at home.

Correlation between the liver transection line localization and future liver remnant hypertrophy in associating liver partition and portal vein ligation for staged hepatectomy.

Background and aims: Colorectal liver metastases (CRLMs) represent the most prevalent form of secondary liver tumors, and insufficient future liver remnant (FLR) often leads to unresectability. To tackle this challenge, various methods for stimulating liver hypertrophy have been developed including portal vein embolization (PVE), associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and the newest one, liver venous deprivation (LVD). ALPPS was thoroughly studied over the last decade and it has been shown to induce rapid and intensive FLR hypertrophy. The objective of this study was to assess whether the localization of the liver transection line during the initial stage of ALPPS correlates with the degree of FLR hypertrophy. Methods: A retrospective, multicentric study was conducted, and we analyzed all consecutive patients with CRLMs who underwent ALPPS over the eight-year period. Patients were categorized into two groups based on the type of resection-right trisectionectomy (ERH) or right hemihepatectomy (RH) respectively. The degree of hypertrophy (DH), its correlation with FLR and postoperative outcomes were assessed. Results: The cohort consisted of 136 patients (72 in the ERH group and 64 in the RH group). Baseline characteristics, hypertrophy interval, and total liver volume showed no significant differences between the groups. DH was greater in the ERH group (83.2% vs. 62.5%, p = 0.025). A strong negative correlation was observed between FLR volume and DH in both groups. Postoperative outcomes and one-year survival were comparable between the groups. Conclusions: FLR hypertrophy is influenced by the localization of the liver transection line in ALPPS. Furthermore, correlation analysis indicated that a smaller estimated FLR is associated with greater DH. No statistical difference in outcomes was noted between the groups.

Step-Up versus Open Approach in the Treatment of Acute Necrotizing Pancreatitis: A Case-Matched Analysis of Clinical Outcomes and Long-Term Pancreatic Sufficiency.

Background/Objectives: Acute necrotizing pancreatitis (ANP) with secondary infection of necrotic tissue is associated with a high rate of complications and mortality. The optimal approach is still debatable, but the minimally invasive modality has gained great attention in the last decade as it follows the principle of applying minimal surgical trauma to achieve a satisfying therapeutic objective. We compared clinical outcomes between the step-up approach (SUA) and open necrosectomy (ON) in the treatment of acute necrotizing pancreatitis. Methods: A prospective cohort study over the period of 2011-2021 in a university teaching hospital was performed. Results of 99 consecutive patients with ANP who required surgical/radiological intervention were collected. A case match analysis (2:1) was performed, and the final groups comprised 40 patients in the OA group and 20 patients in the SUA group. Demographic, clinicopathologic, and treatment data were reviewed. Results: Baseline characteristics and disease severity were comparable between the two groups. The patients from the SUA group had a significantly lower morbidity rate and rate of pancreatic insufficiency. Death occurred in 4 of 20 patients (20%) in the SUA group and in 11 of 40 patients (27.5%) in the ON group (risk ratio with the step-up approach, 0.72; 95% confidence interval, 0.26 to 1.99; p = 0.53). Conclusions: A minimally invasive step-up approach provides comparable outcomes to open necrosectomy in the treatment of ANP with infected pancreatic necrosis. While mortality and hospital stay were comparable between the groups, morbidity and pancreatic insufficiency were significantly lower in the SUA group. Further studies on a larger number of patients are required to define the place of SUA in the modern treatment of ANP.

Maternal choledochal cysts in pregnancy: A systematic review of case reports and case series.

BACKGROUND: Choledochal cysts (CC) are cystic dilatations of the biliary tract, usually diagnosed during childhood, with an estimated incidence in the general population of 1:100000. Complications related to CC include rupture, biliary obstruction, and cholangitis. Maternal CC in pregnancy are rarely reported, and there are no guidelines on optimal management. AIM: To systematically review maternal CC diagnosed during pregnancy or postpartum with regard to the clinical presentation of CC, the mode of treatment and delivery, and maternal outcomes. METHODS: A literature search of cases and case series of maternal CC in pregnancy and postpartum was conducted using MEDLINE/PubMed, Web of Science, Google Scholar, and Embase. There were no restrictions on language or publication year. Databases were lastly accessed on September 1, 2022. RESULTS: Overall, 71 publications met the inclusion criteria, reporting 97 cases. Eighty-eight cases were diagnosed during pregnancy and nine in the puerperium. The most common symptoms were abdominal pain (81.2%) and jaundice (60.4%). Interventions for CC complications were required in 52.5% of the cases, and 34% of pregnancies were induced. Urgent cesarean section (CS) was done in 24.7%. The maternal mortality was 7.2%, while fetal mortality was inconsistently reported. Cholangitis, CC > 15 cm, and bilirubin levels > 80 mmol/L were associated with a higher likelihood of urgent CS and surgical intervention for CC. Bilirubin levels positively correlated with CC size. There was no correlation between age and cyst dimension, gestational age at cyst discovery, and CC size. CONCLUSION: Although rare, maternal CC in pregnancy should be included in the evaluation of jaundice with upper abdominal pain. Symptomatology and clinical course are variable, and treatment may range from an expectative approach to emergent surgical CC treatment and urgent CS. While most cases were managed by conservative measures or drainage procedures, CC > 15 cm and progressive cholangitis carry the risk of CC rupture and septic complications, which may increase the rates of unfavorable maternal and fetal outcomes. Therefore, such cases require specific surgical and obstetric interventions.

Colorectal adenocarcinoma presenting with a pathological fracture due to a solitary bone metastasis to the tibia: a case report and literature review.

Introduction: Solitary bone metastasis of colorectal carcinoma (CRC) without other metastasis sites is extremely rare and can be found in less than 1% of patients with CRC. Aim: In the present study, we report the first case of a solitary tibia metastasis and its pathologic fracture as the first presenting feature of a colorectal adenocarcinoma. Material and methods: A 78-year-old female patient presented to our emergency department due to atraumatic pretibial swelling. Plain radiography did not detect any pathology. The swelling was incised and serous-bloody collection was evacuated, and the patient was discharged. On the 17th postoperative day, during a regular walk, the patient fell down and broke her leg, which transpired to be a pathologic fracture of the proximal tibial diaphysis, confirmed by X-ray. A biopsy of the altered bone tissue from the fracture site revealed metastatic colorectal adenocarcinoma. On colonoscopy, a circular mass in the upper rectum was found. Conclusions: Solitary bone metastases are most commonly found in bones that are related to venous drainage via the paravertebral plexus of Batson - the pelvis, vertebrae, and sacrum. Long bones are extremely rare localizations of solitary CRC metastases, with only few cases published so far in medical literature. In our case, the patient`s first symptom was related to the osseous tibial metastasis - leg swelling. No tumour was suspected until the pathologic fracture occurred. It is important to consider osseous metastasis in every patient with unexplained swelling, haematoma, or pain of the extremities and make a bone scan to recognize the metastasis early.

Colonic gallstone ileus: a systematic literature review with a diagnostic-therapeutic algorithm.

Rare complication of gallstone disease is gallstone ileus. The common location is the small intestine, followed by the stomach. The rarest location is colonic gallstone ileus (CGI). To summarize and define the most appropriate diagnostic methods and therapeutic options for CGI based on the paucity of published data. Literature searches of English-, German-, Spanish-, Italian-, Japanese-, Dutch- and Portuguese language articles included and Italian-language articles using PubMed, EMBASE, Web of Science, The Cochrane Library, and Google Scholar. Additional studies were identified from the references of retrieved studies. 113 cases of CGI were recorded with a male to female patient ratio of 1:2.9. The average patient age was 77.7 years (range 45-95 years). The usual location of stone impaction was the sigmoid colon (85.8%), followed by a descending colon (6.6%), transverse colon (4.7%), rectum (1.9%), and lastly, ascending colon (0.9%). Gallstones ranged from 2 to 10 cm. The duration of symptoms was variable (1 day to 2 months), with commonly reported abdominal distension, obstipation, and vomiting; 85.2% of patients had previous biliary symptoms. Diverticular disease was present in 81.8% of patients. During the last 23 years, CT scan was the most common imaging method (91.5%), confirming the ectopic gallstone in 86.7% of cases, pneumobilia in 65.3%, and cholecytocolonic fistula in 68%. The treatment option included laparotomy with cololithotomy and primary closure (24.7%), laparotomy and cololithotomy with diverting stoma (14.2%), colonic resection with anastomosis (7.9%), colonic resection with a colostomy (12.4%), laparoscopy with cololithotomy with primary closure (2.6%), laparoscopy with cololithotomy with a colostomy (0.9%), colostomy without gallstone extraction (5.3%), endoscopic mechanical lithotripsy (success rate 41.1%), extracorporeal shock wave lithotripsy (1.8%). The cholecystectomy rate was 46.7%; during the initial procedure 25%, and as a separate procedure, 21.7%; 53.3% of patients had no cholecystectomy. The survival rate was 87%. CGI is the rarest presentation of gallstone ileus, mainly in women over 70 years of age, with gallstones over 2 cm, and predominantly in the sigmoid colon. Abdominal CT is diagnostic. Nonoperative treatment, particularly in subacute presentations, should be the first-line treatment. Laparotomy with cololithotomy or colonic resection is a standard procedure with favorable outcomes. There are no robust data on whether primary or delayed cholecystectomy is mandatory as a part of CGI management.

Case report: Sevelamer-associated colitis-a cause of pseudotumor formation with colon perforation and life-threatening bleeding.

Chronic kidney disease (CKD) is a very common chronic non-communicable disease. Phosphate and calcium metabolism disorders are one of the most common features of CKD. Sevelamer carbonate is the most widely used non-calcium phosphate binder. Gastrointestinal (GI) injury associated with sevelamer use is a documented adverse effect but is underrecognized as a cause of gastrointestinal symptoms in patients with CKD. We report a case of a 74-year-old woman taking low-dose sevelamer with serious gastrointestinal adverse effects causing colon rupture and severe gastrointestinal bleeding.