Unique endoscopic features of primary biliary diffuse large B-cell lymphoma: A case report with literature review (with video).

A 67-year-old man visited our hospital complaining of dark-colored urine and upper abdominal pain. Magnetic resonance cholangiopancreatography showed stricture of the distal bile duct, and contrast-enhanced computed tomography showed irregular thickening of the distal bile duct wall. However, no enlarged lymph nodes, pancreatic tumors, or other neoplastic lesions were apparent around the bile duct. Endoscopic ultrasonography and intraductal ultrasonography showed irregular thickening of the inner hypoechoic layer without the disappearance of the innermost thin hyperechoic layer. On the basis of these findings, we considered that the bile duct lesion was of non-epithelial origin. Thus, we repeatedly performed bile duct biopsies from the same site under fluoroscopy to obtain a sample of the submucosal tissue. The pathological diagnosis was diffuse large B-cell lymphoma, and the patient received systemic chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). After six courses of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone, positron emission tomography-computed tomography showed the disappearance of 18-fluorodeoxyglucose uptake in the bile duct and endoscopic retrograde cholangiography showed improvement of the bile duct stricture. Endoscopic findings and repeated biopsies were useful in making the diagnosis of primary biliary diffuse large B-cell lymphoma.

Unilateral drainage and chemotherapy prolong the patency of a plastic stent placed above the sphincter of Oddi in patients with malignant hilar biliary obstruction.

Objectives: To evaluate the results of inside stent therapy for unresectable malignant hilar biliary obstruction and identify factors related to stent patency duration. Methods: Of 44 patients who underwent initial inside-stent placement above the sphincter of Oddi from April 2017 to December 2022, 42 with the resolution of jaundice (clinical success rate, 95.5%) were retrospectively analyzed. Univariate and multivariate logistic regression analysis identified factors associated with stent patency duration. Results: Univariate analysis revealed significant differences in the drainage method (406 days for unilateral drainage vs. 305 days for bilateral drainage of the right and left liver lobes, p = 0.022) with or without chemotherapy (406 days with vs. 154 days without, p = 0.038). Multivariate analysis (Cox proportional hazards analysis) revealed similar results, with unilateral drainage (p = 0.031) and chemotherapy (p = 0.048) identified as independent factors associated with prolonged stent patency. Early adverse events were observed in two patients (4.8%; one cholangitis, one pancreatitis). Conclusions: Inside-stent therapy was safely performed in patients with malignant hilar biliary obstruction. Simple unilateral drainage and chemotherapy may prolong stent patency.

Efficacy and safety of uncovered self-expandable metal stents for distal malignant biliary obstruction in unresectable non-pancreatic cancer.

Objectives: The efficacy of uncovered self-expandable metal stents (UCSEMS) versus fully covered self-expandable metal stents for distal malignant biliary obstruction remains controversial. Additionally, the heterogeneity of the disease conditions has been indicated in previous studies because pancreatic and non-pancreatic cancers have different characteristics in clinical course. Therefore, the etiology of biliary obstruction necessitates investigations stratified by primary disease. This study aimed to evaluate the outcomes of UCSEMS, specifically for non-pancreatic cancer-induced distal malignant biliary obstruction. Methods: We conducted a single-center retrospective review to evaluate the time to recurrent biliary obstruction and frequency of adverse events (AEs) in patients receiving UCSEMS for unresectable non-pancreatic cancer-induced malignant biliary obstruction. Results: Overall, 32 patients were enrolled in the study between January 2016 and December 2023. The median time to recurrent biliary obstruction was 140 days. AE rates were low at 3.1% for both pancreatitis and cholecystitis, suggesting a potential benefit of UCSEMS in reducing post-procedural AEs. Conclusion: UCSEMS may reduce the risk of post-procedural AEs and should be considered in patients at high risk of post-endoscopic retrograde cholangiopancreatography pancreatitis. However, the patency period may be shorter, necessitating future comparative research with fully covered self-expandable metal stents to determine the optimal stent choice.

Incidência de obstrução em cateteres periféricos intravenosos em adultos e fatores relacionados / Incidence of obstruction in peripheral intravenous catheters in adults and related factors / Incidencia de obstrucción en catéteres intravenosos periféricos en adultos y factores relacionados

Objetivo: analisar a incidência e os fatores relacionados à obstrução de cateter intravenoso periférico em adultos hospitalizados. Método: uma coorte prospectiva, realizada a partir da observação de 203 cateteres, entre fevereiro de 2019 e maio de 2020, em hospital público e de ensino brasileiro. Foram consideradas variáveis clínicas e do cateter. Os dados foram analisados descritivamente e por estatística inferencial. Resultados: o tempo de permanência variou entre um a 15 dias e a obstrução ocorreu em 7,5% das observações. Houve aumento do risco de obstrução em relação ao sexo (RR=0,49 / p=0,186), à idade (RR=1,20/ p=0,732), aos cateteres de maior calibre (RR=0,53/ p=0,250), à inserção no dorso da mão até antebraço (RR=2,33/ p=0,114) e ao tempo do cateter in situ (RR=033/ p=0,433). Conclusão: O cuidado diário e observação do cateter intravenoso periférico são importantes para minimizar o surgimento de complicações locais e sistêmicas e manter a patência do dispositivo.

Objective: to analyze the incidence and factors related to peripheral intravenous catheter obstruction in hospitalized adults. Method: a prospective cohort, based on the observation of 203 catheters, between February 2019 and May 2020, in a Brazilian public teaching hospital. Clinical and catheter variables were taken into account. The data was analyzed descriptively and using inferential statistics. Results: the length of stay ranged from one to 15 days and obstruction occurred in 7.5% of the observations. There was an increased obstruction risk in relation to gender (RR=0.49 / p=0.186), age (RR=1.20/ p=0.732), larger catheters (RR=0.53/ p=0.250), insertion in the back of the hand up to the forearm (RR=2.33/ p=0.114) and the time length the catheter was in situ (RR=033/ p=0.433). Conclusion: Daily care and observation of the peripheral intravenous catheter is important to minimize the appearance of local and systemic complications and maintain the patency of the device.

Objetivo: analizar la incidencia y los factores relacionados con la obstrucción del catéter intravenoso periférico en adultos hospitalizados. Método: cohorte prospectiva, realizada mediante la observación de 203 catéteres, entre febrero de 2019 y mayo de 2020, en un hospital escuela público brasileño. Se consideraron variables clínicas y del catéter. Los datos se analizaron de forma descriptiva y mediante estadística inferencial. Resultados: el tiempo de permanencia varió entre uno y 15 días y la obstrucción ocurrió en el 7,5% de las observaciones. Hubo mayor riesgo de obstrucción en relación con el sexo (RR=0,49 / p=0,186), la edad (RR=1,20 / p=0,732), los catéteres de mayor calibre (RR=0,53 / p= 0,250), la inserción en el dorso de la mano hasta el antebrazo (RR=2,33/ p=0,114) y el tiempo del catéter in situ (RR=033/ p=0,433). Conclusión: el cuidado diario y la observación del catéter intravenoso periférico son importantes para minimizar la aparición de complicaciones locales y sistémicas y mantener la permeabilidad del dispositivo.

Translation and validation of the Bahasa Malaysia version of the Nasal Obstruction Symptom Evaluation scale (M-NOSE).

Background: The Nasal Obstruction Symptom Evaluation (NOSE) is a questionnaire to assess patients with nasal obstruction. The aim of this study was to translate and validate NOSE to the Malay version NOSE (M-NOSE). Methods: The NOSE questionnaire was translated to Malay language and back to English. Psychometric properties consisting of reliability, reproducibility, validity, responsiveness were appraised in patients with nasal obstruction due to deviated nasal septum and healthy asymptomatic controls. Results: A total of 126 participants were recruited. There was significant difference between patients and controls for all items and the total score (all p < 0.001). The correlation was moderate to strong between all items and total score (r = 0.71 to 0.8) and fair to moderate for the inter-items correlations (r= 0.31 to 0.70). Internal consistency for M-NOSE was good (α = 0.81). The test-retest for each item demonstrated no significant difference. There was significant difference of the pre- and post-operative mean for each item and total score (all p < 0.001) with good response sensitivity (effect size, d = 4.91). Conclusions: The M-NOSE has satisfactory reliability, internal consistency, reproducibility and responsiveness. It is a valid and convenient tool in the assessment of the impact and treatment outcome of nasal obstruction.

Burkitt's lymphoma revealed by intestinal obstruction: A case report.

Intestinal obstruction is a surgical emergency frequently encountered in routine practice, usually caused by abdominal adhesions. Although extra nodal lymphoma is most often localized in the gastrointestinal tract and may be responsible for intestinal obstruction, Burkitt's lymphoma is a very rare cause in adults. We report a case of Burkitt's lymphoma mimicking an intestinal obstruction in a 48-year-old adult who presented with an obstructive syndrome and altered general condition. Imaging and anatomopathological examination after immunohistochemical analysis concluded to a multi-systemic Burkitt's lymphoma. Chemotherapy was immediately started with complete remission.

Left Ventricular Outflow Tract and Transcatheter Mitral Valve Replacement Obstruction and TMVR: Predictors, Evaluation, and Solutions.

In this issue of Structural Heart, high-impact presentations from Transcatheter Valve Therapies 2023 are reviewed. Dr Jaffar Khan provided updates on the current understanding of left ventricular outflow tract obstruction in the field of transcatheter mitral valve replacement, highlighting known predictors of obstruction, a generally agreed-upon strategy for preprocedure assessment, and a host of management strategies in various stages of development and study.

Swallowed secrets - Plastic bezoar-induced gastric outlet obstruction in a 14-year-old girl: A case report.

INTRODUCTION: Gastric outlet obstruction (GOO) is a rare but serious condition that can arise from various etiologies, including foreign body ingestion. We present a unique case of GOO in a 14-year-old girl resulting from the accumulation of plastic materials, known as a plastic bezoar, due to pica behavior. CASE PRESENTATION: A 14-year-old girl with a history of pica presented with symptoms suggestive of acute gastric obstruction. Imaging studies revealed the presence of a large foreign body extending from the stomach to the jejunum, consistent with a plastic bezoar. Despite attempts at endoscopic removal, surgical intervention was ultimately required due to the size and location of the bezoar. DISCUSSION: This case underscores the challenges associated with diagnosing and managing gastric outlet obstruction secondary to plastic bezoar formation, particularly in pediatric patients with underlying pica behavior. The diagnostic workup involved a multidisciplinary approach, including imaging studies and endoscopic evaluation. Surgical intervention, although invasive, proved necessary for definitive treatment in this case. Postoperative care focused on monitoring for complications and addressing the underlying pica behavior through psychological intervention and support. CONCLUSION: This case highlights the importance of early recognition, thorough diagnostic evaluation, and prompt intervention to prevent complications and ensure favorable outcomes. Collaborative efforts between medical and surgical teams are essential for the comprehensive management of such cases, emphasizing the need for tailored approaches to address both the physical and psychological aspects of care.

Differential impact of chronic intermittent hypoxia and stress changes on condylar development.

OBJECTIVES: This study aimed to determine the effects of chronic intermittent hypoxia (CIH) and stress change (SC) on the development of the condyle in mouth breathing rats. DESIGN: A total of 120 4-week-old rats were randomly assigned to one of five groups. The control (Ctrl) group was the blank control and the intermittent nasal obstruction (INO) group was the positive control. Mild CIH (mCIH) and severe CIH (sCIH) groups were developed by adjusting environmental oxygen concentration and monitoring real-time blood oxygen saturation (SpO2). The SC group was developed using INO, increased environmental oxygen concentration, and real-time SpO2 monitoring. Six rats from each group were sacrificed for analysis at 0, 1, 2, or 4 weeks. RESULTS: Similar to the INO group, condyle and mandibular body development in the sCIH group, but not in the mCIH group, was significantly inhibited compared with the Ctrl group. The SC group had inhibited development of the condyle, especially of the posterior zone, but had minimal impact on the growth of the mandible. CONCLUSION: The inhibitory effects of CIH on the development of the condyle and mandibular body were SpO2-dose-dependent. When SC occurred, inhibited development was observed in the posterior zone of condyle but not the whole mandible. These findings provide important insights for targeted interventions that address the consequences of mouth breathing in children.

Upper gastrointestinal Obstruction as an unusual presentation of Thoracoabdominal huge aortic aneurysm; a case report.

INTRODUCTION AND IMPORTANCE: Giant aortic aneurysms, defined as those exceeding 10 cm in diameter, present considerable risk to life if not addressed. Thoracoabdominal aortic aneurysms (TAAAs) are particularly perilous due to their propensity for rupture. CASE PRESENTATION: We report a case of gastrointestinal obstruction manifesting from a giant thoracoabdominal aortic aneurysm with a contained leak and acute rupture. The patient presented with abdominal pain, nausea, vomiting, and intolerance to oral intake. CLINICAL DISCUSSION: Certain conditions and infections predispose individuals to the development and expansion of giant aneurysms. This report details a massive chronic TAAA with a confined leak that led to a circumferential mural thrombus and an acute rupture within it. The patient was resuscitated and underwent urgent aorto-renal reconstruction surgery due to the presentation of upper gastrointestinal obstruction. CONCLUSION: Though upper gastrointestinal obstruction is an extremely rare manifestation of giant thoracoabdominal aneurysm, it should be considered as a differential diagnosis in similar cases.

Ganglion Cell Density and Colonic Microbiome Profile in Pseudo-obstruction Syndrome: A Case Series / Densidad de Células Ganglionares y Perfil del Microbioma Colónico en Síndrome de Pseudoobstrucción: una Serie de Casos

Background: During clinical practice, it has been observed that cases of sigmoid volvulus can develop complications post-treatment corresponding to acute colonic pseudo-obstruction (ACPO) and chronic intestinal pseudo-obstruction (CIPO), with the acute form, also known as Ogilvie's syndrome, being more common. The cause and underlying mechanism for the development of these conditions are not fully understood. Although potential causes have been described in other studies, research focused on the status of ganglion cells and the patient's microbiome is limited. This study aims to contribute to the medical literature by examining the ganglion cell content and microbial diversity in six patients diagnosed with acute and chronic colonic pseudo-obstruction observed in patients from the high Andean region of southern Peru. Case Presentation: The common background characterizing and grouping the reported cases is the previous sigmoidectomy for sigmoid volvulus, along with the presence of signs and symptoms of an acute and chronic functional obstructive condition. In all cases, the clinical diagnosis following the treatment of sigmoid volvulus was ACPO or CIPO. These diagnoses were confirmed by abdominal X-ray and tomography. A conservative medical treatment with Neostigmine was initiated. The lack of response to this treatment led to various surgical techniques being performed. Conclusion: All patients presented with hypoganglionosis. According to microbiome analysis, in four of them, the predominant phylum was Firmicutes and the predominant enterotype was Prevotella. In the other two patients, a high percentage of Proteobacteria was observed, with Bacteroides as the predominant enterotype. The average Firmicutes/Bacteroidetes ratio was 4.9. Our study shows the existence of bacterial dysbiosis in two patients with colonic hypoganglionosis, which could be related to the pathophysiology of ACPO and CIPO. Additionally, we report alterations in the relative frequency of bacteria associated with flavonoid metabolism.

Antecedentes: Durante la práctica clínica se ha observado que los casos de vólvulo sigmoideo pueden tener complicaciones posteriores a su tratamiento correspondientes al síndrome de pseudoobstrucción colónica aguda (ACPO, por sus siglas en inglés) y crónica (CIPO, por sus siglas en inglés), siendo mucho más frecuente su forma aguda también llamado síndrome de Ogilvie. No se comprende completamente la causa y el mecanismo subyacente al desarrollo de estas condiciones. Aunque se han descrito posibles causas en otros estudios, la investigación enfocada en el estado de las células ganglionares y el microbioma del paciente es limitada. Este estudio tiene como objetivo aportar a la literatura médica el conteo de las células ganglionares y la diversidad microbiana de seis pacientes diagnosticados con pseudoobstrucción colónica aguda y crónica observada en pacientes de la zona altoandina del sur del Perú. Presentación de caso: El antecedente común que caracteriza y agrupa a los casos reportados es la sigmoidectomía previa por vólvulo de sigmoides, junto con la presencia de signos y síntomas de un cuadro obstructivo funcional agudo y crónico. En todos los casos, el diagnóstico clínico posterior al tratamiento de vólvulo sigmoideo fue ACPO o CIPO. Estos diagnósticos fueron confirmados mediante radiografía de abdomen y tomografía. Se inició un tratamiento médico conservador con Neostigmina. La falta de respuesta al tratamiento conllevó a realizar diversas técnicas quirúrgicas. Conclusión: Todos los pacientes mostraron hipoganglionosis. Según el análisis del microbioma, en cuatro de ellos, el filo predominante fue Firmicutes y el enterotipo predominante fue Prevotella. En los otros dos pacientes, se observó un porcentaje elevado de Proteobacterias, con Bacteroides como enterotipo predominante. La relación de Firmicutes/Bacteroidetes promedio fue de 4.9. Nuestro estudio muestra la existencia de disbiosis bacteriana en dos pacientes con hipoganglionosis colónica, que podría estar relacionada con la fisiopatología del ACPO y del CIPO. Adicionalmente, reportamos alteraciones en la frecuencia relativa de bacterias asociadas al metabolismo de flavonoides.

Diuresis-led volume replacement strategy in extremely low birth weight infants.

AIM: In extremely low birth weight infants, fluid overload has been associated with bronchopulmonary dysplasia and death. Excessive weight loss may increase the risk of meconium obstruction and intestinal perforation. As these infants display oliguria followed by polyuria, we embarked on a diuresis-led volume replacement strategy as of January 2020. METHODS: This single-centre analysis presents data of infants <1000 g birth weight surviving for more than 3 days admitted 2017-2019 (n = 217, daily volume increase) versus 2020-2022 (n = 2022, diuresis-led volume replacement). RESULTS: The second cohort had lower gestational age (median [interquartile range]: 253/7 [243/7-264/7] vs. 263/7 [251/7-282/7] weeks), less antenatal steroids (58% vs. 69%), more indomethacin (66% vs. 47%) and higher initial diuresis (5.6 [4.9-6.8] vs. 4.8 [4.2-5.5] mL/kg/h) but did not differ by relative weight loss at Day 7 of life. Employing binary logistic regression with gestational age, antenatal steroids and indomethacin as covariates, the cohorts did not differ by rates of patent ductus arteriosus, abdominal surgery or severe retinopathy of prematurity, while there were significant declines in sepsis (from 32% to 19%), bronchopulmonary dysplasia (from 26% to 23%) and mortality (from 13% to 7%). CONCLUSION: Diuresis-led volume replacement appears to be safe and maybe beneficial.

Does Colorectal Stenting as a Bridge to Surgery for Obstructive Colorectal Cancer Increase Perineural Invasion?

Objectives: To clarify whether self-expandable metallic stent (SEMS) placement for obstructive colorectal cancer (CRC) increases perineural invasion (PNI), thereby worsening the prognosis. Methods: In total, 1022 patients with pathological T3 or T4 colon or rectosigmoid cancer who underwent resection were retrospectively reviewed. The study patients were divided into a no obstruction group (n=693), obstruction without stent group (n=251), and obstruction with stent group (n=78), and factors demonstrating an independent association with PNI, the difference in PNI incidence and severity between groups, and the association between PNI and the duration from SEMS placement to surgery were investigated. Survival analysis was performed for each group. Results: On multivariate analysis, SEMS placement (hazard ratio [HR]: 2.08) was independently associated with PNI whereas SEMS placement was not. PNI occurred in 39%, 45%, and 68% of the no obstruction, obstruction without stent, and obstruction with stent group, respectively. In the obstruction with stent group, the proportion of PNI was not associated with the duration from SEMS placement to surgery. Extramural PNI, an advanced form of PNI, demonstrated no increase with increasing interval. The five-year OS was 86.3%, 76.7%, and 73.1% in no obstruction, obstruction without stent, and obstruction with stent group, respectively. On multivariate analysis, obstruction was an independent risk factor of decreased OS (HR: 1.57) whereas SEMS placement was not. Conclusions: The prognosis was comparable between patients with SEMS placement and those with an obstruction who did not undergo SEMS placement, thus demonstrating that SEMS is a viable, therapeutic option for BTS.

Effect of rapid rehabilitation nursing on improving clinical outcomes in postoperative patients with colorectal cancer.

BACKGROUND: Surgical resection is the cornerstone treatment for colorectal cancer. Rapid rehabilitation care predicated on evidence-based medical theory aims to improve postoperative nursing care, subsequently reducing the physical and mental traumatic stress response and helping patients who undergo surgery recover rapidly. AIM: To assess the effect of rapid rehabilitation care on clinical outcomes, including overall postoperative complications, anastomotic leaks, wound infections, and intestinal obstruction in patients with colorectal cancer. METHODS: We searched the PubMed, Web of Science, Embase, Elsevier Science Direct, and Springer Link databases from January 1, 2010, to January 1, 2024, to screen eligible studies on rapid rehabilitation care among patients who underwent colorectal cancer surgery. Patients were screened based on the inclusion and exclusion criteria. RevMan 5.4 software was used for statistical analysis of the data. RESULTS: Twelve studies were enrolled, which included 2420 patients. The results showed that rapid rehabilitation care decreased the incidence of overall postoperative complications (OR: 0.44, 95%CI: 0.26-0.74, P = 0.002), anastomotic leaks (OR: 0.68, 95%CI: 0.41-1.12, P = 0.13), wound infections (OR: 0.45, 95%CI: 0.29-0.72, P = 0.0007), and intestinal obstruction (OR: 0.54, 95%CI: 0.34-0.86, P = 0.01) compared to conventional care. Further trials and studies are needed to confirm these results. CONCLUSION: Rapid rehabilitation care decreased the occurrence of postoperative complications, anastomotic leaks, wound infections, and intestinal obstruction compared to conventional care in patients who underwent colorectal surgery. Therefore, promoting the application of rapid rehabilitation care in clinical practice cannot be overemphasized.

Role of endoscopic-ultrasound-guided biliary drainage with electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction.

In this editorial, we discuss the article by Peng et al in the recent issue of the World Journal of Gastrointestinal Surgery, focusing on the evolving role of endoscopic-ultrasound-guided biliary drainage (EUS-BD) with electrocautery lumen apposing metal stent (LAMS) for distal malignant biliary obstruction. Therapeutic endoscopy has rapidly advanced in decompression techniques, with growing evidence of its safety and efficacy surpassing percutaneous and surgical approaches. While endoscopic retrograde cholangiopancreatography (ERCP) has been the gold standard for biliary decompression, its failure rate approaches 10.0%, prompting the exploration of alternatives like EUS-BD. This random-effects meta-analysis demonstrated high technical and clinical success of over 90.0% and an adverse event rate of 17.5%, mainly in the form of stent dysfunction. Outcomes based on stent size were not reported but the majority used 6 mm and 8 mm stents. As the body of literature continues to demonstrate the effectiveness of this technique, the challenges of stent dysfunction need to be addressed in future studies. One strategy that has shown promise is placement of double-pigtail stents, only 18% received the prophylactic intervention in this study. We expect this to improve with time as the technique continues to be refined and standardized. The results above establish EUS-BD with LAMS as a reliable alternative after failed ERCP and considering EUS to ERCP upfront in the same session is an effective strategy. Given the promising results, studies must explore the role of EUS-BD as first-line therapy for biliary decompression.

Unveiling the potential of electrocautery-enhanced lumen-apposing metal stents in endoscopic ultrasound-guided biliary drainage.

This editorial delves into Peng et al's article, published in the World Journal of Gastrointestinal Surgery. Peng et al's meta-analysis investigates the effectiveness of electrocautery-enhanced lumen-apposing metal stents (ECE-LAMS) in ultrasound-guided biliary drainage for alleviating malignant biliary obstruction. Examining 14 studies encompassing 620 participants, the research underscores a robust technical success rate of 96.7%, highlighting the efficacy of ECE-LAMS, particularly in challenging cases which have failed endoscopic retrograde cholangio pancreatography. A clinical success rate of 91.0% underscores its impact on symptom alleviation, while a reasonably tolerable adverse event rate of 17.5% is observed. However, the 7.3% re-intervention rate stresses the need for post-procedural monitoring. Subgroup analyses validate consistent outcomes, bolstering the applicability of ECE-LAMS. These findings advocate for the adoption of ECE-LAMS as an appropriate approach for biliary palliation, urging further exploration in real-world clinical contexts. They offer valuable insights for optimizing interventions targeting malignant biliary obstruction management.

A Case of Acute Right Coronary Artery Ostial Obstruction Six Days After Surgical Aortic Valve Replacement Requiring Emergent Coronary Artery Bypass Grafting.

Acute coronary artery obstruction after surgical aortic valve replacement (SAVR) is a rare but potentially life-threatening event that must be prevented. Here, we report a rare case of an 84-year-old woman who underwent SAVR with a 19-mm aortic bioprosthetic valve for severe aortic stenosis and who suddenly developed ST-elevation myocardial infarction six days after surgery as a result of right coronary artery (RCA) ostial obstruction. She experienced cardiogenic shock, and mechanical support devices were introduced; however, she underwent emergency coronary artery bypass grafting (CABG) to the RCA (#3) and survived. We were aware of the risk of RCA ostial obstruction intraoperatively but were unable to prevent it because blood flow was preserved in the early postoperative period. The present case is worth reporting because the patient developed fatal STEMI at a time when she would normally be considered for discharge. A major learning point from this case is that a coronary artery ostium that is patent immediately after SAVR may not be sufficient for patients considered at high risk of coronary artery occlusion.

Adult Jejunojejunal Intussusception Caused by Small Bowel Leiomyoma.

This article reports a case of a patient with intestinal obstruction admitted to the hospital whose presumed diagnosis by CT was jejunojejunal intussusception. The patient underwent exploratory laparotomy with an enterectomy of the invaginated segment. The histopathological and immunohistochemical results of the surgical specimen confirmed the presence of a small bowel leiomyoma. This case highlights the importance of a detailed clinical evaluation of patients with an intestinal obstruction who seek emergency care. The cause of intestinal obstruction is a diagnostic challenge due to the numerous pathologies that can lead to the development of the condition. Guided anamnesis, detailed physical examinations, and accurate subsidiary exams that do not delay diagnosis are the cornerstones of emergency room care. Knowing the ideal time to refer the patient to the operating room requires knowledge and practice. The patient reported in this article with jejunal leiomyoma as a cause of intestinal intussusception is surprising for its rarity and illustrates the range of pathologies that can lead to intestinal obstruction.