Assessment of Oral Microbiome Changes in Healthy and COVID-19-Affected Pregnant Women: A Narrative Review.

During pregnancy, there are several metabolic changes and an alteration in the composition of microorganisms that inhabit the oral cavity, with an increase in pathogenic bacteria that promote the onset of gingival diseases. This review is based on research in reference to the PICO model (Problem/Intervention/Comparison/Outcome), related to changes in the oral microbiome of pregnant women and possible oral consequences in patients with COVID-19. The results showed a growth of some pathogenic bacteria in pregnant women, including Aggregatibacter actinomycetemcomitans and Fusobacterium nucleatum, and the selective growth of the Prevotella intermedia, Porphyromonas gingivalis and Tannerella species, probably due to the fact that these bacteria use progesterone as a source of nutrition. These same bacteria are implicated in the development of periodontal disease. Periodontal pockets have bidirectional interactions between the oral cavity and the systemic circulatory system through the peripheral gingival blood vessels. The affinity of the SARS-CoV-2 virus to specific membrane receptors is now clear, and could involve the internal and external epithelial lining or the fibroblasts of the periodontal ligament. According to the results of the present review, the control of oral microbiome changes during pregnancy would be welcomed. The use of probiotics could help clinicians manage pregnant patients, reducing inflammatory indexes. Future studies should focus not only on changes in the level of the oral microbiome in pregnancy or the correlation between periodontal disease and COVID-19, but also on oral changes induced by both clinical situations.

Assessment of Genetical, Pre, Peri and Post Natal Risk Factors of Deciduous Molar Hypomineralization (DMH), Hypomineralized Second Primary Molar (HSPM) and Molar Incisor Hypomineralization (MIH): A Narrative Review.

OBJECTIVES: Analyze defects in the state of maturation of the enamel result in an adequate volume of enamel, but in an insufficient mineralization, which can affect both deciduous teeth and permanent teeth. Among the most common defects, we recognize Deciduous Molar Hypominerlization (DMH), Hypomineralized Second Primary Molar (HSPM), and Molar Incisor Hypomineralization (MIH). These, in fact, affect the first deciduous molars, the second deciduous molars and molars, and permanent incisors, respectively, but their etiology remains unclear. The objective of the paper is to review studies that focus on investigating possible associations between genetic factors or prenatal, perinatal, and postnatal causes and these enamel defects. MATERIALS AND METHODS: A comprehensive and bibliometric search for publications until January 2021 was conducted. The research question was formulated following the Population, Intervention, Comparison, Outcome strategy. Case-control, cross-sectional, cohort studies, and clinical trials investigating genetic and environmental etiological factors of enamel defects were included. RESULTS: Twenty-five articles are included. For genetic factors, there is a statistical relevance for SNPs expressed in the secretion or maturation stage of amelogenesis (16% of studies and 80% of studies that investigated these factors). For prenatal, perinatal, and postnatal causes, there is a statistical relevance for postnatal factors, such as the breastfeeding period (2%), asthma (16%), high fever episodes (20%), infections/illnesses (20%), chickenpox (12%), antibiotic intake (8%), diarrhea (4%), and pneumonia (4%). CONCLUSIONS: The results are in agreement with the multifactorial idea of the dental enamel defects etiology, but to prove this, further studies enrolling larger, well-diagnosed, and different ethnic populations are necessary to expand the investigation of the genetic and environmental factors that might influence the occurrence of DMH, HPSM, and MIH.

Geotrichum capitatum Invasive Infection Early After Liver Transplant.

Geotrichum capitatum is a rare fungal pathogen that has infrequently affected immunocompromised patients with onco-hematologic diseases. Geotrichum capitatum invasive infection has been associated with poor prognosis, with a mortality rate ranging from 50% to 90%. Here, we report the first case of Geotrichum capitatum invasive fungal infection in a liver transplant recipient from an unrelated deceased donor, who was effectively treated with amphotericin B and voriconazole. We also reviewed the available literature in the field.

A Probable Fatal Case of Oleander (Nerium oleander) Poisoning on a Cattle Farm: A New Method of Detection and Quantification of the Oleandrin Toxin in Rumen.

Oleander (Nerium oleander) is an ornamental plant common in tropical and sub-tropical regions that is becoming increasingly widespread, even in temperate regions. Oleander poisoning may occur in animals and humans. The main active components contained in the plant are cardiac glycosides belonging to the class of cardenolides that are toxic to many species, from human to insects. This work describes a case of oleander poisoning that occurred on a small cattle farm and resulted in the fatality of all six resident animals. Furthermore, the investigation of the poisonous agent is described, with particular focus on the characterization of the oleandrin toxin that was recovered from the forage and rumen contents. The innovation of this study is the first description of the detection and quantification of the oleandrin toxin by liquid chromatography-high resolution mass spectrometry (LC-HRMS) in rumen.

Veterinary forensic sciences to solve a fatal case of predation on flamingos (Phoenicopterus roseus).

The present case study concerns a case of predation of 4 individuals of captive pink flamingo in Emilia Romagna Region, Northeastern Italy. The pink flamingo (Phoenicopterus roseus) is a species included in the Red List of Threatened Species established by the International Union for Conservation of Nature (IUCN) which lists species in danger of extinction. During the Winter of 2013, 4 flamingos (2 in the Comacchio area, and 2 from Argenta and Codigoro oases - Ferrara province) were found dead some of them headless, with their bodies severely bitten. At first, a fox (Vulpes vulpes) was suspected to be the predator responsible for the killing and the birds were taken to the laboratory for further investigations. The investigations included: field observations, study of the predator behaviour, necropsy examinations, assessment of the intercanine distance, and genetic analysis on the predator's traces. The intercanine distance indicated that the predator could not have been a fox. The analysis of salivary DNA samples enabled us to establish that the predator was in fact a dog. This case highlights the importance of co-operation among the various branches of forensic sciences and the great usefulness of the roles filled by other veterinary forensic experts involved in solving crime.

The diatoms test in veterinary medicine: A pilot study on cetaceans and sea turtles.

Fishing activities are considered one of the most relevant threats for cetaceans and sea turtles conservation since these animals are sometimes found dead entangled in fishing gears. Currently, postmortem diagnosis is based mainly on the presence of nets and lines on the body and the related marks and injuries evident at gross examination. A more detailed and objective evidence is needed to clarify doubts cases and the diatoms technique, used in forensic human medicine, could support drowning diagnosis also in this field. Diatoms' investigation was implemented to be applied in marine vertebrate on 8 striped (Stenella coeruleoalba) and 1 bottlenose (Tursiops truncatus) dolphins and 5 sea turtles (Caretta caretta) stranded along the Italian coastlines with a likely cause of death hypothized on necropsies carried out by veterinary pathologists. Diatoms were microscopically searched in the bone marrow collected from long bones implementing protocols used in human medicine and their presence was observed in 4 cetaceans and 2 sea turtles. Despite a clear relation between diatoms' presence and amount and the likely cause of death was not proved due to the poor number of samples, the higher burden of diatoms was found in 3 animals deemed to be death for the interaction with human activity. Despite more studied are necessary to identify the possible relation between the cause of death and diatoms' findings, the present study implemented this technique to be adapted to marine animals, confirming its possible application also in veterinary forensic medicine.

A Social Media-Based Acute Alcohol Consumption Behavior (NekNomination): Case Series in Italian Emergency Departments.

BACKGROUND: NekNomination, also known as NekNominate, Neck and Nominate, or Neck Nomination, is a social network-based drinking game which is thought to have originated in Australia and spread all over the world between 2013 and 2014. Individuals record videos of themselves while rapidly drinking excessive quantities of alcoholic drinks (necking) and then nominate friends to outdo them within 24 hours; the videos are then posted on social media such as Facebook or YouTube. The consequences of this drinking game have been very dangerous; at least 5 people under age 30 years have died after drinking deadly cocktails, and many others have suffered from alcohol intoxication. OBJECTIVE: The goal of the research is to evaluate data about clinically important acute alcohol intoxication among teenagers and young adults and inform and educate the general public, especially parents, teachers, and health workers, about the spreading craze of dangerous Internet-related behavior among today's teenagers and young people up to the age of 23 years. METHODS: Patients aged 15 to 23 years with acute alcohol intoxication who came to the emergency department (ED) of 2 major hospitals in Italy from January 1, 2011, to June 30, 2014, were included in this study. Data were retrieved from prehospital and intrahospital medical records and included personal information, methods of intoxication, triage color code, date and time of access to the ED, any relevant signs and symptoms, blood alcohol concentration, and diagnosis at discharge. RESULTS: A total of 450 young patients (male 277/450, 61.5%, female 173/450, 38.5%; age 15 to 16 years 15/450, 3.3%, age 17 to 18 years 184/450, 40.9%, age 19 to 23 years 251/450, 55.8%) were recruited. The causes of intoxication were happy hour, binge drinking, NekNominate, eyeballing, other alcoholic games, or a mix of them. Happy hour was found to be more common among the older patients, whereas NekNominate accounted for almost half of the youngest group of hospitalizations. Eyeballing occurred in 1.6% (7/450) of cases; binge drinking and other alcoholic games caused 23.3% (105/450) and 23.8% (107/450) of hospitalizations, respectively. On admission, 44.2% (199/450) of patients were assigned a red or yellow color code requiring immediate medical attention; about 14% of them required additional medical assistance (after being in the ED) or hospitalization, some in semi-intensive care units. CONCLUSIONS: Our study shows that the increased numbers of hospitalizations due to alcohol intoxication in the adolescent age group, as a consequence of NekNominate or other drinking games, is alarming and represents a serious public health issue. The potential markers of improper use of social networks must be clearly identified, including categories at risk of alcohol abuse, in order to develop intervention and prevention strategies in terms of education and awareness, which may help in averting potentially fatal episodes.

The Rise of New Alcoholic Games Among Adolescents and the Consequences in the Emergency Department: Observational Retrospective Study.

BACKGROUND: The links between the internet and teenager behavior are difficult situations to control and may lead to the development of new and excessive methods of drinking alcohol during alcoholic games. Findings indicate that reported cases are very useful sources for better understanding of alcoholic games, yielding successful measures promoting health among adolescents. Admittance of adolescents to hospital emergency departments (EDs) after consumption of excessive amounts of alcohol has become the norm in developed countries. The harmful effects of acute alcohol abuse are reported in this paper. OBJECTIVE: The aim of this work was to investigate the close connections between new drinking behaviors among adolescents and study the increase in new alcoholic games, together with the challenges that cause acute alcohol intoxication, the influence of the internet and social networks, and their consequences for public health services. METHODS: Data came from prehospital and intrahospital admissions attributable to alcohol consumption. From 2013 to 2015, 3742 patients were admitted to EDs due to acute alcohol intoxication: 830 of them were aged 15 to 30 years, and 225 were adolescents and young adults between 15 and 20 years who had been playing alcoholic games. Retrospectively, diagnostic data associated with extrahospital anamneses were selected by one of the hospital management information systems, Qlik. As a result of our previous experience, questionnaires and face-to-face interviews were performed at a later stage, when a clinical audit for intoxicated adolescent patients was described, with the overall goal of establishing a potential methodological workflow and adding important information to research carried out so far. RESULTS: Between 2013 and 2015, 830 young patients aged 15 to 30 years were admitted to EDs for acute alcohol intoxication. About 20% (166/830) of the sample confirmed that they had drunk more than 5 alcoholic units within 2 hours twice during the past 30 days as a result of binge drinking. Referring to new alcoholic games, 41% of the sample stated that they knew what neknomination is and also that at least one of their friends had accepted this challenge, describing symptoms such as vomiting, headache, altered behavior, increased talkativeness, and sociability. The median value of the weighted average cost of the diagnosis-related group relating to interventions provided by hospitals was the same for both genders, €46,091 (US $56,497; minimum €17,349 and maximum €46,091). CONCLUSIONS: Drinking games encourage young people to consume large quantities of alcohol within a short period of time putting them at risk of alcohol poisoning, which can potentially lead to accidental injuries, unsafe sex, suicide, sexual assault, and traffic accidents. The spread of these games through the internet and social networks is becoming a serious health problem facing physicians and medical professionals every day, especially in the ED; for this reason, it is necessary to be aware of the risks represented by such behaviors in order to recognize and identify preliminary symptoms and develop useful prevention programs. The strategic role of emergency services is to monitor and define the problem right from the start in order to control the epidemic, support planning, coordinate the delivery of assistance in the emergency phase, and provide medical education. Hospital-based interdisciplinary health care researchers collected specific data on hazardous drinking practices linked to evaluation of increased alcohol-related consequences and cases admitted to the ED.

Pedestrian Inattention Blindness While Playing Pokémon Go as an Emerging Health-Risk Behavior: A Case Report.

BACKGROUND: Cases of trauma resulting from the use of mobile phones while driving motor vehicles have become quite common in recent years. Road injuries incurred by people playing video games on mobile phones (or other media devices) while walking have also become a cause for concern. Pokémon Go has been the world's most popular game since it was launched in July 2016, with more than 15 million players trying to catch all Pokémon available in the game; however, the case detailed here is the first reported accident in the medical literature caused by a pedestrian distracted by the game while crossing a street. OBJECTIVE: We aim to provide additional information on the innovative nature of distractions that generate risks in road-users, and to explore the underreporting of pedestrian-motor vehicle collisions due to mobile device usage. METHODS: We included in this case report a 25-year-old male who suddenly crossed a road while playing Pokémon Go and was hit by a van, reporting several injuries and being assisted by the Emergency Medical Service of our hospital (Padova, Italy). The patient's history, the circumstances in which the collision happened, imaging data, and clinical course information were recorded per our hospital's privacy policy. RESULTS: The patient hit by the van was playing Pokémon Go on his mobile phone while crossing a street, despite red traffic lights, which he did not notice due to of the distraction induced by the game. CONCLUSIONS: Mobile videogames that imply movement (ie, walking, running, cycling) to play are an effective way to improve physical activity practice, especially in adolescents and young adults. Nevertheless, cases like the one presented here point out that these games could pose a significant risk to users who play while walking, cycling, or driving in unsafe areas such as city streets, because players become distracted and may ignore surrounding hazards. Comprehensive, multilevel interventions are needed to reduce accidents caused by distraction, and to stress findings on the positive and negative effects of video games, which are becoming a source of public health concern. Health care providers should be aware of their chief role in these possible prevention strategies, based on their direct interactions with road incident victims.

Planking or the "Lying-Down Game:" Two Case Reports.

BACKGROUND: The monitoring and management of risks regarding children and young people admitted to the emergency department as a result of dangerous behaviors distributed via the Internet should be based on clinical reasoning and knowledge about these social media-related phenomena. Here we examine 2 cases of teenagers who reported severe injuries while performing the "planking" craze, a challenge that consists in lying face-down stiffly like a board on any kind of surface. OBJECTIVE: Our objective is to examine and describe the Internet craze called planking, also known as the "lying-down game," through 2 case reports from our experience, enriching this study with information gained through discussions with secondary school teenagers. METHODS: Details of the 2 case reports were taken from electronic medical records giving information on care support processes, care management, and the costs of traumatic episodes. Demographic data, hemoglobin and serum lactate values, and Injury Severity Scores were evaluated. The study took place in secondary schools of our city from 2013 to 2014 during medical education courses, with the aim of analyzing the influence of social media on teenagers' activities and behaviors. RESULTS: Both patients suffered multiple trauma injuries and needed high-level health assistance. The first patient underwent a splenectomy and the second one a nephrectomy; both of them required a long hospital stay (14 and 20 days, respectively), and the costs for their management have been estimated at US $27,000 and US $37,000, respectively. Their decision to perform the planking in dangerous locations was due to their ambition to gain peers' acclaim through shared videos and pictures. CONCLUSIONS: Reporting and understanding these cases may potentially help prevent future events occurring in similar circumstances: the scientific community cannot leave this problem unaddressed. There is also a role of education resources for health care professionals; for this, we must identify and follow up strange or misleading information found on websites. A key element of this research study was to report physicians' misperceptions concerning planking and, with these cases used for teaching purposes, improve knowledge of the clinical and forensic aspects of this emerging problem.

Neurological disorders in liver transplant candidates: Pathophysiology and clinical assessment.

Compromised liver function, as a consequence of acute liver insufficiency or severe chronic liver disease may be associated with various neurological syndromes, which involve both central and peripheral nervous system. Acute and severe hyperammoniemia inducing cellular metabolic alterations, prolonged state of "neuroinflammation", activation of brain microglia, accumulation of manganese and ammonia, and systemic inflammation are the main causative factors of brain damage in liver failure. The most widely recognized neurological complications of serious hepatocellular failure include hepatic encephalopathy, diffuse cerebral edema, Wilson disease, hepatic myelopathy, acquired hepatocerebral degeneration, cirrhosis-related Parkinsonism and osmotic demyelination syndrome. Neurological disorders affecting liver transplant candidates while in the waiting list may not only significantly influence preoperative morbidity and even mortality, but also represent important predictive factors for post-transplant neurological manifestations. Careful pre-transplant neurological evaluation is essential to define severity and distribution of the neurological impairment, to identify the abnormalities still responsive to current treatment, and to potentially predict the inherent post-operative prognosis. The preferred specific indices of neurological pre-transplant assessment may vary among centers, however, even with the aid of the current biochemical, neurophysiological, neuropsychological and neuroimaging diagnostic tools, the correct diagnosis and differential diagnosis of various syndromes may be difficult. In this article the relevant pathophysiological and clinical aspects of the most frequent brain and peripheral nervous system diseases affecting liver transplant candidates with acute or advanced chronic liver failure are briefly reported. The practical diagnostic findings useful for the preoperative assessment and treatment, as well as the expected neurological evolution after liver transplantation are also evaluated.

Cisatracurium- and rocuronium-associated residual neuromuscular dysfunction under intraoperative neuromuscular monitoring and postoperative neostigmine reversal: a single-blind randomized trial.

BACKGROUND: Postoperative residual neuromuscular blockade (RNMB) is a common complication in the postanesthesia care unit (PACU), but also one of the most controversial issues. Many studies and trials demonstrated that some methods and techniques can reduce the incidence and the extent of the phenomenon. STUDY OBJECTIVE: To determine the incidence of RNMB in the PACU at standardized times after extubation with the implementation of a protocol of careful neuromuscular blockade management. DESIGN: Randomized, single-blinded controlled clinical trial. SETTING: Operating room and PACU. PATIENTS: A total of 120 patients of either sex with American Society of Anesthesiologists grades 1, 2, and 3, aged 18 to 80 years were scheduled to undergo elective abdominal surgical procedures lasting for at least 60 minutes. INTERVENTIONS: Patients were randomized to receive either cisatracurium (n=60) or rocuronium (n=60) at the time of intubation and during surgery. Every patient received quantitative neuromuscular monitoring during general anesthesia. On completion of surgery, patients were given neostigmine 0.05 mg kg-1. Patients were extubated at a train-of-four (TOF) ratio≥0.9. MEASUREMENTS: TOF measurements were performed 15, 30, and 60 minutes after extubation. Tolerability of neuromuscular monitoring was evaluated with a scale from 1 to 10 (with 1 meaning no discomfort at all and 10 meaning maximal discomfort or pain). RESULTS: Six, 11, and 14 patients (5.0%, 9.2%, and 11.7%) exhibited a TOF ratio <0.9 at 15, 30, and 60 minutes after extubation, respectively. No statistically significant difference in the postoperative RNMB between cisatracurium and rocuronium was found. The median tolerability score for neuromuscular monitoring was 3. CONCLUSION: Careful conduction, monitoring, and subsequent reversal of neuromuscular block may allow for obtaining considerably low incidence of residual neuromuscular block. However, our trial shows that some mid- and long-term cases of TOF ratios <0.9 can still occur, possibly jeopardizing the patients' postoperative recovery.

Thoracic Epidural Blood Patches in the Treatment of Spontaneous Intracranial Hypotension: A Retrospective Case Series.

BACKGROUND: Spontaneous intracranial hypotension (SIH) results from leaks developing in the dura mater. The major symptom is orthostatic headache which gradually disappears after lying down. Lumbar epidural blood patches (EBPs) can be effective in relieving headaches, however, thoracic and cervical EBPs have also been applied to alleviate the symptoms. OBJECTIVE AND METHODS: Retrospective collection of the main characteristics of SIH, site and amount of blood injection, and clinical outcomes of 18 patients who underwent thoracic EBPs for intractable SIH. STUDY DESIGN: Retrospective case series RESULTS: All thoracic autologous EBPs except 3 were performed in the sitting position. Patients undergoing epidural puncture at lower thoracic levels (T10-T12) received 25 mL of autologous blood, 15 mL and 18 mL were injected at spinal segments T5-T7 (mid-thoracic) and T2-T4 (upper- thoracic), respectively. Thoracic EBPs did not lead to immediate resolution of symptoms in 3 of 18 patients; one of them underwent early repetition with complete headache relief, one refused a second EBP, and one experienced partial resolution, followed by a recurrence, and then satisfactory improvement with a second high thoracic EBP. In long-term follow-up only 2 patients complained of symptoms or relapses. LIMITATIONS: Retrospective nature of the case series, single center experience. CONCLUSIONS: Performing thoracic-targeted EBPs as the preferred approach theoretically improves results with respect to those observed with lumbar EBPs. The immediate response was comparable with that of other reports, but the long-term success rate (90%) turned out to be very effective in terms of both quality of headache relief and very low incidence of recurrence.

Perioperative thrombotic complications in liver transplantation.

Although the perioperative bleeding complications and the major side effects of blood transfusion have always been the primary concern in liver transplantation (OLT), the possible cohesion of an underestimated intrinsic hypercoagulative state during and after the transplant procedure may pose a major threat to both patient and graft survival. Thromboembolism during OLT is characterized not only by a complex aetiology, but also by unpredictable onset and evolution of the disease. The initiation of a procoagulant process may be triggered by various factors, such as inflammation, venous stasis, ischemia-reperfusion injury, vascular clamping, anatomical and technical abnormalities, genetic factors, deficiency of profibrinolytic activity, and platelet activation. The involvement of the arterial system, intracardiac thrombosis, pulmonary emboli, portal vein thrombosis, and deep vein thrombosis, are among the most serious thrombotic events in the perioperative period. The rapid detection of occlusive vascular events is of paramount importance as it heavily influences the prognosis, particularly when these events occur intraoperatively or early after OLT. Regardless of the lack of studies and guidelines on anticoagulant prophylaxis in this setting, many institutions recommend such an approach especially in the subset of patients at high risk. However, the decision of when, how and in what doses to use the various chemical anticoagulants is still a difficult task, since there is no common consensus, even for high-risk cases. The risk of postoperative thromboembolism causing severe hemodynamic events, or even loss of graft function, must be weighed and compared with the risk of an important bleeding. In this article we briefly review the risk factors and the possible predictors of major thrombotic complications occurring in the perioperative period, as well as their incidence and clinical features. Moreover, the indications to pharmacological prophylaxis and the current treatment strategies are also summarized.

Risk factors for central pontine and extrapontine myelinolysis after liver transplantation: a single-center study.

BACKGROUND: Central pontine and extrapontine myelinolysis (CPM/EPM) are severe neurologic complications after liver transplantation. METHODS: The present work retrospectively evaluated single-center prevalence of CPM/EPM and associated risk factors: cause of liver disease, hepatic encephalopathy, preoperative, intraoperative, and perioperative blood components use, serum levels, and variation of Na, Cl, and K and immunosuppression were compared between CPM/EPM patients and control group of transplanted patients without neurologic complications. RESULTS: Among 997 transplants, CPM/EPM were diagnosed in 11 patients (1.1%), of whom four were CPM, one was EPM, and six were associated CPM and EPM. Control group consisted of 44 transplanted patients. Central pontine and extrapontine myelinolysis patients experienced higher intraoperative and perioperative serum Na/24 hr variations compared to controls (16.69 ± 5.17 vs. 9.8 ± 3.4 mEq/L, P = 0.001). Maximum peak of intraoperative or perioperative serum Na was significantly higher in patients compared to controls (151.5 ± 3.3 vs. 140.8 ± 6.2 mEq/L, P ≤ 0.001), but no difference in preoperative serum Na was detected. Three patients presented hypernatremia as isolated risk factor. CONCLUSION: Extrapontine myelinolysis can be found isolated or associated with CPM in up to two of three liver transplanted patients with myelinolysis. A marked variation of perioperative serum Na remains the main risk factor even in patients without preexisting hyponatremia; however, isolated hypernatremia may be solely responsible in some cases.

Totally laparoscopic caudate lobe resection: technical aspects and literature review.

The particular anatomic location of the hepatic caudate lobe between the hilar plate and inferior vena cava means that it is still considered unsuitable for laparoscopic measures and a difficult site even for conventional surgery. Here we describe the first case to be reported in the literature of caudate lobe resection for a single metastasis from breast adenocarcinoma that was completed using an exclusively laparoscopic procedure and a simplified scheme involving the placement of 4 trocars, without any need for conversion or the Pringle maneuver. The patient was 31 years old with a history of radical right mastectomy and chemotherapy. The patient's postoperative course was uneventful and she was discharged 4 days after the surgery. Twelve months on, she is currently alive and disease free.