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.

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.

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.

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.

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.

Case report: Urgent liver pathologies: All in one.

Ruptured hepatocellular carcinoma (HCC) is a well-known serious complication of this most common primary liver malignancy. However, when HCC rupture is associated with other focal liver lesions, the diagnosis and therapy may be very challenging. Correct differentiation of focal liver lesions is of paramount importance for successful treatment. The aim of this report is to present a unique case of HCC rupture complicated with liver abscess, hematoma and portal vein thrombosis. We discuss possible pathophysiological mechanisms and radiologic findings of such clinical scenarios and review literature related to the management of HCC rupture.

Case report: two cases of spontaneous intramural duodenal hematoma associated with pancreatitis.

Intramural duodenal hematoma (IDH) is a rare entity and is generally associated with trauma. Spontaneous (nontraumatic) intramural duodenal hematoma is associated with bleeding disorders, anticoagulation therapy, alcoholism, pancreatitis, tumours  and duodenal ulcers. We report two cases of spontaneous intramural duodenal hematoma in middle-aged men who subsequently developed pancreatitis. The underlying pathophysiology is still unclear. In the cases described, it is not clear whether the intramural duodenal hematoma contributed to the development of pancreatitis or pancreatitis has contributed to the development of IDH.

Optimal control of networked reaction-diffusion systems.

Patterns in nature are fascinating both aesthetically and scientifically. Alan Turing's celebrated reaction-diffusion model of pattern formation from the 1950s has been extended to an astounding diversity of applications: from cancer medicine, via nanoparticle fabrication, to computer architecture. Recently, several authors have studied pattern formation in underlying networks, but thus far, controlling a reaction-diffusion system in a network to obtain a particular pattern has remained elusive. We present a solution to this problem in the form of an analytical framework and numerical algorithm for optimal control of Turing patterns in networks. We demonstrate our method's effectiveness and discuss factors that affect its performance. We also pave the way for multidisciplinary applications of our framework beyond reaction-diffusion models.

Association of Atraumatic Splenic Rupture and Acute Pancreatitis: Case Report with Literature Review.

Atraumatic splenic rupture is an uncommon complication of acute pancreatitis. This article presents a case of a 35-year-old patient presenting with acute pancreatitis who subsequently developed a splenic vein thrombosis and splenic rupture requiring a laparotomy and splenectomy. This rare but life-threatening complication requires prompt recognition and management in patients with pancreatitis who develop sudden hemodynamic instability.

Jejunal Lipoma Causing Intussusception in an Adult.

First described by Barbette in 1674, intestinal intussusception represents a telescoping of proximal bowel segment into the lumen of the adjacent aboral segment. Adult intussusception comprises only about 5% of all intussusceptions. We present a case of 28-year male patient who complained of colicky, intermittent epigastric pain for the last one month. Imaging detected specific signs of intussusception. Laparotomy revealed enteric intussusception of the jejunum caused by an intraluminal tumour, confirmed to be a benign lipoma on histology. Small bowel obstruction caused by jejunal lipoma in adults is a rare clinical entity and must be kept in mind when evaluating adult patients with abdominal pain. Key Words: Intussusception, Lipoma, Ileus, Jejunum.

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.

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.

Concomitant Presence of Hydatid Cyst and Colorectal Liver Metastasis

A 65-year-old man, with signs of acute colon obstruction, was diagnosed with rectal tumour and liver hydatid cyst. Additionally, a focal liver lesion in segment 1 was detected. Moreover, physical examination revealed hepatomegaly and abdominal distension. Thus, rectal resection and small liver lesion biopsy was performed. Serological and pathohistological analyses showed concomitant presence of hydatid cyst and colorectal metastasis in the liver. Hence, the cyst was treated with anthelmintic therapy, and patient lived another year after the diagnosis. To the best of our knowledge, cases of concomitant hydatid cyst and colorectal liver metastasis has never been reported; thus, this article addresses a unique case of coexistence between these two serious liver diseases.

Rare Complication of Necrotizing Pancreatitis: Extension of Retroperitoneal Abscess into Femoral Region.

Distant abscesses are uncommon during the episode of acute pancreatitis (AP). However, these are possible sequalae of necrotizing pancreatitis and should be treated appropriately to prevent serious septic complications. We demonstrate a case of a 56-year-old male patient who presented with severe necrotizing pancreatitis and distant retroperitoneal abscess that reached femoral region and was detected on diagnostic imaging scans. Combination of surgical and supportive therapy was employed, and the patient recovered well with no permanent consequences. Our article highlights the importance of quick and accurate diagnosis and timely intervention in this rare type of pancreatitis complication.

Conservative treatment of postintubation tracheal laceration with pneumomediastinum, bilateral pneumothorax, and massive subcutaneous emphysema.

Postintubation tracheal laceration (PITL) is a rare, potentially life-threatening complication requiring prompt diagnosis and treatment. Patients typically present with subcutaneous emphysema and pneumomediastinum, whereas concomitant pneumothorax is rarely reported. A conservative treatment is indicated in selected respiratory stable patients with small lacerations. Herein, we reported an unusual case of PITL with bilateral pneumothorax that was treated with chest tube drainage and conservative measures in the intensive care unit. The key success of the PITL management is early recognition of signs and symptoms and an adequate selection of management approaches.

Intramural Stomach Gas with Hepatic Portal Venous Gas Indicating Spontaneous Stomach Necrosis.

Intramural gas in the stomach associated with hepatic portal venous gas is a rare entity, which suggests ischemic or infectious pathology of the stomach. We report a case of a 73-year-old man who presented with epigastric pain and nausea of 6 hours duration followed by hematemesis. The patient had pale skin, anemia, and a diffusively tender and distended abdomen. Abdominal radiography and computed tomography (CT) revealed gas in thickened gastric wall and gas in intrahepatic portal vein branches. Surgery was indicated, which consisted of partial gastrectomy with Roux en esophago-jejunal anastomosis. Postoperative course was uneventful, and pathohistological analysis indicated stomach wall necrosis with emphysametous gastritis (EG). The patient was free of symptoms at 2 years follow-up. Intramural gas in the stomach should always be meticulously investigated to differentiate between emphysematous gastritis and gastric emphysema, as this would direct the therapeutic approach to be adopted.

Extensive Abdominal Skin Necrosis Following Anterior Component Separation for a Large Ventral Hernia: A Case Report.

Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality. Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy. Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.