Rare presentations of small bowel endometriosis.

Despite endometriosis being a relatively common chronic gynecological condition in women of childbearing age, small bowel endometriosis is rare. Presentations can vary from completely asymptomatic to reported symptoms of abdominal pain, bloating, and diarrhea. The following two cases depict very atypical manifestations of ileal endometriosis that presented as obscure intermittent gastrointestinal bleeding and bowel obstruction requiring surgical intervention. The first case describes a previously healthy 40-year-old woman with severe symptomatic iron deficiency anemia and intermittent melena. A small bowel enteroscopy diagnosed multiple ulcerated strictures in the distal small bowel as the likely culprit. Despite nonsteroidal anti-inflammatory drug-induced enteropathy being initially considered as the likely etiology, histopathological examination of the resected distal ileal segment revealed evidence of endometriosis. The second case describes a 66-year-old with a presumptive diagnosis of Crohn's disease who reported a 10-year history of intermittent perimenstrual abdominal pain, diarrhea, and nausea with vomiting. Following two subsequent episodes of acute bowel obstruction and surgical resection of the patient's stricturing terminal ileal disease, histopathological examination demonstrated active chronic inflammation with endometriosis. Small bowel endometriosis should be considered as an unusual differential diagnosis in women who may present with obscure gastrointestinal bleeding from the small bowel or recurrent bowel obstruction.

Symptomatic uncomplicated diverticular disease: a critical appraisal.

INTRODUCTION: Symptomatic uncomplicated diverticular disease (SUDD) is a clinical condition included in the spectrum of symptomatic diverticular disease. The symptom profile associated with SUDD is highly heterogeneous, as there are currently discordant definitions, that encompass many clinical scenarios. AREAS COVERED: We conducted a narrative review to assess the symptom profile and diagnostic criteria of SUDD based on the available evidence. A thorough literature search was performed on PubMed following the SANRA scale. Abdominal pain, regardless of its duration and location, emerges as the cardinal symptom of SUDD, suggesting that it should be central to its diagnosis. Although abdominal bloating and changes in bowel habits are commonly reported, they do not appear to be specifically attributable to SUDD. Other issues considered are the possible overlap with irritable bowel syndrome and the identification of a subcategory of SUDD patients with chronic symptoms following an episode of acute diverticulitis. EXPERT OPINION: The future agenda should include the development of shared diagnostic criteria for SUDD, including well-defined inclusion and exclusion clinical features and symptom patterns.

Acute mesenteric ischemia due to superior mesenteric artery thrombosis in a patient with protein S deficiency: A case report.

INTRODUCTION: Protein S deficiency resulting in mesenteric vein thrombosis has been reported in previous studies however those causing SMA thrombosis has been rarely reported. Multidisciplinary approach involving general surgeon, a vascular surgeon, an interventional radiologist, and an intensivist are crucial for management of SMA thrombosis. CASE PRESENTATION: A 39-year-old non-smoker hypertensive female who was diagnosed with partially occlusive thrombus in the superior mesenteric artery via Contrast-enhanced computed tomography (CECT) re-presented after 5 days and CECT revealed a partially occlusive thrombus in the superior mesenteric artery and Protein S deficiency (free protein S:15 %). She was managed by lysis of thrombus with streptokinase by interventional radiology team. The patient is on anticoagulants and without abdominal complaints on follow-up at 24 months. DISCUSSION: Computed tomography angiography should be done immediately in any patient suspected of AMI since delay in diagnosis accounts for high mortality rates of 30-70 %. The surgical treatment of the condition is well established and consists of revascularization and/or resection of nonviable bowel. Endovascular techniques have emerged as an alternative for occlusion of the SMA. Patients with protein C and/or S deficiency treated for AMI require lifelong anticoagulant/antiplatelet therapy to prevent relapse. CONCLUSION: Hereditary thrombophilia should be suspected in young people with unusual thrombotic presentations. Earlier diagnosis and aggressive antithrombotic therapy in individuals with hypercoagulable states can improve outcomes. Treatment involving a multidisciplinary approach improves outcomes.

Utilization of abdominal radiography in the emergency department: Appropriateness, interpretation, radiation protection and costs.

INTRODUCTION: The use of abdominal radiography (AXR) apparently continues to be widespread despite its limited indications, the potential radiation and unnecessary costs associated. In addition, the interpretation and its report seem variable and not always performed by a radiologist. Our objective is to analyze the use, adequacy and usefulness of AXR in the emergency of a tertiary referral hospital. MATERIAL AND METHODS: We retrospectively reviewed all the AXR performed in January 2020 in the emergency of our centre, as well as the patient's demographics and medical records, technical quality of the radiographs, indications according to the SERAM (Spanish Society of Radiology) Appropriateness Guidelines, presence of a formal radiology report, and impact on the clinical management of the patient. Of all non-appropriated AXR we calculated the radiation received by the patients and its extra costs. RESULTS: In January 2020, 429 AXR (9.1% of all radiographies) were performed in the emergency of our centre. The most frequent indication was abdominal pain (40%, n = 176), followed by low back pain (21.4%, n = 92). 12.4% of AXR requested did not include any clinical information. Most of the AXR (79.6%) had sufficient technical quality. 61.3% (n = 263) of the AXR performed were not indicated, assuming an average unjustified radiation dose per patient of 0.50 ±â€¯0.33 mSv, and a total additional cost of 6575;. Only 6% of the inadequate AXRs led to a change in the clinical management of the patient, compared to 29% of the adequate AXR (p < 0.001). Only 3% of the AXR had a formal radiology report. CONCLUSIONS: AXR is still common in the emergency setting, although most of them might be inadequate according to the SERAM Appropriateness Guidelines. Its use should be optimized to avoid unnecessary radiation and costs. Radiologists must have a more active participation in the management of AXR.

The usefulness of contrast-enhanced subtraction magnetic resonance imaging for detecting endoleaks after endovascular aortic repair with prophylactic intraoperative sac embolization.

BACKGROUND: Metallic and hyperdense artifacts and T1-shortening substances in the abdominal aortic aneurysm (AAA) sac generated by embolic materials and lipiodol pose challenges in the identification of endoleaks on follow-up computed tomography (CT) or magnetic resonance imaging (MRI). PURPOSE: To evaluate the usefulness of contrast-enhanced subtraction MRI (CES-MRI) for detecting endoleaks after endovascular abdominal aortic aneurysm repair (EVAR) with intraoperative AAA sac embolization compared with CE-CT, this study was conducted. MATERIAL AND METHODS: In this study, 28 consecutive patients who underwent EVAR with prophylactic AAA sac embolization were included. All patients underwent CES-MRI and CE-CT to detect endoleaks. The definitive diagnosis of endoleaks was a consensus reading of CE-CT and CES-MRI by two certified radiologists, in addition to angiography or reproducible radiological findings in the observational examination. Analysis was performed to evaluate which examination was better for detecting endoleaks. RESULTS: The sensitivity, specificity, and area under the curve of CE-CT and CES-MRI according to observer 1 were 50%, 100%, and 0.813 (95% confidence interval [CI] = 0.625-1.00) and 100%, 95%, and 0.997 (95% CI = 0.984-1.00), respectively, and those according to observer 2 were 50%, 100%, and 0.750 (95% CI = 0.514-0.986) and 100%, 95%, and 0.969 (95% CI = 0.903-1.00), respectively. Intolerable artifacts were significantly observed on CE-CT. The severity of the artifacts did not depend on the stent graft on CT and MRI. CONCLUSION: Although no significant difference was observed, CES-MRI tended to have better accuracy for endoleak detection in EVAR with intraoperative AAA sac embolization than CE-CT.

Leiomyosarcoma of the abdomen and retroperitoneum; a systematic review.

Background: Intraabdominal and retroperitoneal leiomyosarcomas are rare cancers, which cause significant morbidity and mortality. Symptoms, treatment and follow up differs from other cancers, and proper diagnosis and treatment of intraabdominal and retroperitoneal leiomyosarcomas is of utmost importance. We performed a systematic review to collect and summarize available evidence for diagnosis and treatment for these tumours. Methods: We performed a systematic literature search of Pubmed from the earliest entry possible, until January 2021. Our search phrase was (((((colon) OR (rectum)) OR (intestine)) OR (abdomen)) OR (retroperitoneum)) AND (leiomyosarcoma). All hits were evaluated by two of the authors. Results: Our predefined search identified 1983 hits, we selected 218 hits and retrieved full-text copies of these. 144 studies were included in the review. Discussion: This review summarizes the current knowledge and evidence on non-uterine abdominal and retroperitoneal leiomyosarcomas. The review has revealed a lack of high-quality evidence, and randomized clinical trials. There is a great need for more substantial and high-quality research in the area of leiomyosarcomas of the abdomen and retroperitoneum. Systematic Review Registration: PROSPERO, identifier, CRD42023480527.

No small dilemma: small bowel volvulus mimicking acute coronary syndrome.

Acute abdominal pathologies can cause electrocardiogram (ECG) changes mimicking an acute coronary syndrome (ACS), resulting in diagnostic uncertainty and delay. We report a 65-year-old male with multiple risk factors for ACS who presented with four hours of progressive epigastric and chest pain that resolved in the emergency department. ECG findings were concerning for new deeply inverted T-waves with normal troponins, raising concerns for Wellens Syndrome. Emergent heart catheterization was negative but abdominal computed tomography angiography showed occlusion of the superior mesenteric vessels. Subsequent exploratory laparotomy revealed a small bowel volvulus with extensive necrosis, resulting in a 430 cm resection.

Correlation between abdominal computed tomography signs and postoperative prognosis for patients with colorectal cancer.

BACKGROUND: Patients with different stages of colorectal cancer (CRC) exhibit different abdominal computed tomography (CT) signs. Therefore, the influence of CT signs on CRC prognosis must be determined. AIM: To observe abdominal CT signs in patients with CRC and analyze the correlation between the CT signs and postoperative prognosis. METHODS: The clinical history and CT imaging results of 88 patients with CRC who underwent radical surgery at Xingtan Hospital Affiliated to Shunde Hospital of Southern Medical University were retrospectively analyzed. Univariate and multivariate Cox regression analyses were used to explore the independent risk factors for postoperative death in patients with CRC. The three-year survival rate was analyzed using the Kaplan-Meier curve, and the correlation between postoperative survival time and abdominal CT signs in patients with CRC was analyzed using Spearman correlation analysis. RESULTS: For patients with CRC, the three-year survival rate was 73.86%. The death group exhibited more severe characteristics than the survival group. A multivariate Cox regression model analysis showed that body mass index (BMI), degree of periintestinal infiltration, tumor size, and lymph node CT value were independent factors influencing postoperative death (P < 0.05 for all). Patients with characteristics typical to the death group had a low three-year survival rate (log-rank χ 2 = 66.487, 11.346, 12.500, and 27.672, respectively, P < 0.05 for all). The survival time of CRC patients was negatively correlated with BMI, degree of periintestinal infiltration, tumor size, lymph node CT value, mean tumor long-axis diameter, and mean tumor short-axis diameter (r = -0.559, 0.679, -0.430, -0.585, -0.425, and -0.385, respectively, P < 0.05 for all). BMI was positively correlated with the degree of periintestinal invasion, lymph node CT value, and mean tumor short-axis diameter (r = 0.303, 0.431, and 0.437, respectively, P < 0.05 for all). CONCLUSION: The degree of periintestinal infiltration, tumor size, and lymph node CT value are crucial for evaluating the prognosis of patients with CRC.

Clinical and computed tomography angiography characteristics of infected vs. non-infected abdominal aortic aneurysm: a comparative study.

PURPOSE: The aim of this study was to investigate the clinical and multi-slice spiral computed tomography angiography (MSCTA) characteristics for the diagnosis of infected AAA. METHODS: This retrospective comparative study included patients who were diagnosed with AAA at our hospital between January 2014 and May 2023. RESULTS: A total of 40 patients were included, comprising 20 with infected AAA and 20 with non-infected AAA. Patients with infected AAA were more likely to be younger (62.9 ± 10.1 vs. 70.0 ± 4.4 years, P = 0.007) and to present with fever [7 (35%) vs. 1 (5%), P = 0.026], pain [15 (75%) vs. 2 (10%), P < 0.001], higher C-reactive protein levels (60.4 ± 57.0 vs. 4.1 ± 2.9 mg/l, P = 0.005), and higher erythrocyte sedimentation rates (47.7 ± 23.4 vs. 15.2 ± 8.3 mm/h, P < 0.001) compared to those with non-infected AAA. Moreover, those with infected AAA exhibited significantly more eccentric saccular morphology [17 (85%) vs. 1 (5%), P = 0.002], a smaller longitudinal-transverse ratio (1.12 ± 0.33 vs. 2.33 ± 0.54, P = 0.001), thicker peri-aneurysmal soft tissue (2.29 ± 1.48 vs. 0.73 ± 0.55 cm, P < 0.001), more lobulated margins [18 (90%) vs. 1 (5%), P = 0.001], lower aortic calcification scores (49 vs. 56, P < 0.001), more pneumatosis [6 (30%) vs. 0 (0%), P = 0.014], more ruptures [15 (75%) vs. 5 (20%), P = 0.002], more blurred peri-abdominal aortic fat spaces [16 (80%) vs. 2 (10%), P = 0.001], more adjacent bone destruction [5 (25%) vs. 0 (0%), P = 0.025], more involvement of the psoas major muscle [8 (40%) vs. 1 (5%), P = 0.005], more lymphadenectasis [8 (40%) vs. 1 (5%), P = 0.020], and less tortuous aortas [2 (10%) vs. 9 (45%), P = 0.034] compared with those with non-infected AAA. CONCLUSION: The clinical manifestations and MSCTA characteristics may differ between infected and non-infected AAA.

Two cases of sigmoid colon cancer with intussusception prolapsing through the anus in adults: consideration of preoperative reduction and surgical approaches: case reports.

Background: Adult intussusception is a rare condition that is often associated with a high incidence of malignancy. The optimal management strategy remains controversial, particularly regarding the necessity for bowel reduction before resection. To date, there is a paucity of data on adult intussusception in the English literature. We present two cases of sigmoid colon cancer with intussusception prolapsing through the anus and highlight the different surgical approaches. Case Description: Case 1: an 84-year-old woman presented with sigmoid colon prolapse and biopsy-confirmed adenocarcinoma. Urgent surgery revealed intussusception. Despite unsuccessful manual reduction, the Hutchinson technique successfully resolved the intussusception. Resection with a temporary colostomy was performed. Histopathological examination revealed mucinous adenocarcinoma without metastasis; the patient recovered well. Case 2: a 76-year-old woman with sigmoid colon prolapse presented with abdominal pain and blood-streaked stools. Emergency surgery was performed because of failed reduction attempts and persistent symptoms. Intussusception resolution was achieved through transanal insertion of a circular sizer. Resection with temporary colostomy was performed, after which tubular adenocarcinoma was identified. The patient remains symptom-free 3 years post-surgery. Conclusions: Choice of the surgical approach depends on the ease of intussusception reduction. In cases wherein reduction is straightforward, routine preoperative examinations are preferred given the low risk of injury or cancer cell dissemination. Conversely, in situations such as ours, gentle reduction under general anesthesia might be crucial. In addition, laparoscopic surgery could be beneficial. Importantly, accumulation of reports on adult intussusception could contribute to the standardization of this approach.

Managing patients' reports of abdominal pain and irritable bowel syndrome-like symptoms during quiescent inflammatory bowel disease: a role for shared sensemaking.

Background: Patients with inflammatory bowel disease (IBD) are often faced with distressing and confusing abdominal pain during remission. Some people respond adversely to healthcare professionals' (HCPs) suggestions that this pain and related symptoms are due to secondary irritable bowel syndrome (IBS). Exploring how HCPs view, manage, and explain pain during quiescent disease may provide insights into how communication can be improved to increase understanding and mitigate negative responses. Methods: In-depth semi-structured interviews were conducted with 12 IBD-nurses (n = 4) and gastroenterologists (n = 8) working in the United Kingdom or the Netherlands. Reflexive thematic analysis was used to analyse interviews. Results: Findings suggest that HCPs pay relatively little attention to pain when there is no underlying pathology and prefer to concentrate on objectifiable causes of symptoms and treating disease activity (Theme 1: Focus on disease activity, not pain and associated symptoms). Explanations of abdominal pain and IBS-like symptoms during remission were not standardised (Theme 2: Idiosyncratic and uncertain explanations for pain during remission). Processes of shared decision-making were outlined and shared sensemaking was reported as a strategy to enhance acceptance of IBS explanations (Theme 3: Shared decision making versus shared sensemaking). Conclusion: Future work should focus on establishing how pain during remission may be best defined, when to diagnose IBS in the context of IBD, and how to explain both to patients. The formulation of standardised explanations is recommended as they might help HCPs to adopt practices of shared sensemaking and shared decision-making. Explanations should be adaptable to specific symptom presentations and different health literacy levels.

Robotic Evaluation and Repair of Penetrating Injury of the Abdominal Wall.

This case demonstrated the feasibility of robotic-assisted exploratory laparoscopy in a hemodynamically stable trauma patient and abdominal wall repair with a favorable outcome. The patient presented with a stab wound at the left middle posterior flank. A computer tomography scan of the abdomen and pelvis demonstrated penetrating soft tissue injury to the left lateral abdominal wall with herniation of the omentum. A robotic-assisted laparoscopic approach was implemented to evaluate for visceral injury and to repair the abdominal wall. Diagnostic laparoscopy ruled out visceral and diaphragmatic injuries, and robotic primary tissue repair of the abdominal wall was performed. The patient was discharged home the following day. Laparoscopy for hemodynamically stable trauma patients has shown the benefit of decreased morbidity and decreased hospital stay compared to laparotomy. In turn, the robotic surgical approach has all the benefits of laparoscopy while bringing additional benefits of improved surgical dexterity, visualization, range of motion, and ergonomics.

Achieving Enteral Autonomy in Children with Intestinal Failure Following Inpatient Admission: A Case Series.

We describe cases of intestinal failure wherein inpatient admission was critical toward enteral autonomy. We performed a retrospective chart review of 6 children with long-term parenteral nutrition dependence who were weaned from parenteral nutrition following admission. Admissions included feeding and medication titration, interdisciplinary care, and home parenteral nutrition team consultation.

Abdominal actinomycosis presented as acute abdomen with intra-abdominal multiple tumors: A case report.

INTRODUCTION AND IMPORTANCE: Actinomycosis, a rare infection caused by Actinomyces spp., typically presents as a chronic condition affecting various regions, particularly the cervicofacial, thoracic, and abdominal areas. Its diagnosis is often difficult due to symptom overlap with malignancies and other infections. This report details a case of abdominal actinomycosis mimicking multiple intra-abdominal tumors, complicating diagnosis and treatment. CASE PRESENTATION: A 67-year-old male with uncontrolled type 2 diabetes presented with generalized abdominal pain, nausea, vomiting, constipation, and significant weight loss. Physical examination revealed distention and severe abdominal tenderness. Laboratory tests showed leukocytosis and anemia. Diagnostic laparotomy revealed multiple intra-abdominal tumors. Histopathology confirmed actinomycosis without malignancy or tuberculosis. Intravenous amoxicillin was started; however, the patient discharged himself against medical advice after two days due to personal reasons unrelated to his treatment plan. He returned three months later with persistent abdominal pain and additional hepatic lesions. Extended antibiotic therapy for 12 months led to the resolution of symptoms during follow-up. CLINICAL DISCUSSION: Abdominal actinomycosis is rare and often associated with conditions like diabetes. This case underscores the infection's potential to mimic malignancy and highlights the need for considering actinomycosis in differential diagnoses of acute abdomen, especially in immunocompromised patients. The patient's uncontrolled diabetes likely contributed to the infection's development and spread. CONCLUSION: Abdominal actinomycosis can present acutely, mimicking neoplastic diseases with multiple intra-abdominal masses. Early recognition and prolonged antibiotic therapy are essential to prevent systemic spread, especially in immunocompromised individuals. Clinicians should consider actinomycosis in patients with poorly controlled diabetes and abdominal symptoms.

Identifying risk factors for postoperative ileus following open abdominal aortic aneurysm repair.

INTRODUCTION: Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI following abdominal surgery is from the gastrointestinal and urologic literature. These data have been extrapolated to vascular surgery, especially with regards to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery. METHODS: This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone non-elective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus. RESULTS: A total of 123 patients met study criteria with an overall POI rate of 8.9% (n=11). Patients who developed a POI had significantly lower BMIs (24.3 kg/m2 versus 27.1 kg/m2, P=.003), were more likely to undergo a transperitoneal approach (81.8% versus 42.0%, P=.022), midline laparotomy (81.8% versus 37.5%, P=.008), longer total clamp times (151.6 minutes versus 97.7 minutes, P=.018), larger amounts of intraoperative crystalloid infusion (3495 mL versus 2628 mL, P=.029), and were more likely to return to the operating room (27.3% versus 3.6%, P=.016). Proximal clamp site was not associated with POI (P=.463). POI patients also had higher rates of post-operative vasopressor use (100% versus 61.1%, P=.014) and larger amounts of oral morphine equivalents in the first 3 post-operative days (488.0 mg + 216.0 versus 203.8 mg + 29.6 P=.016). Patients who developed POI had longer lengths of stay (12.5 days versus 7.6 days, P<.001), longer duration of NGT decompression (5.9 days versus 2.2 days, P<.001), and a longer period of time before diet tolerance (9.1 days versus 3.7 days, P<.001). Of those that developed a POI (n=11), 4 (36.4%) required total parental nutrition during the admission. CONCLUSION: POI is a morbid complication amongst patients undergoing elective open AAA surgery that significantly prolongs hospital stay. Patients at risk for developing a POI are those with lower BMIs, had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, post-operative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important peri-operative opportunities to reduce the prevalence of POI.

Abdominal aneurysm sac thrombus CT density and volume after EVAR: which association with underlying endoleak?

BACKGROUND: Our aim was to analyse abdominal aneurysm sac thrombus density and volume on computed tomography (CT) after endovascular aneurysm repair (EVAR). METHODS: Patients who underwent EVAR between January 2005 and December 2010 and had at least four follow-up CT exams available over the first five years of follow-up were included in this retrospective single-centre study. Thrombus density and aneurysm sac volume were calculated on unenhanced CT scans. Linear mixed models were used for data analysis. RESULTS: Out of 82 patients, 44 (54%) had an endoleak on post-EVAR contrast-enhanced CT. Thrombus density significantly increased over time in both the endoleak and non-endoleak groups, with a slope of 0.159 UH/month (95% confidence interval [CI] 0.115-0.202), p < 0.0001) and 0.052 UH/month (95% CI 0.002-0.102, p = 0.041). In patients without endoleak, a significant decrease in aneurysm sac volume was identified over time (slope -0.891 cc/month, 95% CI -1.200 to -0.581); p < 0.001) compared to patients with endoleak (slope 0.284 cc/month, 95% CI -0.031 to 0.523, p = 0.082). The association between thrombus density and aneurysm sac volume was positive in the endoleak group (slope 1.543 UH/cc, 95% CI 0.948-2.138, p < 0.001) and negative in the non-endoleak group (slope -1.450 UH/cc, 95% CI -2.326 to -0.574, p = 0.001). CONCLUSION: We observed a progressive increase in thrombus density of the aneurysm sac after EVAR in patients with and without endoleak, more pronounced in patients with endoleak. The association between aneurysm volume and thrombus density was positive in patients with and negative in those without endoleak. RELEVANCE STATEMENT: A progressive increase in thrombus density and volume of abdominal aortic aneurysm sac on unenhanced CT might suggest underlying endoleak lately after EVAR. KEY POINTS: Thrombus density of the aneurysm sac after EVAR increased over time. Progressive increase in thrombus density was significantly associated to the underlying endoleak. The association between aneurysm volume and thrombus density was positive in patients with and negative in those without endoleak.

Extracranial pressure (ECP) monitoring in severe traumatic brain injury (TBI): A prospective study validating intra-abdominal pressure (IAP) measurement for predicting intracranial pressure (ICP).

Background: Intracranial pressure (ICP)--guided therapy is the standard of care in the management of severe traumatic brain injury (TBI). Ideal ICP monitoring technique is not yet available, based on its risks associated with bleeding, infection, or its unavailability at major centers. Authors propose that ICP can be gauged based on measuring pressures of other anatomical cavities, for example, the abdominal cavity. Researchers explored the possibility of monitoring intra-abdominal pressure (IAP) to predict ICP in severe TBI patients. Methods: We measured ICP and IAP in severe TBI patients. ICP was measured using standard right frontal external ventricular drain (EVD) insertion and connecting it to the transducer. IAP was measured using a well-established technique of vesical pressure measurement through a manometer. Results: A total of 28 patients (n = 28) with an age range of 18-65 years (mean of 32.36 years ± 13.52 years [Standard deviation]) and the median age of 28.00 years with an interquartile range (21.00-42.00 years) were recruited in this prospective study. About 57.1% (n = 16) of these patients were in the age range of 18-30 years. About 92.9% (n = 26) of the patients were male. The most common mode of injury (78.6%) was road traffic accidents (n = 22) and the mean Glasgow Coma Scale at presentation was 4.04 (range 3-9). The mean ICP measured at the presentation of this patient cohort was 20.04 mmHg. This mean ICP (mmHg) decreased from a maximum of 20.04 at the 0 h' time point (at the time of insertion of EVD) to a minimum of 12.09 at the 96 hr time point. This change in mean ICP (from 0 h to 96 h) was found to be statistically significant (Friedman Test: χ2 = 87.6, P ≤ 0.001). The mean IAP (cmH2O) decreased from a maximum of 16.71 at the 0 h' time point to a minimum of 9.68 at the 96 h' time point. This change was statistically significant (Friedman Test: χ2 = 71.8, P ≤ 0.001). The per unit percentage change in IAP on per unit percentage change in ICP we observed was correlated to each other. The correlation coefficient between these variables varied from 0.71 to 0.89 at different time frames. It followed a trend in a directly proportional manner and was found to be statistically significant (P < 0.001) in each time frame of the study. The rise in one parameter followed the rise in another parameter and vice versa. Conclusion: In this study, we established that the ICP of severe TBI patients correlates well with IAP at presentation. This correlation was strong and constant, irrespective of the timeframe during the treatment and monitoring. This study also established that draining cerebrospinal fluid to decrease ICP in severe TBI patients is reflected in IAP. The study validates that IAP is a strong proxy of ICP in severe TBI patients.

Low-profile versus standard-profile stent grafts in the treatment of abdominal aortic aneurysm: a case-matched study.

Introduction: Endovascular aortic repair (EVAR) is nowadays a widespread method of managing abdominal aortic aneurysm (AAA). Low-profile stent grafts (LPSGs) enable treatment of patients with complex and anatomically challenging aneurysms, and facilitate a percutaneous and thus less invasive procedure. Aim: To assess the outcomes of EVAR with low-profile versus standard-profile stent grafts (SPSGs). Material and methods: Thirty-one patients with abdominal aortic aneurysms (AAA) were treated by endovascular aortic repair (EVAR) using LPSGs. The control group of patients treated with SPSGs was matched with MedCalc software. The clinical records and the preoperative and follow-up computed tomography angiography of patients who underwent endovascular treatment of AAA were included in this study. Results: Patients in the LPSG group had significantly more often low access vessel diameter (< 6 mm) compared to the SPSG group (38.7% vs. 6.7%, p = 0.003). In 1-year follow-up, there was no rupture, no infection, no conversion to open repair and no aneurysm-related death. Five secondary interventions were necessary in the SPSG group and only 1 in the LPSG group (p = 0.09). Type of stent graft was not a risk factor of perioperative complications, presence of endoleak or reintervention (p > 0.05). Risk factors for perioperative complications were COPD and conical neck (OR = 6.3, 95% CI: 1.5-25, p = 0.01 and OR = 6.2, 95% CI: 1-39.76, p = 0.04). The risk factor for endoleak was lower maximal aneurysm diameter. The risk factor for reintervention was proximal neck diameter (OR = 0.77, 95% CI: 0.-0.97, p = 0.03). Conclusions: Our study showed that use of LPSGs is a safe and viable method for patients with narrow access vessels who are not eligible for standard-profile systems.

Anatomical Variation of Abdominal Wall Musculature: An Objective Assessment Using Cross-Sectional Imaging.

Purpose: To determine normal anatomical variation of abdominal wall musculature. Methods: A retrospective analysis of CT scans was performed on adults (>18 years) with normal abdominal wall muscles. Two radiologists analysed the images independently. Distances from three fixed points in the midline were measured. The fixed points were; P1, mid-way between xiphoid and umbilicus, P2, at the umbilicus, and P3, mid-way between umbilicus and pubic symphysis. From these three fixed points the following measurements were recorded; midline to lateral innermost border of the abdominal wall musculature, midline to lateral edge of rectus abdominis muscle, and midline to medial edges of all three lateral abdominal wall muscles. To obtain aponeurotic width, rectus abdominis width was subtracted from the distance to medial edge of lateral abdominal wall muscle. Results: Fifty normal CT scan were evaluated from between March 2023 to August 2023. Mean width of external oblique aponeurosis at P1 was 16.2 mm (IQR 9.2 mm to 20.7 mm), at P2 was 23.5 mm (IQR 14 mm to 33 mm), and at P3 no external oblique muscle was visible. Mean width of the internal oblique aponeurosis at P1 was 32.1 mm (IQR 17.5 mm to 45 mm), at P2 was 10.13 (IQR 1 mm to 17.5 mm), and at P3 was 9.2 mm (IQR 3.0 mm to 13.7 mm). Mean width of the transversus abdominis aponeurosis at P1 was -25.1 mm (IQR 37.8 mm to -15.0 mm), at P2 was 29.4 mm (IQR 20 mm to 39.8 mm), and at P3 was 20.3 mm (IQR 12 mm to 29 mm). Conclusion: In this study we describe normal anatomical variation of the abdominal wall muscles. Assessing this variability on the pre-operative CT scans of ventral hernia patients allows for detailed operative planning and decision making.