Cecal volvulus as a rare complication of internal hernia after Roux-en-Y gastric bypass: a case report and literature review.

This case report describes a rare instance of cecal volvulus resulting from an internal hernia through Petersen's space, occurring 20 years after Roux-en-Y gastric bypass surgery, marking it as the second such case in English literature. An 81-year-old female presented with symptoms of bowel obstruction, and imaging findings concerning for cecal volvulus. Emergency surgery revealed necrotic bowel due to an internal hernia, necessitating a right hemicolectomy, with subsequent successful anastomosis and hernia defect closure. The incidence of internal hernias post-gastric bypass is notable, emphasizing the critical need for surgical vigilance. This case underscores the importance of considering internal hernias in differential diagnoses for bowel obstruction in post-bariatric surgery patients, highlighting the life-saving role of prompt surgical intervention in the management of cecal volvulus complications.

Ruptured gastro-intestinal stromal tumor as a surgical emergency: A case report and literature review.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs of the small bowel are rare, and often present with an abdominal mass and/or bleeding. Chemotherapy and surgery are the mainstay of therapy. Here, we discuss an unusual case of a ruptured jejunal GIST with hemoperitoneum and recurrence despite surgical excision followed by Imatinib treatment. Forty-five cases of ruptured small intestinal GISTs were identified in the literature. Most cases were in males and were found to be at the site of the jejunum.

Successful use of endovascular aneurysm repair in the treatment of acute aortoduodenal syndrome.

Aortoduodenal syndrome is a rare phenomenon, described as a duodenal obstruction secondary to direct compression from an abdominal aortic aneurysm. Although traditionally managed with gastrointestinal bypass and subsequent open aortic aneurysm repair, such procedures hold high mortality. Therefore, there is great value in treating this syndrome with an endovascular, minimally invasive technique that is both consistent and successful. This case report recounts how an endovascular aneurysm repair successfully treated a patient with acute aortoduodenal syndrome. No postoperative complications occurred and the duodenal obstruction was relieved without the need for surgical re-intervention. This conveys the advantageous utility of endovascular aneurysm repair in treating patients with aortoduodenal syndrome.

Large uterine leiomyoma presenting as pseudo-Meigs' syndrome with an elevated ca125: a case report and literature review.

Ascites, pelvic mass and elevated CA-125 in females carry a grim prognosis, likely an ovarian carcinoma. However, more benign etiologies such as Meigs' and pseudo-Meigs' syndrome must be considered. Pseudo-Meigs' syndrome presenting with an elevated CA-125 is rare and presents a diagnostic challenge. Medline and PubMed were queried for pseudo-Meigs' syndrome cases. We present a 35-year-old female patient who presented with abdominal swelling and weight gain. Imaging demonstrated a 29-cm large intraabdominal mass with significant ascites with elevation of CA-125. Surgical resection was performed, and pathology identified uterine leiomyoma. Twenty-one cases of pseudo-Meigs' syndrome were identified in the literature. Most patients presented with abdominal distention, and some also reported dyspnea. All patients, including our case, were treated surgically. No recurrence reported among these cases. Surgery is the mainstay for radical treatment in pseudo-Meigs' syndrome. Resolution of the ascites and hydrothorax occurs following resection of the tumor.

Traumatic rupture of a hemorrhagic hepatic cyst: a case presentation and literature review.

Hemorrhagic hepatic cyst with or without rupture is rare cause of acute abdomen with less than 20 cases reported in the literature. A standardardized management algorithm is currently not present, but literature suggests surgical management is ideal for definitive treatment and successful patient outcome. We report a case of a 39-year-old female with a chief complaint of sudden onset abdominal pain, nausea and vomiting. Abdominal computed tomography scan showed a large, 12-cm cyst in the right hepatic lobe with a hemorrhagic component. Successful laparoscopic operative management was conducted without post-operative complications such as recurrent bleeding. When managing patients with an acute abdomen, ruptured hepatic hemorrhagic cysts should be considered in the differential diagnosis and prompt surgical management should be considered as primary management.

Gallbladder adenosquamous carcinoma: a case report and literature review.

Representing 90-95% of all malignant gallbladder neoplasms, adenocarcinoma is by far the most common subtype. Adenosquamous carcinoma is a rare subtype, accounting for only 1-5% of all gallbladder carcinomas. These tumors have been shown to have aggressive biologic behavior, commonly extending to adjacent structures. Some studies have shown that the squamous component often displayed a greater proliferative capacity than the adenocarcinomatous component (possibly even up to twice as fast). Complete surgical resection is currently the mainstay of treatment but the prognosis is often poor. In this paper, we present a case of a 69-year-old male with an AJCC Stage IV moderately differentiated adenosquamous carcinoma of the gallbladder treated with radical cholecystectomy including liver segments IVb, V, VI.

Abdominal wall endometrioma presenting as a cystic abdominal wall mass: a case report and literature review.

Endometriosis is classically defined as 'the presence of endometrial glands and stroma outside of the uterine cavity and musculature'. Although it most commonly occurs in the pelvis, various extrapelvic locations have been reported in the literature. There seems to be a strong association between abdominal wall endometriomas and previous surgical scars. In female patients presenting with a cyclically painful abdominal wall mass, a high index of suspicion for endometrioma must be maintained, especially in the setting of previous gynecologic surgery. Although there may be a role for medical management of symptoms, the most definitive treatment of an abdominal wall endometrioma appears to be wide local excision with negative margins. This paper presents a 39-year-old female with an extensive gynecologic surgical history presenting with a 6 × 6 cm cyclically tender abdominal wall endometrioma treated with wide local excision.

Giant sliding inguinal hernia requiring intraoperative aspiration of fluid: a case report and literature review.

Giant inguinal hernias are defined as inguinal hernias that extend below the midpoint of the inner thigh when the patient is in the standing position or an anteroposterior diameter of at least 30 cm or a laterolateral diameter of ~50 cm with non-reducibility for >10 years. This article presents a 39-year-old male with a five-year history of a giant left inguinal hernia that was treated with left inguinal hernia repair with mesh, orchiectomy, complicated scrotoplasty, intraoperative ultrasound and aspiration of 3.9 L of fluid from the hernia sac. Surgical repair of giant inguinal hernias can be challenging and is associated with a variety of complications. Various modalities have been described to assist in hernia reduction including debulking, or, as in this case, aspiration of the hernia sac and a preperitoneal incision. Although the Lichtenstein tension free repair is commonly used, no standard approach has been accepted.

Giant siliconoma mimicking locally advanced breast cancer: A case report and review of literature.

INTRODUCTION: Silicone prosthetics are widely used for breast augmentation and reconstruction. These devices may extrude free silicone into surrounding tissue, stimulating a granulomatous foreign body reaction. The resulting mass can mimic breast cancer. PRESENTATION OF CASE: 71 year old female with a history of a ruptured silicone implant presents with an enlarging left breast mass. Exam demonstrated and ulcerated, fungating mass with active infection. CT scan demonstrated a 23 × 15 cm mass involving the breast and chest wall with axillary lymphadenopathy. Preoperative biopsies were inconclusive and the patient underwent a modified radical mastectomy. Pathology demonstrated a siliconoma. DISCUSSION: While benign, silicone granulomas of the breast can present similarly to malignancy and are an important differential in the diagnosis of a breast or axillary mass for appropriate patients. MRI is the study of choice and core needle biopsies cannot always establish the diagnosis preoperatively. PET scans can be falsely positive and the diagnosis requires an extensive workup to rule out cancer. CONCLUSION: Siliconomas develop as a result of implant rupture and present with many of the signs and symptoms of breast cancer. The majority of patients should undergo surgery for symptom relief or to rule out cancer.

Primary intrahepatic mesotheliomas: A case presentation and literature review.

INTRODUCTION: Primary Intrahepatic mesotheliomas are malignant tumors arising from the mesothelial cell layer covering Glisson's capsule of the liver. They are exceedingly rare with only fourteen cases reported in the literature. They have nonspecific signs and symptoms and need a high index of suspicion and an extensive workup prior to surgery. Surgery remains the mainstay of treatment. PRESENTATION OF CASE: 48 year old male presented with a 3 months history of abdominal pain, productive cough, anemia and weight loss. He had no history of asbestos exposure. A computed tomography scan and magnetic resonance study demonstrated a heterogeneous subscapular mass within the dome of the right hepatic lobe measuring 11.3 × 6.1 cm involving the diaphragm. Combined resection of the liver and diaphragm was performed to achieve negative margins. Pathology demonstrated an epithelioid necrotic intrahepatic mesothelioma that stained positive for calretinin, CK AE1/AE3, WT-1, D2-40 and CK7. DISCUSSION: Primary intrahepatic mesotheliomas originate from the mesothelial cells lining Glisson's capsule of the liver. They predominantly invade the liver but may also abut or involve the diaphragm. Surgery should include a diagnostic laparoscopy to rule out occult disease or diffuse peritoneal mesothelioma. Complete resection with negative margins should be attempted while maintaining an adequate future liver remnant. Attempts at dissecting the tumor off the involved diaphragm will result in excessive bleeding and may leave residual disease behind. CONCLUSION: Intrahepatic mesotheliomas are rare peripherally-located malignant tumors of the liver. They require a high index of suspicion and a comprehensive workup prior to operative intervention.

Ethanol potentiates heat response in the carotid artery via TRPV1.

AIM: Ethanol is one of the most widely used recreational drugs in the world. At high concentrations, it can induce carotid artery vasoconstriction. Hyperthermia potentiates its effects resulting in carotid artery vasoconstriction at any concentration. The aim of this study is to investigate the interaction between ethanol and heating and to understand the underlying mechanisms leading to their synergistic effect. MATERIALS AND METHODS: Isometric tension of rabbit carotid artery ring segments suspended in organ baths filled with Krebs solution was recorded. Different concentrations of ethanol were examined at 37°C and during temperature elevation to39-43°C. Capsaicin and capsazepine were used to examine the mechanism of action of ethanol. KEY FINDINGS: Ethanol induced contraction at 37°C when the concentration reached 100mM. Contraction was observed at any concentration at higher temperatures. Ethanol potentiated heat-induced contraction. Capsaicin, the vanilloid receptor subtype1 (TRPV1) agonist, potentiated the vasoconstriction due to heating. While capsazepine, TRPV1 antagonist, abolished the effect of ethanol and its potentiation of heating-induced contraction, but it did not abolish the heating effect. SIGNIFICANCE: Ethanol's mechanism of action and its effect on heating induced-vasoconstriction of the carotid artery is being mediated by TRPV1. The combination of ethanol and hyperthermia can lead to a synergistic effect on carotid vasoconstriction. This effect may induce brain damage and heat stroke. Development of new drugs act as TRPV1 antagonist can be used to prevent these fatal effects.

Using endoscopy to minimize the extent of resection in the management of giant GISTs of the stomach.

INTRODUCTION: The stomach is the most common site for GISTs. Wide local resection to achieve negative margins is the standard of care. Giants GISTs requiring extensive resection are usually managed with neo-adjuvant therapy followed by partial or total gastrectomy. PRESENTATION OF CASE: We present a case report of a giant GIST on the lesser curvature of the stomach. Neo-adjuvant therapy was administered. Intra-operative endoscopy was used to reduce the extent of gastric resection. DISCUSSION: Simultaneous intra-operative endoscopy demonstrated a 2mm fistula on the lesser curvature of the stomach. A stapler was used to encompass the mass and the fistulous opening. A frozen-section showed clear margins and the endoscope was used to perform an air-leak test. The patient recovered without complications. CONCLUSION: Intra-operative endoscopy can reduce the extent of gastric resection for large GISTs while maintaining the oncologic principles of negative margins and minimal tissue handling.

The morbidity and mortality of hepaticojejunostomies for complex bile duct injuries: a multi-institutional analysis of risk factors and outcomes using NSQIP.

INTRODUCTION: Bile duct injury (BDI) is an infrequent but morbid complication of cholecystectomy. High-grade BDI repairs requiring hepaticojejunostomies are complex and associated with increased morbidity and mortality. This study sought to establish the increased risk associated with complex bile duct repair at a multi-institutional level in the United States. METHODS: Using the ACS-NSQIP Participant Use File, all patients who underwent a hepaticojejunostomy for bile duct repair between 2005 and 2012 were identified. Clinical data, perioperative risk factors and morbidity and mortality rates were calculated. RESULTS: Of the 293 BDI patients, 102 (65.2%) were female and the mean age was 49.8 years. The 30-day morbidity and mortality rates were 26.3% and 2%, respectively. Univariable analysis identified male gender, ASA class, functional status, diabetes, hypertension and chronic steroid use to be associated with increased morbidity. A higher ASA class was associated with increased postoperative sepsis and chronic steroid use was associated with increased overall morbidity on multivariable analysis. The morbidity rates for BDI repair within 30 days of injury vs. later repair were similar (24% vs. 23%), but the mortality rate was higher for the earlier repair group (5% vs. 0%, p = 0.012). CONCLUSIONS: Within the largest multi-institutional analysis of 30-day outcomes after hepaticojejunostomies for BDI in the US, morbidity and mortality rates were established at 26.3% and 2% respectively. ASA class and preoperative functional status remain the main risk factors for surgery. Earlier repair in the face of ongoing sepsis and disability is associated with worse outcomes. A multidisciplinary approach at a specialized center aimed at controlling infection and improving functional status prior to surgical reconstruction is recommended.

Spontaneous endometriosis associated with an umbilical hernia: A case report and review of the literature.

INTRODUCTION: Umbilical endometriosis occurring in the presence of an underlying hernia is extremely rare and presents a diagnostic challenge for the general surgeon. We present an interesting case and perform a comprehensive review of the literature. METHODS: Medline and PubMed were queried for all cases of spontaneous umbilical endometriosis associated with an umbilical hernia. Data was analyzed and is presented along with an interesting case. RESULTS: Only 7 cases have been reported in the literature. Median age was 38 years. Time to presentation was long (up to 5 years) and the majority had cyclical symptoms related to menstruation. All patients, including our case, were treated surgically. DISCUSSION: Spontaneous umbilical endometriosis with an underlying hernia is often missed preoperatively. Preoperative suspicion warrants axial imaging for better operative planning and patient counseling. Surgery consists of enbloc excision of the umbilicus, implant and the hernia sac to avoid residual disease and reduce recurrence. The hernia defect can be repaired primarily or using mesh and the umbilicus reconstructed using skin flaps if necessary. CONCLUSIONS: Surgery is the mainstay of therapy for umbilical endometriosis associated with an underlying hernia. Clinical suspicion warrants preoperative imaging, and follow-up with a gynecologist is essential to address any pelvic disease.

Intestinal stenosis of Garré: A rare cause of small bowel obstruction in the virgin abdomen.

INTRODUCTION: Small bowel obstruction (SBO) in the virgin abdomen usually requires operative intervention. Intestinal stenosis of Garré is a rare and frequently missed cause of SBO following hernia repair. METHODS: We describe a case of intestinal stenosis of Garré and provide a comprehensive review of the literature. Statistical analysis was performed using IBM SPSS Statistics V.22 software and included descriptive analysis. RESULTS: Most males developed a delayed stricture following an inguinal hernia repair (93.3%). 84.6% of females, on the other hand, developed intestinal stenosis following repair of a femoral hernia. 87.5% of strictures developed on the right side. The timing of development of a bowel obstruction is very variable and ranges from 5days to 22 years. 22 patients (68.8%), however, presented with an obstruction within 5 months of hernia repair. CONCLUSIONS: Intestinal stenosis of Garré is an under-reported cause of delayed stricture formation.It is most common following right inguinal hernia repair in men and right femoral hernia repair in women.

Optimal management of GIST tumors located near the gastroesophageal junction: Case report and review of the literature.

INTRODUCTION: The safety and oncologic outcome of laparoscopic gastric GIST resection is well established especially for lesions <5cm in diameter. The optimal management of GIST tumors near the GE junction remains unclear. METHODS: We present a case-report of a 4.7cm GIST tumor near the GE junction managed by endoscopically-assisted laparoscopic wedge resection (EAWR). We present a review of the literature highlighting the various combined laparo-endoscopic techniques available. RESULTS: We used the non-touch lesion-lifting method to laparoscopically resect the GIST tumor under endoscopic guidance. There were no complications and the patient was discharged on postoperative day 3. CONCLUSIONS: Endoscopically-assisted laparoscopic wedge resections are feasible and safe for GIST tumors near the GE junction.

Evaluating the Clinical Applicability of the European Staging System for Perihilar Cholangiocarcinoma.

BACKGROUND: In 2011, a new European Staging System (ESS) for perihilar cholangiocarcinoma (PHC) was proposed with the expressed purpose of comparing treatment and outcomes data between institutions. The goal of this study was to evaluate the feasibility of ESS data capture. STUDY DESIGN: Forty-seven consecutive patients who underwent surgical resection for PHC between 1999 and 2013 were studied. Demographic variables, components of various staging systems (including the ESS), preoperative and perioperative details, pathology, and outcomes were recorded. RESULTS: The mean patient age was 63.2 and 62% were male. Preoperative imaging included high-resolution CT in all patients, MRI in 34%, and PET in 11%. R0 resection was accomplished in 80% of patients. Four patients (8.5%) and 18 patients (38.3%), respectively, received neoadjuvant or adjuvant therapy. During a mean follow-up of 36 months, recurrence rate was 51.3% and 2- and 5-year survival rates were 69.4 and 33.3%, respectively. Analysis of data capture found that tumor (T) classification was indeterminable in 7/47 patients (14.9%). For two patients, the form (F) designation had insufficient data. The extent of vascular involvement (PV/HA) was different compared to preoperative imaging in nine patients (19.1%). The liver remnant volume (V) was calculated in only 18 patients (38.3%). The liver disease (D) variable did not account for four patients with inflammation/cirrhosis. In total, only 15 patients (31.9%) had all required elements to complete the ESS. CONCLUSIONS: Without templated radiology, surgery, and pathology reports, the ESS cannot be applied to current clinical/research practice. Although resection continues to provide significant survival benefit to patients with perihilar cholangiocarcinoma, lack of an accurate prognostic tool for resectability and outcomes continues to be a major impediment to progress in the field.

Reactivity of diabetic urinary bladder to the cholinesterase inhibitor neostigmine.

OBJECTIVE: To examine the effects of neostigmine, an acetylcholinesterase inhibitor that has been used to treat impaired bladder emptying on diabetic rat urinary bladder smooth muscle. METHODS: Rat urinary detrusor muscle strips were suspended in organ baths containing Krebs' solution for isometric tension recording. Streptozotocin-diabetic (12 weeks) bladder tissue activity compared with control was assessed by using electrical field stimulation (EFS) in the presence and absence of the cholinesterase inhibitor, neostigmine. RESULTS: EFS-induced contractions; a major part of it is cholinergic in origin. Neostigmine significantly enhanced EFS-induced contractions in diabetic strips than control at all frequencies. Neostigmine caused concentration-dependent contractions of control and diabetic bladder tissues, which were completely abolished by atropine. Carbachol-induced bladder contraction was significantly reduced in diabetes. CONCLUSION: In diabetes mellitus, cholinesterase modulation (increase) may play a role in the development of inadequate bladder contraction, seen in later stage diabetic bladder dysfunction.

Adverse effects of preoperative steroid use on surgical outcomes.

BACKGROUND: Preoperative steroid use has been associated with increased postoperative complications. We sought to establish these risks using data from the National Surgical Quality Improvement Program (NSQIP). METHODS: NSQIP public use files from 2005 to 2008 were analyzed for preoperative steroid use and postoperative adverse events. RESULTS: Of 635,265 patients identified, 20,434 (3.2%) used steroids preoperatively. Superficial surgical site infections (SSI) increased from 2.9% to 5% using steroids (odds ratio, 1.724). Deep SSIs increased from .8% to 1.8% (odds ratio, 2.353). Organ/space SSIs and dehiscence increased 2 to 3-fold with steroid use (odds ratios, 2.469 and 3.338, respectively). Mortality increased almost 4-fold (1.6% to 6.0%; odds ratio, 3.920). All results were significant (P < .001). CONCLUSIONS: Previous concerns related to surgical risks in patients on chronic steroid regimens appear valid. These results may assist in counselling patients regarding the increased risk of surgery. They may also help the surgeon plan and modify the procedure if possible.