Atypical case of bow hunter's syndrome linked to aberrantly coursing vertebral artery: A case report.

BACKGROUND: In bow hunter's syndrome (BHS), also known as rotational vertebral artery (VA) syndrome, there is dynamic/rotational compression of the VA producing vertebrobasilar insufficiency. Most occurrences involve atlantoaxial rather than mid-cervical VA compromise, the latter being rarely reported. Herein, we detail successful VA decompression at mid-cervical spine, given a departure from its usual course. CASE SUMMARY: The patient, a 45-year-old man, presented to our hospital with occipital headache and vertigo. Computed tomography angiography showed anomalous C4 entry of right VA, with compression upon head rotation to that side. Thyroid cartilage and anterior tubercle of C5 transverse process were visibly at fault. We opted for surgery, using an anterior cervical approach to remove the anterior tubercle. Patient recovery was uneventful and brought resolution of all preoperative symptoms. CONCLUSION: BHS is an important consideration where aberrant coursing of VA and neurologic symptoms coexist.

Initial experience of abdominal total mesorectal excision for rectal cancer using the da Vinci single port system.

From November 2021 to February 2022, 15 patients underwent total abdominal mesorectal excision for rectal cancer using the da Vinci single port system. The clinical and pathological results were analyzed retrospectively. All surgeries were performed without conversion. The mean distance from the tumor to the anal verge was 10 cm (range, 2-15 cm). The mean operative time was 191 minutes, the median docking time was 4 minutes (range, 2-10 minutes), and the estimated blood loss was 20 mL (range, 20-50 mL). The mean number of lymph nodes harvested was 16.5, the mean distal resection margin was 3.52 cm, and all patients had circumferential and distal tumor-free resection margins. One patient had minor anastomotic leakage. The mean length of hospital stay was 5.8 ± 2.5 days. Abdominal total mesorectal excision using the da Vinci single port system for rectal cancer is technically feasible and safe, with acceptable pathological and short-term clinical outcomes.

A comparative study on the short-term clinical outcomes of Da Vinci SP versus Da Vinci Xi for rectal cancer surgery.

PURPOSE: The Da Vinci SP robot system was recently introduced, but its safety and feasibility for rectal cancer compared with the currently used robot system have not been reported. METHODS: This was a single-centre retrospective study. Data from patients who underwent abdominal total mesorectal excision (TME) from October 2015 to October 2022 were analysed. After propensity score matching, the short-term outcomes were compared. RESULTS: A total of 56 patient data were analysed. Intersphincteric resection was more common in the SP group (7 cases (25%) vs. 0 case (0%), p = 0.001). The operation time was significantly shorter in SP (184 vs. 227.5 min, p < 0.0001), but the docking time was similar. The postoperative complications were similar. There were no differences in the postoperative pain score and length of hospital stay. CONCLUSION: The SP robotic system for abdominal TME has acceptable short-term and is safe and technically feasible.

Immediate urinary catheter removal after colorectal surgery with the enhanced recovery after surgery protocol.

PURPOSE: The Enhanced Recovery After Surgery protocol for colorectal surgery recommends early urinary catheter (UC) removal after surgery. However, the optimal timing remains controversial. We aimed to evaluate the safety of immediate UC removal and risk factors of postoperative urinary retention (POUR) after colorectal cancer surgery. METHODS: From November 2019 and April 2022, patients who underwent elective colorectal cancer surgery at Seoul St. Mary's hospital were collected retrospectively. A UC was inserted in the operating room after general anesthesia and removed in the operating room immediately after surgery. The primary outcome was the occurrence of POUR following immediate UC removal after surgery, and the secondary outcomes were the identification of POUR-related risk factors and postoperative complications. RESULTS: Among 737 patients, 81 (10%) had POUR immediately after UC removal. No patient had urinary tract infection. The incidence of POUR was significantly higher in male and in those with a history of urinary disease. However, there were no significant differences in tumor location, surgical procedure, or approach. The mean operative time was significantly longer in the POUR group. Postoperative morbidity and mortality rates did not differ significantly between two groups. Multivariate analysis showed that risk factors for POUR were male, a history of urinary disease, and intrathecal morphine injection. CONCLUSIONS: Immediate removal of UC immediately after colorectal surgery is safe and feasible in the trend of ERAS. Male, a history of benign prostatic hyperplasia, and intrathecal morphine injection were risk factors for POUR.

Experience of surgical treatment in a granular cell tumor in the qscending colon: a case report.

We report a case about successful surgical treatment of a granular cell tumor in the ascending colon. A 36-year-old man underwent screening colonoscopy. An endoscopic examination revealed a 10-mm yellowish and hemispheric mass in the ascending colon, and lower endoscopic ultrasonography revealed a hypoechoic-to-isoechoic mass invaded the submucosal layer. The mass was suspected to be a colonic carcinoid tumor. Based on the preoperative evaluation, endoscopic complete resection was considered difficult. Therefore, the lesion was removed via laparoscopic right hemicolectomy. Histological examination revealed that the tumor consisted of nests of polygonal cells with abundant granular eosinophilic cytoplasm. Immunohistochemical staining revealed diffuse positivity for S100 and CD68. Therefore, the tumor was diagnosed as a granular cell tumor. We suggest that surgical resection should be considered if it is located in the thin-walled ascending colon prone to perforation, difficult to rule out malignant tumor due to submucosal invasion, or to remove endoscopically.

Schwannoma of the breast presenting as a painful lump: A case report.

RATIONALE: Schwannoma in the breast parenchyma is very unusual. It usually develops on the head, neck, and extensor surfaces of the upper and lower extremities. PATIENT CONCERNS: We report a case of a 60-year-old woman with a palpable and painful mass. Clinically, she experienced neuropathic pain at the mass site. DIAGNOSES: The tumor was a 1 cm, well-circumscribed mass, and revealed schwannoma on core needle biopsy. INTERVENTIONS: The patient underwent wide excision. OUTCOMES: No postoperative complications were observed. A six-month follow-up revealed no recurrence. LESSONS SUBSECTIONS: Although breast schwannoma is a very rare tumor, it is a very important consideration in case of a Breast Imaging-Report and Data System 4A lesion with a painful and palpable mass.

Perioperative Considerations for Acute Appendicitis in Patients With Coronavirus Infection: Two Cases Report.

We report considerations related with surgery through 2 cases of acute appendicitis (AA) with coronavirus disease 2019 (COVID-19) infection. In November and December 2020, AA occurred in 2 patients with COVID-19, who underwent emergency surgery. In case 1, an 84-year-old woman was asymptomatic and diagnosed with AA on the 20th day of infection. She was discharged after surgery without complication. In contrast, case 2 was that a 69-year-old man with pneumonia was treated with antibiotics, steroids, and remdesivir. After surgery, he was hospitalized for a long duration due to persistent pneumonia and wound complications. We should perform in well-established negative pressure operating rooms, personal protective equipment, and protocols. Since the physical examination and blood tests were limited, image examination like computed tomography scan should be considered if AA is suspected. If pneumonia is accompanied before surgery, pneumonia may worsen after surgery, or complications such as wound infection may occur.

Adult Langerhans cell histiocytosis of skull in a patient with synchronous papillary thyroid carcinoma and Castleman disease.

We report an extremely rare case of adult Langerhans cell histiocytosis (LCH) in a patient with papillary thyroid carcinoma (PTC) and Castleman disease (CD). A 46-year-old man visited our hospital with anaemia; systemic imaging showed an abdominal and a left thyroid mass. Biopsy confirmed CD for the abdominal mass and PTC for the thyroid mass. Two months after, he presented with headache and a right parietal lump. Brain CT and enhanced MRI revealed an osteolytic mass with enhancement in the right parietal skull. Surgical removal and biopsy confirmed the diagnosis of skull LCH. The BRAF mutation was positive on PTC and negative on CD and LCH. We conducted surgical resection only for PTC and LCH; surgical resection with siltuximab for multicentric CD. At the 25-month follow-up, there was no recurrence or progression. We may consider of syndromic nature of these diseases to establish a treatment strategy.

Is it really post-irradiation morphea or oleoma of the breast?-A case report and literature review.

We report the case of a 65-year-old woman who underwent breast-conserving surgery (BCS) and radiotherapy for breast cancer with hyperpigmentation and skin thickening of the treated breast site 10 years after the surgery. The patient was injected with a liquid foreign body in both breasts 30 years ago. Theses clinical features were considered scleroderma, post-irradiation morphea (PIM), and recurrent breast cancer for differential diagnosis. We performed breast magnetic resonance imaging (MRI), however, the patient had no abnormal findings. Owing to the pain, increased hyperpigmentation, and possibility of cancer recurrence, the patient underwent a simple mastectomy. The final pathologic diagnosis was oleoma with post-radiation fibrosis among drug-induced and toxic scleroderma-like disorders. The patient tolerated surgical therapy without complications. This case report highlight is that difficult to distinguish between PIM and oleoma in patients with a complex history. In this case, the patient had both a history of radiotherapy and a history of foreign body injection, making the clinical diagnosis difficult. PIM and oleoma are non-malignant but can impair a patient's quality of life owing to symptoms and the clinical presentation is similar to that of local recurrence of breast cancer. Thus, arriving at the correct diagnosis typically requires a multidisciplinary approach, including imaging follow-up, skin punch biopsy, or surgery for a definitive diagnosis.

Laparoscopic Local Resection through Subserosal Dissection with Endoscopic Air-Insufflation for Submucosal Tumors Located Near the Esophagogastric Junction.

Purpose: A novel resection method, namely, laparoscopic local resection through subserosal dissection with endoscopic air-insuff lation (LRSDEA) was used for submucosal tumors located near the esophagogastric junction (SMT-EGJ) to avoid major gastric resection. Methods: A total of 9 cases underwent LRSDEA. We sequentially performed: laparoscopic dissections around EGJ, subserosal dissections around SMTs using laparoscopic electrocautery and ultrasonic shears, and finally, enucleation of SMTs. During these procedures, intraoperative endoscopic tumor localization, as well as endoscopic air-insufflation allowed for safe resection. These procedures are shown in the supplementary video clip. The clinicopathological characteristics and surgical results were analyzed. Results: All laparoscopic procedures were successfully performed without requiring a major gastrectomy. The mean operation time was 126.1 minutes, and estimated blood loss was 12.0 ml. There were no postoperative complications. Pathological diagnoses were 6 leiomyomas, 2 gastrointestinal stromal tumors, and 1 gastric duplication. Conclusion: LRSDEA is an effective and safe treatment option for SMT-EGJ, as major resection of the stomach is avoided.

Acute brain reaction to DBS electrodes after deep brain stimulation: chronological observation.

BACKGROUND: As increasing numbers of deep brain stimulation (DBS) procedures are performed, rare abnormal findings on postoperative images that are not attributable to well-known complications are reported. Between 2005 and 2012, we encountered several symptomatic patients with transient abnormal low-attenuation lesions on postoperative computed tomography (CT) scans. The aim of this study was to clarify this rare phenomenon using chronological observations and to suggest a feasible mechanism. RESULTS: In this period, seven (3.2 %) patients displayed transient increased low-attenuation signals, circumferentially surrounding the DBS electrodes and extending into the subcortical white matter. All these patients suffered from unexpected but transient neurological symptoms during the postoperative period. The abnormal low-attenuation lesions only disappeared completely a considerable time after the clinical symptoms had disappeared, without treatment in most patients. CONCLUSIONS: We report here our chronological observations of acute brain reactions after DBS procedures, which we believe are neither infectious nor vascular, but are possibly caused by the mechanical breakdown of the blood-brain barrier by microelectrode recordings or by anchored DBS electrodes. These lesions are thought to constitute a self-limiting disorder requiring no further treatment.

The clinical impact of precise electrode positioning in STN DBS on three-year outcomes.

Few studies have analyzed the clinical impact of subthalamic nucleus (STN) deep brain stimulation (DBS) as a function of the positioning of the inserted electrode. We investigated retrospectively the three-year outcomes in Parkinson's disease (PD) patients following bilateral STN DBS in terms of the electrode positions. Forty-one advanced PD patients were followed up for over three years following bilateral STN DBS. Patients were evaluated with the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr staging, Schwab and England Activities of Daily Living (ADL), and the Short Form-36 Health Survey (SF-36) before surgery and one, two, and three years after surgery. The patients were divided into two groups according to the electrode position based on the fused preoperative MRI and postoperative CT images: group I included patients who had both electrodes in the STN (n=30) while group II included patients who had one of the electrodes in the STN (n=11). The UPDRS, the Hoehn & Yahr staging, the Schwab and England ADL, and the SF-36 scores showed significant improvements with decreased l-dopa equivalent daily doses (LEDDs) in both groups as well as in the group as a whole for up to three years following bilateral STN DBS. However, the off-medication UPDRS total and motor (part III) scores significantly deteriorated with increased LEDDs for patients in group II three years after STN DBS compared to that of the group I patients. We conclude that more accurate electrode positioning in the STN leads to better long-term outcomes in advanced PD patients following DBS.

Central neurocytoma: long-term outcomes of multimodal treatments and management strategies based on 30 years' experience in a single institute.

BACKGROUND: A thorough investigation of the long-term outcomes of central neurocytoma (CN) after different treatments is required to establish optimal management strategies. OBJECTIVE: We retrospectively reviewed the long-term clinical outcomes of patients with CN according to various treatments and suggest treatment strategies based on 30 years of experience in a single institution. METHODS: Fifty-eight consecutive patients with CN were treated at our institution between 1982 and 2008. Patient demographics, overall survival, local control rates according to multimodal treatments, and functional outcomes were evaluated. The mean clinical and radiological follow-up periods were 119 months (range, 18-304 months) and 98 months (range, 13-245 months), respectively. RESULTS: The initial treatment modality was classified into 4 subgroups: operation only (34 patients), operation followed by radiation therapy (7 patients) or radiosurgery (7 patients), and radiosurgery alone (10 patients). The actuarial overall survival was 91% at 5 years and 88% at 10 years. The actuarial overall survival and local tumor control rate did not differ significantly according to the various treatments and the initial extent of the surgical resection. However, functional outcomes, such as the postoperative seizure outcome at the last follow-up, differed according to the surgical approach. CONCLUSION: The long-term clinical outcomes of CN after multimodal treatment seem to be excellent. Our study suggests that treatment strategies for CN should focus on the patient's quality of life, as well as on tumor control, because of the benign nature of CN.

Atypical teratoid/rhabdoid tumors: the need for more active therapeutic measures in younger patients.

Despite active and aggressive therapeutic measures, atypical teratoid/rhabdoid tumors (AT/RTs) are without doubt one of the most malignant brain tumors that occur during childhood. These tumors are more prevalent in children less than 3 years of age, and the prognosis is worse in these young children. Medical records of 14 patients diagnosed at our institution were reviewed. Patients diagnosed with AT/RT at our institution between 1997 and 2009 were identified. Clinical data for those patients with pathologic confirmation of AT/RTs were reviewed regarding surgery, adjuvant treatment, and survival. A total of 14 patients were identified. One patient who died 3 days after initial surgery was excluded, and 13 patients were recruited. Of the 13 patients, 7 were less than 1 year of age, and only 2 were over 3 years of age. Nine patients showed dissemination at diagnosis. Four patients were treated with radiation therapy (RTx), and 2 of these were less than 3 years of age. Ten patients had chemotherapy (CTx), and 3 of these underwent high dose chemotherapy and autologous peripheral blood stem cell transplantation. The median progression-free survival (PFS) was 4 months, and the median overall survival (OS) was 9 months. Univariable analysis revealed age more than 1 year, CTx, and RTx to be significant factors for better PFS and OS. None of the variables were significant in multivariable analysis. Young patients with AT/RT have a bad prognosis. An aggressive therapeutic strategy needs to be profiled for this age group.

Developmental changes of misconception and misperception of projectiles.

This study investigated the developmental changes of perceptual and cognitive commonsense physical knowledge. Children 4 to 9 years old (N = 156; 79 boys, 77 girls) participated. Each child was asked to predict the landing positions of balls that rolled down and fell off a virtual ramp and to choose the most natural-looking motion from different projectile motions depicted. The landing position of the most natural-looking projectile was compared with the predicted landing position and also compared with the actual landing position. The results showed children predicted the ball's landing position closer to the ramp than the actual position. Children also chose the depiction in which the ball fell closer to the ramp than the accurate position, although the error in the prediction task was larger than in the perception task and decreased with age. The results indicated the developmental convergence of explicit reasoning and implicit perception, which suggest a single knowledge system with representational re-description.

Chiari 1.5 malformation : an advanced form of Chiari I malformation.

The Chiari 1.5 malformation is defined as a tonsillar herniation within a Chiari I malformation with additional caudal descent of the brainstem through the foramen magnum. We describe a patient with Chiari I malformation who evolved to Chiari 1.5 malformation during longitudinal follow-up. A 15-year-old girl presented with neck pain during exercise for two years. She had been diagnosed with Chiari I malformation with mild hydrocephalus after minor cervical trauma at the age of six years. At that time, she was asymptomatic. After she complained of aggravated neck pain, neuroimaging (nine years after first imaging) revealed caudal descent of the brainstem and syringomyelia in addition to progression of tonsillar herniation. Posterior fossa decompressive surgery resulted in complete resolution of neck pain. Based on neuroimaging and operative findings, she was diagnosed as Chiari 1.5 malformation. Neuroimaging performed seven months after surgery showed an increased anterior-posterior diameter of the medulla oblongata and markedly decreased syringomyelia. This case demonstrates progressive developmental process of the Chiari 1.5 malformation as an advanced form of the Chiari I malformation.

Non-functional parathyroid adenoma presenting as a massive cervical hematoma: a case report.

Parathyroid adenoma usually manifests with symptoms related to hypercalcemia, such as urinary stone and bone fracture. It may also present with asymptomatic hypercalcemia. However, spontaneous cervical hematoma may occur very rarely as a result of extracapsular hemorrhage of a cervical parathyroid adenoma causing acute painful cervical swelling, bruising, dyspnea, hoarseness and dysphagia. We report a 44-year-old woman who manifested as a spontaneous cervical hematoma without any clinical evidence of hyperparathyroidism.