How do we treat severely prolapsed true ectopia cordis?

Ectopia cordis is an extremely rare condition where the heart displaces outside the thoracic cavity. Treating this, especially when accompanied by congenital heart diseases and severe protrusion, is challenging. Here, we present a case of successful treatment involving intracardiac repair and delayed sternal closure using local skin flaps.

Resolving conjunctival prolapse following severe blepharoptosis correction: A simple sutureless direct excision technique and systematic review.

BACKGROUND: Conjunctival prolapse (CP) is an uncommon but challenging condition following maximal levator resection (MLR) and other extensive periorbital procedures. MLR extending beyond the Whitnall's ligament is frequently performed to address severe blepharoptosis with poor levator function (LF). Patients with CP may encounter symptoms such as ocular discomfort, tearing, vision impairment, persistent conjunctival chemosis, lagophthalmos, or exposure keratopathy. Typically, surgical intervention becomes necessary if conservative measures prove to be ineffective; nevertheless, there is no consensus regarding the optimal treatment approach. OBJECTIVES: This study aimed to propose a simple sutureless direct excision method and explore the surgical advancements in CP correction through a systematic review. METHODS: Patients with recurrent CP after MLR who underwent sutureless direct excision of the conjunctiva using loupe magnifiers at a tertiary hospital were included in this study. The clinical evolution and surgical results were recorded. PubMed, MEDLINE, EMBASE, and Web of Science databases were queried following The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. RESULTS: The comprehensive analysis of 1858 articles identified 88 patients from 24 studies, highlighting that blepharoptosis surgery is predominantly associated with CP (36.6%). Surgically treated CP showed a higher resolution rate compared to those managed conservatively (54.8% vs. 45.2%; p = 0.034). No relapse was observed in patients treated with sutureless direct excision of CP in long-term follow-up. CONCLUSION: We proposed a simple sutureless direct excision technique that offers a straightforward and efficient approach in treating CP, which is particularly suitable for cases requiring excision lengths >16 mm during MLR. Furthermore, stitch removal can be obviated after surgery.

Risk factors analysis and multidisciplinary team first-aid simulation training for umbilical cord prolapse can improve neonatal outcomes.

OBJECTIVE: In the present study, we sought to identify risk factors for umbilical cord prolapse (UCP) and adapt the multidisciplinary team (MDT) first-aid simulation training for UCP patients. We evaluated the usefulness of the MDT first-aid simulation by comparing delivery outcomes for UCP patients before and after its implementation. MATERIAL AND METHODS: A retrospective review was conducted on 149 UCP cases (48 overt and 101 occult) and 298 control deliveries that occurred at the Third Affiliated Hospital of Sun Yat-sen University from January 1998 to December 2022. Patient data were compared between the groups. One-way analysis of variance (ANOVA) was used for means comparison, and the chi-square test was used for categorical data. Univariate and multivariate logistic regression analyses were performed to identify factors significantly associated with UCP. RESULTS: Overt UCP was strongly associated with all adverse delivery outcomes. Both univariate and multivariate analyses identified multiparity, breech presentation, polyhydramnios, and low birth weight as independent risk factors for overt UCP (all odds ratios [OR] > 1; all p < 0.05). Preterm labor and abnormal placental cord insertion were identified as independent risk factors for occult UCP (all OR > 1; all p < 0.05). After 2014, when obstetrical staff received MDT first-aid simulation training, patients with overt UCP experienced shorter decision-to-delivery intervals due to more timely cesarean sections. They also had higher Apgar scores at 1, 5, and 10 min, and lower admission rates to the neonatal intensive care unit compared to patients before 2014 (all p < 0.05). CONCLUSION: MDT first-aid simulation training for overt UCP can improve neonatal outcomes. However, medical simulation training efforts should initially focus on the early identification of risk factors for both overt and occult UCP.

Overt umbilical cord prolapse (UCP) is an obstetric emergency that can lead to adverse delivery outcomes. Early identification of risk factors for both overt and occult UCP is beneficial for facilitating early interventions. Multidisciplinary team first-aid simulation training specifically for overt UCP has been shown to effectively improve neonatal outcomes.

Extensor tendon rupture and preoperative mri confirmations of suture anchor prolapse: a case report and literature review.

BACKGROUND: While suture anchors are widely used in medical procedures for their advantages, they can sometimes lead to complications, including anchor prolapse. This article presents a unique case of suture anchor prolapse at the base of the distal phalanx of the little finger after extensor tendon rupture reconstruction surgery. CASE PRESENTATION: A 35-year-old male, underwent extensor tendon rupture reconstruction using a non-absorbable suture anchor. After seven years the patient visited our outpatients complaining of stiffness, pain, and protrusion at the surgical site. Initial X-ray imaging suggested suggesting either a fracture of the distal phalanx or tendon adhesion but lacked a definitive diagnosis. Subsequent magnetic resonance imaging (MRI) revealed bone connectivity between the middle and distal phalanges with irregular signal shadow and unclear boundaries while maintaining a regular finger shape. MRI proved superior in diagnosing prolapsed suture anchors, marking the first reported case of its kind. Surgical intervention confirmed MRI findings. CONCLUSIONS: Suture anchor complications, such as prolapse, are a concern in medical practice. This case underscores the significance of MRI for accurate diagnosis and the importance of tailored surgical management in addressing this uncommon complication.

Diagnosis and Treatment of Lacrimal Gland Prolapse: A Narrative Review.

BACKGROUND: Lacrimal gland prolapse (LGP) is considered to be one of the causes for upper eyelid contour abnormality that should be recognized and treated properly to yield satisfactory outcomes in blepharoplasty. To describe current findings about the prevalence, pre- and intraoperative diagnosis of LGP and its treatment options. METHODS: PubMed and Google Scholar were thoroughly searched for articles published describing the diagnosis and treatment of LGP. RESULTS: The reported prevalence of LGP by various authors varies between 10 and 60% based on their preoperative or intraoperative reports. Techniques such as dacryoadenopexy, modified dacryoadenopexy, and dacryoplasty have been described to secure the prolapsed lacrimal gland back into its original position. Additionally, creating a Whitnall's barrier has also been suggested as a method to reposition the gland. While all these surgical procedures have shown promising immediate results, there is a lack of published data on their long-term outcomes. CONCLUSION: Diagnosis and proper treatment of LGP could enhance the cosmetic results of upper eyelid blepharoplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Aesthetic and Functional Outcomes of Upper Blepharoplasty Combined with Dacryoadenopexy in Lacrimal Gland Prolapse.

INTRODUCTION: Lacrimal gland prolapse (LGP) is a term used to describe a benign, anterior displacement of the lacrimal gland. If this condition is not properly addressed during upper blepharoplasty, the aesthetic and functional results are less than optimal. This study aimed to report the surgical outcomes of upper blepharoplasty combined with dacryoadenopexy in patients with LGP. METHODS: We reported an unusual case of severe LGP in a young patient. In addition, we performed a systematic review of the English literature on surgical cases of LGP published between 1973 and 2023. Eligible articles were analyzed for individual patient data (IPD) and aggregate patient data (APD). The primary predictor variable was the surgical technique used for lacrimal gland repositioning/suspension. The primary outcome variable was relapse rate. RESULTS: The bibliographic search retrieved 488 surgical cases of LGP: 12 in IPD, and 476 in APD datasets. The relapse rates in the IPD and APD cohorts were 8.3% (1/12) and 1.2% (6/476), respectively. Within the APD dataset, no significant difference in the relapse rates between dacryoadenopexy via suture suspension and Whitnall's ligament suspension (5/409 and 1/20, respectively; P > 0.05) was observed. Light cauterization of the lacrimal gland capsule and surrounding soft tissues was performed in mild LGP cases (< 4 mm prolapse), with a relapse rate of 0% (0/47). CONCLUSION: Upper blepharoplasty combined with dacryoadenopexy proved to be a safe surgical procedure with very satisfactory aesthetic outcome and minimal relapse rate. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Severe orbital hematoma with third eyelid swelling and prolapse following a blind maxillary nerve block in a horse.

A 20-year-old quarter horse gelding was presented for routine dental examination. Periodontal disease and luxation of tooth 108 was diagnosed and oral extraction was planned. After an unsuccessful blind maxillary nerve block, it was elected to perform the procedure under total intravenous anesthesia. Following recovery, a focal superficial corneal ulcer, severe retrobulbar swelling, mild exophthalmos, and marked swelling and prolapse of the third eyelid (nictitating membrane) were observed. Clinical signs persisted beyond 48 h despite the use of systemic anti-inflammatories and topical ocular anti-inflammatories and antibiotics. A temporary tarsorrhaphy was subsequently done at 48 h and the horse was discharged after 5 d of hospitalization and regression of clinical signs. Although it is very useful for easing dental extractions, the blind maxillary nerve block is associated with potential complications due to inadvertent vascular puncture. This case report describes a rare complication of prolapse of the third eyelid in a horse after a maxillary nerve block and successful treatment with a temporary tarsorrhaphy. Key clinical message: This case report explains how nictitating membrane swelling and prolapse can occur following a blind maxillary nerve block in the horse and describes treatment with a temporary tarsorrhaphy.

Hématome orbitaire sévère avec gonflement de la troisième paupière et prolapsus à la suite d'un bloc du nerf maxillaire à l'aveugle chez un cheval. Un hongre quarter horse de 20 ans a été présenté pour un examen dentaire de routine. Une maladie parodontale et une luxation de la dent 108 ont été diagnostiquées et une extraction orale a été planifiée. Après l'échec d'un bloc du nerf maxillaire à l'aveugle, il a été décidé d'effectuer la procédure sous anesthésie intraveineuse. Après la guérison, un ulcère cornéen superficiel focal, un gonflement rétrobulbaire sévère, une légère exophtalmie ainsi qu'un gonflement et un prolapsus marqués de la troisième paupière (membrane nictitante) ont été observés. Les signes cliniques ont persisté au-delà de 48 heures malgré l'utilisation d'anti-inflammatoires systémiques et d'anti-inflammatoires oculaires topiques et d'antibiotiques. Une tarsorraphie temporaire a ensuite été réalisée à 48 heures et le cheval est sorti après 5 jours d'hospitalisation et de régression des signes cliniques. Bien qu'il soit très utile pour faciliter les extractions dentaires, le bloc du nerf maxillaire à l'aveugle est associé à des complications potentielles dues à une ponction vasculaire involontaire. Ce rapport de cas décrit une complication rare de prolapsus de la troisième paupière chez un cheval après un bloc nerveux maxillaire et un traitement réussi par tarsorraphie temporaire.Message clinique clé:Ce rapport de cas explique comment un gonflement et un prolapsus de la membrane nictitante peuvent survenir à la suite d'un bloc du nerf maxillaire à l'aveugle chez le cheval et décrit le traitement par tarsorraphie temporaire.(Traduit par Dr Serge Messier).

Risk factors for stoma prolapse after laparoscopic loop colostomy.

BACKGROUND: Stoma prolapse (SP) is a common stoma-related complication, particularly in loop colostomies. This study aimed to investigate potential risk factors for SP development after laparoscopic loop colostomy. METHODS: In total, data from 140 patients who underwent laparoscopic loop colostomy were analyzed between September 2016 and March 2022. Risk factors for SP were investigated retrospectively. RESULTS: The median follow-up duration after colostomy was 12.5 months, and SP occurred in 33 (23.6%) patients. Multivariate analysis showed that being overweight (body mass index ≥ 25; odds ratio [OR], 8.69; 95% confidential interval [CI], 1.61-46.72; p = 0.012) and having a thin rectus abdominis penetration of the stoma (< 8.9 mm; OR, 8.22; 95% CI, 2.50-27.05; p < 0.001) were independent risk factors for SP. Other patient characteristics and surgical factors associated with stoma construction were unrelated to SP development. CONCLUSIONS: Being overweight and the route penetrating the thinner rectus abdominis during stoma construction was associated with a significantly higher incidence of SP after laparoscopic loop colostomy. Selecting a construction site that penetrates the thicker rectus abdominis muscle may be crucial for preventing SP.

Postpartum Necrotizing Myositis With Endometrial Prolapse.

BACKGROUND: Postpartum necrotizing myositis is a rare condition, typically presenting as a complication after uterine artery embolization or uterine compression suturing. Uterine ischemia can cause endometrial necrosis and even myometrial necrosis, which can lead to systemic infection. If a systemic infection is not promptly and actively treated, it may pose significant risk. CASE: A 35-year-old patient who had undergone bilateral uterine artery ligation, modified B-Lynch suture, and multiple compression sutures due to refractory postpartum hemorrhage frequently presented to clinic after postpartum discharge due to persistent fever and vaginal discharge. A bag-like prolapse from the vagina measuring 10×5 cm, accompanied by purulent discharge, was noted 78 days postsurgery. Subsequent pelvic magnetic resonance imaging revealed a uterine basal abscess and postpartum necrotizing myositis; an emergency laparoscopic supracervical hysterectomy was performed, with postoperative pathology confirming the diagnosis. After the patient's discharge, she was readmitted for inpatient treatment of a pelvic abscess. CONCLUSIONS: Although rare, postpartum necrotizing myositis should be considered in postpartum patients presenting with fever, abdominal pain, severe infection symptoms, and abnormal vaginal discharge. Culture and sensitivity testing are recommended to direct appropriate antibiotic therapy.

Characteristics Associated With Recurrent Urinary Tract Infections: A Case-Control Study.

IMPORTANCE: Recurrent urinary tract infections (rUTIs) affect 2-10% of adult women and are associated with a significant effect on quality of life, daily activities, and mental health. OBJECTIVE: The aim of this study was to identify clinical characteristics associated with rUTIs among women seeking care for pelvic floor disorders at an academic tertiary urogynecology clinic. STUDY DESIGN: A retrospective case-control study of women presenting to an academic tertiary urogynecology clinic was conducted. Cases were women with rUTIs, defined as ≥2 UTIs in 6 months or ≥3 within 1 year. Controls were women with no culture documented UTIs. Cases were matched 2:1 to controls by age and body mass index. Demographic and clinical characteristics were compared between cases and controls, and bivariate characteristics with P values ≤0.2 were assessed for an independent association with rUTIs by multivariable logistic regression. RESULTS: A total of 285 cases with rUTIs were identified, and 150 matched controls had a mean (SD) age of 72 (11.8) years and a body mass index of 29.6 (6.7; calculated as weight in kilograms divided by height in meters squared). Multivariable analysis revealed that prolapse beyond the introitus (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.13-0.60), parity (OR, 1.33; 95% CI, 1.08-1.64), Charlson Comorbidity Index (OR, 1.66; 95% CI, 1.37-2.03), and postvoid residual volume ≥100 mL (OR, 4.05; 95% CI, 2.01, 8.18) were associated with rUTIs. CONCLUSIONS: In this ambulatory urogynecologic population, prolapse through the introitus was negatively associated with rUTIs, whereas parity, increased medical comorbidities, and elevated postvoid residual volume were positively associated with rUTI. Future research should seek an increased understanding of these factors associated with rUTI to implement effective preventive strategies.

Anatomical Anal Stenosis after PPH: Insights from a Retrospective Study and Rat Model.

High-grade hemorrhoids are usually recommended to receive operational treatments. However, these traditional surgeries are associated with severe postoperative pain. A procedure for prolapse and hemorrhoids (PPH), a circular staple device, has been developed to improve short-term outcomes, including reducing the severity of postoperative pain. PPH, compared to conventional surgery, has been associated with the incidence of anatomical anal stenosis. The causes of stenosis after PPH are not yet clear. We first analyzed the complications of our patients with PPH, and then developed a rat model to verify the tension force of PPH using Hematoxylin-eosin, Masson's trichrome, immunohistochemistry, and immunofluorescence staining. Our clinical data showed that PPH significantly improved postoperative pain, but that it resulted in higher incidences of complications, including anal stenosis, than hemorrhoidectomy. We simulated the status of PPH and developed a rat model to verify PPH's tension force, including the scarring area and the deposition of proinflammatory factors, angiogenic factors, and fibrotic factors. The tension wound histological data showed more extensive granulation tissue and inflammatory cell infiltration and a thicker epidermis than the control group on day 12 post-operation and tension treatment. In addition to IL-1ß and IL-10 cytokines on day 3 and IL-1ß, IL-6, and IL-10 cytokines on day 12 post-operation in the tension group, two angiogenic factors, CD31 and VEGF-A, were found to have a more significant expression on day 7 post-operation in the tension group. The mean scar area was larger and the distribution of fibrotic proteins (collagen 1, α-SMA, CTGF, and MMP2) in the tension group was significantly broader than in the control on day 12 post-operation and tension treatment. Based on the findings of our animal model, the development of a lesser tensile force for PPH to decrease the deposition of proinflammatory factors, angiogenic factors, and fibrotic factors is urgently required.

Epithelial ingrowth in descemet membrane endothelial keratoplasty associated with vitreous loss.

BACKGROUND: Epithelial ingrowth is a rare but potentially sight-threatening complication caused by the invasion of corneal or conjunctival epithelial cells into the eye during ocular surgeries. DMEK is emerging as a widely used surgery for endothelial keratoplasty with its improved safety profile. We describe a case of epithelial ingrowth in the graft-host interface after uneventful DMEK associated with vitreous prolapse in the anterior chamber. CASE PRESENTATION: An 81-year-old female with Fuchs endothelial dystrophy underwent DMEK for corneal decompensation following cataract surgery. During the DMEK procedure, vitreous prolapse was observed around the intraocular lens (IOL). Her early postoperative course was unremarkable, but a dense paracentral interface opacity was observed during the 3-month follow-up. The area of epithelial ingrowth was imaged with optical coherence tomography (OCT) as a uniform nodule with a discrete increase in interface hyperreflectivity. A low-energy YAG laser was applied to remove the opacity. She maintained good vision and clear cornea without reoccurrence after treatment. CONCLUSIONS: We propose that, in addition to the introduction of epithelial cells during surgery, vitreous retention in the anterior chamber may be a risk factor by providing a scaffold that potentially aggravates epithelial ingrowth in DMEK. Our case demonstrated that early YAG intervention may disrupt interface epithelial cell growth, and the transmitted laser energy may fragment the scaffold vitreous noninvasively.

A Multi-Institutional Study Comparing Stoma Location in Neonates With Intestinal Perforation.

INTRODUCTION: Neonates with intestinal perforation often require laparotomy and intestinal stoma creation, with the stoma placed in either the laparotomy incision or a separate site. We aimed to investigate if stoma location is associated with risk of postoperative wound complications. METHODS: A multi-institutional retrospective review was performed for neonates ≤3 mo who underwent emergent laparotomy and intestinal stoma creation for intestinal perforation between January 1, 2009 and April 1, 2021. Patients were stratified by stoma location (laparotomy incision versus separate site). Outcomes included wound infection/dehiscence, stoma irritation, retraction, stricture, and prolapse. Multivariable regression identified factors associated with postoperative wound complications, controlling for gestational age, age and weight at surgery, and diagnosis. RESULTS: Overall, 79 neonates of median gestational age 28.8 wk (interquartile range [IQR]: 26.0-34.2 wk), median age 5 d (IQR: 2-11 d) and median weight 1.4 kg (IQR: 0.9-2.42 kg) had perforated bowel from necrotizing enterocolitis (40.5%), focal intestinal perforation (31.6%), or other etiologies (27.8%). Stomas were placed in the laparotomy incision for 41 (51.9%) patients and separate sites in 38 (48.1%) patients. Wound infection/dehiscence occurred in 7 (17.1%) neonates with laparotomy stomas and 5 (13.2%) neonates with separate site stomas (P = 0.63). There were no significant differences in peristomal irritation, stoma retraction, or stoma stricture between the two groups. On multivariable regression, separate site stomas were associated with increased likelihood of prolapse (odds ratio 6.54; 95% confidence interval: 1.14-37.5). CONCLUSIONS: Stoma incorporation within the laparotomy incision is not associated with wound complications. Separate site stomas may be associated with prolapse. Patient factors should be considered when planning stoma location in neonates undergoing surgery for intestinal perforation.

Angle-closure glaucoma associated with vitreous prolapse after neodymium-doped yttrium-aluminumgarnet laser posterior capsulotomy.

Capsulotomy with neodymium-doped yttriumaluminum-garnet (Nd:YAG) laser is an effective treatment for posterior capsule opacification following cataract surgery. A wide opening of the posterior capsule associated with the ruptured anterior hyaloid can cause anterior chamber vitreous prolapse. Two patients who developed angle-closure glaucoma associated with vitreous prolapse following Nd:YAG laser posterior capsulotomy were successfully treated with antiglaucoma medication and peripheral iridotomies. Patient identification for potential risk factors and a careful postoperative follow-up are essential to avoid these serious complications.

A new technique to prevent conjunctival prolapse in Asian patients for correcting severe blepharoptosis.

BACKGROUND: In Asian patients with severe ptosis,the use of conjoint fascia sheath (CFS) suspension or levator aponeurosis fascia complex shortening surgery can correct the ptosis. During these surgery, a significant amount of levator aponeurosis fascia shortening is performed, which often leads to serious complications such as conjunctival prolapse.This study compares two surgical approaches for correcting severe blepharoptosis:Conjoint fascial sheath (CFS) + levator aponeurosis and muller's muscle complex (LM complex) suspension and conjoint fascial sheath (CFS) + LM complex+conjunctival suspension.The postoperative efficacy and the incidence of complications such as conjunctival prolapse are investigated for both procedures. METHODS: This study retrospectively analyzed 70 patients (77eyes) with severe blepharoptosis from January 2019 to December 2021. The patients were divided into the experimental group (34 cases, 38 eyes) and the control group (36 cases, 39 eyes). The experimental group was treated with CFS+LM complex + conjunctival suspension, and the control group was treated with CFS+LM complex suspension.The curative effect of blepharoptosis, the incidence of complications such as conjunctival prolapse and patient satisfaction were compared between the two different surgical methods. RESULTS: There was no significant difference in the correction effective rate between the experimental group (84.21%) and the control group (82.05%) (P > 0.05). There was no significant difference in the total incidence of complications between the experimental group (23.68%) and the control group (38.46%) (P > 0.05), but in the complication of conjunctival prolapse, the incidence of conjunctival prolapse in the experimental group was significantly lower than that in the control group. The difference was statistically significant (P < 0.05). In the survey of patient satisfaction rate, the satisfaction rate of the experimental group was significantly higher than that of the control group,which was statistically significant (P < 0.05). CONCLUSIONS: Compared to CFS+LM complex suspension surgery, the CFS+LM complex + conjunctival suspension has a definite effect in preventing postoperative conjunctival prolapse .The procedure has a high feasibility, good corrective effect, and improves patient satisfaction after surgery.

Zone 1 trauma: wound dehiscence compared to primary trauma.

PURPOSE: The study aims to assess if Zone 1 globe injuries hold a favorable prognosis for all situations, including wound dehiscence, or just primary traumatic injuries. METHODS: Retrospective cross-sectional chart review of patients who underwent open globe repair from 1/1/2019 to 12/1/2020 at an urban hospital setting was evaluated for final visual outcomes, associated ocular pathology, long-term complications, and need for further surgeries. RESULTS: Fifty-eight eyes were identified-38 primary trauma and 20 dehisced wounds (11 penetrating keratoplasties, five clear corneal incisions, one laceration, one extracapsular cataract extraction, one radial keratotomy, and one tectonic graft). Dehisced wounds had more posterior segment pathology vs primary trauma, i.e., hemorrhagic choroidal, vitreous hemorrhage, retinal detachment, choroidal effusion (all 20% vs 2.63%, 5.26%, 5.26%, and 0%, respectively), vitreous prolapse (20% vs 2.63%), and uveal prolapse (80% vs 36.84%). Dehisced wounds had more traumatic aphakia (40% vs 0%) and dislocated lenses (15% vs 0%). Primary trauma was more likely to have traumatic cataracts (55.26% vs 10%) or no lens changes (44.74% vs 25%). About 10% dehisced wounds required enucleation (0% primary trauma). Cataract/secondary intraocular lens surgery was performed in 34% of the primary traumas (10% in dehisced wounds). Primary traumas achieved 20/40 vision or better in 44.74% (10% dehisced wounds). About 7.89% of patients with wound dehiscence ended with no light perception (none in primary trauma). CONCLUSION: Zone 1 open globe injuries due to wound dehiscence may exhibit worse prognosis compared to primary trauma open globe injury. More important than the zone of injury may be the source.

Ileal prolapse through patent omphalomesenteric duct in a two year-old boy: a case report.

BACKGROUND: Patent omphalomesenteric duct is one of the birth defects included in the spectrum of vitelline duct abnormalities. It is a rare anomaly with estimated prevalence of 0.13-0.2% in the general population. The most common presentation of patent vitelline duct is yellowish or mucoid type umbilical discharge which is usually noted in neonatal age or infancy. The main stay of diagnosis is clinical and outcome is favorable as long as timely surgical correction is offered. Here we present a 2 years old male child who presented with ileal prolapse through patent vitelline duct which is an exceptional mode of presentation of this pathology. CASE PRESENTATION: 2 years old Ethiopian male child who was noticed to have umbilical discharge since early infancy presented with protrusion of pinkish mass per the umbilicus of 4 h duration. He had no signs and symptoms of bowel obstruction. Abdominal examination revealed a prolapsed bowel which was viable via the umbilicus which was about 6 cm long. Otherwise, he had no abdominal tenderness or rigidity. He was explored with a smiley incision just above the umbilicus. The prolapsed bowel was reduced gently to the abdominal cavity. The tract of the Patent vitelline duct was identified and completely resected along with a wedge of ileum at its base. Primary repair of the ileal end where the tract was inserted was done in two layers and abdomen was closed in layers. The child had smooth post op course and was discharged on the 4th post-operative day. CONCLUSION: Prolapse of a bowel through the umbilicus is unusual presentation of a rare anomaly namely patent vitelline duct. This presentation warrants early surgical intervention before bowel ischemia issues. Hence, all clinicians dealing with children should be aware of this rare pathology so that urgent surgical management can be offered.

Haemorrhoidal artery distribution in patients with grade III and IV haemorrhoids treated with artery ligation and rectoanal repair. Assessment of Doppler guidance / Distribución de las arterias hemorroidales en pacientes con hemorroides de grado III y IV tratados mediante ligadura arterial y reparación rectoanal. Evaluación del guiado Doppler

Introduction: While haemorrhoidal dearterialization and mucopexy are accepted as a valid alternative to haemorrhoidectomy, differences exist regarding the fixed or variable location of the arteries to be ligated. Our aim was to shed light on this issue of arterial distribution in candidates for surgery. Methods: The study included consecutive patients diagnosed with Goligher grade III and IV haemorrhoids, who had undergone Doppler-guided haemorrhoidal artery ligation (DG-HAL) and rectoanal repair (RAR) at 2 medical centres in Spain. The main objective was to evaluate the number and 12-h clock locations of arterial ligatures necessary to achieve Doppler silence. Results: In total, 146 patients were included: 111 (76%) men, and 35 (24%) women. Average age was 54 years (21–84). Grade III and grade IV haemorrhoids were diagnosed in 106 (72.6%) and 40 (27.4%) patients, respectively. The average number of ligatures per patient was 7 (range 2–12). Ligature percentages greater than 60% occurred at clock positions 7, 11, 10, 12, 9, and 1. The average number of mucopexies per patient was 3 (range 1–4). The most frequent mucopexy locations were the left posterior, right posterior, and right anterior octants. Conclusions: While the greatest frequency of arterial ligatures occurred in odd-numbered clock positions, non-negligible percentages occurred in even-numbered clock positions, which, in our opinion, makes the use of Doppler necessary, given that arterial distribution is not the same in all patients. We also noted that more ligatures and mucopexies were needed on the right half of the rectal circumference than on the left side, suggesting greater right-side vascularization.(AU)

Introducción: Aunque la desarterialización hemorroidal y mucopexia es técnica aceptada como alternativa válida a la hemorroidectomía, existen divergencias en lo que se refiere a una localización fija o variable de las arterias a ligar. Nuestro objetivo ha sido arrojar luz sobre esta cuestionada distribución arterial en pacientes quirúrgicos. Métodos: Se han incluido consecutivamente pacientes con diagnóstico de hemorroides de III y IV grado operados mediante desarterialización hemorroidal guiada por Doppler (D-HAL) y reparación rectoanal (RAR) en dos centros hospitalarios españoles. El principal objetivo fue evaluar el número necesario de ligaduras arteriales y su localización horaria para conseguir un silencio Doppler. Resultados: Se han incluido consecutivamente 146 pacientes, 111 (76%) varones y 35 (24%) mujeres, con una media de edad de 54 años (21–84), 106 (73%) fueron diagnosticados como grado III y 40 (27%) como grado IV. La media de ligaduras por paciente fue de 7 (2–12). Se encontraron porcentajes de ligaduras superiores al 60% en las posiciones horarias 7, 11, 10, 12, 9 y 1. La media de mucopexias por paciente fue 3 (1–4), siendo las localizaciones más frecuentes los octantes posterior izquierdo, posterior derecho y anterior derecho. Conclusiones: Aunque los puntos horarios impares son los de mayor frecuencia de localización arterial, porcentajes no despreciables de localización ocurren en las posiciones pares lo que, en nuestra opinión, hace que el uso del Doppler sea necesario dado que la distribución arterial no es constante en todos los pacientes. Hemos podido constatar también que en la semicircunferencia derecha han sido necesarias más ligaduras y pexias que en el lado izquierdo, lo que sugiere una mayor vascularización derecha.(AU)