Synthol systemic complications: Hypercalcemia and pulmonary granulomatosis. A case report.

INTRODUCTION: Synthol injection for body contouring has been used by bodybuilders for some time. We report two extremely rare systemic complications; pulmonary granulomatosis and hypercalcemia, in a woman who has received Synthol injections for buttocks augmentation. PRESENTATION OF CASE: The case discussed in this report is of a 36-year-old lady who presented for severe hypercalcemia and nephrocalcinosis. Subsequent workup revealed granulomas in the buttocks and in the lungs. Upon questioning, it was discovered that she had received Synthol injection for buttocks augmentation a few months earlier. Labs were consistent with calcitriol mediated hypercalcemia, a phenomenon observed in granulomatous diseases. A diagnosis of foreign body granulomatosis with pulmonary migration and secondary hypercalcemia was made. The patient was started on prednisone and showed an initial positive response. DISCUSSION: Reported complications of Synthol include pain, muscle deformity, and ulceration at the injection site. Hypercalcemia secondary to foreign body granulomatosis after Synthol injection has been reported only once previously, and here we report a second case. The hypercalcemia is thought to be calcitriol mediated, where overexpression of CYP27B1 in the macrophages forming the granulomas leads to pathological extrarenal calcitriol production. Pulmonary granulomatosis, theorized to be secondary to hematologic migration of the injected material, has never been reported previously with Synthol use. CONCLUSION: Synthol injection for body contouring may be a cause of extensive local and pulmonary foreign body granulomatosis leading to calcitriol mediated hypercalcemia. History of cosmetic injections should not be disregarded during history taking.

Laparoscopic treatment of pudendal nerve and artery entrapment improves erectile dysfunction in healthy young males.

Erectile dysfunction (ED) is increasingly becoming more common in young healthy males and is attributed mainly to psychogenic causes in these patients. Recent studies have reported that ED could be secondary to pudendal nerve or artery entrapment. This perspective assessed the efficacy of laparoscopic pudendal nerve and artery decompression in young patients suffering from refractory ED, associated to a pudendal nerve entrapment syndrome. After excluding patients with psychological ED and venous leakage, five young male patients with a history of both ED and pudendal nerve entrapment syndrome diagnosed based on the Nantes criteria were recruited. Pudendal nerve and artery release was performed using a laparoscopic transperitoneal approach. International Index for Erectile Function (IIEF-5) and erectile hardness score (EHS) improved significantly in all patients, 3 months after surgery. Pudendal nerve and artery entrapment could be therefore a reversible cause of ED in young healthy males, and its treatment by laparoscopic pudendal nerve and artery decompression seems to be safe and effective.

Laparoscopic transperitoneal pudendal nerve and artery release for pudendal entrapment syndrome.

INTRODUCTION: Pudendal nerve and artery entrapment is an underdiagnosed pathology responsible of several urinary, sexual and anorectal complaints. The aim of our study was to evaluate safety and feasibility of laparoscopic transperitoneal pudendal nerve and artery release in a large retrospective cohort of patients with pudendal nerve entrapment syndrome with both a short and long-term follow-up. Technical details and outcomes are also reported. METHODS: A series of 235 patients with pudendal syndrome underwent laparoscopic transperitoneal pudendal canal release between June 2015 and February 2020. Operative data were recorded prospectively for all patients. A complete history, pain visual analog scale (VAS) for perineodynia, and three scores evaluating the main symptoms (USP, IIEF-5, PAC-SYM) were obtained before and at least 24 months after surgery for 32 patients only. Post-operative complications were also evaluated using Clavien-Dindo classification at regular interval. RESULTS: The mean operating time per side was 33.9 ± 6.8 min and the average hospital stay was 1.9 ± 0.3 days. Blood loss was 20 cc ± 10 cc with no patients needing transfusion. The only significant per-operative complication was hemorrhage (600 ml) in one patient induced by a pudendal artery laceration, successfully treated by laparoscopic suturing. Post-operative complications were noted in 18.7% of patients with no serious Clavien-Dindo complications. Perineodynia VAS dropped from 6.8 ± 0.9 to 2.2 ± 1.8 after surgery (p < 0.001). Mean IIEF-5 scores significantly improved one month after the surgery (15.2 vs 19.3, p = 0.036). Mean USP scores significantly improved for the dysuria domain (4.2 vs 1.6, p = 0.021) but not for stress urinary incontinence (3.9 vs 4.1, p = 0.082) or overactive bladder symptoms (14.1 vs 13.8, p = 0.079). Mean PAC-SYM scores significantly improved after the procedure (1.8 vs 1.1, p < 0.001). CONCLUSION: A complete laparoscopic pudendal nerve and artery release, from the sciatic spine through the Alcock's canal, is a fast and safe surgery with promising functional results. A large prospective trial is needed to validate such an approach.

Periampullary Neuroendocrine Tumor as a Cause of Acute Pancreatitis.

BACKGROUND Duodenal and ampullary carcinoids are very rare tumors accounting respectively for 2% and 0.03% of all carcinoid tumors. Clinical findings vary according to the location of the tumor within the periampullary region; with epigastric pain being the most common presenting symptom in duodenal carcinoids and jaundice the most common clinical finding in ampullary carcinoids. Treatment options include pancreaticoduodenectomy, local excision, and endoscopic excision. CASE REPORT In this case report, we present a 60-year-old male who presented with a one-week history of intractable epigastric pain. He was diagnosed with duodenal periampullary carcinoid tumor and treated with local excision. CONCLUSIONS Although duodenal and ampullary carcinoid tumors may have different clinical presentations, as well as histochemistry characteristics and metastatic potential, they appear to benefit from the same surgical treatment.