Retroperitoneal cecal volvulus: a complication of a rare internal hernia - a case report.

Introduction and importance: The foramen of Winslow hernia (FWH) is a rare type of internal hernia. In one-third of cases, the cecum was found in the lesser sac. More rarely, the herniated cecum might be volvulated, which represents 1-1.5% of the causes of intestinal obstruction. Once diagnosed, surgical reduction and/or resection of the nonviable herniated bowel is crucial for a positive outcome. Case presentation: The authors report a case of retroperitoneal cecal volvulus that complicated FWH in a patient with a history of laparoscopic cholecystectomy. Clinical discussion: A delay in the diagnosis is associated with high morbidity and even higher mortality. Because of lacking a consensus, the treatment of FWH depends on the team's surgical experience. Conclusion: Reporting this case will help us to keep in mind this differential diagnosis while treating patients in our daily practice.

Recurrent sigmoid volvulus secondary to a large pedunculated colonic lipoma.

Symptomatic colon lipoma is a rare occurrence in clinical practice, and its association with sigmoid volvulus is even rarer. We present a case of a man in his 70s who presented to our emergency department with suspected intestinal obstruction. Upon examination, sigmoid volvulus was diagnosed and successfully treated endoscopically through decompression and detorsion. However, the patient experienced a recurrence, leading to the decision to perform sigmoid resection as a Hartmann's procedure. Subsequently, a prolapsed tumor was observed through the stoma, which was endoscopically resected, revealing a pedunculated submucous colonic lipoma. This case report highlights the potential association between sigmoid volvulus and the presence of a large colon lipoma. Thus, giant colonic lipoma should be considered as a differential diagnosis among the causes of colonic volvulus.

C. perfringens Blood Stream Infection due to Nontransmural Ischemia of the Esophagus, Stomach, and Left Colon: Case Report.

We report the case of a 74-year-old female with abdominal pain, tarry stools, and tachycardia. Previous history included diabetes mellitus with micro- and macroangiopathy. Imaging revealed portal gas, left sided colitis, and emphysematous gastritis, besides severe atherosclerosis with subtotal celiac trunk occlusion and moderate stenosis of the inferior mesenteric artery. Upper endoscopy revealed findings consistent with focal necrotizing gastritis at the greater curvature and acute esophageal necrosis. Blood cultures immediately grew Clostridium perfringens. The patient was treated with broad spectrum antibiotics and was discharged after 21 days in the hospital. This case demonstrates the rare coincident occurrence of nontransmural ischemia of the left colon, the esophagus, and the stomach as a result of low-flow circulatory compromise, which then precipitated C. perfringens associated emphysematous gastritis and blood stream infection.

Apical bulkheads accumulate as adaptive response to impaired bile flow in liver disease.

Hepatocytes form bile canaliculi that dynamically respond to the signalling activity of bile acids and bile flow. Little is known about their responses to intraluminal pressure. During embryonic development, hepatocytes assemble apical bulkheads that increase the canalicular resistance to intraluminal pressure. Here, we investigate whether they also protect bile canaliculi against elevated pressure upon impaired bile flow in adult liver. Apical bulkheads accumulate upon bile flow obstruction in mouse models and patients with primary sclerosing cholangitis (PSC). Their loss under these conditions leads to abnormally dilated canaliculi, resembling liver cell rosettes described in other hepatic diseases. 3D reconstruction reveals that these structures are sections of cysts and tubes formed by hepatocytes. Mathematical modelling establishes that they positively correlate with canalicular pressure and occur in early PSC stages. Using primary hepatocytes and 3D organoids, we demonstrate that excessive canalicular pressure causes the loss of apical bulkheads and formation of rosettes. Our results suggest that apical bulkheads are a protective mechanism of hepatocytes against impaired bile flow, highlighting the role of canalicular pressure in liver diseases.

A critical spotlight on the paradigms of FFPE-DNA sequencing.

In the late 19th century, formalin fixation with paraffin-embedding (FFPE) of tissues was developed as a fixation and conservation method and is still used to this day in routine clinical and pathological practice. The implementation of state-of-the-art nucleic acid sequencing technologies has sparked much interest for using historical FFPE samples stored in biobanks as they hold promise in extracting new information from these valuable samples. However, formalin fixation chemically modifies DNA, which potentially leads to incorrect sequences or misinterpretations in downstream processing and data analysis. Many publications have concentrated on one type of DNA damage, but few have addressed the complete spectrum of FFPE-DNA damage. Here, we review mitigation strategies in (I) pre-analytical sample quality control, (II) DNA repair treatments, (III) analytical sample preparation and (IV) bioinformatic analysis of FFPE-DNA. We then provide recommendations that are tested and illustrated with DNA from 13-year-old liver specimens, one FFPE preserved and one fresh frozen, applying target-enriched sequencing. Thus, we show how DNA damage can be compensated, even when using low quantities (50 ng) of fragmented FFPE-DNA (DNA integrity number 2.0) that cannot be amplified well (Q129 bp/Q41 bp = 5%). Finally, we provide a checklist called 'ERROR-FFPE-DNA' that summarises recommendations for the minimal information in publications required for assessing fitness-for-purpose and inter-study comparison when using FFPE samples.

Endoscopic Vacuum Therapy for Treating an Esophago-Pulmonary Fistula after Esophagectomy: A Case Report and Review of the Literature.

An acquired esophago-respiratory fistula represents an abnormal connection between the esophagus and the respiratory system. It is usually caused by malignancy and infection, or it occurs as a complication after surgery or radiation therapy. It can be divided according to its anatomical level into esophago-tracheal fistula, esophago-bronchial fistula, and in the rarest case, esophago-pulmonary fistula (EPF). We present a case of EPF aggravating an anastomotic leak (AL) after the Ivor-Lewis operation for esophageal cancer. The leak was treated with endoscopic vacuum therapy (EVT) using the Eso-Sponge® system (B. Braun Melsungen AG, Melsungen, Germany). In the further course of treatment, an EPF was suspected by a new onset of severe cough after oral fluid intake. The suspicion was confirmed by injecting methylene blue dye into the paraesophageal-extraluminal cavity during endoscopy and attesting to its presence in the respiratory tract by simultaneous bronchoscopy. Furthermore, an oral contrast computed tomography scan showed the presence of contrast in the right lower lobe of the lung. This complication was treated conservatively with EVT and antibiotics. Nutrition was administered through the existing jejunostomy. Both fistulas and the paraesophageal cavity were fully healed, oral intake was maintained, and the patient was discharged. This rare life-threatening complication can be treated conservatively. Its management is challenging, controversial, and lacks a general consensus.

Conservative therapy of severe acute pancreatitis is a safe option - results of a 15-year long-term follow-up cohort study.

Treatment of severe acute pancreatitis can be challenging with high mortality. In 2012 we reported a significantly reduced in-hospital mortality if these patients are treated conservatively for at least the first 3 weeks in the course of the disease as compared to early necrosectomy. We performed a long-term follow-up and compared the outcome of these two study groups (group 1 - early necrosectomy, n=20 versus group 2 - primary conservative treatment, n=24). Materials and methods: Follow-up of the study patients by personal contact, phone survey, or data from primary care physician. Median follow-up was 15 years (range 10-22 years). This trial is registered at: Research Registry UIN researchregistry8697. Results: Eleven survivors of group 1 and 22 survivors of group 2 were discharged after initial treatment. Ten of 11 surviving patients of group 1 (90.9%) and 20 of 22 surviving patients of group 2 (90.9%) were included in this study. Between groups, there were no statistical differences in the rate of resubmission (P=0.23), development of diabetes (P=0.78), or development of exocrine insufficiency (P=1.0). However, long-term survival in group 2 was significantly better than that of group 1 (P=0.049). Conclusion: Primary conservative treatment of severe acute pancreatitis without early necrosectomy does not lead to early complications and even shows an advantage in long-term survival. Therefore conservative treatment of severe acute pancreatitis is safe and there is no absolute need for necrosectomy in severe acute pancreatitis.

Ileocolonic Healing after Small Ileocecal Resection in Mice: NOD2 Deficiency Impairs Anastomotic Healing by Local Mechanisms.

Ileocecal resection (ICR) is frequently performed in Crohn's disease (CD). NOD2 mutations are risk factors for CD. Nod2 knockout (ko) mice show impaired anastomotic healing after extended ICR. We further investigated the role of NOD2 after limited ICR. C57B16/J (wt) and Nod2 ko littermates underwent limited ICR including 1-2 cm terminal ileum and were randomly assigned to vehicle or MDP treatment. Bursting pressure was measured on POD 5, and the anastomosis was analyzed for matrix turn-over and granulation tissue. Wound fibroblasts from subcutaneously implanted sponges were used for comparison. The M1/M2 macrophage plasma cytokines were analyzed. Mortality was not different between groups. Bursting pressure was significantly decreased in ko mice. This was associated with less granulation tissue but was not affected by MDP. However, anastomotic leak (AL) rate tended to be lower in MDP-treated ko mice (29% vs. 11%, p = 0.07). mRNA expression of collagen-1α (col1 α), collagen-3α (col3 α), matrix metalloproteinase (mmp)2 and mmp9 was increased in ko mice, indicating increased matrix turn-over, specifically in the anastomosis. Systemic TNF-α expression was significantly lower in ko mice. Ileocolonic healing is impaired in Nod2 ko mice after limited ICR by local mechanisms maybe including local dysbiosis.

[Surgical emergencies during the COVID-19 pandemic]. / Chirurgische Notfälle während der COVID-19-Pandemie.

BACKGROUND: Within a few months coronavirus disease 2019 (COVID-19) spread around the world. Some studies showed a significant reduction in medical consultations. Due to new discussions about restrictions in the case of rising COVID-19 case numbers, this study investigated the consequences of the COVID-19 pandemic on surgical emergencies at the Rostock University Medical Center and compared the results to the years before. MATERIAL AND METHODS: The aim of the study was to compare the case numbers of the surgical emergency department of the Rostock University Medical Center from the period 2020 and 2021 to the years before (2018, 2019). Furthermore, the consequences of COVID-19 case numbers for the case numbers of the surgical emergency department were investigated. RESULTS: A total of 74,936 patient cases could be included in this study. The results showed a significant reduction of surgical emergencies during the COVID-19 pandemic (p < 0.001). There was a significant negative correlation with the COVID-19 case numbers (p < 0.001). The restrictions of the government showed a direct influence on COVID-19 case numbers and emergency visits. CONCLUSION: The results showed a correlation of COVID-19 case numbers with the case numbers of the surgical emergency department. Due to difficult workforce planning during a pandemic, this can be important information for workforce management in similar future events.

Quality of Life after Desarda Technique for Inguinal Hernia Repair-A Comparative Retrospective Multicenter Study of 120 Patients.

Inguinal hernia repair, according to Desarda, is a pure tissue surgical technique using external oblique fascia to reinforce the posterior wall of the inguinal canal. This has provided an impetus for the rethinking of guideline adherence toward minimally invasive and mesh-based surgery of inguinal hernia. In this study, a retrospective analysis of this technique was conducted in two German hospitals. Between 6/2013 and 12/2020, 120 operations were performed. Analysis included patient characteristics, duration of operation, length of hospital stay, and perioperative complications. Data were used to achieve a matched-pair analysis comparing Desarda to laparoscopic transabdominal preperitoneal (TAPP) hernia repair. Propensity scores were calculated based on five preoperative variables, including sex, age, American Society of Anesthesiology classification, localization, and width of the inguinal hernia in order to achieve comparability. Additionally, we assessed pain level and quality of life (QoL) 12 months postoperatively. The focus of our study was a comparison of QoL to a reference population and TAPP cohort. The study population consisted of 106 male and 14 female patients, and the median age was 37.5 years. The median operation time was 50 min, and the median length of hospital stay was 2 days. At a follow-up of 17 months, the median recurrence rate was 0.8%, and two cases of chronic postoperative pain were recorded. Postoperative QoL does not significantly differ between Desarda and TAPP. In contrast, Desarda patients had a significantly higher QoL compared with the reference population. In summary, Desarda's procedure is a good option as a pure tissue method for inguinal hernia repair.

Genetic variation in TERT modifies the risk of hepatocellular carcinoma in alcohol-related cirrhosis: results from a genome-wide case-control study.

OBJECTIVE: Hepatocellular carcinoma (HCC) often develops in patients with alcohol-related cirrhosis at an annual risk of up to 2.5%. Some host genetic risk factors have been identified but do not account for the majority of the variance in occurrence. This study aimed to identify novel susceptibility loci for the development of HCC in people with alcohol related cirrhosis. DESIGN: Patients with alcohol-related cirrhosis and HCC (cases: n=1214) and controls without HCC (n=1866), recruited from Germany, Austria, Switzerland, Italy and the UK, were included in a two-stage genome-wide association study using a case-control design. A validation cohort of 1520 people misusing alcohol but with no evidence of liver disease was included to control for possible association effects with alcohol misuse. Genotyping was performed using the InfiniumGlobal Screening Array (V.24v2, Illumina) and the OmniExpress Array (V.24v1-0a, Illumina). RESULTS: Associations with variants rs738409 in PNPLA3 and rs58542926 in TM6SF2 previously associated with an increased risk of HCC in patients with alcohol-related cirrhosis were confirmed at genome-wide significance. A novel locus rs2242652(A) in TERT (telomerase reverse transcriptase) was also associated with a decreased risk of HCC, in the combined meta-analysis, at genome-wide significance (p=6.41×10-9, OR=0.61 (95% CI 0.52 to 0.70). This protective association remained significant after correction for sex, age, body mass index and type 2 diabetes (p=7.94×10-5, OR=0.63 (95% CI 0.50 to 0.79). Carriage of rs2242652(A) in TERT was associated with an increased leucocyte telomere length (p=2.12×10-44). CONCLUSION: This study identifies rs2242652 in TERT as a novel protective factor for HCC in patients with alcohol-related cirrhosis.

More than 30 Years of POSSUM: Are Scoring Systems Still Relevant Today for Colorectal Surgery?

BACKGROUND: The Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) weights the patient's individual health status and the extent of the surgical procedure to estimate the probability of postoperative complications and death of general surgery patients. The variations Portsmouth-POSSUM (P-POSSUM) and colorectal POSSUM (CR-POSSUM) were developed for estimating mortality in patients with low perioperative risk and for patients with colorectal carcinoma, respectively. The aim of the present study was to evaluate the significance of POSSUM, P-POSSUM, and CR-POSSUM in two independent colorectal cancer cohorts undergoing surgery, with an emphasis on laparoscopic procedures. METHODS: For each patient, an individual physiological score (PS) and operative severity score (OS) was attributed to calculate the predicted morbidity and mortality, respectively. Logistic regression analysis was used to evaluate the possible correlation between the subscores and the probability of postoperative complications and mortality. RESULTS: The POSSUM equation significantly overpredicted postoperative morbidity, and all three scoring systems considerably overpredicted in-hospital mortality. However, the POSSUM score identified patients at risk of anastomotic leakage, sepsis, and the need for reoperation. Logistic regression analysis demonstrated a strong correlation between the subscores and the probability of postoperative complications and mortality, respectively. CONCLUSION: Our results suggest that the three scoring systems are too imprecise for the estimation of perioperative complications and mortality of patients undergoing colorectal surgery in the present day. Since the subscores proved valid, a revision of the scoring systems could increase their reliability in the clinical setting.

The HSF1-CPT1a Pathway Is Differentially Regulated in NAFLD Progression.

Obesity and obesity-associated diseases represent one of the key health challenges of our time. In this context, aberrant hepatic lipid accumulation is a central pathological aspect of non-alcoholic fatty liver disease (NAFLD). By comparing methylation signatures of liver biopsies before and after bariatric surgery, we recently demonstrated the strong enrichment of differentially methylated heat shock factor 1 (HSF1) binding sites (>400-fold) in the process of liver remodeling, indicating a crucial role of HSF1 in modulating central aspects of NAFLD pathogenesis. Using cellular models of NAFLD, we were able to show that HSF1 is activated during fat accumulation in hepatocytes, mimicking conditions in patients before bariatric surgery. This induction was abolished by starving the cells, mimicking the situation after bariatric surgery. Regarding this connection, carnitine palmitoyltransferase 1 isoform A (CTP1a), a central regulator of lipid beta-oxidation, was identified as a HSF1 target gene by promoter analysis and HSF1 knockdown experiments. Finally, pharmacological activation of HSF1 through celastrol reduced fat accumulation in the cells in a HSF1-dependent manner. In conclusion, we were able to confirm the relevance of HSF1 activity and described a functional HSF1-CPT1a pathway in NAFLD pathogenesis.

Proof-of-Concept Standardized Approach Using a Single-Disk Method Analogous to Antibiotic Disk Diffusion Assays for Routine Phage Susceptibility Testing in Diagnostic Laboratories.

Application of bacteriophages is increasingly being implemented in clinical therapies. Prior susceptibility testing should be regarded as mandatory, but standards are lacking. The objective of this research was to develop a highly standardized methodology to facilitate phage susceptibility testing (PST) in clinical microbiology routine laboratories. Therefore, EUCAST methods established for single disk-based antibiotic susceptibility testing (AST) were adapted. In a first step, basic parameters were evaluated using well-studied Escherichia phage T4-Escherichia coli combinations. In addition, test results were compared to those from conventional spot test and efficiency of plating (EOP) approaches. In a second step, the applicability of the methodology and the most promising test parameters were demonstrated for five other frequently isolated clinical bacterial species and their corresponding phages. At present, the method predominantly leads to qualitative rather than quantitative results. This disk-based approach provides a standardized, easy-to-handle, reproducible and reliable PST protocol by relying on well-established routine procedures in diagnostic laboratories. IMPORTANCE Application of bacteriophages in clinical therapies is attractive due to increasing rates of isolation of multidrug-resistant bacteria worldwide. As the phage effect is highly specific, prior susceptibility testing of target bacteria is mandatory. Of note, established standards are lacking. In this research, we adapted the single-disk method for antibiotic susceptibility testing to phage susceptibility testing (PST) in order to provide a standardized, easy-to-handle, reproducible, and reliable PST protocol for application in diagnostic routine laboratories.

Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome.

BACKGROUND: Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT). METHODS: In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies. RESULTS: In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches. CONCLUSIONS: Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.

An Extremely Rare Cause of an Obstructive Jaundice in Adults: Limited Langerhans Cell Histiocytosis of the Extrahepatic Bile Duct.

Langerhans cell histiocytosis (LCH) is a rare group of idiopathic disorders (previously termed "histiocytosis X") which is characterized by the presence of cells with characteristics similar to bone marrow-derived Langerhans cells which infiltrate various tissues and organs. Like Langerhans cells located in the skin, they express histiocytic markers such as S100, CD1a, and CD68 and contain Birbeck granules, which are rod-shaped intracytoplasmic organelles best demonstrated in electron microscopy. LCH primarily affects the skeleton, but lung, skin, liver, and lymph node involvement may occur alike. Hepatic involvement is well recognized in children, with sclerosing cholangitis occurring in 10-15% of those with multisystemic involvement, whereas LCH confined to the liver appears to be very unusual in adults. Up to date, only one case of a solitary LCH affliction of the extrahepatic bile duct lacking liver involvement in adulthood has been reported on in the literature. We here report on a 60-year-old male patient with classical indolent progressive obstructive jaundice. The diagnostic workup revealed a tumorous lesion in the middle third of the common hepatic bile duct, initially being highly suspicious of an extrahepatic cholangiocarcinoma. CT scans further suspected an infiltration of the right portal vein, implicating a potentially extensive tumor growth, but a preoperative histological confirmation was not feasible. The serum tumor marker CA19-9 was 48 U/mL. The patient then underwent an explorative laparotomy with a pylorus preserving pancreaticoduodenectomy, as all frozen section tissue specimens revealed no tumor infiltration. The final result of the histopathological examination revealed an isolated LCH in the extrahepatic bile duct with a consecutive secondary sclerosing cholangitis. To complete the tumor staging, a thorax CT scan was performed and a generalized histiocytosis was ruled out, hence confirming the localized character of the disease. To the best of our knowledge and after a comprehensive literature review, we report on the second case globally, which describes a primary LCH limited to the extrahepatic bile duct in adulthood. A generalized sclerosing cholangitis in the liver was ruled out by radiological imaging. Preoperative histological affirmation of such findings is very confined due to the complexity and hence can only be diagnosed in the postoperative specimen. However, patients with nondisseminated sole findings, usually report a good prognostic outcome after surgical resection despite the paucity of corresponding data.

Relatives Experience More Psychological Distress Due to COVID-19 Pandemic-Related Visitation Restrictions Than In-Patients.

Background: The COVID-19 pandemic led to visiting restrictions (VRs) of patients in hospitals. Social contacts between patients' relatives play an important role in convalescence. Isolation may cause new psychological comorbidity. The present study investigated the psychological distress of VR in in-patients and their relatives. Methods: From April 1, 2020 to May 20, 2020, 313 in-patients (≥14 years) of the University Medical Center Rostock were interviewed by questionnaires and 51 relatives by phone. Subjective psychological distress was assessed by a distress thermometer [0 (not at all)-100 (extreme)]. The study also investigated stressors due to VR, psychological distress in dependence on demographic or disease-related data, currently used communication channels and desired alternatives and support. Results: Relatives were more psychologically distressed by VR than in-patients (59 ± 34 vs. 38 ± 30, p = 0.002). Loss of direct physical contact and facial expressions/gestures resulted in the most distress. Psychological distress due to VR was independent of demographics and indicates small positive correlations with the severity of physical restriction and the general psychological distress of in-patients. The most frequent ways of communication were via phone and social media. Frequently requested alternatives for patients were other interlocutors and free phone/tablet use, for relatives visiting rooms with partitions. Conclusion: VRs are a stressor for patients and their relatives. The establishment of visiting rooms with partitions and the free use of phones/tablets could reduce the additional distress.