African lungfish genome sheds light on the vertebrate water-to-land transition.

Lungfishes are the closest extant relatives of tetrapods and preserve ancestral traits linked with the water-to-land transition. However, their huge genome sizes have hindered understanding of this key transition in evolution. Here, we report a 40-Gb chromosome-level assembly of the African lungfish (Protopterus annectens) genome, which is the largest genome assembly ever reported and has a contig and chromosome N50 of 1.60 Mb and 2.81 Gb, respectively. The large size of the lungfish genome is due mainly to retrotransposons. Genes with ultra-long length show similar expression levels to other genes, indicating that lungfishes have evolved high transcription efficacy to keep gene expression balanced. Together with transcriptome and experimental data, we identified potential genes and regulatory elements related to such terrestrial adaptation traits as pulmonary surfactant, anxiolytic ability, pentadactyl limbs, and pharyngeal remodeling. Our results provide insights and key resources for understanding the evolutionary pathway leading from fishes to humans.

Hard X-ray operation of X-ray gas monitors at the European XFEL.

X-ray gas monitors (XGMs) are operated at the European XFEL for non-invasive single-shot pulse energy measurements and average beam-position monitoring. The underlying measurement principle is the photo-ionization of rare gas atoms at low gas pressures and the detection of the photo-ions and photo-electrons created. These are essential for tuning and sustaining self-amplified spontaneous emission (SASE) operation, machine radiation safety, and sorting single-shot experimental data according to pulse energy. In this paper, the first results from XGM operation at photon energies up to 30 keV are presented, which are far beyond the original specification of this device. Here, the Huge Aperture MultiPlier (HAMP) is used for single-shot pulse energy measurements since the standard X-ray gas monitor detectors (XGMDs) do not provide a sufficient signal-to-noise ratio, even at the highest operating gas pressures. A single-shot correlation coefficient of 0.98 is measured between consecutive XGMs operated with HAMP, which is as good as measuring with the standard XGMD detectors. An intra-train non-linearity of the HAMP signal is discovered, and operation parameters to mitigate this effect are studied. The upper repetition rate limit of HAMP operation at 2.25 MHz is also determined. Finally, the possibilities and limits for future XGM operation at photon energies up to 50 keV are discussed.

Fabrication of Fully Positively Charged Layer-by-Layer Polyelectrolyte Nanofilms with pH-Dependent Swelling Properties.

Nanofilms fabricated by layer-by-layer (LbL) assembly from polyelectrolytes (PEs) are important materials for various applications. However, PE films cannot retain the charges along the polymer chains during fabrication, resulting in a low charge density. In this study, the preparation of LbL nanofilms with preserved positive charges via a controllable and efficient approach was achieved. To fabricate fully positively charged (FPC) LbL nanofilms, a polycation, poly-l-lysine, was partially grafted with azide and alkyne groups. Through copper-catalyzed azide-alkyne cycloaddition and the LbL procedure, nanofilms were fabricated with all of the individual layers covalently bonded, improving the pH stability of the nanofilms. Because the resulting nanofilms had a high charge density with positive charges both inside and on the surface, they showed unique pH-dependent swelling properties and adsorption of negatively charged molecules compared with those of traditional polyelectrolyte LbL nanofilms. This kind of FPC nanofilm has great potential for use in sensors, diagnostics, and filter nanomaterials in the biomedical and environmental fields.

Laparoscopic versus open liver resection for huge hepatocellular carcinoma (≥ than 10 cm): a retrospective analysis from a high-volume referral center.

BACKGROUND: There is still poor evidence about the safety and feasibility of laparoscopic liver resection (LLR) for huge (> 10 cm) hepatocellular carcinomas (HCC). The aim of this study was to assess the short- and long-term outcomes of LLR versus open liver resection (OLR) for patients with huge HCC from real-life data from consecutive patients. METHODS: Data regarding all consecutive patients undergoing liver resection for huge HCC were retrospectively collected from a Korean referral HPB center. Primary outcomes were the postoperative results, while secondary outcomes were the oncologic survivals. RESULTS: Sixty-three patients were included in the study: 46 undergoing OLR and 17 LLR. Regarding postoperative outcomes, there were no statistically significant differences in estimated blood loss, operation time, transfusions, postoperative bile leak, ascites, severe complications, and R1 resection rates. After a median follow-up of 48.4 (95% CI 8.9-86.8) months, there were no statistically significant differences in 3 years OS (59.3 ± 8.7 months vs. 85.2 ± 9.8 months) and 5 years OS (31.1 ± 9 months vs. 73.1 ± 14.1 months), after OLR and LLR, respectively (p = 0.10). Similarly, there was not a statistically significant difference in both 3 years DFS (23.5% ± 8.1 months vs. 51.6 ± months) and 5 years DFS (15.7 ± 7.1 months vs. 38.7 ± 15.3 months), respectively (p = 0.13), despite a potential clinically significant difference. CONCLUSION: LLR for huge HCC may be safe and effective in selected cases. Further studies with larger sample size and more appropriate design are needed to confirm these results.

Combined CO2 Laser Vaporization and Bleomycin Injection to Treat Huge Adult Laryngeal Vascular Anomalies: Innovative Application of CO2 Laser in Otolaryngology.

OBJECTIVES: The aim of this study was to assess the value of CO2 laser vaporization in treating huge adult laryngeal vascular anomalies (HALVAs) by combining it with bleomycin injection. MATERIALS AND METHODS: This study retrospectively reviewed the records of 13 adult patients who underwent 18 different procedures. Methods to treat HALVAs include traditional bleomycin injection and CO2 laser vaporization combined with bleomycin injection between September 2009 and January 2023. Treatment results were evaluated by the grade of lumen constriction. RESULTS: A total of five males and eight females, with an average age of 46.3 years (range, 22-66 years), were included in the study. The huge adult laryngeal vascular anomalies in our study were greater than 1633.71 mm3, and the long diameters of the bases were longer than 15 mm. Compared with the bleomycin injection-only group, the results with the CO2 laser vaporization and bleomycin injection combined were better. CONCLUSIONS: Both bleomycin injection and CO2 laser vaporization are safe treatment methods. Their combination may produce better results for huge adult laryngeal vascular anomalies.

Huge hydrocephalus: a rare case series with insights into management and outcomes of this neglected cohort.

PURPOSE: This study aims to discuss the management challenges of huge hydrocephalus (HH), a severe subset of hydrocephalus, presenting predominantly in underprivileged backgrounds. Insights into the condition's characteristics, factors affecting outcomes, and associated morbidity are discussed. METHODS: A retrospective review of all operated cases of hydrocephalus with head circumference greater than body length (HC>L) was conducted (January 2019-January 2023). Data on epidemiological parameters, associated cranial abnormalities, cortical mantle thickness, peri-conceptional folic acid intake, surgical interventions, age-appropriate milestones, and complications were collected. Follow-up was conducted for at least 12 months or until expiration. RESULTS: The cohort consisted of 7 males and 5 females with age ranging from 3 to 48 months. 33% of them had associated neurological abnormalities, and 18 surgical interventions were needed for these 12 cases, including ventriculoperitoneal shunt or endoscopic diversion. A 17% wound breakdown rate requiring re-suturing was present, and 33% of cases had postoperative CSF infection, with 33% mortality, with only one case having age-appropriate development seen. The average hospital stay was 11.9 days, six times our center's average. All cases with an Evans index with an average of 0.7 expired within 12 months. None of the 12 mothers took peri-conceptional folic acid, and no case agreed to reduction cranioplasty. CONCLUSION: Huge hydrocephalus is a rare cohort with significant management challenges and poor prognosis even after treatment. Factors such as delayed intervention and low socioeconomic status contribute to adverse outcomes. Prevention through peri-conceptual folic acid intake and addressing socioeconomic disparities is crucial in reducing disease burden and improving prognosis.

Extracorporeal membrane oxygenation (ECMO) assisted huge mediastinal tumor resection combined with superior vena cava replacement: A case report and literature review.

As to huge solid mediastinal tumor which direct compression or invasion of the superior/inferior vena cava (SVC/IVC), surgical resection remains the main lifesaving treatment. However, it would present formidable anesthetic challenges due to the extremely high risks of cardiorespiratory compromise, drastic hemodynamic fluctuations and death at all perioperative stages. Here, we report a case of huge anterior mediastinal tumor resection combined with SVC replacement under the assistance of venoarterial extracorporeal membrane oxygenation (VA ECMO), and stable hemodynamics were maintained as well as high internal jugular vein pressure being avoided during the operation procedure. He was weaned off ECMO successfully just after surgery and eventually discharged. No signs of postoperatively neurological complications occurred. Therefore, the use of ECMO assistance in huge mediastinal tumor resection combined with SVC replacement is feasible and safe, which may provide the possibility of surgical treatment for such patients and improve outcomes.

Cirrhotic and non-cirrhotic huge hepatocellular carcinoma (≥ 10 cm): a comparative study of surgical management and follow-up treatment in a single institution.

PURPOSE: Liver resection (LR) of huge hepatocellular carcinoma (HCC) has increasingly been regarded as a viable option of enhanced efficacy for patients, but most studies have focused on comparing various tumor sizes and the outcomes of surgery. The study aim was to evaluate the clinicopathologic characteristics and surgical outcomes of huge HCC with and without cirrhosis that underwent LR, and to delineate the treatment for recurrence. METHODS: Sixty-three patients with huge HCC who underwent hepatectomy from 2010 to 2019 were enrolled and reviewed. Clinicopathological findings, surgical outcomes of the entire cohort, and differences between the cirrhotic and non-cirrhotic groups were analyzed. RESULTS: Forty patients (60.3%) had huge HCC with cirrhosis. Clinicopathological findings were not different between the two groups, except tumor size ≥ 15 cm (40% in cirrhosis vs 17.4% in non-cirrhosis, p = 0.024) and major portal vein tumor thrombus were detected only in the cirrhosis group (11 patients, p = 0.006). Extended LR was performed in 13 cirrhotic patients (32.5%) and in 1 non-cirrhotic patient (4.4%) (p = 0.010). Operative data, postoperative complications including postoperative liver failure, and pattern of recurrence were not different between the two groups. For the entire cohort, mortality rate was 1.5%. The 1-, 3-, and 5-year overall survival rates (OS) were 81%, 54%, and 39%. Multivariate analysis showed resection margin ≥ 0.1 cm was a good prognostic factor for OS (HR 0.247 (p = 0.017)). For tumor recurrence, local ablative treatment for liver recurrence and resection for lung recurrence provided good long-term outcomes. CONCLUSION: Although huge HCC with cirrhosis has been a more unfavorable tumor, LR still provided long-term survival with acceptable risk morbidity and mortality.

A systematic review and case presentation: Giant abdominal aortic aneurysm.

OBJECTIVE: An abdominal aortic aneurysm is considered giant when its transverse diameter is greater than 10-13 cm in diameter. A giant abdominal aortic aneurysm is rare but with a significant risk of rupture if it is not diagnosed or left untreated. METHOD: The authors have performed a systematic review of the evidence that has looked into the clinical presentations, and management methods employed and have presented a 14 cm giant abdominal aortic aneurysm patient. RESULTS: The systematic review has been based on level-IV evidence due to the rarity of the condition. The final analysis included 61 relevant reported cases. The mean age was 72.4 years, the male to female ratio was 52: 8, and the average size of a giant abdominal aortic aneurysm was 14.7 cm. These were mostly infra renal (72.58%). Rupture of these aneurysms was found in 23 (37.1%) patients, and was treated by laparotomy in 51 (82.25%) cases. There were 11 (17.74%) mortalities. CONCLUSION: The size of an abdominal aortic aneurysm is known to be the biggest factor in the rupture of an aneurysm. The reason abdominal aortic aneurysms can reach such size without rupturing is unclear but needs further exploring. Early diagnosis with effective screening programmes is essential to diagnose in a timely manner to avoid life-threatening consequences.

A rare case of squamous cell carcinoma associated with a huge ovarian dermoid cyst in a postmenopausal woman.

Malignant transformation of mature cystic teratoma (MCT) is a well-known but uncommon phenomenon seen mostly in postmenopause women. We report a case of a 65-year-old postmenopausal woman with a malignant transformation of MCT and with a low-grade squamous intraepithelial lesion in her cervix. She was treated surgically by total abdominal hysterectomy with bilateral salpingo-oophorectomy with a preoperative diagnosis of right ovarian teratoma. Her postoperative period was uneventful. On follow-up, the histopathology report revealed a right ovarian dermoid cyst with well-differentiated squamous cell carcinoma; there was no evidence of malignancy elsewhere, including the cervix. Ascitic fluid was also free of malignant cells, and the disease was at stage Ia. The patient did not receive any adjuvant chemotherapy and was followed up with clinical examination postoperatively for 1 year, and there was no evidence of any relapse clinically. Preoperative diagnosis of malignant transformation of squamous cell carcinoma (SCC) is difficult, as there is no specific screening marker and no consensus or standard guidelines available regarding the optimum management of this relatively poorly known entity. Here we emphasize the need for a high index of suspicion of malignant transformation with the presence of factors such as elderly age, the huge size of the tumor, and large solid components in the tumor. Considering the scarcity of case reports and studies about SCC arising from MCT, every experience with malignant transformation of MCT should be reported for a better understanding of the disease presentation and management.

Benefits of step-by-step debulking microwave ablation for huge unresectable hepatocellular carcinoma patients after transcatheter arterial chemoembolization refractoriness.

OBJECTIVES: To compare the safety and efficacy of step-by-step debulking Microwave Ablation (MWA) with Transarterial Chemoembolization (TACE) monotherapy for huge (≥10 cm in diameter) unresectable hepatocellular carcinoma (HCC) after TACE refractoriness. METHODS: This is a multi-center retrospective study carried out on 599 patients with huge unresectable HCC who received TACE as first-line therapy at five hospitals from January 2009 to December 2018. A total of 103 patients with TACE refractoriness were divided into two cohorts: monthly step-by-step debulking MWA (n = 52) or continued TACE (n = 51). Overall survival (OS) and progression-free survival (PFS) after refractory TACE were evaluated. Residual liver and tumor volume were recorded for the MWA group. RESULTS: Median follow-up period was 24.3 months and median OS and PFS were significantly longer in the MWA group than in the TACE group (OS 21.0 vs. 11.7 months, PFS 6.1 vs. 3.0 months, both p < 0.001). The one-, two-, and three-year OS rates in the MWA and TACE groups were 73.1%, 46.6%, and 37.2% versus 43.1%, 15.5%, and 2.9%, respectively. Furthermore, the 0.5-, 1-, and 2-year PFS rates in the MWA and TACE groups were 51.9%, 36.5%, and 25.0% versus 27.5%, 11.8%, and 0, respectively. Multivariate analyses confirmed that switching to debulking MWA treatment was an independent favorable prognostic factor for PFS and OS. In the MWA group, the average additions of residual liver volume/total liver volume were 7.7% ± 6.7%, 7.2% ± 10.2%, and 10.1% ± 8.8% after the first, second, and third MWA procedure. CONCLUSION: Step-by-step debulking MWA can significantly improve long-term OS and PFS in patients with huge unresectable HCCs compared with repeated TACE after TACE refractoriness. Key PointThe debulking MWA therapy provides significantly longer OS and PFS than continued TACE for patients with huge unresectable HCCs after TACE-refractory, especially with complete tumor ablation.The most common complications were fever (48.1%) and pain (46.2%) in the MWA group. Two major complications (abdominal infection) were recorded in the MWA group, which recovered after symptomatic treatment.During the course of repeated MWAs, liver hyperplasia appeared mainly after the second MWA procedure and the average maximum increased RLV/TLV rate was 16.3%±12.7%.

An mALBI-Child-Pugh-based nomogram for predicting post-hepatectomy liver failure grade B-C in patients with huge hepatocellular carcinoma: a multi-institutional study.

OBJECTIVE: Post-hepatectomy liver failure (PHLF) is a severe complication in patients with hepatocellular carcinoma (HCC) who underwent hepatectomy. This study aims to develop a nomogram of PHLF grade B-C in patients with huge HCC (diameter ≥ 10 cm). METHODS: We retrospectively collected clinical information of 514 and 97 patients who underwent hepatectomy for huge HCC at two medical centers between 2016 and 2021. Univariate and multivariate analysis were carried out to screen the independent risk factors of PHLF grade B-C, which were visualized as a nomogram. RESULTS: Three Hundred Forty Three Thousand One Hundred Seventy One  and 97 HCC patients were included in the training cohort, internal validation cohort, and external validation cohort, with probabilities of PHLF grade B-C of 15.1%, 12.9%, and 22.7%, respectively. Pre-operative modified albumin-bilirubin (mALBI) grade (p < 0.001), Child-Pugh classification (p = 0.044), international normalized ratio (INR) (p = 0.005), cirrhosis (p = 0.019), and intraoperative blood loss (p = 0.004) were found to be independently associated with PHLF grade B-C in the training cohort. All the five independent factors were considered in the establishment of the nomogram model. In the internal validation cohort and external validation cohort, the area under receiver operating characteristic curve for the nomogram in PHLF grade B-C prediction reached 0.823 and 0.740, respectively. Divided into different risk groups according to the optimal cut-off value, patients in the high-risk group reported significantly higher frequency of PHLF grade B-C than those in the low-risk group, both in the training cohort and the validation cohort (p < 0.001). CONCLUSIONS: The proposed noninvasive nomogram based on mALBI-Child-Pugh and three other indicators achieved optimal prediction performance of PHLF grade B-C in patients with huge HCC.

Immunohistopathological Analysis of Extramedullary Hematopoiesis and Angiogenesis of Spleen in a Case of Primary Myelofibrosis with Huge Splenomegaly.

Although splenomegaly is one of the important signs of primary myelofibrosis, the differential diagnosis varies from malignant disorders to benign disorders, including malignant lymphoma and sarcoidosis. The patient was a 67-year-old male who developed anemia and huge splenomegaly. The laboratory findings include human T-cell leukemia virus type 1 (HTLV-1) antibody, elevated soluble interleukin-2 receptor, hypocellular bone marrow, and uptake in the spleen on positron emission tomography/computed tomography scan. Additionally, we performed laparoscopic splenectomy to alleviate the clinical symptoms and to rule out malignant lymphoma. Histological findings revealed extramedullary hematopoiesis, characterized by the presence of erythroid islands and clusters of dysplastic megakaryocytes with increased reticulin fibrosis. Immunohistochemical staining revealed the presence of von Willebrand factor, dysplastic megakaryocytes, myeloperoxidase, myeloid-predominant proliferations, and CD34 immature myeloid cells. Furthermore, regarding the angiogenesis in the spleen, the endothelial cells of the capillaries and those of the sinusoidal vascular system that were reactive for CD34 and CD8, respectively, were also detected. Consequently, the histological findings revealed both extramedullary hematopoiesis and angiogenesis in spleen. Based on the histological findings and the identification of Janus activating kinase 2 (JAK-2) mutation, the patient was diagnosed with primary myelofibrosis. Splenectomy reduces blood transfusion requirements after surgery. The patient was carefully followed-up without further treatments. Thus, primary myelofibrosis is the crucial differential diagnosis of huge splenomegaly.

An asymptomatic huge primary retroperitoneal pseudocyst: a case report and review of the literature.

BACKGROUND: Retroperitoneal non-pancreatic or idiopathic pseudocysts are very rare lesions. This case report aimed to present our patient and to check all the available literature on this kind of rare disease. CASE PRESENTATION: Our patient was a 67-year-old Iranian man admitted with mild abdominal discomfort for three months. Ultrasonography and CT scan revealed a huge cystic structure within the retroperitoneal space. The lesion was excised through midline laparotomy and opening of the retro-peritoneum. The histopathology of the cyst wall revealed a benign cystic lesion with no epithelial lining. A histologic diagnosis of non-neoplastic retroperitoneal pseudocyst was made. CONCLUSION: The primary non-pancreatic retroperitoneal pseudocysts are rare lesions and have to be distinguished from other differential diagnoses of retroperitoneal lesions, and a surgeon should be aware of the possible occurrence of these lesions with unknown origin. Surgical excision is the only way to exclude malignancy and confirm the diagnosis.

Multi-institutional validation of novel models for predicting the prognosis of patients with huge hepatocellular carcinoma.

The population of patients with huge hepatocellular carcinoma (H-HCC diameter > 10.0 cm) is an odd group that is not well adjudicated in the current staging systems, whose prognosis after curative resection varies. We aimed to develop novel models to predict the long-term outcomes of patients with H-HCC without portal vein tumor thrombus after hepatectomy. There were 1076 H-HCC patients enrolled who underwent curative liver resection in five institutions in China. In total, 670 patients were recruited from our center and randomly divided into the training cohort (n = 502) and internal validation (n = 168) cohorts. Additionally, 406 patients selected from other four centers as the external validation cohort. Novel models were constructed based on independent preoperative and postoperative predictors of postsurgical recurrence (PSR) and postsurgical mortality (PSM) determined in multivariable cox regression analysis. The predictive accuracy and discriminative ability of the model were measured using Harrell's concordance index (C index) and calibration curve and compared with five conventional HCC staging systems. PSR model and PSM model were constructed based on tumor number, microscopic vascular invasion, tumor differentiation, preoperative alpha-fetoprotein level, albumin-bilirubin grade, liver segment invasion, neutrophil-to-lymphocyte ratio or platelet-to-neutrophil ratio, and surgical margin or intraoperative blood transfusion. The C-indexes were 0.84 (95% CI, 0.78-0.90) and 0.85 (95% CI, 0.78-0.91) for the PSR and PSM models, respectively, which were substantially higher than those of the five conventional HCC staging systems (0.63-0.75 for PSR; 0.66-0.77 for PSM). The two novel models achieved more accurate prognostic predictions of PSR and PSM for H-HCC patients after curative liver resection.

Efficacy of the association liver partition and portal vein ligation for staged hepatectomy for the treatment of solitary huge hepatocellular carcinoma: a retrospective single-center study.

BACKGROUND: The feasibility of association liver partition and portal vein ligation for staged hepatectomy (ALPPS) for solitary huge hepatocellular carcinoma (HCC, maximal diameter ≥ 10 cm) remains uncertain. This study aims to evaluate the safety and the efficacy of ALPPS for patients with solitary huge HCC. METHODS: Twenty patients with solitary huge HCC who received ALPPS during January 2017 and December 2019 were retrospectively analyzed. The oncological characteristics of contemporaneous patients who underwent one-stage resection and transcatheter arterial chemoembolization (TACE) were compared using propensity score matching (PSM). RESULTS: All patients underwent complete two-staged ALPPS. The median future liver remnant from the ALPPS-I stage to the ALPPS-II stage increased by 64.5% (range = 22.3-221.9%) with a median interval of 18 days (range = 10-54 days). The 90-day mortality rate after the ALPPS-II stage was 5%. The 1- and 3-year overall survival (OS) rates were 70.0% and 57.4%, respectively, whereas the 1- and 3-year progression-free survival (PFS) rates were 60.0% and 43.0%, respectively. In the one-to-one PSM analysis, the long-term survival of patients who received ALPPS was significantly better than those who received TACE (OS, P = 0.007; PFS, P = 0.011) but comparable with those who underwent one-stage resection (OS, P = 0.463; PFS, P = 0.786). CONCLUSION: The surgical outcomes of ALPPS were superior to those of TACE and similar to those of one-stage resection. ALPPS is a safe and effective treatment strategy for patients with unresectable solitary huge HCC.

Neck exploration for a huge synovial sarcoma, case report and literature review.

A 47-year-old woman presented in the outpatient department of EAST Surgical ward of MAYO Hospital Lahore, Pakistan, on February 2019 with complaint of swelling in the front section of the neck since five months which increased gradually in size and had been causing pain since two months. She had no comorbidities and insignificant family history. Examination revealed a 23×20 cm mass on the right side of the posterior triangle of the neck. Fine Needle Aspiration Cytology (FNAC) was inconclusive and CT of the neck showed a huge mass on the right side of the neck with cervical lymph nodes. Exploration was planned, and modified radical neck dissection Type III (Also known as Functional Neck dissection) was performed. The biopsy revealed synovial sarcoma of the neck. The patient's post-operative condition was satisfactory and she was discharged on the fifth post-operative day.

Fast Leak-Proof, Intraumbilical, Single-Incision Laparoscopic Ovarian Cystectomy for Huge Ovarian Masses: "Hybrid Cystectomy and Reimplantation" Method.

Background and Objectives: To introduce a new technique for fast leakage-proof, intraumbilical, single-incision laparoscopic ovarian cystectomy for huge ovarian masses (>10 cm) Materials and Methods: Seven consecutive, reproductive-aged women, including three adolescents, with huge ovarian masses (mature cystic teratoma, n = 4; endometrioma, n = 2; and mucinous cystadenoma, n = 1) who underwent transumbilical single-incision ovarian cystectomy with the new "hybrid cystectomy and reimplantation" method were included. The procedure was: (1) trans-umbilical single-incision laparoscopy; (2) inspection of the pelvic cavity and placing the mass in a laparoscopic endo-bag for cystic content leakage prevention; (3) in-bag resection using cold scissors and minimal cauterization of the cystectomy site; (4) in-bag tissue extraction; (5) rapid extracorporeal cystectomy with traction without electrocautery; (6) re-insertion of the retrieved ovarian cortex intracorporeally through the single port, and (7) intracorporeal suture of the retrieved tissue to the in situ ovary. Results: The mean patient age was 24.71 ± 6.56 (range 17-37) years and the mean maximal diameter of the masses was 17.71 ± 2.86 (range 13-22) cm. There was no case of unintended intracorporeal cyst rupture and no need for copious irrigation for washing and suctioning the leaked mass content. The mean total operating time was 76.42 ± 6.39 (range 65-85) min, the total volume of saline used for irrigation was 814.28 ± 331.35 (range 500-1500) mL, and the estimated blood loss was 107.14 ± 47.72 (range 50-200) mL. There were no perioperative complications. All patients except the two endometriosis patients had regular, normal menstruation. Conclusions: Our preliminary findings were encouraging in terms of the safety and efficiency of the new method. Future trials need to elucidate the benefits of this method in terms of fertility preservation.

Efficacy of combined bland embolization and chemoembolization for huge (≥10 cm) hepatocellular carcinoma.

INTRODUCTION: To assess the efficacy of combined therapy involving bland transarterial embolization using gelatin sponge particles (bland GS-TAE) followed by transarterial chemoembolization using lipiodol mixed with anticancer agents and GS particles (Lip-TACE) to reduce the adverse events and increase the therapeutic effect of Lip-TACE in the treatment of huge (≥10 cm) hepatocellular carcinoma (HCC). MATERIAL AND METHODS: Twenty-one consecutive patients with huge HCCs (≥10 cm in diameter) were enrolled in this study. First, bland GS-TAE was performed to reduce the tumor volume, and then Lip-TACE was performed to control the remaining tumor at intervals of around three weeks. Tumor response, survival, and adverse events of this combined therapy were assessed. RESULTS: The tumor response was assessed three months after combined TACE, with complete response in 38.1% and partial response in 57.1% of cases. Severe adverse events were seen in two patients, acute cholecystitis and tumor rupture. The median survival time was 2.7 years, and the one-, two-, three-, and five-year overall survival rates were 76.2%, 66.7%, 42.9%, and 25.0%, respectively. CONCLUSION: Combined therapy involving bland GS-TAE followed by Lip-TACE can be performed safety and may improve survival in patients with huge HCCs.

Pfannenstiel incision for surgical excision of a huge pelvi-abdominal cystadenoma: a case report.

A 56-year-old post-menopausal woman, with 3 previous caesarean sections (CSs), presented to the emergency department with abdominal distension, without abdominal pain, tenderness, and/or rigidity. The abdominal examination of the studied woman showed a mobile, pelvi-abdominal mass 4 fingers breadth above the umbilicus. Magnetic resonance imaging study of the mass showed a large, well-defined, multi-locular cystic mass measuring 25.5 x 21 cm, which was most probably a right ovarian cystadenoma. The studied woman signed a written consent form for total abdominal hysterectomy and bilateral salpingo-oophorectomy, after the normal tumour markers, and pre-operative investigations. Under general anaesthesia, an elliptical Pfannenstiel skin incision was done to remove the old CSs scars, followed by opening of the patient's anterior abdominal wall in layers. Total abdominal hysterectomy and unilateral left SO were done first, to deliver the ovarian mass easily and intact outside the abdomen after the uterus. Due to failure to deliver the mass outside the abdomen after removal of the uterus, the right infundibulopelvic ligament was ligated behind the mass, while the mass was still inside the abdomen. A longitudinal midline incision in the upper flap of the rectus sheath (not involving the skin) was added to deliver the excised right ovarian mass outside the abdomen. Successfully, the right ovarian mass delivered intact outside the abdomen after the added longitudinal midline incision. This report highlights that the midline vertical incision is not the standard abdominal incision. Moreover, the transverse Pfannenstiel incision is cosmetically better, and should be routinely used to avoid unnecessary vertical abdominal incision.