The PROCESS 2020 Guideline: Updating Consensus Preferred Reporting Of CasESeries in Surgery (PROCESS) Guidelines

Surgical management of giant hepatic hemangioma: A 10-year single center experience

Background

Hepatic hemangiomas are the most typical benign mesenchymal lesions of the liver. Most of these lesions are asymptomatic. Giant hepatic hemangiomas (GHH) (>10 cm) are often symptomatic and require surgical intervention. This study aimed to describe the clinical findings, risk factors, diagnostic approach and management of GHH.

Methods

We performed a retrospective analysis of patients with GHH treated at our hospital from January 2008 to December 2018. The medical records of each patient were reviewed to obtain the clinical and surgical data.

Results

Twelve patients with GHH were treated during the study period. 9 were female and 3 were male. The mean age of diagnosis was 48,2 years. The most common presenting symptom was abdominal pain. Eight patients presented an abdominal mass. Indications for surgical resections were rupture (n = 2), Kasabach-Merritt syndrome (n = 1) and abdominal pain (n = 9). Right hepatectomy was done in four patients, left lobectomy in four patients, and enucleation in four patients. Embolization was performed in 4 patients, but due to the persistence of symptoms or bleeding, surgery was indicated. The mean operative time was 3.5 h, and median blood loss was 870 ml. The median hospital stay was 5.3 days. For four patients, we registered postoperative complications causing death in one case. All alive patients were asymptomatic at a median follow-up of 55 months.

Conclusion

Despite limitations and alternative modalities, surgery remains the only effective curative treatment for GHH.

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Hepatic hemangiomas are the most common benign tumors of the liver with the incidence of 0.4–20%.

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Giant hepatic hemangiomas (GHH) are usually responsible for overt clinical symptoms and complications.

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Management of liver hemangiomas ranges from close observation to surgery depending upon the site, size and symptoms.

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Surgical resection is indicated in patients with abdominal complaints or complications, or when diagnosis remains inconclusive.

A common but unknown disease; A case series study

Background

The present study is conducted to introduce a common disease of abdominal wall which has received less attention in scientific resources. In traditional medicine sources Some scholars believe that this condition occurs due to the movement of the abdominal muscle near the umbilicus or nave laterally movement of nave.

Design

A case series study.

Method

the study did not receive any funding. This study was a case series study. The study population was all patients who following repeated hospital visits did not improve, and for their last try, they visited a traditional clinic, and were diagnosed with umbilical hernia during a period of 5 months. Data were collected using demographic information questionnaire, and a complete health history taking.

Results

nave sliding is an abdominal wall defect and gastrointestinal and psychological problems are listed as the most prominent sign and symptoms. higher body mass index and presence of a first-degree relative with the same problem could be a predictor factor.

Conclusion

Nave sliding is a common disease that there are a few scientific literatures about it and needs more attention from clinicians to avoid false diagnoses and requires more academic research to clarify any ambiguous side about it to promote the treatment process in a more scientific and approved methods.

Ski- and snowboard related open peroneal nerve injury: A 20-year retrospective case series study

Introduction

Traumatic peroneal nerve injury (PNI) caused by ski or snowboard edges is a severe but scarcely reported accident.

Methods

In a 20-year retrospective study, all skiers and snowboarders with this injury treated surgically at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Innsbruck, Austria, were included, covering a period from 1999/2000 to 2018/2019.

Results

In total, 34 patients were included in this study (30 males (88.2%) and 4 (11.8%) females). Of these 34 injured skiers or snowboarders, 33 (97.1%) were recreational athletes and Non-Austrian citizens, and 21 (61.8%) patients sustained accidental injuries without collision. All of the injuries under investigation, i.e., open lacerations, most often with complete transection, were the patients’ main injuries. Surgery was performed with direct coaptation in 24 patients (70.6%), and with a suralis nerve graft in the other 10 patients (29.4%).

Conclusion

Traumatic laceration of the peroneal nerve at the knee level by sharp ski or snowboard edges is a rare but severe injury. Causes for this injury may be multifactorial. Recommendations to reduce the risk of such an injury may follow general instructions and warnings to skiers and snowboarders regarding equipment, familiarity with the region, as well as appropriate skills and training.

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In accidents of skiers and snowboarders traumatic laceration of the peroneal nerve is a severe, but rare injury.

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This injury type is rarely reported.

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The injuries are caused by the sharp edges of modern skies or snowboards and require urgent microsurgical intervention.

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Our 20 years study shows that this injury type primarily affects recreational athletes and guest skiers.

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Current equipment, e.g. ski trousers do not protect the affected region on the lateral side of the knee.

Technical characteristics and quality of grafts in liver procurement from brain-dead donors: A single-center study in Vietnamese population

Introduction

Donor liver graft quality plays an especially important role that contributes to the success of organ transplantation. Almost all local and international authors are interested in the techniques and results of transplantation, however, in Vietnam, there have not been any studies that report the results of liver procurement from brain-dead donors from a technical perspective as well as the morphology and function of the transplanted organ.

Materials and method

This study is descriptive cross-section study with analysis of retrospective occurrences of a series of cases of liver procurement from brain-dead donors from March 2010 to March 2020. All cases were proceeded the multiple organ procurement with warm liver dissection and in vivo cannulation and perfusion.

Results

The average age of brain-dead donors was 29.7 ± 10.7 (18–69), 92.16% of the harvested organs were of good quality macroscopically; and the rate of anatomical modification was 33.3% that occurred mostly in the left hepatic artery (LHA). Technically, warm dissection was proceeded in majority of cases (98,0%), the graft implantation was performed by this technique with mean cold ischemia time (CIT) of 190,0 ± 100,5 min and WIT of 74,0 ± 39,2 s. There were no complications relating to graft injuries occurring during procurement and no primary liver failure, good results accounted for 94.1% of the total number of transplants postoperatively.

Conclusion

Multiple organ procurement with warm liver dissection and in vivo cannulation and perfusion was a safe technique and may be effective by avoiding any donor's damages in cold-phase dissection.

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Liver transplantation in brain-dead donors had developed rapidly in recent decades.

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Several techniques were proceeded depend on experience and faculties of institute.

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In vivo perfusion and warm dissection can avoid graft's damages in cold dissection.

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Long-term follow-up is needed to evaluate quality of graft and overall survival.

Predictive factors of mortality related to COVID-19: A retrospective cohort study of 600 cases in the intensive care unit of the university hospital of Oujda

Introduction

Although the corona virus is responsible in the majority of cases for mild symptoms, there are sometimes severe and even lethal forms of this disease. Our study aimed to identify clinical and para-clinical predictors of mortality related to COVID-19.

Materials and methods

This is a single-center retrospective cohort study conducted from March 2020 to December 2020 at intensive care unit department of Mohamed VI University Hospital Oujda, Morocco including 600 patients with COVID-19.

Results

We included 600 patients, the mortality rate was 32.50%, the predictors of mortality identified in our study were: associated heart disease (RR: 1.826; CI: [1.081–3.084]; p:0.024), high D-dimer level at admission (RR:1.027; CI: [1.011–1.047]; p:0.001), need for mechanical ventilation (RR: 4.158; CI: [2.648–6.530]; p: <0.0001).

Conclusion

Based on these results, we were able to identify 3 predictors of COVID 19 mortality (associated heart failure, high D-dimer level on admission, and need for mechanical ventilation). These predictors could help clinicians to identify early patients with high risk of lethality in order to reduce mortality related to corona virus.

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Covid-19 is an infection with a high rate of mortality and morbidity.

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Several studies have shown severals predictive factors of mortality.

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D-Dimers, History of heart disease and necessity of mechanical ventilation are the predictive factors of mortality.

Case report: Management of septic knee arthritis with Pseudomonas aeruginosa by arthroscopic debridement and lavage with diluted povidone iodine

INTRODUCTION

Septic knee arthritis after elective arthroscopic procedures is a rare surgical emergency, with Pseudomonas aeruginosa even more rarely causing the infection. The treatment by arthroscopic debridement and lavage with diluted Povidone-Iodine has potential benefits that may be useful in improving the prognosis for patients. This case report discusses the potential benefits of using antiseptics like Povidone-Iodine in the washout of the affected joint.

PRESENTATION OF CASE

We present a patient with post arthroscopic septic knee arthritis caused by P. aeruginosa treated successfully by arthroscopic synovectomy and washout with normal saline and diluted povidone‑iodine, and prolonged antimicrobial therapy.

DISCUSSION

Preceding reports of P. aeruginosa suggest intraoperative factors, postoperative factors, and host factors that may lead to this uncommon infection. There is controversy over the optimal management regarding arthroscopic versus open debridement, and the choice of the irrigating fluid.

CONCLUSION

The use of antiseptics like Povidone-Iodine in the washout procedure may lead to improved outcomes if used for a short controlled period of time and followed by copious irrigation with saline. Further studies must be done to determine the efficacy and risk-to-benefit ratio of this method.

The efficacy of ilizarov method for management of long tibial bone and soft tissue defect

INTRODUCTION

Patients with open fracture Gustillo-Anderson grade 3 had undergone several surgical procedures, but still ended up with expose long dead bone or infected. Illizarov method was used to address long bone and soft tissue defect after re-debridement with radical resection of long dead bone or infected segment.

METHODS

We included 14 patients (mean age: 30.86 ± 11.49) with non-union tibial fracture with long dead and infected bone segment who had undergone several debridement, bone grafting or spacer and soft tissue closure procedure due to open fracture of tibia grade 3. The subjects underwent re-debridement with radical resection of dead or infected bone segment followed by Illizarov method to perform bone transport procedure for bone defect filling and simultaneously restore severe soft tissue loss and bone lengthening procedure.

RESULTS

All subjects had achieved satisfactory results with mean docking period of bone transport 3.78 ± 0.54 months, union time at the docking side 7 (5.5-9) months. Soft tissue was covered and no recurrence of infection. Three subjects had Leg Length Discrepancy (LLD) of 1 cm, whereas the remaining had zero discrepancy. No significant pain was observed at final follow-up and 4 patients had ankle joint stiffness.

CONCLUSION

The Illizarov method can effectively address long bone and soft tissue defects by distraction osteogenesis through bone transport procedure that filling the defect gradually without bone graft and simultaneously enhancing soft tissue closure without tertiary soft tissue procedure subsequently followed with bone lengthening procedure to correct the limb length discrepancy.

Locoregional anesthesia for removal osteosynthesis hardware from healed corpus mandibularis fractures: A descriptive study of a series of 40 cases

INTRODUCTION

Locoregional anesthesia represents a very interesting modality for the removal of osteosynthesis hardware of the corpus mandibularis. Several procedures have been described, but each is dedicated to a single mandibular segment.

MATERIAL AND METHODS

The surgical records of 40 patients treated with rigid internal fixation after maxillofacial traumas were reviewed. Study variables included age, sex, site and number of plates, time of plate removal, reasons for plate removal, and postoperative.

RESULTS

Our study enrolled 40 patients, 45% of whom had single-focal plate placement and 55% of whom had bifocal plate placement. 66% of the patients with bifocal plate placement had the plates removed during the same operation. The average operative time was 45 min for bifocal and 28 min for single-focal approaches. Postoperative complications were observed only for the truncal analgesia procedure of the inferior alveolar nerve at the mandibular foramen. Anesthesia failure was reported in 2 patients.

DISCUSSION

Various locoregional anesthetic procedures are used to remove mandibular body plates but each has its indication depending on the mandibular segment being treated. Factors that can lead to failure of locoregional anesthesia are dominated by the state of inflammation at the site and patient anxiety which can be minimized by premedication with anxiolytics.

CONCLUSION

Locoregional anesthesia for removal of osteosynthesis hardware of the corpus mandibularis remains a good anesthetic method that is performed in good conditions when it is done in compliance with standards. Its use avoids the usual risks and complications that can occur under general anesthesia.

Intraoperative Cochlear Nerve Monitoring for Vestibular Schwannoma Resection and Simultaneous Cochlear Implantation in Neurofibromatosis Type 2: A Case Series

BACKGROUND

Neurofibromatosis type 2 (NF2) often results in profound hearing loss and cochlear implantation is an emerging hearing rehabilitation option. However, cochlear implant (CI) outcomes in this population vary, and intraoperative monitoring to predict cochlear nerve viability and subsequent outcomes is not well-established.

OBJECTIVE

To review the use of intraoperative electrically evoked cochlear nerve monitoring in patients with NF2 simultaneous translabyrinthine (TL) vestibular schwannoma (VS) resection and cochlear implantation.

METHODS

A retrospective review was performed of 3 patients with NF2 that underwent simultaneous TL VS resection and cochlear implantation with electrical auditory brainstem response (eABR) measured throughout tumor resection. Patient demographics, preoperative assessments, surgical procedures, and outcomes were reviewed.

RESULTS

Patients 1 and 3 had a reliable eABR throughout tumor removal. Patient 2 had eABR pretumor removal, but post-tumor removal eABR presence could not be reliably determined because of electrical artifact interference. All patients achieved auditory percepts upon CI activation. Patients 1 and 2 experienced a decline in CI performance after 1 yr and after 3 mo, respectively. Patient 3 continues to perform well at 9 mo. Patients 2 and 3 are daily users of their CI.

CONCLUSION

Cochlear implantation is attainable in cases of NF2-associated VS resection. Intraoperative eABR may facilitate cochlear nerve preservation during tumor removal, though more data and long-term outcomes are needed to refine eABR methodology and predictive value for this population.

The wisdom behind the third molars removal: A prospective study of 106 cases

Purpose

This paper aims to evaluate the decision-making of wisdom teeth extractions (M3s extraction) and the epidemiological profile in the targeted population.

Materials and method

This was a prospective analysis study of 106 patients at our hospital august 20, 1953 specialist hospital, which is a referral center between January 1, 2020 and January 1, 2021. The patients are divided into 2 groups according decision-making of wisdom teeth removal based on scientific evidence if it's right or wrong.

Results

There was no statistically significant difference between the groups regarding sex (P = 0.478), educational level (P = 0.718), or working status (P = 0.606). Furthermore, there was no statistically significant difference between the groups regarding general co-morbidity (P = 1.00) or oral history (P = 0.28). The mean age of the sample was 32.12 years (SD = 11.337 years, range = 17–70 years, median = 30 -years). We reported that only 28% of the third molars were surgically extracted. We included in Group (I), 81 patients who were treated for third molars removal which the decision-making was justified. In Group (II), 25 patients were treated for third molars removal which the decision-making was unjustified. Group (I) comprised 30 men and 51 women with a mean age of 30 years. Group (II) comprised 7 men and 18 women with a mean age of 27 years. The assessment of surgical outcomes (operating time, blood loss, hospital stay) showed no difference between groups.

Discussion

Monitoring asymptomatic wisdom teeth appears to be an appropriate strategy. Regarding retention versus prophylactic extraction of asymptomatic wisdom teeth, decision-making should be based on the best evidence combined with clinical experience.76.4% had a reason for extraction that was justified. The reasons why extraction of the wisdom tooth was not justified in our study population was either: extraction for prophylaxis or in the case of asymptomatic non-pathological third molars; without scientific evidence.

Conclusion

This subject, which is perpetually debated, requires updating dental health authorities by evaluating new conservative procedures.

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Third molars are a major focus of interest in dentistry.

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Preliminary indication and wrong decision-making for teeth extraction have resulted in many healthy teeth being sacrificed.

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Debate continues about the best strategies for the management of wisdom teeth.

Hepatic lymphorrhea following pancreaticoduodenectomy: Preliminary diagnosis and treatment experience from case series of four patients

Introduction

Hepatic lymphorrhea (HL) is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy.

Case presentation

We herein report a case series of four patients with HL following pancreaticoduodenectomy that presented to the department with a severe clinical picture with the discovery in imaging and intraperitoneal fluid's tests. All our patients presented with a condition of Hepatic lymphorrhea secondary to pancreaticoduodenectomy, which were treated successfully with percutaneous hepatic lymphangiography (HLG).

Discussion

Hepatic lymphorrhea is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Periportal lymphatic vessels, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous Hepatic Lymphangiography (HLG).

Conclusion

HLG with percutaneous access could be effective to identify and terminate the chylous fistula from periportal lymphatic vessels after pancreaticoduodenectomy.

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Hepatic lymphorrhea is a rare, life-threatening complication of pancreaticoduodenectomy.

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Periportal lymphatic vessels was a potential location of lymphatic fistula and leakage.

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This complication can be diagnosed with imaging and intraperitoneal fluid's tests.

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Hepatic lymphangiography is a minor-invasive therapy to close the lymphatic fistula.

Symptomatic subclavian steal syndrome: Report of four Moroccan cases and literature review

Introduction

Subclavian steal syndrome (SSS) is the hemodynamic phenomenon of blood flow reversal in the vertebral artery due to significant stenosis or occlusion of the proximal ipsilateral subclavian artery.

Materials and methods

Four patients with subclavian steal syndrome were treated in our center. Percutaneous radial approach was used for angioplasty, primary stenting of subclavian artery was performed, surgical techniques in particular carotid-subclavian bypass and carotid-subclavian transposition were used.

Results

We report the cases of four patients, three of which are male, with an average age of 60 years. All of them were symptomatic. Diagnosis was made by duplex ultrasound, supplemented by CT-angiography and arteriography. Endovascular treatment was attempted in all four patients, which was successful in two patients, who underwent primary stenting, and failed for the two others, for whom surgical treatment was considered. One had a subclavio-carotid bypass graft with a polytetrafluorethylene (PTFE) prosthesis and the other had a subclavio-carotid transposition. The technical results were satisfactory in all patients with symptoms resolution. The postoperative evolution was without notable complications and the postoperative checkups were satisfactory.

Discussion

There are excellent screening tools and effective medical therapies which can be instituted if the SSS is diagnosed early. When the need for revascularization arises, percutaneous modalities are favored given their proven long-term efficacy, decreased morbidity and mortality, and cost-effectiveness. Nevertheless, large, prospective, randomized and controlled trials are needed to compare the long-term patency rates between the endovascular and surgical techniques.

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SSS is caused by the reversal of blood flow in the vertebral artery.

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Doppler ultrasound is the ultimate screening tool for diagnosis.

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Treatment of symptomatic SSS is always indicated.

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Endovascular approach is the first-line treatment.

Outcomes and Surgical Considerations for Neurosurgical Patients Hospitalized with COVID-19-A Multicenter Case Series

Objective

Neurosurgical patients are at a higher risk of having a severe course of coronavirus disease 2019 (COVID-19). The objective of this study was to determine morbidity, hospital course, and mortality of neurosurgical patients during the coronavirus disease 2019 (COVID-19) pandemic in a multicenter health care system.

Methods

A retrospective observational study was conducted to identify all hospitalized neurosurgical patients positive for COVID-19 from March 11, 2020 to November 2, 2020 at Mayo Clinic and the Mayo Clinic Health System.

Results

Eleven hospitalized neurosurgical patients (0.68%) were positive for COVID-19. Four patients (36.6%) were men and 7 (63.3%) were women. The mean age was 65.7 years (range, 35–81 years). All patients had comorbidities. The mean length of stay was 13.4 days (range, 4–30 days). Seven patients had a central nervous system malignancy (4 metastases, 1 meningioma, 1 glioblastoma, and 1 schwannoma). Three patients presented with cerebrovascular complications, comprising 2 spontaneous intraparenchymal hemorrhages and 1 ischemic large-vessel stroke. One patient presented with an unstable traumatic spinal burst fracture. Four patients underwent neurosurgical/neuroendovascular interventions. Discharge disposition was to home in 5 patients, rehabilitation facility in 3, and hospice in 3. Five patients had died at follow-up, 3 within 30 days from COVID-19 complications and 2 from progression of their metastatic cancer.

Conclusions

COVID-19 is rare among the inpatient neurosurgical population. In all cases, patients had multiple comorbidities. All symptomatic patients from the respiratory standpoint had complications during their hospitalization. Deaths of 3 patients who died within 30 days of hospitalization were all related to COVID-19 complications. Neurosurgical procedures were performed only if deemed emergent.

Benefits of Tocilizumab in patients with a severe form of SARS-CoV-2 infection: Experience of the intensive care unit of the Mohammed VI university hospital, Oujda

BACKGROUND

COVID-19 is a new disease that appeared in December 2019. Millions of people have been infected and died from this infection. Until today, the pathophysiology and treatment of this infection remain unknown, but a lot of studies are trying to solve the mystery. The trail of inflammation remains the most convincing, especially the Interleukin 6 (IL-6) which could play an important role in a reaction cascade leading to a cytokine storm. According to studies, although few in number, the Tociluzimab (TCZ), which is an anti-IL6, could prevent or even suppress this storm, leading to a less severe clinical state of the disease and a faster recovery. This could decrease the use of oxygen, avoid the risk of intubation and mortality.

PATIENTS AND METHODS

This single-center retrospective observational case review brought together 557 COVID-19 seriously ill patients (pulmonary involvement> 25% + SatO2AA <90%) admitted to the intensive care unit of our university hospital from March 1st, 2020 to February 28th, 2021. They were divided into 2 groups a Tociluzimab group (TCZ group) and a Non Tociluzimab group (NON TCZ) to facilitate the comparison. The aim of the study was to compare the length of hospital stay, the use of mechanical ventilation and the mortality in the TCZ group versus the NON TCZ group.

RESULTS

The average age of our patients was 62,05 years (±13.51) and 62.61 years (±16.33) respectively in the TCZ versus NON TCZ group. 76 (76%) were men while 24 were women (24%) in the TCZ group; and there was 313 (68.49%) men and 144 (31.51%) women in the NON TCZ group. Their average BMI was 28 kg/m2 (±4.52) in the TCZ group versus 27.89 kg/m2 (±4.73) in the NON TCZ group. Among them, the TCZ group included 38 (38%) diabetic patients, 38 hypertensive (38%), 12 heart disease (12%) and 2 chronic renal failure (2%), while the NON TCZ group regrouped 35 (7.65%) diabetics, 33 (7.22%) hypertensive, 12 heart disease (2.67%), and 5 chronic renal failure (1.09%) patients. The mean time to consultation of patients was almost similar in the two groups: 8.86 (±7,28) days for TCZ and 8.83 (±7,03) days for NON TCZ group. The mean length of ICU hospital stay was 9 days (4,94) for the TCZ group and 8,75 days (4,73) for the other one. The saturation at admission was at 74.92% (10.45) for the TCZ group ranging from 40% to 92%, and at 73,56% for the NON TCZ group. Lung damage from COVID-19 was extensive in 12%, severe in 32%, and critical in 56% of TCZ group enrolled cases. Meanwhile it was extensive in 23.63%, severe in 41,35%, and critical in 35,01% of the NON TCZ group. The biological findings found average of white blood cells at 12256/12082 e/mm3, lymphocytes at 761/842 e/mm3, CRP at 181/199 mg/L, ferritin at 1747/528 μg/L, and fibrinogen at 6.92/6.27 g/L for the TCZ group versus NON TCZ group. Medical care was based on isolation, oxygenotherapy, azithromycin, vitamin C, zinc, vitamin D, salicylic acid, dexamethasone followed with methylprednisolone, and anticoagulation for all hospitalized patients. The TCZ group received at least 1 course of Tociluzimab dosed at 400 mg (2 patients received 2 doses and 1 patient received 3 doses). The indication of a Tociluzimab course in our department was based on a set of arguments: an increase in oxygen requirements, a progression of lesions on chest-computed tomography and an increase in inflammation markers including IL-6, CRP, ferritin, fibrinogen, and a decrease in the percentage of lymphocytes. The invasive mechanical ventilation was indicated for 4 (4%) patients in the TCZ group versus 192 (42,01%) in the NON TCZ. Among the 100 patients included in our cohort in the TCZ group, 40% died in intensive care unit and 60% had a favorable evolution with a decrease of the biological markers of inflammation. However, in the NON TCZ group, 197 (43,10%) passed away.

CONCLUSION

The use of Tociluzimab in ICU patients with severe COVID-19 pneumonia did not contribute to a significant difference in the reduction of hospital stay. However, the invasive mechanical ventilation was less needed in patients receiving Tociluzimab than the others. Moreover, there was a mortality benefit associated with the use of Tociluzimab, but only before 10 days of hospitalization.

Vascular Malformation of the Colorectum in Children: Case Series of 27 Patients

BACKGROUND

Vascular malformation of the colorectum is a rare disease that presents most commonly in early childhood. Some pull-through procedures have been performed for its treatment. However, laparotomy was routinely required. The aim of this study was to present features of this disease, as well as the outcomes of transanal endorectal pull-through (TEPT) with or without laparotomy.

METHODS

A retrospective analysis was performed on consecutive patients with vascular malformation of the colorectum who underwent TEPT with or without laparotomy in our hospital between January 2010 and December 2019. Follow-up information included hematochezia, other bleeding and bowel function. Bowel function was assessed using the Rintala score.

RESULTS

Twenty-seven patients were included (14 boys and 13 girls). Hematochezia and anemia were the main chief complaints. Perianal vasodilatation and prolapse of rectal mucosa with spurting blood were detected in 13 (48.1%) and 9 (33.3%), respectively. Eighteen patients (66.7%) underwent TEPT with laparotomy, and 9 patients underwent TEPT without laparotomy (including 5 TEPT under laparoscopic supervision) for lesions located beyond the distal sigmoid colon. Compared to TEPT with laparotomy, the length of resected bowel and operative time was significantly shorter in TEPT without laparotomy (p = 0.001 and p = 0.004). There was no statistical difference for intraoperative blood loss. Other vascular malformations were detected in 9 patients (33.3%); 3 were detected by laparoscopy. Three patients (11.1%) experienced postoperative complications. Follow-up was held with 24 patients (3 were lost to follow-up). The mean follow-up time was 51.9 ± 32.8 months. Four patients occasionally had bloody stools, without anemia. None had hematuria or vaginal bleeding. Median bowel function score was 20 (range 17-20).

CONCLUSION

Hematochezia, anemia and hemorrhoid-like manifestations might be an indication for vascular malformation of the colorectum in children. TEPT was effective for vascular malformation of the colorectum, and TEPT without laparotomy was more suitable for the short lesions.

Endoscopic Placement of Fourth Ventricular Catheter Using Seldinger Technique: Description of Technique and Case Series

BACKGROUND

Neonatal intraventricular hemorrhage remains a significant source of morbidity in premature and low-weight patients. Approximately 15% of patients who require cerebrospinal fluid shunting develop trapped fourth ventricle (TFV). Surgical treatment presents challenges with short- and long-term complications.

OBJECTIVE

To describe a technique that applies the Seldinger technique with image-guided endoscopy for direct visualization of catheter placement.

METHODS

A guidewire is passed down the endoscope while it is positioned in the fourth ventricle. The endoscope is removed while the guidewire is held in place. The catheter is slid down the guidewire. The guidewire is removed and placement is confirmed with image guidance.

RESULTS

Three patients, all less than 14 mo old, with history of prematurity and intraventricular hemorrhage with ventriculoperitoneal shunts, presented with loculated hydrocephalus with TFV. They each underwent image-guided endoscopic fenestration of the fourth ventricle with placement of a fourth ventricular catheter performed by our described technique. All 3 patients recovered well and were discharged on postoperative day 1. Follow-up imaging showed decompression of the fourth ventricle and good placement of the fourth ventricular catheter. None have had complications from catheter placement, and one revision of a fourth ventricular catheter was needed, which was completed with the same described technique.

CONCLUSION

This technique is well suited for cases in which a fourth ventricular catheter or a difficult trajectory catheter is needed during endoscopic fenestration or when distorted anatomy is present that would make a straight trajectory with a pen endoscope more difficult or higher risk.

Fields of Forel Brain Stimulation Improves Levodopa-Unresponsive Gait and Balance Disorders in Parkinson's Disease

BACKGROUND

Gait and balance disturbance are challenging symptoms in advanced Parkinson's disease (PD). Anatomic and clinical data suggest that the fields of Forel may be a potential surgical target to treat these symptoms.

OBJECTIVE

To test whether bilateral stimulation centered at the fields of Forel improves levodopa unresponsive freezing of gait (FOG), balance problems, postural instability, and falls in PD.

METHODS

A total of 13 patients with levodopa-unresponsive gait disturbance (Hoehn and Yahr stage ≥3) were included. Patients were evaluated before (on-medication condition) and 1 yr after surgery (on-medication-on-stimulation condition). Motor symptoms and quality of life were assessed with the Unified Parkinson's Disease Rating scale (UPDRS III) and Quality of Life scale (PDQ-39). Clinical and instrumented analyses assessed gait, balance, postural instability, and falls.

RESULTS

Surgery improved balance by 43% (95% confidence interval [CI]: 21.2-36.4 to 35.2-47.1; P = .0012), reduced FOG by 35% (95% CI: 15.1-20.3 to 8.1-15.3; P = .0021), and the monthly number of falls by 82.2% (95% CI: 2.2-6.9 to -0.2-1.7; P = .0039). Anticipatory postural adjustments, velocity to turn, and postural sway measurements also improved 1 yr after deep brain stimulation (DBS). UPDRS III motor scores were reduced by 27.2% postoperatively (95% CI: 42.6-54.3 to 30.2-40.5; P < .0001). Quality of life improved 27.5% (95% CI: 34.6-48.8 to 22.4-37.9; P = .0100).

CONCLUSION

Our results suggest that DBS of the fields of Forel improved motor symptoms in PD, as well as the FOG, falls, balance, postural instability, and quality of life.

Pattern of orthopedic injuries among Victims of Road Traffic Accidents in Aseer region, Saudi Arabia

Background

Road Traffic Accidents (RTA) are one of the most common causes of morbidity and mortality in Saudi Arabia despite preventive measures and programs. The major factors for the increase in the incidence of mortality and morbidity are due to human factors, such as over speeding, not obeying traffic laws, fatigue, and driving before the legal age. In this study, we aim to report the pattern of orthopedic injuries (OIs) from RTA in the south-western region of Saudi Arabia and to explore the healthcare outcomes of OIs.

Method

This is a retrospective, record-based, case series study including RTA patients who were admitted to the Emergency Department (ED) at a tertiary hospital in the south-western region of Saudi Arabia. The data was collected for 531 admitted RTA patients with OIs over for five years from May 2011 to May 2016. Patients who were 15 years of age or above were included in this study. The data were analyzed using the statistical package for social science (SPSS) version 21.

Results

A total of 531 patients were included with an age range between 15 and 90 years with an average age of 29 ± 2 years. Most of the population was male constituting 91.3% of the sample while 91.9% of the sample were Saudis. About 75% of the OIs had simple fractures and complex fractures were recorded among 10.2% of the cases. About half of the cases (52%) had lower limb fractures and 32% had upper limb fractures.

Conclusions

RTA and the resultant OIs, death, and permanent disabilities cause a tremendous burden on economic resources and should be of concern for local authorities. More attention and regularities should be paid to avoid life-threatening driving behaviors.

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Road traffic accidents are one of the most common causes of mortality.

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Many factors have a role in the incidence of road traffic accidents.

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It is crucial to understand all aspects and factors and determine the patterns accordingly.

The effectiveness of oral propranolol for infantile hemangioma on the head and neck region: A case series

Introduction

Infantile hemangioma is the most common tumor in infancy, with 60% occurring on the face and neck. A large tumor involving the facial region will cause significant aesthetic and functional impairment and isn't always easy to treat surgically. A non-invasive treatment is needed for this condition. Propranolol has recently been used as a choice of treatment in infantile hemangioma.

Presentation of case

We presented two cases of large problematic infantile hemangioma that were successfully managed with oral propranolol.

Discussion

Large problematic lesions that ulcerate and bleed often need surgery; however, a substantial defect resulting from surgery is tricky to reconstruct and can cause significant scar. Propranolol is used because of its efficacy and low risk characteristics.

Conclusion

Propranolol is an effective treatment to reduce the need of surgical intervention in problematic hemangioma.

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Hemangioma is the most common tumor in infancy, grows rapidly, slowly regress, and never recur

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Not all hemangioma with ulceration and bleeding are good candidates for surgery due to the large defect it may produce

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Propanolol is an effective alternative treatment before surgery in problematic hemangioma, especially if given during proliferative phase

Floating clavicle after a high velocity biking accident: A case report of an acromioclavicular dislocation with simultaneous proximal clavicle fracture managed surgically

Introduction

Clavicle fractures and acromioclavicular joint dislocations are very common injuries. However, the combination of both, known as “floating clavicle” is extremely rare, with approximately 40 cases reported.

Presentation of case

We report a case of a healthy 51-year-old male who suffered a high-velocity biking accident, with a bipolar clavicle injury (type IV acromioclavicular joint dislocation and proximal clavicle fracture), with concomitant rib fractures and pulmonary contusion. He received early surgical treatment by open reduction and osteosynthesis of the proximal clavicle (distal ulna plate, Protean®) and open reduction and stabilization with a MINAR® implant for the acromioclavicular joint. After an initial one-month immobilization, he started physical therapy. In the 10-month follow-up he presented with a pain-free full range of motion, a good cosmetic result, and radiological consolidation.

Discussion

Bipolar clavicle injury is a rare clinical entity that encompasses a spectrum of combined clavicle fractures, acromioclavicular or sternoclavicular joint dislocations. They are sustained in a high-energy context, and accompanying injuries must be sought. Diagnosis is made through X-Ray and CT. Despite the lack of clinical guidelines, most authors agree on surgical management of at least one of the injuries, with multiple surgical techniques available. There is an emphasis in surgical treatment of the young and active patient. Conservative treatment is associated with poorer results.

Conclusion

It is advisable to have a high index of suspicion for floating clavicle in a high-energy trauma patient, given possible life-threatening injuries, and long-term shoulder sequelae. Surgery should be considered in a young and active patient.

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“Floating clavicle” is a rare injury that should be suspected in a high energy accident.

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Other life-threatening injuries must be ruled out.

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There are no guidelines regarding best treatment.

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Surgical treatment is usually advocated for young and active patients.

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ORIF of sternoclavicular fracture and acromioclavicular joint dislocation yields good results.

Intra-operative enteroscopic polypectomy-An innovative hybrid approach using straight sticks

Background

Peutz-Jeghers Syndrome (PJS) is an uncommon intestinal polyposis disorder. Bowel obstructions are a recurring problem in PJS and as many as 50% of these patients require surgery. The current standard of care for these patients is to perform a flexible enteroscopic polypectomy. The traditional push-pull enteroscopy however, might be unavailable or unsuitable in an emergency setting. Alternatively, repeated laparotomies with multiple small bowel resections can lead to short bowel syndrome.

Methods

In our series, we describe an innovative technique where a short midline laparotomy permitted sufficient access to reduce the intussusception(s) and perform a bowel walk. Rigid laparoscopic instruments were introduced within the small bowel lumen via enterotomies, to perform polypectomies along the entire small bowel length. This precludes the need for small bowel resections which can thwart the development of short bowel syndrome.

Results

Two patients with PJS presenting with acute small bowel obstruction underwent surgery using the described approach. Another two patients with PJS having multiple intussusceptions on CT underwent an elective prophylactic polypectomy using the same approach. We were able to run the bowel in its entirety and a maximum of 41 polyps were retrieved from the port site enterotomy. The operating times were modest and no unique complications pertaining to this technique were encountered.

Conclusion

Small bowel polypectomy using rigid instrumentation employing a limited midline laparotomy is an attractive option for both emergency and elective settings in patients with PJS.

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Bowel obstructions are a recurring problem in PJS.

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Polypectomy using rigid instrumentation serves as an attractive option for patients with PJS, undergoing a laparotomy for acute bowel obstruction.

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This technique can be empolyed in both, elective as well as emergency settings.

Open Reduction on very late-presenting unreduced posterior elbow dislocation: Still promising treatment option

Background

Neglected dislocation of the elbow is associated with instability, pain, and limitation of elbow function. In developing countries, neglected dislocations of the elbow are quite common, and most patients initially go to local bonesetters, which only aggravates the problem.

Presentation of case

Two patients with a history of unreduced posterior elbow dislocation for more than 1 year and were treated by a traditional bonesetter were included in this case study. The first case was a 65-year-old female with a history of injury around her right elbow around 12 months before admission. The patient underwent open reduction with triceps lengthening and immobilization with plaster of paris for 3 weeks. The second case was a 53-year-old male with a history of injury caused by a fall on an outstretched hand around 18 months before admission. The patient underwent arthrolysis followed by triceps lengthening, internal fixation with transarticular k-wire, and immobilization with elbow slab for 3 weeks.

Discussion

To optimize treatment goals and patient function, various surgical approaches have been described for treating chronic elbow dislocations. The benefit of the V—Y triceps lengthening is to simplify the reduction procedure, especially in the elbow dislocations with greater chronicity. The downside of the V—Y lengthening is possible triceps weakness, delayed physiotherapy, and increased postsurgical pain. On the basis of this study, open reduction should remain a treatment option for patients regardless of age and chronicity of injury.

Conclusion

Operative treatment of late-presenting, unreduced elbow dislocation is effective in restoring the joint to a painless, stable, and functional limb.

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Old unreduced posterior dislocation of the elbow is not uncommon in developing countries.

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The posterior elbow approach with V—Y triceps lengthening, arthrofibrolysis, open reduction, and fixation with k-wire is showing a promising outcome.

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Open reduction should remain a treatment option for patients with neglected posterior elbow dislocation, regardless of age and chronicity of injury.

Pathologic femur fractures following surgery and radiotherapy for soft tissue sarcomas: A case series

Introduction

Combined limb-sparing surgery and radiation therapy are considered the standard of care for higher grade soft tissue sarcomas (STS) of the extremities. The risk of post-radiation fracture after this treatment modality is well known, but still underestimated, and can end in serious long-term secondary problems years later.

Presentation of case

We reviewed the records of three patients with pathological femur fractures years after wide local excision of an STS of the proximal lower extremity. All patients received more than 50 Gy (Gy) to the entire femur circumference. During surgery, all patients had bone exposure, and in two patients with stripping of the periosteum. The median time from surgery to fracture was 116 months (range from 84 to 156 months). The median age at the time of diagnosis was 66 years old. Despite standard operative fracture treatment, all three patients developed a non-union. One patient later died due to uncontrolled pulmonary metastasis independent from the femoral non-union. In the second case, an exarticulation at hip level due to an uncontrolled infected non-union had to be performed. The third patient finally achieved fracture union after two years of treatment.

Discussion

Our study confirms the high occurrence rate of postoperative complications and difficulties one encounters in treating these pathologic fractures. Only in one patient, following several revisions with intramedullary nailing, the fracture healed. In pathologic femur shaft fractures we recommend a minimal invasive procedure using intramedullary nailing devices.

Conclusion

The risk of pathological fractures at the former treatment site is high, even years later. The rate of non-unions after a difficult fracture treatment in this particular clinical situation seems to be very high and may be associated with severe complications.

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3 patients with pathological femur fractures after excision of sarcoma are reviewed.

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Risk of post-radiation fracture after this treatment modality is underestimated.

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Despite standard operative fracture treatment, rate of non-unions is very high.

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We recommend a minimal invasive procedure using intramedullary nailing devices.

Temporary Kirschner wire fixation of the first metatarsophalangeal joint before osteotomy for hallux valgus

INTRODUCTION

Numerous operative procedures have been described for correction of hallux valgus, including distal step-cut osteotomy such as the Mitchell osteotomy. However, overcorrection can occur due to technical problems with the initial metatarsal osteotomy. Here, we describe a modified Mitchell osteotomy with a novel method, the temporary Kirschner wire fixation of the first metatarsophalangeal joint (TeKFiM) method (Tonogai method), that can be used before osteotomy for hallux valgus to avoid incongruency and overcorrection.

OPERATIVE TECHNIQUE

A skin incision and Y-shaped capsulotomy are performed and the medial exostosis is excised. Lateral capsule release is done if the first metatarsophalangeal (MTP) joint cannot be reduced manually. Next, a Kirschner wire (K-wire) is inserted subcutaneously through the medial side of the first proximal phalanx to the lateral side of the first metatarsal to preserve the correct congruency of the first MTP joint during surgery. To correct pronation of the distal fragment, step-off transverse cuts are made in the distal fragment, as described by Mitchell, reaching one-second to two-thirds of the transverse diameter of the neck from the plantar medial side. After the osteotomies are completed, the lateral spike of the proximal fragment is flattened. The distal fragment is displaced laterally and slightly plantarward, and the pronation deformity of the distal fragment is corrected by inserting a K-wire to act as a joystick. The osteotomy site is stabilized using two Herbert-type screws. After removal of the K-wire, the operation is completed by closing the medial capsule of the first MTP joint and the skin. A plantar cast is applied for 2 weeks, followed by a special heel brace for 4-6 weeks. Sutures are removed 2 weeks after surgery. Patients are allowed to start weightbearing gradually as tolerated from 2 weeks after surgery.

DISCUSSION

After osteotomy, it is difficult to maintain the correct congruency of the first MTP joint due to instability of the distal fragment. The TeKFiM method (Tonogai method) reliably maintains this congruency during surgery. Also, by using a K-wire as a joystick to fix the joint in correct congruency, the first toe is rotated and pronation is corrected by supinating the distal fragment. The K-wire also serves as a landmark for determining how far the distal fragment is shifted plantarward.

CONCLUSIONS

We have developed a modified Mitchell osteotomy with the novel TeKFiM method (Tonogai method) before osteotomy for hallux valgus to avoid incongruency and overcorrection. This method also provides a landmark to correct pronation and plantarward shifting.

Effective and safe reduction in visceral fat using a formula diet in a short period before highly invasive endoscopic surgery - Case series

Introduction

We retrospectively assessed the efficacy and safety of use of short-term formula diet therapy to achieve preoperative reduction in visceral fat immediately prior to highly invasive endoscopic surgery.

Presentation of case

We reviewed 5 cancer patients who underwent thoracoscopic and/or laparoscopic-assisted esophagectomy or gastrectomy. The cases were those with a BMI ≥30 kg/m² or waist circumference ≥100 cm. Patients replaced one meal out of the three main meals with one or two sachets of formula diet (170–340 kcal). The other two meals were set to 600 kcal. The dietary therapy was implemented approximately 1 month before the operation. Weight loss achieved after dietary therapy ranged from 6.4% to 14.1% (p < 0.01). With the exception of one case, the decrease in visceral fat area ranged from 17.0%–40.7% (p = 0.03). Postoperative complications were anastomotic insufficiency in two cases.

Discussion

Although the decreases of the visceral fat were effectively implemented, the adverse effects on postoperative complications must be examined in the farther study.

Conclusion

It was suggested that use of formula diet to achieve preoperative visceral fat reduction in a short period of time immediately prior to highly invasive endoscopic cancer surgery would be an effective and safe strategy.

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We assessed efficacy of formula diet therapy to highly invasive endoscopic surgery.

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The decrease in visceral fat area ranged from 17.0% to 40.7% (p = 0.03).

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It should be emphasized that there were no more serious life-threatening cardiopulmonary complications.

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Preoperative formula diet therapy may be an effective means to reduce visceral fat.

Malignant pheochromocytoma: A diagnostic and therapeutic dilemma

Introduction

Malignant pheochromocytomas are rare endocrine tumors that develop within chromaffin tissue. The diagnosis of malignancy is based on neoplastic recurrence or the presence of metastasis in organs that lack chromaffin tissue. We report a series of four cases because of their diagnostic and therapeutic particularities.

Presentation of case

we describe four clinical cases of patients with malignant pheochromocytoma whose Menard triad “headache-palpitations-sweating” was present in three out of four patients, the methoxylated derivatives were measured in 4 patients, 3 of which had high values, all of our patients carried out a CT scan which objectified signs of malignancy, MRI was performed on a single patient; presenting with a neoplastic recurrence; looking for a locoregional invasion.

Discussion

Pheochromocytoma (PC) is a rare neuroendocrine tumor derived from the chromaffin cells of the adrenal medulla. Its annual incidence is 2 to 8 per million adults. A peak frequency is observed between 30 and 40 years of age. Approximately 10% of pheochromocytomas are malignant and in 10% of cases, bilateral localization is observed. Criteria for malignancy include the invasion of neighboring organs, a large tumor, the presence of lymphadenopathy on imaging, or fixation on scintigraphy. Surgery for MAP is not always curative. In the case of multiple liver metastases, treatment is based on adrenalectomy, which can be effectively combined with chemoembolization, cryoablation, or radiofrequency techniques.

Conclusion

The main prognostic factors of the malignant pheochromocytomas are a large tumor volume, the existence or number of visceral metastases, and the presence of a mutation in the SDHB (Succinate dehydrogenase B) gene.

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Malignant pheochromocytomas are rare endocrine tumors that develop within chromaffin tissue.

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A very large part of pheochromocytomas are of genetic origin which can be part of hereditary syndromes.

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Criteria for malignancy include the invasion of neighboring organs, a large tumor, the presence of lymphadenopathy on imaging, or fixation on scintigraphy.

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Adequate management of this pathology requires a multidisciplinary consultation meeting

Use of the ligamentum teres hepatis for outflow reconstruction during ex vivo liver resection and autotransplantation in patients with hepatic alveolar echinococcosis: A case series of 24 patients

BACKGROUND

Patients with extensive hepatic alveolar echinococcosis might require ex vivo liver resection and autotransplantation to remove the lesion. Patients with extensive vascular invasion will need reconstruction, but the selection of the proper graft is complicated. This study aimed to investigate the effectiveness and adverse events of using the ligamentum teres hepatis as a vascular replacement graft in ex vivo liver resection and autotransplantation.

METHODS

This was a retrospective case series of patients with hepatic alveolar echinococcosis who underwent ex vivo liver resection and autotransplantation between August 2010 and October 2018 and in whom the ligamentum teres hepatis was used to repair the remnant liver. The operative outcomes, recurrence, and survival were examined.

RESULTS

Twenty-four patients were included (10 men, 14 women). The anhepatic period was 290 to 672 minutes (median of 450 minutes). The ratio of the remnant liver volume to the standard liver volume was 0.43 to 0.97 (median of 0.71). The blood loss was 1,000 (500-5,000) mL. The postoperative hospital stay was 23 (1-85) days. Of the 24 patients, 3 died after the operation, but those deaths were unrelated to liver vascular complications.

CONCLUSION

The ligamentum teres hepatis could be used as a vascular replacement graft in ex vivo liver resection and autotransplantation. It has the advantages of convenient specimen extraction, no donor site injury, and no immunological rejection, which has promising clinical application prospects.

A breakthrough in Maxillary LeFort II fracture reconstruction: Case series of rhinoplasty using diced cartilage fascia graft simultaneously with ORIF

Maxillary Le Fort II fracture reconstruction plays one of the challenging surgery in the field of maxillofacial trauma. The goal of treatment is reduction, reposition, fixation of fractures and restoration of occlusion. However, it is often not enough to bring back the appearance aesthetically. The challenge that we face today is that patients frequently complain about their nose postoperatively, hence, they believe that the deformity still remains. Secondary rhinoplasty post-trauma is often performed to overcome this deformity. We proposed direct rhinoplasty using diced cartilage fascia graft in Maxillary Le Fort II fracture reconstruction to provides better post-op aesthetic appearance. Reporting three cases of Maxillary Le Fort II fractures. All patients had undergone open reduction and internal fixation combined with rhinoplasty using diced cartilage wrapped with fascia. The graft provides a better nasal contour and shape, also camouflage irregularities. There was no clinical signs of graft absorption or infection. The patients were satisfied, and none of the patients complaint about their nose after surgery. Rhinoplasty using diced cartilage fascia graft simultaneously with ORIF is a breakthrough in Maxillary Le Fort II reconstruction. It brings off the incorporation of aesthetic surgery concept into reconstruction, annihilating post-op complaint from patients and preventing secondary rhinoplasty due to previous trauma.

Prevention of cerebrospinal fluid leak after vestibular schwannoma surgery: a case-series focus on mastoid air cells' partition

BACKGROUND

Petrous bone pneumatization may be related to cerebrospinal fluid (CSF) leak secondary to vestibular schwannoma surgery.

OBJECTIVE

To assess the association between petrous bone pneumatization and CSF leak in vestibular schwannoma surgery.

METHODS

A retrospective study included 222 consecutive vestibular schwannoma patients treated via a retrosigmoid or translabyrinthine approach in a 17-year period in one University Hospital. Association of CSF leak and petrous bone pneumatization, as seen on CT scans, was assessed on ANOVA and Student's t or Chi-squared test in case of non-parametric distribution.

RESULTS

One hundred and 75 resections were performed on a retrosigmoid approach and 47 on a translabyrinthine approach. Mean age was 53.6 ± 12.9 years. Mean follow-up was 5 years 6 months. Twenty-six patients (11.7%) showed CSF leak and 8 (3.6%) meningitis. Approach (p = 0.800), gender (p = 0.904), age (p = 0.234), body-mass index (p = 0.462), tumor stage (p = 0.681) and history of schwannoma surgery (p = 0.192) did not increase the risk of CSF leak. This risk was unrelated to mastoid pneumatization (p = 0.266). There was a highly significant correlation between internal acousticus meatus (IAM) posterior wall pneumatization and CSF leak after retrosigmoid surgery (p = 0.008). Eustachian tube packing in the translabyrinthine approach did not decrease risk of CSF leak (p = 0.571).

CONCLUSION

Degree of petrous bone pneumatization was not significantly related to risk of CSF leak, but pneumatization of the posterior IAM wall increased this risk in retrosigmoid surgery. Eustachian tube packing in the translabyrinthine approach is not sufficient to prevent postoperative CSF leak. Both approaches had similar rates of CSF leaks, around 12%.

Vigilance to misleading information is required to avoid delayed diagnosis: Case series of acral melanomas

INTRODUCTION

Melanoma is considered a rare cancer among Asians with a wide range of mucocutaneous manifestations. Failure to recognize a lesion as melanoma at first presentation might delay surgery aimed at complete resection. Acral melanoma has been related with the highest rate of misdiagnosis (~30%) causing further delayed diagnosis. Reliability of patient' history taking in melanoma has not yet been systematically reported.

PRESENTED CASES

Two patients visited our oncology clinic with pigmented lesions in their soles. A 66-year-old man disclosed it appeared since a year ago after accidently hitting a stone while farming. Physical examination showed a black-brown irregular 100 × 80 mm lesion covering the distal third of the right sole with ulceration in the central lesion. The second patient was a geriatric woman with a black-purple 25 × 27 mm lesion with slight protrusion and ulceration in the central, irregular border, and partial hyperkeratosis. She explained the lesion emerged two years ago after she accidently stepped on a nail. Both patients were then diagnosed with acral melanomas and were treated with wide-excision, closure with skin grafting, and inguinal dissection.

DISCUSSION

Both patients reported history of traumas in lesions later confirmed as acral melanomas. Although history taking can provide up to 80% of the information for accurate diagnosis, in ambivalent cases, careful anamnesis, clinical examination, and biopsy are required to confirm diagnosis of acral melanoma. Early disease identification to establish definitive diagnosis of cancer is generally associated with better clinical outcomes. In suspected cases, vigilance toward misleading information in history taking is required.

Rare case report of anorectal malformation and intestinal atresia

Introduction

Intestinal malformations, such as intestinal atresia, malrotation, and anorectal malformation, are rare events, but concurrent intestinal atresia and anorectal malformation are rare in combination. These anomalies have similar in utero and perinatal symptoms, which can make the diagnosis of both defects prenatally challenging.

Presentation of case

We present a case of a male infant with a prenatal diagnosis of truncus arteriosus who on a 32-week routine prenatal ultrasound was suspected to have an intestinal malformation. On day of life one, the patient was taken to the operating room and found to have both type IIIa ileal atresia and anorectal malformation with normal bowel in between. A complete work up for vertebral defects, anorectal malformation, cardiac septal defects, esophageal atresia, renal anomalies, and radial limb defects (VACTERL) anomalies did not reveal additional anomalies.

Discussion

In this case, prenatal information supported intestinal obstruction, and the rare combination of both intestinal atresia and anorectal malformation proved surprising and interesting.

Conclusion

We suggest providers be aware of the potential of multiple alimentary tract malformations to improve operative preparation and reduce the morbidity or mortality risk from repeat procedures when possible.

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The combination of anorectal malformation and intestinal atresia is exceedingly rare.

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This unique combination was found in a twin with the other twin having a normal intestinal tract.

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A VACTERL workup is key to rule out other malformations.

Gluteus maximus transfer and mass graft (Capsulorraphy) in recurrent hip dislocation with the history of total hip replacement: A case series

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Post THR dislocation has been a significant complication.

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Four patients operated by soft tissue procedure of gluteus maximus transfer as an abductor replacement and along with capsule augmentation using synthetic mesh as a synthetic capsule to strengthen and provide more stability.

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The use of mesh in soft tissue procedures, such as capsulorraphy, with the addition gluteus maximus transfer may assist to prevent (re)dislocations of the hip.

Introduction

Post THR dislocation has been a significant complication that interferes with the patient’s life. Detection of risk factors, careful planning, proper operative procedures, and patient education is essential to prevent the incidence of dislocation. Several operative measures have been studied to achieve this, including the use of mesh for soft tissue procedures and capsulorraphy.

Case Presentation

A total of four patients is included in this case series. Two had a history of trauma that contributes to the necessity of the procedure while the other two had degenerative joint issues. All were operated by soft tissue procedure of gluteus maximus transfer as an abductor replacement and along with capsule augmentation using synthetic mesh as a synthetic capsule to strengthen and provide more stability.

Discussion

The abductor strength from this gluteus maximus procedure is sufficient to stabilize the pelvis and prevent pelvic sag. The primary material of the mesh should produce inflammatory reaction so that a fibro capsular structure is formed surrounding the hip joint to add stability.

Conclusion

The use of mesh in soft tissue procedures, such as capsulorraphy, with the addition gluteus maximus transfer may assist to prevent (re)dislocations of the hip. However, further study should be conducted to validate the routine use of mesh and gluteus maximus transfer to prevent dislocation after the procedure.

Zaragoza technique of laparoscopic appendicectomy

Introduction

Appendectomy is one of the most frequent emergency surgical procedures, currently with a preference for laparoscopic management worldwide.

Objective

To report a new laparoscopic appendectomy technique and its results.

Material and methods

Cohort study of patients with a diagnosis of appendicitis who are managed laparoscopically. In a total 1063 patients, 148 were operated on with the Zaragoza technique during the period from January 2002 to December 2018. The technique consists of making a window in the appendicular base between the meso and the appendicular wall, two prolene or silk sutures are placed, and the cecal appendix is cut between the two sutures, finally the mesoappendix is sectioned with a harmonic scalpel or bipolar clamp.

Results

From our results, we had 1.4% residual abscesses, 1.4% umbilical surgical wound infection and 0% mortality.

Discussion

Various laparoscopic management methods for appendectomy are reported in the literature, with a wide range in the results. We have obtained good results in patients subjected to our technique.

Conclusions

The Zaragoza technique for laparoscopic appendectomy is an effective and safe option that prevents excessive manipulation of the inflamed appendix and is easily reproducible.

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Acute appendicitis is one of the most common problems in daily practice.

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Our technique is a safe method.

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It is a reproducible and economical technique.

The lateral curved osteotomy for cubitus varus deformity in children: A case report and literature review

Introduction

Cubitus varus deformity after malunited supracondylar humerus fracture has various surgical techniques, implant configurations, and approaches. We describe a combination of French and Dome osteotomy and novel internal fixation technique to deliver an easy, safe, fast and reproducible result based on the current best evidence.

Presentation of case

Two cases of malunited supracondylar humerus are described. The first case involves a 3-year-old girl who presented with outstretched and supinated left arm after falling during bike riding 3 weeks earlier. We found no abnormality in radial and median nerve function, but the left arm radiographs showed a callus formation and the early stages of a malunited fracture of the supracondylar humerus. We waited two months for further radiographic evaluation and the radiographs showed the malunited supracondylar humerus with elbow flexion of only 105° and elbow hyperextension of 20°. The cubitus varus was recorded with clinical carrying angle of varus 10°. We used a combination of original French and Dome osteotomy, lateral approach, and our novel fixation technique with excellent results. The second case involved a 8-year-old boy with malunited right elbow and the surgery was done in the same manner, with the result of restoration to normal elbow range of motion. We also assessed the pain score and disabilities of the arm, shoulder and hand (DASH) score and recorded satisfactory results.

Conclusions

The combination of French and Dome osteotomy for treatment of cubitus varus deformity can provide an easy, safe, and reproducible result.

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Cubitus varus deformity.

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Malunited supracondylar humerus.

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French osteotomy.

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Dome osteotomy.

Cardiovascular injuries during COVID-19 infection: A PROCESS-compliant case series from the Eastern Morocco

Background

To date, more than 105,805,951 cases of COVID-19 have been diagnosed including 2,312,278 deaths. Many patients have cardiovascular risk-factors and/or co-morbidities and a lot of them developed de novo heart conditions during the active or the post-infectious phase of the infection. A number of studies tried to demonstrate an association between poor prognostic outcomes and cardiovascular comorbidities and related damages, but the quality of current evidence is still weak.

Patients and methods

The aim of this single-center report is to describe the prevalence of cardiac injuries among our COVID-19 patients, to explore their association with survival outcomes and to demonstrate the medical care provided in our real-world setting. Our study included 610 COVID-19 patients admitted to the intensive care unit of our university hospital of whom13.77% (n = 84) presented cardiovascular injuries and which we included in this case series.

Results

The average age of our patients was 65 years (27–90). 60 were men (71.42%) while 24 were women (28.55%). Their average BMI was 29.7 kg/m². Among them, 50 had a pulmonary embolism (59.52%), 12 patients had a myocardial infarction (14.28%), 10 presented pericarditis (11.9%) and 3 developed myocarditis (3.57%). There were 6 cases of ischemia (7.14%), 2 cases of stroke (2.38%), and 1 case of decompensated heart failure (1.19%). Among our patients, 46.42% had diabetes, 32.14% had a high blood pressure, 13.09% had a chronic renal failure and 14.28% had a history of ischemic heart disease. 14 patients (16.66%) had an elevated troponin with higher levels than 1000 ng/mL. The D-dimer value was high in almost all patients (80.95%). Lung damage from COVID-19 was extensive in 27.38%, severe in 32.14%, and critical in 40.47% of enrolled cases. CT chest angiography, ECG, and cardiac ultrasound were performed to the paraclinical confirmatory exploration of cardiac damages of these patients. Medical care was based on isolation, azithromycin, vitamin C, zinc, vitamin D, salicylic acid, dexamethasone followed with methylprednisolone, and anticoagulation for all hospitalized patients. Tocilizumab was indicated for 17 patients with hyperferritinemia (20.23% of patients). The initial respiratory care of our patients required oxygen therapy using nasal cannula (7.14%) high concentration masks (33.33%), high flow nasal cannula treatment (11.9%), non-invasive ventilation (NIV) (5.95%), and mechanical ventilation (41.66%). Thrombolysis was performed in three subjects with myocardial infarction and 2 underwent angioplasty with placement of an active stent at the proximal interventricular anterior artery, which all were successful. Three massive pulmonary embolisms died despite adequate treatment. Colchicine and salicylic acid were administered for pericarditis cases. Thromboprophylaxis was indicated for all patients and was reinforced if a venous thrombotic episode was confirmed. Patients with limb ischemia underwent surgical treatment. Among the 84 patients included in our cohort, 34 (40.47%) died in intensive care unit and 50 (59.52%) had a favorable evolution.

Conclusion

Cardiovascular involvement during COVID-19 should not be neglected and are associated with severe outcomes.

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Several studies have demonstrated an association between poor prognostic outcomes and cardiovascular comorbidities in COVID-19.

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The cardiovascular events in our case series confirmed these findings.

•

Cardiovascular involvement during COVID-19 should not be neglected as it is associated with severe outcomes.

Intracranial Angioplasty with Enterprise Stent for Intracranial Atherosclerotic Stenosis: A Single-Center Experience and a Systematic Review

Background

The high rate of periprocedural complications for the endovascular stent procedure in the Stenting Versus Aggressive Medical Management Therapy for Intracranial Arterial Stenosis (SAMMPRIS) trial resulted in it being less recommended than medical therapy to treat intracranial atherosclerotic stenosis (ICAS). Because Enterprise stent use might reduce the incidence of complications in ICAS treatment compared to other frequently used stents, this paper evaluated the safety and effectiveness of the Enterprise stent for the treatment of ICAS.

Methods

We performed a comprehensive literature search for reports on intracranial angioplasty using the Enterprise stent for ICAS treatment from the earliest date available from each database to May 2020 for PubMed, EMBASE, Web of Science, Cochrane, and Clinical Trials databases. We also reviewed the single-center experience of the First Affiliated Hospital of Harbin Medical University. We extracted information regarding periprocedural complications, procedure-related morbidity, mortality, immediate angiographic outcome, and long-term clinical and angiographic outcomes, among others. Event rates were pooled across studies using random-effects or fixed-effects models depending on the heterogeneity.

Results

Five hundred fifty-seven patients with 588 lesions from seven studies, including the institutional series, were included in the analysis. The incidence of stroke or death within 30 days was 7.4% (95% confidence interval (CI), 5.5%-10.1%). The incidence of ischemic stroke or TIA in the territory of the qualifying artery beyond 30 days and during follow-up was 3.2% (95% CI, 1.1%-9.5%). The incidence of in-stent restenosis was 10.1% (95% CI, 4.6%-22.2%), and the incidence of symptomatic restenosis was 4.1% (95% CI, 1.7%-9.9%).

Conclusions

Intracranial angioplasty utilizing the Enterprise stent for ICAS treatment was relatively safe and effective but required further verification using additional sources for evidence.

Modified Mitchell technique for treating hallux valgus: Retrospective case series on a Middle-Eastern population and literature review

Introduction

The hallux valgus deformity is a complex deformity of the first ray of the foot, with more than 100 procedures developed for its treatment. The aim of this retrospective study was to assess the clinical and radiographic outcomes of a modified Mitchell's technique.

Methods

Between 2007 and 2018, 75 patients underwent the procedure. Clinical results were assessed by the AOFAS score. Radiological studies were evaluated by measuring pre-operative and post-operative HVA and IMA angles as well as the relative shortening of the first metatarsal.

Results

Of the initial 75 patients, 42 patients remained eligible with a total of 67 feet. The mean age and follow-up were 47.8 and 5.2 years respectively. Global AOFAS score improved from 45.3 to 88.8 (p < 0.01). Mean HVA and IMA improved from 37.0 to 10.2 (p < 0,01) and 12.1 to 5.6 (p < 0.01), respectively. The mean metatarsal shortening was 3.0 mm (p < 0.01). The statistical analysis showed no significant correlation between preoperative HVA and IMA angles with postoperative shortening, metatarsalgia, AOFAS scores nor the difference between the preoperative and postoperative AOFAS scores.

Conclusion

Short- and long-term outcomes of this modified Mitchell's osteotomy have been reported. Compared to other studies, these modifications proved to result in very good clinical and radiological outcomes even in severe cases with HVA>40. It has shown to be reliable, reproducible, and cost-efficient with low complication rates. We would like to highlight the importance of proper patient selection, limited soft tissue stripping, and adherence to the proposed surgical steps to avoid unwanted complications.

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The Modified Mitchell Technique has been shown to be reliable, reproducible, and cost-efficient with low complication rates.

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The addition of intra-articular lateral soft tissue release, preventing a lateral incision, decreasing wound and soft tissue complications.

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The use of autologous bone graft adjacent to the osteotomy stump helps improve union.

Fertility preservation in women with peritoneal surface malignancies: A case series

The advent of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has improved survival in patients with peritoneal surface malignancies. Not surprisingly, there is now a growing interest on the possible means to preserve fertility to ensure future childbearing. In this study, we report on five women with peritoneal surface malignancies who performed ovarian hyper-stimulation and oocytes cryostorage prior to undergo CRS and HIPEC. The presence of the disease complicated follicular growth monitoring but the oocytes retrievals could be always performed and were uneventful. At last follow-up, all women were alive and disease-free. None has yet returned to thaw her oocytes. Overall, these cases suggest that oocytes cryopreservation before CRS and HIPEC should be considered.

Catastrophic wear in uncemented acetabular cups after Total Hip Arthroplasty. A case series

INTRODUCTION

Catastrophic wear is a rare outcome following Total Hip Arthroplasty (THA), documented to happen in less than 0.5% of THA. We present 5 cases of revision THA performed successfully on 5 patients presenting Catastrophic wear, following Total Hip Arthroplasty (THA). Specifically, Catastrophic wear cases were selected, emphasizing differential diagnosis, and a revision THA was performed in all of them and resulted in a good long-term outcome. The purpose of this case series is to contribute to the literature in evaluating both the causes of implant failure as well as the outcomes after their revisions.

METHODS

We evaluated 5 patients that presented Catastrophic rupture of acetabular implants in a 3-week period in our prosthesis center.

RESULTS

The 5 patients were females, the mean age was 56 years (44-65), the mean post-surgery time was 20 years (17-23), 4/5 of the coupling wear was ceramic-polyethylene and only one case was metal-polyethylene; 4/5 had bilateral total hip replacement. In the 5 cases a revision THA was performed, all with a successful outcome.

CONCLUSION

Catastrophic failure is an unusual entity; however, when a patient with a prosthesis presents with sudden pain, an immediate image study is indicated, with careful attention to the differential diagnosis, so as to accurately advice receiving a revision THA. The main causes of implant failure are implant duration, volumetric wear and subsequent rupture. Patients with Catastrophic wear and implant rupture, treated with a revision THA, usually have a good long-term outcome.

Cervical elongation caused by big cervical fibroid resembling malignant cervical prolapse? Management via vaginal surgery

INTRODUCTION

Cervical elongation could lead to cervical elongation thus worsen the descent of uterine prolapse. In certain cases, this hypertrophic and hyperplastic mass could have fragile surface with some bleeding and necrotic, resembling cervical cancer. As case of cervical elongation due to cervical fibroid is quite rare, such cases are valuable to be reported. We present two cases of cervical fibroid with cervical elongation resembling cervical malignancy.

PRESENTATION OF CASE

First case was A 59-year-old lady with intractable vaginal mass since one day before admission. Bleeding from the mass was positive. We found a bulky vaginal mass exceeding hymenal ring, 14 × 7 × 6 cm sized, with some necrotic and discharge, foul smelling, and some bleeding area. Ultrasound evaluation revealed a cervical fibroid with differential diagnosis cervical malignancy. The second case was Mrs 53-year-old with vaginal mass since last year. For the last 7 months the mass has been bigger and could not be inserted into vagina, with some bleeding. We found globular vaginal mass 12 × 9 × 6 cm exceeding hymenal ring, with some necrotic and reddish surface, foul smelling, discharge, and some blood. Ultrasound evaluation revealed cervical mass on anterior lip with elongated cervices. Both cases have been menopaused. As the clinical presentation resembling malignancy, we did biopsy. The biopsy results were no evidence of malignancy, then we did Manchester fothergill, and colporaphy as needed.

DISCUSSION

Length between internal to external cervical ostium ≥ 5 cm correlated to cervical elongation. Growing cervical mass could drag the cervix, predisposing to cervical elongation and prolapse. Cervical fibroids protruded through vagina was usually pedunculated. But in our cases, the fibroids were not pedunculated but manifested as a bulky mass on the cervical tissue with some bleeding and necrotics, mimicking cervical malignancy. The most important initial management besides ultrasound evaluation was mass biopsy.

CONCLUSION

In such cervical fibroids with cervical elongation resembling cervical malignancy, biopsy is compulsory to determine the diagnosis and to lead the management.

Double posterior lateral plating arthrodesis for charcot ankle: A case series

Introduction

Ankle arthrodesis is one of the managements for a significantly unstable Charcot ankle. Some of the methods of internal fixation for ankle arthrodesis include the use of intramedullary nails, screws, and plates. Ankle arthrodesis using intramedullary nails has become more popular. However, studies evaluating the use of plate fixation, particularly double posterior lateral plating, are limited. We report the clinical and radiological outcomes of double posterior lateral plating ankle arthrodesis in three diabetic Charcot ankle patients.

Presentation of case

Three patients, aged 73, 67, and 65 years old, complained of ankle pain and with a history of type 2 diabetes mellitus. The physical examination revealed swelling and erythema without a sign of active infection. The radiological examination showed ankle deformity, and the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot scores were 5, 10, and 0, respectively. All patients were diagnosed with a diabetic Charcot ankle and underwent ankle arthrodesis using double posterior lateral plating. Four months and six months follow up revealed talus union, improved ankle deformity, and improved AOFAS Ankle-Hindfoot scores to 70, 76, and 73, respectively.

Discussion

Various methods of ankle arthrodesis are retrograde intramedullary nails, screws, and plates. In this report, we opt for plate fixation because it allows for stable internal fixation, adequate compression, high angular stability, and a lower irreversible deformation in osteoporotic bone.

Conclusion

Double posterior lateral plating ankle arthrodesis provided satisfactory clinical and radiological outcomes. This method can be an alternative for patients with Charcot ankle requiring ankle arthrodesis.

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Double posterior lateral plating ankle arthrodesis is satisfactory.

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This method can be an alternative for patients with Charcot ankle.

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Plate fixation allows stable internal fixation and adequate compression.

Pneumatosis cystoides intestinalis with pneumoperitoneum secondary to stenosing pyloro-duodenal peptic ulcer: Case series of three patients and literature review

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Pneumatosis cystoides intestinalis (PCI) is a rare condition which can be associated to pneumoperitoneum without gastro-intestinal perforation.

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PCI is most often secondary to various diseases and the stenosing peptic ulcer is one of them.

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Careful correlation of the clinical presentation with corroborating biological tests should determine whether a conservative medical approach or emergency surgical exploration is appropriate.

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Knowledge of this pathology is important to avoid unnecessary exploratory laparotomy.

Introduction

Pneumatosis cystoides intestinalis (PCI) is a rare condition, which can affect the entire gastro-intestinal tract. It can be idiopathic or most often secondary to various diseases. The causes remain multiple and the stenosing peptic ulcer is one of them. We report three case reports of pneumatosis cystoides with pneumoperitoneum intestinalis secondary to stenosing pyloro-duodenal peptic ulcer.

Case presentation

We report a case series of three patients with PCI that presented to the emergency department with a reassuring clinical picture with the discovery in imaging of a pneumoperitoneum. All our patients presented with a pyloro-duodenal stenosis secondary to a complicated peptic ulcer, one of which was treated surgically and the other two endoscopically.

Discussion

The objective of this report is to provide an update on pneumatosis cystoides intestinalis secondary to stenosing pyloro-duodenal peptic ulcer, by specifying its etiopathogenic, diagnostic and therapeutic characteristics.

Conclusion

Knowledge of this pathology is necessary in order to avoid unnecessary abusive surgery.

The role of angioembolization and C-clamp fixation: Damaged control orthopaedic in haemodynamically unstable pelvic fracture

INTRODUCTION

Unstable pelvic fracture may emerge to major bleeding complication. Angioembolization is one of method to stop the bleeding effectively. This case series aims to analyze whether the bleeding of unstable pelvic fracture is managed by angioembolization to achieve the better functional outcome.

PRESENTATION OF CASE

Three cases of haemodynamically unstable pelvic fracture were studied retrospectively and prospectively. A staged approach using damage control orthopaedic surgery was performed. Initial resuscitation began from fluid resuscitation, pelvic wrapping using binder. All patients followed with pelvic external fixation, while 2 patients immediately replaced binder to C-Clamp, and 1 patient with anterior frame. Angioembolization was done to all patients. All patients required definitive internal fixation, while only 2 patients reach the definitive surgery. Finally, we measured the functional outcome of all patients using Hannover Pelvic score, Majeed pelvic score, and Iowa Pelvic score.

DISCUSSION

We review some literatures regarding pelvic angioembolization. The previous study suggested to resuscitate patients when the hemodynamic is unstable, the angioembolization procedure is still preferred. The indication and successful definition of this procedure is still unclear, yet it shows decrease of mortality rate of pelvic injury if this procedure starts ahead a schedule.

CONCLUSION

Angioembolization as a part of damaged control orthopaedic has been shown a favorable result in managing unstable pelvic injury.

Penile strangulation injury by metallic ring: A study of 4 cases

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Penila strangulation required emergency management to preserve the organ function.

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Each case managed individually according to its clinical finding and operative settings.

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Management depends on the type and size of constricting object, time after incarceration, degree of injury, available instrument, and experience of the physicians.

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Different methods and tools may arise due to circumstance and individual cases differences.

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Surprisingly, there is no erection problem after removing the strangulation.

Penile strangulation by metallic ring is an emergency situation which requires urgent management. Strangulation of the penis usually performed in order to increase sexual performance or because underlying mental disorder or paraphilia. It is an uncommon urological emergency, if not treated as soon as possible it can lead to complications such as gangrene and amputation of the penis. There is no standard of care that has been found to be superior, with each case managed individually according to its clinical findings and operative settings. In this study, we present four cases of penile strangulation in last two years in a tertiary care hospital.