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

Breast abscess in two Nepalese newborns: An unusual series

Background

Breast abscess in newborns is an exceedingly rare pyogenic inflammation that usually starts as mastitis neonatorum. Although mastitis can respond to antibiotic therapy in the initial stages, once advanced into a purulent collection, decompression may be indicated either in the form of needle aspiration or even surgical drainage. We present two newborns with breast abscesses managed surgically with successful outcomes.

Case presentation

Case 1: A 13-day-old boy presented with swelling and redness over the left breast for a day. Local examination revealed a warm, indurated swelling with redness and fluctuation. Needle aspiration confirmed pus. Intravenous (IV) antibiotics were started right away followed by pus drainage, the culture of which yielded Methicillin-Sensitive Staphylococcus aureus (MSSA). Regular wound care subsequently resulted in complete recovery.

Case 2: A 15-day-old boy presented with swelling, redness and milky discharge from the right breast for two days. The swelling was erythematous, tender and indurated but not cystic or fluctuant. Ultrasonogram was suggestive of an abscess. Once again, IV antibiotics were administered followed by drainage. Pus yielded MSSA. Following regular wound dressings, satisfactory healing was achieved.

Conclusion

Neonatal mastitis and breast abscess are uncommon. Early recognition followed by appropriate antibiotic therapy and drainage of the abscess is the mainstay of treatment.

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Neonatal mastitis and breast abscess are fairly uncommon.

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Breast abscess, an exceedingly rare pyogenic inflammation, starts as mastitis neonatorum.

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Clinical improvement is aided by adequate antibiotic coverage and needle aspiration or surgical drainage of pus.

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Prompt recognition and management are paramount to avoid complications.

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Newborns with breast abscesses are managed surgically with successful outcomes.

Inguinal single-port approach of endoscopic component separation for abdominal wall defects: A case series

Background

The component separation (CS) technique is widely used for abdominal wall defects, particularly in infected wounds. CS is associated with many wound complications due to subcutaneous blood flow disturbance. Endoscopic component separation (ECS) has fewer wound complications compared to CS and has been performed recently. However, there are various port required placements for ECS, and this technique requires proficiency. One approach for ECS is the inguinal single-port approach, which can be performed from an inguinal incision similar to that used in open surgery for inguinal hernias.

Case presentation

We performed ECS with an inguinal single-port approach in three older adults. All patients had abdominal wall defects with infection at the central abdominal wound site. A 2–3-cm incision was created in the middle of the inguinal ligament, and a single-port surgical device with two 5-mm trocars was placed in the incision. The external oblique muscle was separated from the internal oblique muscle, and the external oblique aponeurosis was released. The muscle flap of the abdominal wall was moved to the central line. Tension-free abdominal wall closure was possible using a one-handed approach.

Conclusions

ECS, which has fewer wound complications, requires proficiency. This procedure is a simple and easy-to-perform procedure using an inguinal incision that surgeons are familiar with.

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Component separation is associated with wound complications.

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Endoscopic component separation has fewer complications, but is not easy to approach.

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Inguinal single port approach for endoscopic component separation technique is easy.

Renal primitive neuroectodermal tumor. The first case series from Syria

Primitive neuroectodermal tumor (PNET) mainly arises from soft tissues of the extremities such as humerus, femur, C tibia. It rarely arises from kidney; less than 200 cases have been reported in the literature. The clinical presentation and radiography findings are not specific. Here we first report two cases of renal primitive neuroectodermal tumor in Syria.

the first patient was 26-year-old- female that presented to urology clinic complaining of right flank pain. Ultrasonography of the abdomen showed a large mixed heterogeneous mass in the right kidney with no hemorrhage or calcification and MSCT of abdomen and pelvis demonstrate a mixed well-demarcated heterogeneous mass measuring (74*117) mm in the right kidney right radical nephrectomy was performed.

The second patient 19-year-old-male presented with left flank pain. Ultrasonography of the abdomen showed mixed large mass involving the left kidney, with unmarked border. The CT of the abdomen and pelvis demonstrating a (30*110*90) mm left renal mass and periaortic lymphadenopathy measuring (45*28) mm. The patient underwent Left radical nephrectomy with periaortic lymphadenectomy dissection. The final diagnosis for both cases was Renal PNET based on microscopic and immunohistochemistry examination.

In patient with suspected renal mass in the radiographic images, the diagnosis of renal primitive neuroectodermal tumor should be kept in the mind despite its rarity. The final diagnosis is done by histopathological study in association with immunohistochemical examination.

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Here we will first report two cases of renal PNET in Syria.

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The diagnosis of renal primitive neuroectodermal tumor should be kept in the mind despite its rarity.

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The final diagnosis is done by histopathological study in association with immunohistochemical examination.

Impact of the COVID-19 pandemic on digestive cancer staging, a case series

Introduction

Method

Results

Conclusion

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This is study assesses the impact of The COVID-19 pandemic on the diagnosis delay in digestive cancers and its impact on their staging.

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A three-year study that includes 165 patients, 1 year before the COVID-19 pandemic and two years during.

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The pandemic had a statistically significant impact on the staging of the tumor but no impact on the short-term outcome of the patients.

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The first study of its kind in Morocco.

Calcaneal lengthening osteotomy in the management of idiopathic flatfoot in children: cCase series of twenty-one feet

Introduction

Flatfoot is a frequent reason for consultation in pediatric orthopedics. The calcaneal lengthening osteotomy according to the EVANS technique is a therapeutic alternative. The objective of this work was to evaluate the short and medium term clinical and radiological results of calcaneal lengthening osteotomy in children with idiopathic flat foot valgus.

Methods

This study concerned 12 children and 15 ft treated surgically by calcaneal lengthening osteotomy by an orthopedic surgeon in a pediatric orthopedic surgery center. The evaluation of the results was clinical according AOFAS score and radiological.

Results

The deformity was reducible in all of our patients. The mean preoperative AOFAS score was 61, postoperatively 90. The overall result was excellent in 11 cases (11 ft) and good in 4 cases. The postoperative radiological result was close to normal values.

Conclusion

Calcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot.

Level of evidence: IV, Case series.

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Flatfoot is a frequent reason for consultation in pediatric orthopedics.

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Orthopedic management was recommended up to 9 years old.

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Knowing how to choose the feet to be operated on is important.

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Calcaneal lengthening osteotomy is a reliable and recommended technique for the correction of symptomatic idiopathic flatfoot.

Disorders of sex development (DSD) 46.XY due to type 2 5-α reductase deficiency in three siblings: Case report from a low-resource setting

Introduction and Importance

Disorders of Sexual Development (DSD) is a rare autosomal recessive genetic condition significantly affecting patients' lives in various aspects, particularly psychosocially. Type 2 5-α reductase is a cause of DSD 46,XY. It is rare to find multiple DSDs in the same family. Patients may present with amenorrhea and ambiguous genitalia. This case report is aimed to highlight the genetic aspects of the disease, the challenges to diagnostics and the various management options for the patients.

Methods

Case series of three siblings with DSD 46, XY with relevant discussion.

Outcomes

Three sisters, aged nineteen, seventeen, and fifteen years old came with an identical complaint of late menarche. Their physical examinations revealed elementary breast development and little axillary hair. The external genitals consisted of vulva, major and minor labia. Clitoromegaly was present with short (<5 cm) vagina. No female internal genital was found but undescended testes were palpable. Presences of testes was confirmed via ultrasound. Laboratory results showed reduced estradiol, highly increased follicle stimulating hormone (FSH), normal male testosterone levels and increased testosterone-dihydrotestosterone ratio (T/DHT >20). Karyotype was 46,XY. Diagnoses of DSD 46, XY due to type 2 5-α reductase deficiency were established. Patient 1 chose female as the gender of choice whilst patients 2 and 3 chose male. All patients are due for corrective surgery along with psychotherapy and psychoeducation.

Conclusion

DSD 46, XY due to type 2 5-α reductase deficiency is a rare autosomal recessive genetic disorder requiring comprehensive diagnostics and holistic management to improve patient quality of life.

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Disorder of sexual development (46,XY) due to type 2 5-α reductase deficiency is rare.

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It requires a multidisciplinary team involving a battery of tests, imaging and genetic tests, e.g. karyotyping.

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Informed consent and collaboration with other disciplines are pivotal for holistic management.

The role of acupuncture in pain and swelling control for postoperative tibial fracture treatment

Background

Currently, intramedullary nailing for tibial fractures has very good postoperative treatment results. Combining the advantages of traditional medicine and modern medicine is a comprehensive treatment method that brings the best benefits to the patient.

Methods

The study method was a controlled clinical trial. The study included 60 patients with a definitive diagnosis of tibial fracture who underwent intramedullary nailing surgery. These patients were divided into 2 groups: with and without electroacupuncture treatment.

Results

Electro-acupuncture had a significant analgesic effect in 24–48 h after surgery: After 24 h or electro-acupuncture, the pain difference in the study group and the control groups was 3.03 ± 1.25 and 2.46 ± 1.33, respectively (p < 0.05). The VAS score difference between day 1 and day 2 in the study group and the control group was 0.61 ± 0.71 and 0.59 ± 0.67, respectively (p < 0.05). At 48 h postoperatively, the circumference of the calf on the fractured side in the study group and the control group was 36.1 ± 2.1 and 37.3 ± 2.2 cm, respectively (p < 0.05). At 72 h postoperatively, the circumference of the calf in the study group and the control group was 35.9 ± 2.6 and 37.6 ± 2.8 cm, respectively (p < 0.05). The effect of electro-acupuncture on bone healing did not differ between the study group and the control group (p > 0.05). During 7 days of using the treatment regimen, there were 3.3 % of patients with dizziness, 3.3 % of patients with vomiting/nausea, 3.3 % of patients with bleeding at the injection site. There was no difference in blood pressure, pulse rate, hematological indexes and biochemical indexes of patients before and after using the treatment regimen.

Conclusion

Electro-acupuncture has a significant analgesic effect 24 h–48 h after surgery. The effect of electroacupuncture on bone healing was not different between the two groups. Electroacupuncture is a safe, effective method with few side effects.

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Combining the advantages of traditional medicine and modern medicine is a comprehensive treatment method that brings the best benefits to the patient.

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This study was conducted to evaluate the effect of supporting pain relief and bone healing of electroacupuncture on patients after intramedullary nailing for tibial fractures, and to monitor the undesirable effects of the treatment regimen.

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Sixty patients with tibial fracture undergoing intramedullary nailing surgery were divided into 2 groups, with and without postoperative acupuncture treatment.

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Electro-acupuncture has a significant analgesic effect in 24-48 hours after surgery. The effect of electroacupuncture on bone healing was not different between the two groups.

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Electro-acupuncture is a safe, effective method with few side effects.

Use of Spinal Anesthesia in Lower Thoracic Spine Surgery: A Case Series

BACKGROUND

Spinal anesthesia is a safe and effective alternative to general anesthesia for patients undergoing lumbar spine surgery, and numerous reports have demonstrated its advantages. To the best of our knowledge, no group has specifically reported on the use of spinal anesthesia in thoracic-level spine surgeries because there is a hypothetical risk of injuring the conus medullaris at these levels. With the advantages of spinal anesthesia and the desire for many elderly patients to avoid general anesthesia, our group has uniquely explored the use of this modality on select patients with thoracic pathology requiring surgical intervention.

OBJECTIVE

To investigate the feasibility of performing thoracic-level spinal surgeries under spinal anesthesia and report our experience with 3 patients.

METHODS

A retrospective chart review of medical records was undertaken, involving clinical notes, operative notes, and anesthesia records.

RESULTS

Three spinal stenosis patients underwent thoracic laminectomy under spinal anesthesia. Two surgeries were performed at the T11-T12 level and 1 at the T12-L1 level. The average age was 82 years, average American Society of Anesthesiologists score was 3.3, and 1 identified as female. Two cases used hyperbaric 0.75% bupivacaine dissolved in dextrose, and 1 used isobaric 0.5% bupivacaine dissolved in water.

CONCLUSION

Spinal anesthesia is feasible for thoracic-level spine procedures, even in elderly patients with comorbidities. We describe our cases and technique for safely achieving a thoracic level of analgesia, as well as discuss recommendations, adverse events, and considerations for the use of spinal anesthesia during lower thoracic-level spine operations.

Surgical Site Infection in the Intensive Care Setting After Posterior Spinal Fusion: A Case Series Highlighting the Microbial Profile, Risk Factors, and the Importance of Comorbid Disease Burden

BACKGROUND

Most posterior spinal fusion (PSF) patients do not require admission to an intensive care unit (ICU), and those who do may represent an underinvestigated, high-risk subpopulation.

OBJECTIVE

To identify the microbial profile of and risk factors for surgical site infection (SSI) in PSF patients admitted to the ICU postoperatively.

METHODS

We examined 3965 consecutive PSF patients treated at our institution between 2000 and 2015 and collected demographic, clinical, and procedural data. Comorbid disease burden was quantified using the Charlson Comorbidity Index (CCI). We performed multivariable logistic regression to identify risk factors for SSI, readmission, and reoperation.

RESULTS

Anemia, more levels fused, cervical surgery, and cerebrospinal fluid leak were positively associated with ICU admission, and minimally invasive surgery was negatively associated. The median time to infection was equivalent for ICU patients and non-ICU patients, and microbial culture results were similar between groups. Higher CCI and undergoing a staged procedure were associated with readmission, reoperation, and SSI. When stratified by CCI into quintiles, SSI rates show a strong linear correlation with CCI ( P = .0171, R = 0.941), with a 3-fold higher odds of SSI in the highest risk group than the lowest (odds ratio = 3.15 [1.19, 8.07], P = .032).

CONCLUSION

Procedural characteristics drive the decision to admit to the ICU postoperatively. Patients admitted to the ICU have higher rates of SSI but no difference in the timing of or microorganisms that lead to those infections. Comorbid disease burden drives SSI in this population, with a 3-fold greater odds of SSI for high-risk patients than low-risk patients.

Epidemiology, incidence and treatment of rectal cancer in young women case serie about 11 cases (case series)

Introduction

Rectal cancer constitutes, by its frequency and its gravity, a real concern of the public health in the world, it represents the eighth most frequent cancer. Its incidence is increasing in young people and in particular in women, in whom it remains a rare disease known for its poor prognosis.

The objective of our work is to highlight the epidemiological characteristics of rectal cancer in patients under 40 years of age, determine its incidence and outline the different therapeutic means.

Materials and methods

Our work is a retrospective study with a descriptive aim on a series of 11 female patients aged less than 40 years, operated for rectal cancer in the department of digestive cancer surgery and liver transplantation Casablanca Morocco, over a period of 7 years from January 2013 to December 2019.

Results

The average age of our patients was 34.8 years. The average diagnostic delay was 10 months. The most frequent clinical sign was rectorrhagia (90.9% of cases). On rectal examination, the tumor was inaccessible in 18.8% of cases and externalized in 9.09% of cases. It was located in the lower rectum in 36.36% of cases, the same for the middle rectum. Rectoscopy showed that the majority of tumors were circumferential (36.36%). The budding ulcerative aspect was the most frequently found with 7 cases or 63.63%. The histological study showed the predominance of lieberkühnian adenocarcinoma (63.63%). Thoracic-abdominal-pelvic CT scan showed liver metastases in only one patient (9.09%). Pelvic MRI showed invasion of the mesorectum in 5 cases (45.45%) and of the internal sphincter in 3 cases (27.27%). All our patients underwent laparotomy. Curative surgery was performed in 8 patients and 3 patients had palliative surgery. Preoperative radiotherapy was performed in 81.81% of cases. The evolution was marked by 27.27% of locoregional recurrences. The operative mortality was nil in our series.

Conclusion

Detection of patients with precancerous conditions, screening for cancer in subjects at risk (familial recto-colic cancer, familial recto-colonic polyposis and ulcerative colitis), suspicion of cancer in the presence of any proctological sign, early diagnosis and curative surgical resection preceded by radiotherapy are the means that can improve the prognosis of rectal cancer in young women.

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Rectal cancer constitutes, by its frequency and its gravity, a real concern of the public health in the world.

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It represents the eighth most frequent cancer.

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Its incidence is increasing in young people and in particular in women, in whom it remains a rare disease known for its poor prognosis.

The clinical characteristics of perineal tears: A study carried out on 14 pregnant women in a tertiary center: Case series

Background

The sheer quality of the female genital tract is not always respected at the time of childbirth because no protocol for the management of perineal tears exists in our services these days. The management remains dependent on a gynecologist and obstetrician. The study aimed to describe the characteristics of perineal tears.

Methods

Our cross-sectional, retrospective, and descriptive study focused on patients admitted for childbirth and hospitalized in the obstetrics department of the Saint Luc Tertiary Clinic for a period from March 2021 to March 2022. During this period, we recorded 111 deliveries with 14 perineal tears.

Results

A total of 111 deliveries were recorded with a 12.6% frequency of perineal tears. 64.3% of women aged between 26 and 35 and 71.4% of primiparous women were affected by perineal tears. For delivery, 64.3% of births were eutocic deliveries, with 42.9% of children born with a birth weight greater than 4 kg, and the cephalic presentation delivered 86% of children. For degrees of perineal tears, 64.3% of patients had first-degree perineal tears. For postpartum treatment of perineal tears, analgesics help calm the pain, and antibiotic therapy has been considered. For fourth and third-degree tears, episiotomy was performed as a surgical procedure.

Conclusion

Perineal tears are the trauma often encountered in obstetrics; the first few suffer from it essentially. The high birth weight of children is often the cause. They require immediate management to prevent or avoid infections.

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Women have a very complex anatomy, hence the high risk of trauma or tears of the perineum that are often unavoidable during childbirth. Young primiparous women are the most vulnerable to perineal tears with a very high prevalence.

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The high weight and cephalic presentation of children at delivery are the factors causing perineal tears in women. Vaginal delivery and the number of foetuses has an impact on the integrity of the perineum.

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During childbirth, perineal tears should be brought to the attention of obstetric providers to avoid complications for the woman.

The Lateral Supraorbital Craniotomy Approach for Anterior Circulation Aneurysms: A Modern Surgical Case Series in the Endovascular Era

BACKGROUND

The lateral supraorbital (LSO) approach is a minimally invasive modification of the standard pterional approach to anterior circulation aneurysms. This study aimed to describe a dual-trained cerebrovascular neurosurgeon's first 18-month experience with the LSO approach, including decision-making criteria and lessons learned.

METHODS

This retrospective case series analyzed 50 consecutive patients treated with LSO craniotomy for aneurysm clipping by a single surgeon. Aneurysms were separated into 3 categories by location: internal carotid artery, anterior communicating artery, and middle cerebral artery. Surgical characteristics were evaluated for differences by location and rupture status.

RESULTS

Aneurysm clipping via LSO was performed on 57 aneurysms in 50 patients. Fixed retraction was employed less often in patients with internal carotid artery aneurysms than in patients with anterior communicating artery, middle cerebral artery, or multiple aneurysms (10% vs. 68.2%, 45.5%, and 42.9, P = 0.02). Of patients, 26 (52%) presented with subarachnoid hemorrhage; the majority of patients (92.3%) had Hunt and Hess grade I-III. No differences were noted in intraoperative rupture rates, fixed retractor use, operative duration, or estimated blood loss by rupture status. Adverse events included permanent frontalis nerve palsy in 1 patient (2%), temporalis atrophy in 1 patient, and transient aphasia in 1 patient. No postoperative hematomas or strokes were observed.

CONCLUSIONS

The LSO approach can safely and effectively treat anterior circulation aneurysms and should be considered a viable minimally invasive option for aneurysm clipping. Further studies comparing the LSO approach with other cranial approaches are needed.

Surgical technique of temporal muscle resuspension during cranioplasty for minimizing temporal hollowing: A case series

Background

Temporal hollowing is a common but often overlooked complication following cranioplasty. To minimize temporal hollowing caused by temporal muscle contraction, we present the novel technique for temporal muscle resuspension during cranioplasty.

Methods

This is a retrospective case series which were done by a single surgeon at our university tertiary-A hospital between January 2019 and February 2020. The surgical technique was performed according to the forms of temporal muscle based on preoperative 3-D reconstruction and intraoperative images. All patients were followed up and evaluated on esthetic and functional outcomes.

Results

17 patients with an average age of 39.35 years, frontotemporoparietal cranial defect size of 78.85 cm², and median follow-up of 7 months were included. The main cause of decompressive craniectomy was trauma (n = 15). Techniques of temporal muscle augmentative resuspension were performed. The follow-up esthetic and functional outcome evaluation showed that all patients had good postoperative results. No revision surgery was found among the patients.

Conclusions

This study proposes methods of temporal muscle augmentative resuspension based on forms of the muscle. We believe this might be of use in minimizing temporal hollowing after cranioplasty.

Soft Tissue Sarcomas of the Head and Neck Region with Skull Base/Intracranial Invasion: Review of Surgical Outcomes and Multimodal Treatment Strategies: A Retrospective Case Series

Soft tissue sarcomas (STS) invading the skull base are rare with little data to guide surgical management. Here we aimed to determine the factors affecting tumor control rates and survival in patients with T4 stage head and neck STS involving the skull base. A retrospective review of STS patients, surgically treated at our institution between 1994 and 2017 was conducted. Variables were collected and assessed against progression-free survival. Tumors were graded using the Fédération Nationale des Centres de Lutte Contre le Cancer (FNCLCC) system. A total of 51 patients (mean age of 35) were included, of whom 17 (33.3%) patients were FNCLCC grade 1, 8 (15. 7%) were FNCLCC grade 2 and 26 (51%) were FNCLCC grade 3. The median PFS was 236.4 months while the 5- and 10-year PFS rates were 44% and 17%, respectively. Recurrence occurred in 17 (33.3%) patients. Local recurrence occurred in 10 (58.8%). Univariate analysis revealed R0 resection had a near-significant impact on tumor control in radiation-naïve patients. Otherwise, prior radiation (HR 6.221, CI 1.236–31.314) and cavernous sinus involvement (HR 14.464, CI 3.326–62.901) were negative predictors of PFS. The most common cause of treatment failure was local recurrence. In T4 stage head and neck STS with skull-base involvement, FNCLCC grade, radiation status, and anatomic spread should be considered in determining the overall treatment strategy.

Treatment of lymphangiomas by means of sclerotherapy with OK-432 (Picibanil®) is safe and effective – A retrospective case series

Introduction

Congenital cystic lymphangiomas (CCL) or lymphatic malformations (LMs) are benign malformations due to a developmental disorder of lymphatic vessels. Besides surgical excision, sclerosant therapy of these lesions by intracavitary injection of OK-432 (Picibanil®), a lyophilized mixture of group A Streptococcus pyogenes, is a common therapeutical option.

Methods

In a single center retrospective study we analyzed 37 consecutive patients (30 children, 3 adolescents and 4 adults) who were diagnosed with lymphangioma and subsequently treated with OK-432 (Picibanil®) in a general hospital between October 2000 and November 2021.

Results

The median follow-up period was 2.5 months (range 0.7–56.7 months). The lymphangiomas were localized in the head and neck region (n = 25), the thorax/abdomen (n = 6) and extremities (n = 6). The majority of patients had 1 injection with OK-432 (n = 28), five patients had 2 injections, three patients had 3 injections and one patient had more than 3 injections. The most common complications were swelling (89%), fever (81%), redness at the injection site (81%) and pain (73%). The response to therapy was excellent or good in 32 patients (86.4%), 2 patients had a medium response and 3 patients did not show any response. The clinical reaction after the instillation of OK-432 is not predictive for the quality of outcome.

Conclusion

The application of Picibanil is safe and without serious side effects. Parents and patients prefer local sclerotherapy versus surgery as it has less complications. We therefore suggest that Picibanil sclerotherapy should be the first-line treatment for macrocystic and mixed type lymphangiomas.

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Lymphatic malformations tend to augment in size and may cause life-threatening complications.

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Complete surgical excision of lymphatic malformations often is not possible.

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The treatment of lymphatic malformations with OK-432 has a high rate of excellent/good response.

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Clinical symptoms following the injection of OK-432 are not predictive for the outcome.

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Sclerotherapy has less complications than surgery.

Case series about physiological astigmatism and the impact of pterygium surgery

Introduction

Pterygium is a benign conjunctival fibrovascular neoformation progressively encroaching on the cornea, it can cause corneal distortion and induce astigmatism, or aggravate pre-existing physiological astigmatism, which is defined as ≤ 0.50 D and not requiring optical correction. The radical treatment of pterygium is purely surgical, with conjunctivo-limbal grafting and conjunctival autografting emerging as the surgical techniques of choice. The main objective of the study was to investigate whether pterygium surgery does not worsen the preoperative physiological astigmatism.

Material and methods

This is a prospective cohort study conducted in the ophthalmology department of the Mohammed V Military Hospital in Rabat over a period of 12 months, including 43 stage II/III/IV pterygia that were operated on by conjunctival autograft by the same surgeon. First, we looked for an association between pterygium surgery and variations in astigmatism. For quantitative variables we used the Wilcoxon test. In a second step we split the file into two distinct groups according to the value of preoperative astigmatism≤ 0.5 D or >0.5 D in order to detect the impact of pterygium surgery on physiological astigmatism. Statistical analysis of the data was performed by comparing the distribution of these characteristics.

Results

The median astigmatism was 1 D (0.25; 2.50). 35% of our population had preoperative astigmatism ≤0.5 D. The Wilcoxon test showed that there was a statistically significant difference between preoperative and postoperative astigmatism (p = 0.001). The paired sample T-test showed no statistically significant difference between the preoperative and postoperative outcome in the physiological astigmatism population (p = 0.53).

Conclusion

Many studies have shown the benefits of pterygium excision on astigmatism, but few studies have specified the impact of this surgery on physiological astigmatism. Our study showed that pterygium surgery does not alter physiological astigmatism.

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We have not had any cases under the age of 20.

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Surgical treatment of pterygium generally improves postoperative astigmatism.

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Pterygium surgery was neither a protective nor a risk factor.

Effectiveness of bandage in the incidence of major complications on bichectomy: literature review and case series of 643 bichectomies

Buccal fat pad removal or bichectomy is an esthetic surgical procedure that is gaining notoriety and increasing number worldwide. This paper aims to discuss the effectiveness of bandage in bichectomy postoperative concerning major complications like bleeding and subcutaneous emphysema. This is a retrospective case series according to PROCESS guidelines of 643 bichectomy surgeries performed by two different surgeons with the same technique from January 2018 until December 2020. Effectiveness of bandage is evaluated in complications rate decrease with statistical tests (p < 0.05). A literature review was performed to sediment knowledge about this theme. Female patients search for buccal fat pad removal more for esthetic reasons and male patients for functional purposes. Bichectomy has a low incidence of major complications, and this incidence decreases more with a bandage use (95%CI). Bandages are effective in the decrease of major complications related to bichectomy.

Is C7-T1 cervical disc replacement a viable technique: A case series

Introduction

Cervical disc replacement (CDR) surgery is well established for the treatment of disc degeneration from C3-C7, but there is little data regarding the safety and efficacy of CDR at the cervicothoracic junction, C7-T1. CDR is an appealing option, in terms of range of motion preservation, symptom relief, and absence of risk for nonunion. Currently, C7-T1 CDR is not approved by the Food and Drug Administration, and the existing literature is limited to two case reports that describe the results of a combined two patients. This series explores whether C7-T1 CDR is a reasonable treatment and alternative to fusion.

Methods

We present a case series of seven consecutive patients who underwent CDR at C7-T1 by a single surgeon from January to December of 2019. There were five females and two males with an average age of 61.3 ± 6.4 years.

Results

Average follow up was 18.9 ± 2.5 months. The average postoperative NDI score was 22.6 % ± 14.0. We also recorded qualitative data regarding patient satisfaction and revision surgery status. There was one complication of disc subsidence following three months of complete pain resolution. The six other patients reported being very satisfied with their surgical outcome.

Conclusion

These seven cases dramatically increase the volume of data in the literature on clinical outcomes and patient satisfaction following CDR at the cervicothoracic junction. Additionally, the heterogeneity of cases shows the effectiveness of this treatment in many real-world cases. A greater volume of cases with longer follow up will be necessary to better establish long-term clinical success.

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Cervical disc replacement as an emerging treatment option for preserving motion

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Seven patients with pathology at C7-T1 successfully received disc replacement.

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All resolved symptoms, measured by NDI and survey of patient satisfaction

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CDR as viable treatment option at the cervicothoracic junction

Paratesticular leiomyoma mimicking an inguinal hernia: A rare case report and literature review

Leiomyomas are considered as a rare, benign, slow-growing, and smooth muscle tumours which may present in all regions in the body. The presentation of leiomyoma in genitourinary tract specifically in paratesticular region is extremely rare. The patients may present with palpable, and painful mass in the inguinal region hence mimicking the nature of inguinal hernia. Herewith, we report our experience of 36-year-old male which had been referred for the suspicion of incarcerated inguinal hernia manifesting with painful mass in the right inguinal and testicular region. During testicular exploration surgery, a benign tumour was incidentally discovered. The lesions were then surgically removed by performing radical orchiectomy with the pathology result confirmed the presence of paratesticular leiomyoma. The post-operative course was uneventful and the patient was discharged on first post-operative day. The patient remained free from metastases or local recurrence after 12 months of regular follow up. This case report demonstrated a rare presentation of paratesticular leiomyoma with misleading manifestation of inguinal hernia. Careful and tailored investigation should be performed to avoid misled diagnosis of this case.

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Paratesticular leiomyoma is a rare benign tumour that may present similarly with ingunal hernia.

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Thorough clinical examination, imaging modalities, histopathology and immunohistochemistry may aid in the diagnosis.

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Surgical exploration is the mainstay treatment of paratesticular leiomyomas.

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Radical orchidectomy may be considered if malignancy is suspected.

COVID-19 infection and large intestinal perforation: A case series

Introduction

COVID-19 is a viral illness characterized primarily by respiratory symptoms. However, patients with COVID-19 infection may also present with gastrointestinal symptoms. Subsequent complications can be associated with high morbidity and mortality.

Methods

This is a retrospective observational study of three COVID-19 positive patients who developed large intestinal perforations and an analysis of their clinical characteristics, diagnosis, surgical treatment and outcomes. Three patients aged 45, 51 and 82 years old presented to our institution between November 2021 and March 2022 and were diagnosed with COVID-19 pneumonia requiring admission to the intensive care unit (ICU). All three patients received steroids and underwent surgery during their admission. None of our patients had prior history of bowel perforation or risks factors justifying their presentation.

Presentation of cases

Our first patient was found to have an ascending colon perforation and underwent right colon resection and end ileostomy. Our second patient was found to have a cecal perforation and underwent ileocecectomy with end ileostomy and mucus fistula creation. Our third patient was found to have a large cecal perforation and underwent right hemicolectomy and was left in discontinuity during the index operation.

Discussion

GI perforation is a less common but serious extra-pulmonary complication of COVID-19. The cases in the present study involve ascending colon perforations in the setting of active COVID-19 infection that occurred within two to five weeks after initial COVID-19 diagnosis. Given viral replication in GI cells, the local inflammatory effect of viral infection in the GI may play a role in bowel perforation. Providers should additionally be aware of the risk of perforation with steroids and immunomodulators. Immunosuppressive effects of these therapies may mask the classical signs of abdominal sepsis and lead to possible missed diagnoses.

Conclusion

Gastrointestinal perforation is a rare but serious complication of COVID-19 infection. A high degree of clinical suspicion is necessary for timely diagnosis and management.

•

Gastrointestinal perforation is a rare but serious complication of COVID-19 infection

•

In this case series, ascending colon perforation occurs in each case within two to five weeks of initial COVID-19 diagnosis

•

Steroids and immunomodulators pose additional risk of perforation and may mask the classical signs of abdominal sepsis

Intra-abdominal cystic lymphangioma in adults: A case series of 32 patients and literature review

Introduction

Cystic lymphangioma (CL) is a benign tumor originating from the lymph vessels. Lymphangiomas in the abdominal cavity are extremely rare, particularly in adults.

This article was designed to study the epidemiological, diagnostic difficulties, and therapeutic principles of intra-abdominal cystic lymphangioma (ACL) in adults.

Material and methods

We conducted a single-center, retrospective study of 32 adult patients with ACL admitted to surgical department “A” in “La Rabta Hospital” in Tunis, from January 1998 through December 2020. The demographic, clinical, biological, radiological characteristics, histopathologic, and therapeutic data were collected, as well as the surgical intervention used and the postoperative immediate and late complications.

Results

Thirty-two adult patients with ACL were recruited, including 20 females and 12 males. The median age at treatment was 47 (range 14–80) years. The most prevalent sites were the retroperitoneum (25%), the mesentery (21.9%), and the paracolic gutters (n = 18. 7%). Twenty patients underwent open surgery (62.5%), whereas 12 cases (37.5%) had laparoscopic surgery. Twenty-eight patients received total cystectomy (87%). Three recurrences were observed during follow-up (9.4%).

Conclusion

The clinical features of CL in adults remain unclear. The diagnosis is only confirmed by histopathological examination after complete surgical resection. The laparoscopic approach is considered safe and feasible.

•

Lymphangiomas in the abdominal cavity are extremely rare, particularly in adults.

•

Cystic lymphangioma is a benign tumor originating from the lymph vessels.

•

The clinical presentation is various.

•

Whenever possible, laparoscopic resection should be the treatment of choice.

•

To prevent a recurrence, complete excision is the best option.

The value of dynamic MRI in cervical spondylotic myelopathy: About 24 cases

Dynamic magnetic resonance imaging (MRI) of the cervical spine is extremely useful in assessing pathological changes at the spinal cord, vertebrae, discs, ligaments and facet joints. We attempted to document the radiological changes that the cervical spine undergoes during dynamic maneuvers and the effects of Dynamic MRI in management of cervical myelopathy, emphasizing on the changes in treatment protocol effected by the new findings discovered. Our work is based on 24 consecutive patients with cervical spondylotic myelopathy had cervical MR imaging in neutral position, in flexion and extension of the cervical spine between January 2021 and December 2021. The result found the mean age was 57.9 years (range 26–85 years). Among these 24 patients, there were 11 males and 13 females. Total number of levels of compression were 47 and the additional levels of involvement were 17. Additional levels of compression were noted in 12 patients, among these 17 new levels, 7 were in the posterior and 10 in the anterior. The most affected level was C5C6 with 16 cases. All additional levels of compression were noted in extension; Reduction of the cervical canal was observed in 20 patients only in extension. In the bending sequences we have noticed an increase of the canal diameter in 3 patients. The location of the compression is in 15 cases anterior, 2 cases posterior and 5 cases are mixed anterior and posterior Surgery was considered in 17 patients. Anterior procedures were 11 (ACDF/corpectomy and fusion) and Posterior surgeries were 6 (laminoplasty/laminectomy), and. The rest of the patients did not require surgery and was conservatively treated. A change of the signal was found in 3 patients during the acquisition in extension position a. Most studies have shown a reduction of the root canal with an increase of the compression level, which was the case in our study. MRI is a useful tool for diagnosis of CM, it does not give an exact idea as to which is the offending level in a multilevel compression that requires surgery. Even the approach and procedure cannot be decided on a static examination and hence are subject to significant interpractitioner the role of extension MRI in determining cervical compression levels. Thus, dynamic cervical spine MRI should be an important investigation before we decide to write off surgical treatment in patients with cervical myelopathy and cord signal changes without definitive compression on static MRI. Flexion and extension MRI is an important tool for decision making and planning appropriate management in cervical compressive myelopathy.

•

Dynamic magnetic resonance imaging (MRI) of the cervical spine is extremely useful in assessing pathological changes at the spinal cord. We attempted to document the radiological changes during dynamic maneuvers and the effects of Dynamic MRI in management of cervical myelopathy.

•

Most studies have shown a reduction of the root canal with an increase of the compression level, which was the case in our study. MRI is a useful tool for diagnosis of CM, it does not give an exact idea as to which is the offending level in a multilevel compression that requires surgery. Even the approach and procedure cannot be decided on a static examination and hence are subject to significant interpractitioner the role of extension MRI in determining cervical compression levels. Thus, dynamic cervical spine MRI should be an important investigation before we decide to write off surgical treatment.

•

Flexion and extension MRI is an important tool for decision making and planning appropriate management in cervical compressive myelopathy.

Case series: Interdigitating “Y” flap for transverse vaginal septum management

Introduction

Transverse vaginal septum found in 1/2100 dan 1/72.000 women. The classical management for transvers vaginal septum was septum excision, with risk for vaginal narrowing and vagina shortening after surgery. We reported four cases underwent interdigitating “Y” flap with no vaginal narrowing or shortening after procedure as alternative surgical technique for better result.

Presentation of case

The transverse vaginal septums were right behind hymen to 5 cm proximal from hymen (low to mid location). The post-operative evaluation up to eleven months after surgery found no vaginal narrowing or vaginal shortening. A Case with haematosalphing was re-evaluated one month after surgery and found that the haematosalphing has been resolved and no recurrency on 10 months after surgery. Another case with bigger haematosalphing underwent laparotomy salphingostomy concomitantly with “Y” flap procedure and on 11 months evaluation found no recurrent haematosalphing.

Discussion

As the septum was relatively thick and composed of 2 embryonic origins, dividing them into distal flaps and proximal flaps was possible. Interdigitating “Y” flap technique offer better preservation in vaginal length and less constricture as the technique spread the tissue tension evenly. Cases with haematosalphings implies that adequate drainage through vagina help evacuate the haematosalphing and prevent recurrency. However longer-term evaluation shall be performed.

Conclusion

Interdigitating “Y” Flap offers satisfying outcome besides short hospital stay (less intra operative bleeding, no need for postoperative vaginal dilatation, preserved vaginal length and vaginal caliber).

The utility of the CADISS® system in the dissection of epidural fibrosis in revision lumbar spine surgery (A case series)

Spine surgery and spinal fusion surgery are rising. Revision rates following initial surgery are between 8 and 45%. Epidural fibrosis is a common response to spine surgery for most patients and increases complications in revision surgery. Previous research suggests using MESNA (Sodium 2-mercaptoethane sulfonate) in combination with mechanical blunt dissection safely reduces surgical complications. MESNA is a mucolytic agent which selectively cleaves disulphide bonds involved in the adherence and strength of fibrosis, meaning cutting instruments are not needed. The Chemically Assisted DISSection (CADISS®) System is an optimised non-cutting surgical device, consisting of a reconstitution cartridge for MESNA preparation, irrigated surgical instruments, and a footswitch to control MESNA release. This is the first study to investigate the use of the CADISS® System in revision spine surgery.

Methods

This was a prospective, open label, observational case study. We enrolled 21 patients for revision spine surgery with the CADISS® System at two Belgium sites. The primary assessment was the number of successful removals of epidural fibrosis without cutting. The amount of MESNA used, total dissection and procedure time were recorded. For secondary criterion, the surgeons assessed global satisfaction, facilitation of dissection, quickness of action, usability, bleeding reduction and visualisation of the cleavage plane using an 11-point Likert scale (0–10). Due to the exploratory nature, no formal statistical analysis was planned. We calculated the percentage and confidence interval of successful procedures, the medians and corresponding interquartile range of the Likert criterion, and the mean (±SD) of the amount of MESNA used, CADISS® dissection time and total procedure time.

Results

24 fibrosis dissections were performed in 19 patients and 23 were successful (95.8%, CI: 78.9%; 99.9%). The mean amount of MESNA used, mean dissection time and procedure time were 16 ml (±4.94), 16.5 min (±16.1) and 86.3 min (±25.1), respectively. No dural tears were reported. The mean global satisfaction score was 9.0 (8.0–9.0). All other Likert criterion had scores of 8.0 or 9.0, excluding quickness of action, which scored 7.0 (6.0–9.0).

Conclusions

The CADISS® System in revision spine surgery has potential to effectively reduce dissection complications.

•

Revision rates following initial surgery are between 8 and 45%. Epidural fibrosis is a common response to spine surgery for most patients and increases complications in revision surgery.

•

Previous research suggests using MESNA (Sodium 2-mercaptoethane sulfonate) in combination with mechanical blunt dissection safely reduces surgical complications. MESNA is a mucolytic agent which selectively cleaves disulphide bonds involved in the adherence and strength of fibrosis, meaning cutting instruments are not needed. The Chemically Assisted DISSection (CADISS®) System is an optimised non-cutting surgical device, consisting of a reconstitution cartridge for MESNA preparation, irrigated surgical instruments, and a footswitch to control MESNA release.

•

We enrolled 21 patients for revision spine surgery with the CADISS® System at two Belgium sites. The primary assessment was the number of successful removals of epidural fibrosis without cutting. The CADISS® System in revision spine surgery has potential to effectively reduce dissection complications.

Diagnosis and management of hepatolithiasis in an adult patient: A case report

Hepatolithiasis or intrahepatic calculi are common in South East Asia but are rare in Western nations. The primary symptom of the condition is recurrent pain in the upper abdomen. Stones in the cystic duct or common bile duct are also common findings. Recurrent pyogenic cholangitis is the most frequent complication. Radiological studies and percutaneous procedures are vital for diagnosing and managing this condition. The primary goal in treating the condition is to decrease the chance of developing cholangitis and to stop the progression of the disease, which may lead to biliary cirrhosis.

•

Hepatolithiasis or intrahepatic calculi are common in South East Asia but are rare in Western nations.

•

The primary symptom of the condition is recurrent pain in upper abdomen.

•

It is essential to practice an interdisciplinary approach to best treat and manage these patients.

•

Early diagnosis is crucial; and treatment should be multidisciplinary and complete to avoid recurrence and complications.

Morphometric analysis of the inferior vena cava and its clinical correlations using abdomino-pelvic computed tomography: Series from a Jordanian population

Introduction and importance

This study aimed to determine the impact of DM, HTN and age on IVC dimensions as measured by CT scan relevant to guide interventions in a Jordanian population.

Presentation of cases

Two hundred patients were selected from those referred to the Radiology Department, Jordan University Hospital, Amman, Jordan for clinical evaluation. Patients were divided into three age subgroups. Age, sex, and comorbidities such as DM and HTN were identified and saved for later use. All dimensions of the IVC were measured using an abdomino-pelvic CT scanner.

Clinical discussion

A full morphometric analysis of the IVC would provide a better understanding of the dynamicity of the IVC in relation to its blood flow. Our results revealed that the length of the IVC was significantly shorter with age (P = 0.003). DM significantly affected the length of the IVC (P = 0.044). Hypertension also significantly affected the length of the IVC (P = 0.031), but it did not significantly affect the anterio-posterior or the transverse diameters of the IVC.

Conclusion

The length of the IVC was significantly shorter with age, DM and hypertension. Morphometric measures of the IVC are of great clinical importance as they may assist in medical or surgical intervention and follow-up.

•

Determining the main dimensions of IVC is clinically important.

•

This study revealed significant variability in IVC dimensions in relation to age.

•

Diabetes and hypertension are important in changing the dimensions of IVC.

Outcomes of bowel resection following non-mechanical intestinal obstruction due to mesenteric vein thrombosis in Uganda: A case series

Introduction and importance

Mesenteric venous thrombosis (MVT) is one of the common occlusive causes of compromised bowel perfusion. Contrast-enhanced CT angiography is the diagnostic imaging study of choice for MVT. In-hospital mortality following acute mesenteric infarction is 63 %. Surgical resection may be life saving for patients with peritoneal signs or refractory to conservative management.

Case presentation

We consecutively included records of five patients from Lubaga Hospital with intestinal obstruction who underwent bowel resection following intraoperatively confirmed acute mesenteric ischemia between May 2017 and November 2021. Three of the patients were female. Patients were between 21 and 45 years. One patient had comorbid conditions and an identifiable underlying etiology of polycythemia for MVT. Duration of symptoms ranged from 1 to 11 days. All patients underwent open laparotomy, the length of bowel resection ranged from 77 cm to 600 cm (mean length of 337 cm). Two patients developed short bowel syndrome (SBS) and one patient developed intestinal fistula. There was one in-hospital death due to multi-organ failure.

Clinical discussion

Morbidity and mortality are associated with delay to diagnose the condition. Revascularization is the primary goal, resection of all non-viable regions and preservation of viable bowel. Mortality is commonly related to multi-organ failure. Advanced intensive care and parenteral nutrition have improved survival rates over the years. 2-year and 5-year survival rates have been reported to be 70 % and 50 %.

Conclusion

Good outcomes are still possible for post-operatively optimized patients despite the high mortality and morbidity associated with bowel resection following extensive mesenteric thrombosis.

•

Despite high morbidity and mortality of mesenteric thrombosis, good outcomes are possible in optimized patients.

•

Short bowel syndrome and fistulae are a major course of morbidity in massive bowel resected patients.

•

Surgery is indicated for patients with peritoneal signs and those refractory to conservative management.

The induced membrane technique: A therapeutic option for managing bone defects in the upper extremity: Case series for 7 patients

Introduction

The reconstruction of bone defects of tumoral, infectious or traumatic origin of the limbs remains a major therapeutic challenge for the orthopedic surgeon and the patient, in terms of anatomical and functional results.

Cases presentation

We report the case of 7 patients who underwent induced membrane bone reconstruction of the upper extremity, 5 patients with initial injury to the forearm, and 2 of our patients, to the humerus. In terms of function, the range of prono-supination was 125°, the range of wrist flexion-extension was 165°, and the range of elbow mobility was 170°. All patients achieved union at the time of the last follow-up. Two patients achieved union at 6 months, one patient at 5 months, one patient at 4 months, and three patients at 3 months.

Discussion

The induced membrane (IM) technique has been used for more than 30 years, and it's more and more widely accepted all over the world, as a simple and effective technique for reconstruction of segmental bone defects. The technique comprises 2 surgical stages, The first step involves the total excision of infected and non-viable lesions both bone and soft tissue until tissue with optimal vascularization "Paprika sign", then the strict instrumental stabilization of the skeleton and the realization of a covering flap if necessary, depending on the site of the initial injury initial lesion and the extent of the resection.

Conclusion

The technique of induced membrane has proven its effectiveness in the management of bone loss.

Transanal total mesorectal excision after incomplete endoscopic submucosal dissection for early-stage low rectal cancer: A small case series

Endoscopic submucosal dissection (ESD) for colorectal cancer is challenging but is gradually being performed worldwide. It is less invasive than surgical resection and can be performed on lesions in which malignancy cannot be diagnosed. In low rectal cancers, changes such as scarring after ESD may make it challenging to preserve the anus when additional surgical resection is required. Transanal total mesorectal excision (TaTME) is a novel surgical technique involving transanal endoscopic manipulation. It is useful for lesions in the deep pelvis near the anus. Herein, we report six cases of TaTME after ESD for early-stage low rectal cancer that resulted in incomplete resection. As a representative case, a 77-year-old female was referred to our hospital, and colonoscopy revealed low rectal cancer. ESD was performed, and the pathological diagnosis was an invasion of the submucosal layer and microscopic lymphovascular invasion. We performed an additional laparoscopic low anterior resection with TaTME. Lymph node metastasis was observed, and the final diagnosis was pT1b, pN1a, pStage IIIa, and R0. In other cases, the anus can also be preserved, and the distal margin can be secured. TaTME enabled anal preservation without being affected by the ESD scars. It is considered useful for additional resection after ESD of low rectal cancer.

•

Additional resection after ESD for low rectal cancer is difficult.

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TaTME has become an attractive surgical approach to achieve an accurate DRM.

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TaTME has made it possible to secure the DRM, even after ESD for low rectal cancer.

Surgical revision for pancreatojejunostomy stricture: a case series of 14 patients

Background

Pancreatojejunostomy stricture (PJS) is a rare long-term complication of pancreaticojejunal anastomosis. This study aimed to investigate the role of surgery in the management of pancreatojejunostomy strictures.

Methods

The database of the Pancreas Center of Nanjing Medical University was retrospectively screened for patients who underwent a surgical revision for PJS between June 2012 and August 2019, and their clinical characteristics and management modalities were reviewed.

Results

Fourteen consecutive cases were retrieved, the median age at index operation was 41.1 years (19–71). The average time between the two operations was 70.6 months (8–270 months). Index procedures included pancreaticoduodenectomy (PD) (7/14, 50%), pylorus-preserving PD (4/14, 28.6%), Berger procedure (2/14, 14.3%), and middle pancreatectomy (1/14, 7.1%). The diameter of the main pancreatic duct was < 4 mm in all 14 cases, and nine underwent pancreaticojejunostomy (PJ) stenting during the index operation. The most frequent complaints were abdominal pain (6/14, 42.9%), recurrent acute pancreatitis (6/14, 42.9%), pancreatic fistula (1/14, 7.1%), and abdominal distention (1/14, 7.1%). The diagnosis of PJ stricture was confirmed by computed tomography or magnetic resonance imaging in all cases. All patients had a main duct diameter > 5 mm before surgical revision. All patients underwent wedge excision with interrupted one-layer suturing with absorbable sutures and without stent placement. In this series, only one patient required reoperation. Upon follow-up, 11 of 12 patients had complete resolution of the PJ stricture.

Conclusion

PJS is a long-term complication of pancreatojejunostomy. Surgical revision of the anastomosis is a safe and effective treatment modality.

Virtual Surgical Planning and Customized Subperiosteal Titanium Maxillary Implant (CSTMI) for Three Dimensional Reconstruction and Dental Implants of Maxillary Defects after Oncological Resection: Case Series

Maxillectomies cause malocclusion, masticatory disorders, swallowing disorders and poor nasolabial projection, with consequent esthetic and functional sequelae. Reconstruction can be achieved with conventional approaches, such as closure of the maxillary defect by microvascular free flap surgery or prosthetic obturation. Four patients with segmental maxillary defects that had been reconstructed with customized subperiosteal titanium maxillary implants (CSTMI) through virtual surgical planning (VSP), STL models and CAD/CAM titanium mesh were included. The smallest maxillary defect was 4.1 cm and the largest defect was 9.6 cm, with an average of 7.1 cm. The reconstructed maxillary vertical dimension ranged from 9.3 mm to 17.4 mm, with a mean of 13.17 mm. The transverse dimension of the maxilla at the crestal level was attempted to be reconstructed based on the pre-excision CT scan, and these measurements ranged from 6.5 mm in the premaxilla area to 14.6 mm at the posterior level. All patients were rehabilitated with a fixed prosthesis on subperiosteal implants with good esthetic and functional results. In conclusion, we believe that customized subperiosteal titanium maxillary implants (CSTMI) are a safe alternative for maxillary defects reconstruction, allowing for simultaneous dental rehabilitation while restoring midface projection. Nonetheless, prospective and randomized trials are required with long-term follow-up, to assess its long-term performance and safety.

Case series of high-grade soft tissue sarcoma of the lower limb with delayed diagnosis: Experience at a tertiary hospital in northern Tanzania

INTRODUCTION AND IMPORTANCE

Soft tissue sarcoma is an uncommon form of cancer with poor prognosis. Early diagnosis and treatment are vital for improving the treatment outcomes.

CASE PRESENTATION

We report a series of high-grade soft tissue sarcomas of the lower extremity with delayed diagnosis to gain insight into the presentation, treatments and outcomes for this rare disease and to determine whether limb-salvage surgery yields reasonable outcomes.

CLINICAL DISCUSSION

Timely health seeking has an impact on the outcome of the treatment of any particular disease. Patient delays are usually socio-economic factors. Soft tissues sarcomas are uncommon malignant tumors that even managed adequately have a poor 5-year survival. Limb salvage becomes questionable especially when patients present late with adverse symptoms.

CONCLUSION

In this series, we found that patients presented late and this led to unfavorable oncological outcomes, also limb salvage was not an option due to delayed presentation. Thus, early diagnosis is recommended so as to improve treatment outcome.

Awake Deep Brain Stimulation Surgery Without Intraoperative Imaging Is Accurate and Effective: A Case Series

BACKGROUND

The success of deep brain stimulation (DBS) surgery depends on the accuracy of electrode placement. Several factors can affect this such as brain shift, the quality of preoperative planning, and technical factors. It is crucial to determine whether techniques yield accurate lead placement and effective symptom relief. Many of the studies establishing the accuracy of frameless techniques used intraoperative imaging to further refine lead placement.

OBJECTIVE

To determine whether awake lead placement without intraoperative imaging can achieve similar minimal targeting error while preserving clinical results.

METHODS

Eighty-two trajectories in 47 patients who underwent awake, frameless DBS lead placement with the Fred Haer Corporation STarFix system for essential tremor or Parkinson's disease were analyzed. Neurological testing during lead placement was used to determine appropriate lead locations, and no intraoperative imaging was performed. Accuracy data were compared with previously performed studies.

RESULTS

The Euclidean error for the patient cohort was 1.79 ± 1.02 mm, and the Pythagorean error was 1.40 ± 0.95 mm. The percentage symptom improvement evaluated by the Unified Parkinson's Disease Rating Scale for Parkinson's disease or the Fahn-Tolosa-Marin scale for essential tremor was similar to reported values at 58% ± 17.2% and 67.4% ± 24.7%, respectively. The operative time was 95.0 ± 30.3 minutes for all study patients.

CONCLUSION

Awake, frameless DBS surgery with the Fred Haer Corporation STarFix system does not require intraoperative imaging for stereotactic accuracy or clinical effectiveness.

Sphenoparietal Sinus Dural Arteriovenous Fistulas: A Series of 10 Patients

BACKGROUND

Dural arteriovenous fistulas (DAVFs) of the sphenoparietal sinus or sphenoid wing region are uncommon lesions with unique and interesting angioarchitecture. Understanding appropriate anatomy and recognizing patterns provide important treatment implications.

OBJECTIVE

To describe a single surgeon's experience with open surgical treatment of sphenoparietal sinus DAVFs, the surgical indications for this uncommon lesion, and the microsurgical techniques related to its treatment and to review the literature on its surgical treatment.

METHODS

Consecutive cases of sphenoparietal sinus DAVF treatment conducted by a single surgeon over 24 years (1997-2020) were retrospectively reviewed. Published reports of similar cases were reviewed.

RESULTS

Of 202 surgically treated DAVFs, 10 lesions in 10 patients were sphenoparietal sinus DAVFs. Four patients presented with intracranial hemorrhage, 3 with headache, and 2 with pulsatile tinnitus; 1 patient was incidentally identified as having a DAVF during treatment for a ruptured aneurysm. Most patients (7 of 10) had undergone endovascular embolization previously. Nine patients had Borden type III DAVFs and one had a Borden type II fistula. Surgery in all 10 patients resulted in angiographically confirmed fistula obliteration. Clinical outcomes at the last follow-up, measured by a modified Rankin Scale (mRS) score, were excellent in 6 patients (mRS ≤ 2) and poor in 1 patient (mRS ≥ 3); late outcomes were not available for 3 patients.

CONCLUSION

Sphenoparietal sinus DAVFs are an uncommon anatomic subtype. Careful attention to angiographic detail leads to identification of the site of venous interruption and results in a high rate of surgical cure with excellent clinical outcomes.

Utility of adding electrodes in patients undergoing invasive seizure localization: A case series

Introduction

Surgery can be an effective treatment for epilepsy if the seizure onset is adequately localized. Invasive monitoring is used if noninvasive methods are inconclusive. Initial invasive monitoring may fail if the pre-surgical hypothesis regarding location of epileptic foci is wrong. At this point, a decision must be made whether to remove all electrodes without a clearly defined location of onset or to implant additional electrodes with the aim of achieving localization by expanding coverage.

Methods

Electrodes were placed according to a hypothesis derived from noninvasive monitoring techniques in adult patients with long term epilepsy. Seizure onset was not clearly localized at the end of the invasive monitoring period in ten patients, and additional electrodes were placed based on a new hypothesis that incorporated data from the invasive monitoring period.

Results

Successful localization was achieved in nine patients. There were no complications with adding additional electrodes. At final follow up, four patients were seizure free while four others had at least a 50% reduction in seizures after undergoing surgical intervention.

Conclusion

Seizure foci were localized safely in 90% of adult patients with long term epilepsy after implanting additional electrodes and expanding coverage. Patients undergoing invasive monitoring without clear localization should have additional electrodes placed to expand monitoring coverage as it is safe and effective.

Reoperative Brachial Plexus Neurolysis After Previous Anatomically Complete Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A 10-Year Single-Center Case Series

BACKGROUND

Optimal management of recurrent neurogenic thoracic outlet syndrome (NTOS) remains a considerable challenge.

OBJECTIVE

To assess the safety and effectiveness of reoperative brachial plexus neurolysis in patients with recurrent NTOS.

METHODS

From 2009 to 2019, 85 patients underwent reoperative supraclavicular brachial plexus neurolysis for recurrent NTOS after a previous anatomically complete supraclavicular decompression. Data from a prospectively maintained database were analyzed retrospectively.

RESULTS

The mean patient age at reoperation was 36.9 ± 1.3 (range 15-64) years, 75% were female, and the interval after previous primary operation was 2.5 ± 0.2 years. Intervening injury had precipitated recurrent NTOS in 14 patients (16%), and the mean Disability of the Arm, Shoulder, and Hand (QuickDASH) score before reoperation was 65.2 ± 2.6, reflecting substantial disability. Operative findings consisted of dense fibrous scar tissue surrounding/encasing the brachial plexus. Compared with the previous primary operations, reoperations had a shorter operative time (198 ± 4 vs 161 ± 5 minutes, P < .01) and hospital stay (4.4 ± 0.2 vs 3.6 ± 0.1 days, P < .01), but there were no significant differences in the frequency of prolonged hospitalization (7.1% vs 4.7%), early reoperation (3.5% vs 1.2%), or 30-day hospital readmission (8.2% vs 7.1%). During a median follow-up of 4.8 years, QuickDASH scores improved by 23.3 ± 2.6 (34.2% ± 3.6%; P < .01) and patient-rated outcomes were excellent in 24%, good in 42%, fair in 26%, and poor in 8%.

CONCLUSION

Reoperative supraclavicular brachial plexus neurolysis is technically challenging but safe and effective treatment for recurrent NTOS, with significant improvements in symptoms and function. Diminishing perineural scar tissue development and avoiding secondary injury would likely decrease the need for reoperations.

Evaluating the role of the self-assembling topical haemostat PuraBond® in Transoral Robotic Surgery (TORS) for oropharyngeal cancer: A case series

Background

Methods

Results

Conclusion

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Major haemorrhage is a key concern following transoral robotic surgery (TORS).

•

Purabond® is a synthetic haemostatic agent used in other surgical settings.

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Our series is the first to evaluate the role of Purabond® in TORS.

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We demonstrate excellent outcomes in terms of bleeding and swallowing complications.

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Larger, prospective controlled studies are needed to further assess these outcomes.

Surgical therapy of occipital (Arnold) neuralgia: A case series

Objective

The idea to treat occipital neuralgia patients with a surgical procedure is relatively recent. The aim of this paper was to describe the surgical techniques and our 12-year experience in this field.

Materials and methods

From June 2011 till February 2022 we have performed surgery over 232 patients with occipital neuralgia.

Results

The surgical procedure elicited a positive response in 86% of the patients.

Conclusions

The described techniques allowed to obtain an high rate of positive results with a minimum percentage of complications.

•

The idea to treat occipital (Arnold) neuralgia patients with a surgical procedure is relatively recent.

•

The aim of this paper was to describe the surgical techniques and our 12-year experience in this field.

•

The described techniques allowed to obtain an high rate of positive results with a minimum percentage of complications.

Lessons learned from five patients of persistent Mullerian duct syndrome: A case series

INTRODUCTION

Persistent Mullerian duct syndrome (PMDS) is a genetic disorder characterized by the persistence of Mullerian structures of fallopian tubes, uterus, and upper two-thirds of the vagina in a normal XY male. It is a rare genetic disorder that has been reported less than two hundred times. More rarely it may be seen in association with transverse testicular ectopia (TTE).

PRESENTATION OF CASES

Four patients presented with swelling in the inguinal region and undescended testes. Pre-op ultrasound was done on three of these patients and it showed a hernia with testes inside the hernial sac. Hernia surgery was planned for these patients. One patient presented with a complaint of bilateral cryptorchidism that prompted laparoscopic exploration. In all five patients, on surgical exploration, Mullerian derivatives i.e., fallopian tubes, uterus, and vagina were found in the abdomen. Hernia surgery was done and Mullerian structures were excised. For undescended testes, patients had orchiopexy or orchidectomy depending on their respective age group.

DISCUSSION

PMDS is caused by failure of production of Mullerian inhibiting substance. Mullerian structures other than causing inguinal hernia are also at risk of malignant transformation, which is the most important significance of this condition. In light of the risk of malignant transformation, Mullerian structures must be excised.

CONCLUSION

To prevent the risk of malignant transformation in PMDS, the Mullerian structures must be excised. If PMDS is associated with TTE, orchiopexy must be done for pediatric patients and orchidectomy for adult patients.

Diagnosis and Management of oro-antral fistula: Case series and review

INTRODUCTION AND IMPORTANCE

The oro-antral communication (OAC) is a pathological opening between the maxillary sinus and the oral cavity. When it does not close spontaneously or if it is not treated, it remains permeable and epithelializes to develop into an oro-antral fistula (OAF) and can cause maxillary sinusitis.

CASES PRESENTATION

The authors present through 5 clinical cases the different steps of the surgical protocols opting for the buccal fat pad flap and the advanced buccal flap to treat OAF/OAC.

CLINICAL DISCUSSION

Surgical closure of the OAC within 48 h is recommended to avoid complications. Several alternative techniques have been described over the years for the management of the OAC and OAF, with their advantages and limitations. The most commonly used surgical flaps are of two types: the advanced buccal flap and the buccal fat pad (BFP) flap.

CONCLUSION

The adequate availability of the advanced buccal flap and the buccal fat pad (BFP) flap in the majority of patients, the easy handling, the minimal donor site morbidity as well as the excellent blood supply make them perfect flaps for the closure of OAF/OAC. However, follow-up remains a key point and very important to avoid complications. The present case series was limited by the small number of patients and the authors recommend a study with larger groups.

Cerebellar primary central nervous system lymphoma: Case series report

INTRODUCTION AND IMPORTANCE

Primary central nervous system lymphoma (PCNSL) is a rare cranial malignant haematological tumour. PCNSL in the cerebellar region is less common than PCNSL in other encephalic regions. A diagnosis of cerebellar PCNSL is relatively difficult to make due to its diverse imaging manifestations. The aim of this case series report is to determine whether surgery could be used to confirm the diagnosis of cerebellar PCNSL and the effect of surgical treatment.

METHODS

We report 3 cases of cerebellar PCNSL that underwent neuronavigation microsurgery under general anaesthesia. The operation was performed by author 3 and author 5. One patient underwent left lateral ventricular drainage on the fourth and tenth days after the operation due to postoperative obstructive hydrocephalus. All patients received chemotherapy or radiotherapy after histological confirmation.

OUTCOMES

All patients' tumours were completely removed. One patient developed obstructive hydrocephalus twice during the perioperative period after the operation, was given drainage, and then recovered from the hospital. The other two patients recovered and were discharged smoothly without complications. One patient died 9 months after the operation, and the other two patients survived. The prognosis of 3 patients was related to tumour size and timely follow-up chemo-radiation therapy.

CONCLUSION

The histology of all patients showed diffuse large B-cell lymphoma (GCB phenotype). Suspicious cerebellar PCNSL patients should undergo surgery to confirm the diagnosis, followed by radiotherapy and chemotherapy.

Reconstruction of intraarticular distal radius malunion with 3D printed guide and arthroscopic assisted intraarticular osteotomy

INTRODUCTION

Distal radius fractures are one the most common upper extremity injuries, accounting for 25 % of pediatric fractures and up to 18 % of elderly fractures. Intraarticular malunion is one major complication of distal radius fractures and was reported in 0 to 33 % of total cases. It usually causes pain, deformity, limited range of motion (ROM), and loss of strength. Therefore, proper surgical management to satisfactorily unite the fragment is necessary. Case Illustrations: This is a case series of three adult male and female patients diagnosed with intraarticular distal radius fracture with malunion. They had been diagnosed based on clinical and radiological examinations. Preoperative and postoperative QuickDASH and ROM were measured. Three-dimensional printing was created for planning the osteotomy. Osteotomy was performed using arthroscopy. All patients showed QuickDASH and ROM improvement in all wrist movements.

DISCUSSION

The primary goal of the procedure was to restore normal anatomic alignment to improve wrist function and reduce pain. Osteotomy guided by arthroscopy planned by 3D printed surgical guide successfully reduced the malunion fracture.

CONCLUSION

Osteotomy assisted by arthroscopy combined with the 3D-printed surgical guide is a promising technique to restore challenging intraarticular distal radius malunion.