"Bezoar Egg"-A Rare Cause of Small Bowel Obstruction

Small bowel obstruction is a frequent medical condition with various causes, the most common being postoperative adhesions, volvulus, intussusception, hernias, and tumors. A bezoar-induced blockage of the small intestine is a rare condition that accounts for approximately 4% of all small bowel obstruction cases. Herein, we present the case report of a 71-year-old patient with diffuse abdominal pain caused by a small bowel obstruction due to a calcified bezoar (bezoar egg) resulting from a post-radiation intestinal stricture. The patient underwent a small bowel excision with the extraction of the bezoar, after which a full recovery was made.

Possibility of Using Conventional Computed Tomography Features and Histogram Texture Analysis Parameters as Imaging Biomarkers for Preoperative Prediction of High-Risk Gastrointestinal Stromal Tumors of the Stomach

BACKGROUND

The objective of this study is to determine the morphological computed tomography features of the tumor and texture analysis parameters, which may be a useful diagnostic tool for the preoperative prediction of high-risk gastrointestinal stromal tumors (HR GISTs).

METHODS

This is a prospective cohort study that was carried out in the period from 2019 to 2022. The study included 79 patients who underwent CT examination, texture analysis, surgical resection of a lesion that was suspicious for GIST as well as pathohistological and immunohistochemical analysis.

RESULTS

Textural analysis pointed out min norm (p = 0.032) as a histogram parameter that significantly differed between HR and LR GISTs, while min norm (p = 0.007), skewness (p = 0.035) and kurtosis (p = 0.003) showed significant differences between high-grade and low-grade tumors. Univariate regression analysis identified tumor diameter, margin appearance, growth pattern, lesion shape, structure, mucosal continuity, enlarged peri- and intra-tumoral feeding or draining vessel (EFDV) and max norm as significant predictive factors for HR GISTs. Interrupted mucosa (p < 0.001) and presence of EFDV (p < 0.001) were obtained by multivariate regression analysis as independent predictive factors of high-risk GISTs with an AUC of 0.878 (CI: 0.797-0.959), sensitivity of 94%, specificity of 77% and accuracy of 88%.

CONCLUSION

This result shows that morphological CT features of GIST are of great importance in the prediction of non-invasive preoperative metastatic risk. The incorporation of texture analysis into basic imaging protocols may further improve the preoperative assessment of risk stratification.

Biliary fistula and late recurrence of liver hydatid cyst: Role of cysto-biliary communication: A prospective multicenter study

BACKGROUND

Hydatid cyst disease (HCD) is common in certain locations. Surgery is associated with postoperative biliary fistula (POBF) and recurrence. The primary aim of this study was to identify whether occult cysto-biliary communication (CBC) can predict recurrent HCD. The secondary aim was to assess the role of cystic fluid bilirubin and alkaline phosphatase (ALP) levels in predicting POBF and recurrent HCD.

AIM

To identify whether occult CBC can predict recurrent HCD. The secondary aim was to assess the role of cystic fluid bilirubin and ALP levels in predicting POBF and recurrent HCD.

METHODS

From September 2010 to September 2016, a prospective multicenter study was undertaken involving 244 patients with solitary primary superficial stage cystic echinococcosis 2 and cystic echinococcosis 3b HCD who underwent laparoscopic partial cystectomy with omentoplasty. Univariable logistic regression analysis assessed independent factors determining biliary complications and recurrence.

RESULTS

There was a highly statistically significant association (P ≤ 0.001) between cystic fluid biochemical indices and the development of biliary complications (of 16 patients with POBF, 15 patients had high cyst fluid bilirubin and ALP levels), where patients with high bilirubin-ALP levels were 3405 times more likely to have biliary complications. There was a highly statistically significant association (P ≤ 0.001) between biliary complications, biochemical indices, and the occurrence of recurrent HCD (of 30 patients with recurrent HCD, 15 patients had high cyst fluid bilirubin and ALP; all 16 patients who had POBF later developed recurrent HCD), where patients who developed biliary complications and high bilirubin-ALP were 244.6 and 214 times more likely to have recurrent hydatid cysts, respectively.

CONCLUSION

Occult CBC can predict recurrent HCD. Elevated cyst fluid bilirubin and ALP levels predicted POBF and recurrent HCD.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Fatal gastrointestinal bleeding associated with acute pancreatitis as a complication of Covid-19: a case report

Clinical manifestations of Covid-19 vary widely among patients. Recent studies suggest that up to 15% of patients with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infections develop gastrointestinal symptoms. The location of virus-host cell receptors angiotensin-converting enzyme 2 and transmembrane serine protease 2 has an important role in the pathophysiology and presentation of disease. They are expressed in the respiratory tract, as well as other organs and tissues including exocrine and endocrine pancreatic cells. These cells are therefore a possible target for the virus, which could explain the relationship between SARS-CoV-2 infection and pancreatic injury. We report a disastrous collateral effect of the Covid-19 pandemic on a 33-year-old man with chronic renal insufficiency and asymptomatic SARS-CoV-2 infection, who developed acute pancreatitis. Inflammation progressed rapidly toward necrosis and the development of a peripancreatic pseudoaneurysm which subsequently ruptured, causing death.

Endovascular treatment of a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery as a complication of chronic pancreatitis: a case report

A pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. Prompt diagnosis and appropriate treatment are of great clinical importance. We herein present an unusual case of a pseudoaneurysm of the posterior inferior pancreaticoduodenal artery that developed as a complication of chronic pancreatitis. It was detected in a timely manner and successfully treated with minimally invasive endovascular therapy.

Splenectomy for Visceral Leishmaniasis Out of an Endemic Region: A Case Report and Literature Review

Visceral leishmaniasis (also known as kala-azar) is characterized by fever, weight loss, swelling of the spleen and liver, and pancytopenia. If it is not treated, the fatality rate in developing countries can be as high as 100% within 2 years. In a high risk situation for perioperative bleeding due to severe thrombocytopenia/coagulopathy, we present a rare challenge for urgent splenectomy in a patient with previously undiagnosed visceral leishmaniasis. A histologic examination of the spleen revealed a visceral leishmaniasis, and the patient was successfully treated with amphotericin B.

Encapsulated Omental Necrosis as an Unexpected Postoperative Finding: A Case Report

Postsurgical fat necrosis is a frequent finding in abdominal cross-sectional imaging. Epiploic appendagitis and omental infarction are a result of torsion or vascular occlusion. Surgery or pancreatitis are conditions that can have a traumatic and ischemic effect on fatty tissue. The imaging appearances may raise concerns for recurrent malignancy, but percutaneous biopsy and diagnostic follow-up assist in the accurate diagnosis of omental infarction. Herein we describe a case of encapsulated omental necrosis temporally related to gastric surgery. Preoperative CT and MRI findings showed the characteristics of encapsulated, postcontrast nonviable tumefaction in the epigastrium without clear imaging features of malignancy. Due to the size of the lesion and the patient’s primary disease, tumor recurrence could not be completely ruled out, and the patient underwent surgery. Histopathological analysis confirmed the diagnosis of steatonecrosis of the omentum.

Laparoscopic enucleation of Frantz's tumor of the pancreas: Case report and literature review

Introduction

Frantz's tumor of the pancreas is a rare phenomenon, and it accounts for 1-3% of all neoplasms of the pancreas. Its percentage is much higher in younger persons, especially in younger women, as compared to the rest of the population.

Presentation of case

The present study describes a 32-year-old female patient in whom a preoperative imaging diagnosis confirmed a mass in the junction of the pancreas' body and tail. Based on the anamnesis, the preoperative diagnosis, and the patient's general status, the decision was made to performed laparoscopic enucleation of the pancreatic tumor. The operation and postoperative recovery passed without complications. Definitive histopathological and immunohistochemical findings confirmed a solid pseudopapillary neoplasm of the pancreas.

Discussion

Depending on the localization and the size of the tumor, surgical options range from typical and atypical resections of the pancreas to minimally invasive surgical procedures, such as local excision and enucleation. Laparoscopic procedures have a comparative advantage in cases of enucleation and resection of the pancreas. The low frequency of recidivation and a favorable prognosis, even after repeated surgery, are additional reasons for favoring the laparoscopic approach over the classical surgical approach.

Conclusion

A minimally invasive surgical approach should be applied whenever the dimensions and the localization of the tumor permit it, bearing in mind all the benefits and advantages that this surgical technique offers.

Successful Embolization of Posterior Inferior Pancreaticoduodenal Artery Pseudoaneurysm on the Grounds of Chronic Pancreatitis-Case Report and Literature Review

Pancreatic pseudoaneurysm is a rare but life-threatening clinical entity. In this paper, we present a case of a 74-year-old man, who was admitted to our clinic with a diagnosis of an acute on chronic pancreatitis complicated by walled-off-pancreatic-necrosis, with subsequent development of peripancreatic pseudoaneurysm. After initial conservative management, the patient recovered and was discharged from the hospital. However, he soon returned feeling anxious due to a pulsatile abdominal mass. Abdominal Color–Doppler examination, CT scan, and angiography revealed large pancreatic necrotic collection in the total size of 9 cm, with centrally enhancing area of 3.5 cm that corresponded to pseudoaneurysm originating from the posterior pancreaticoduodenal vascular arcade. Considering the size, location of the pseudoaneurysm, feeding vessel, and poor general patients condition, we opted for minimally invasive treatment. Pseudoaneurysm was successfully managed by endovascular coil embolization, i.e., “sandwich technique”.

Analysis of the surgical treatment of the patients operated on by using laparoscopic and classic splenectomy due to benign disorders of the spleen

Objectives

Laparoscopic splenectomy became the standard surgical procedure in the 1990s. The goal of this study was to analyze the outcome of the patients who underwent laparoscopic splenectomy for the benign hematologic diseases of the spleen and compare its results with open splenectomy.

Material and Methods

The study was conducted as a retrospective cohort study analyzing and comparing the data obtained from 196 patients' case records in the Clinic for Digestive Surgery, Clinical Center of Serbia, for the benign disorders of the spleen, divided into two groups: patients operated with laparoscopic technique and patients in whom classic splenectomy was performed. The analyzed parameters were divided into three groups as preoperative, intraoperative and postoperative.

Results

In the laparoscopic splenectomy group, less intraoperative blood loss, lower incidental intraoperative complications and a shorter duration of surgery were recorded. The incidence of postoperative complications and reoperations was higher in the group of classically operated patients. Postoperative recovery, expressed by the duration of postoperative abdominal drainage, recovery of intestinal peristalsis and length of postoperative hospitalization, was significantly shorter in the laparoscopic group.

Conclusion

Laparoscopic splenectomy is an effective and safe surgical procedure in the treatment of many benign diseases of the spleen. Improvement of the laparoscopic technique of surgical teams and technical improvement of the laparoscopic equipment can lead to even wider application of laparoscopic splenectomy as standard operative procedure, and thus to safer and better quality treatment of patients with wider spectrum diseases of the spleen.

Laparoscopic Management of Initially Unrecognized Splenic Hydatid Cysts: A Case Report and Review of the Literature

We present a case report that demonstrates diagnostic and intraoperative challenges in the laparoscopic management of initially unrecognized splenic hydatid disease. A male patient, aged 44, was admitted to our department with a big unilocular splenic cyst, radiologically (ultrasonography, computed tomography) characterized as a simple cyst. Serological tests for anti-Echonococcus antibody were negative, and chests X-ray findings were unremarkable, so laparoscopic cyst fenestration with omentoplasty was planned. The intraoperative finding did not correspond to a simple splenic cyst. Hydatid daughter cysts were recognized after the careful opening of the cyst wall. The operation was completed without shifting to open procedures. Laparoscopic partial pericystectomy with omentoplasty is a safe and effective surgical procedure for the management of splenic hydatid disease.

Laparoscopic Splenectomy in the Treatment of Hematological Diseases of the Spleen

Methods of surgical treatment of hematological diseases of the spleen have changed significantly in the past decade. The introduction of laparoscopic and minimally invasiveprocedures as standard for solving a significant number of conditions in abdominal surgery, has led surgeons toincreasingly use laparoscopic surgery of the spleen. However, some unique anatomical characteristics of the spleen can lead to limitation in the application of laparoscopy. In this study, we investigated the application of laparoscopic splenectomy in the treatment of haematological disorders of the spleen, intraoperative and postoperative characteristics, the presentation ofoperational technique and the evaluation of the success of this procedure. In the treatment of benign hematological diseases, the effectiveness and efficiency of laparoscopy has been proven. The speculation of medical professionals is that laparoscopic splenectomy is an equal, if not the superior way of treating benign hematological diseases of the spleen in relation to the open procedure, and that there is a chance that laparoscopy might completely replace the classical surgery in most of it’s indications.

Scaling of avalanche queues in directed dissipative sandpiles

Using numerical simulations and analytical methods we study a two-dimensional directed sandpile automaton with nonconservative random defects (concentration c) and varying driving rate r. The automaton is driven only at the top row and driving rate is measured by the number of added particles per time step of avalanche evolution. The probability distribution of duration of elementary avalanches at zero driving rate is exactly given by P1(t,c)=t(-3/2) exp[t ln(1-c)]. For driving rates in the interval 0<r</=1 the avalanches are queuing one after another, increasing the periods of noninterrupted activity of the automaton. Recognizing the probability P1 as a distribution of service time of jobs arriving at a server with frequency r, the model represents an example of the class <E,1,GI/infinity,1> server queue in the queue theory. We study scaling properties of the busy period and dissipated energy of sequences of noninterrupted activity. In the limit c-->0 and varying linear system size L<<1/c we find that at driving rates r</=L(-1/2) the distributions of duration and energy of the avalanche queues are characterized by a multifractal scaling and we determine the corresponding spectral functions. For L>>1/c increasing the driving rate somewhat compensates for the energy losses at defects above the line r approximately sqrt[c]. The scaling exponents of the distributions in this region of phase diagram vary approximately linearly with the driving rate. Using properties of recurrent states and the probability theory we determine analytically the exact upper bound of the probability distribution of busy periods. In the case of conservative dynamics c=0 the probability of a continuous flow increases as F(infinity) approximately r(2) for small driving rates.

Barkhausen avalanches in anisotropic ferromagnets with 180 degrees domain walls

We show that Barkhausen noise in two-dimensional disordered ferromagnets with extended domain walls is characterized by the avalanche size exponent tau(s)=1.54 at low disorder. With increasing disorder the characteristic domain size is reduced relative to the system size due to nucleation of new domains and a dynamic phase transition occurs to the scaling behavior with tau(s)=1.30. The exponents decrease at finite driving rate. The results agree with recently observed behavior in amorphous Metglas and Fe-Co-B ribbons when the applied anisotropic stress is varied.