Iatrogenic Vascular Injuries in Resource-Limited Setting: A 4-Year Experience Monocentric Retrospective Study

Background

Iatrogenic vascular injuries (IVIs) due to diagnostic and therapeutic interventions are known but rare or probably under-reported. We present our four-year findings on patients with IVIs after catheterization or surgery who underwent vascular surgical repairs in a resource-limited setting.

Methods

A retrospective case series study between Jun 2018 and Sep 2022 of 35 patients diagnosed with IVIs and treated surgically at our hospital was included. The data on IVIs including patient characteristics, causes and type of injury, treatment, and outcomes were collected and analyzed.

Results

The mean age was 37.12± 17.0 years, and most patients (65.7%) were male. Of the 35 IVIs, 21 were caused by percutaneous procedures, while 14 occurred intraoperatively and affected various arteries and veins. The main injured vessels were the femoral artery (20%) and direct blood vessel puncture made by non-qualified specialists (42.9%) during dialysis cannulation was the main cause. The intraoperative IVI affected the inferior vena cava in three patients, the aorta in two patients, the external iliac artery in four, the tibial and popliteal arteries in four, and the internal carotid artery in one. The following types of repairs were recorded: direct suture of the vessel with or without endarterectomy (71.4%), synthetic patch placement (25.7%), ligation (8.6%), bypass or interposition graft (14.3%), and thromboembolectomy (5.7%). Vascular repair was successful in 32 (91.4%) patients while three patients (8.6%) were expired. Complications occurred in 7 (20%) patients, of which superficial wound infections were the common complication (11.6%) and were treated with proper antibiotic therapy.

Conclusion

Prompt identification of IVIs, as well as proper triage for future treatment, can enhance patient outcomes. Our data showed that non-qualified specialists seem to be responsible for the majority of IVIs. For that, we emphasize the importance of performing vascular procedures by a qualified specialist with adequate training.

External Fixation as a Primary and Definitive Treatment for Complex Tibial Diaphyseal Fractures: An Underutilized and Efficacious Approach

Background

External fixation is one of the most often utilized treatment options for complicated tibial diaphyseal fractures (TDF). The purpose of this study was to assess the efficacy of unilateral external fixators as primary and definitive therapy for complex TDF in a resource-limited setting.

Materials and Methods

A retrospective study between June 2016 and March 2021 included 110 subjects with TDF who were treated with an external fixator as definitive fixation in hospitals affiliated with Ibb University. The patient's demographic characteristics, complications, and outcomes were gathered and analyzed. Factors associated with pin site infection were also investigated.

Results

The mean age was 42.1 ± 10.1 years, with 92.7% being male. Rural residents accounted for 22.7%. Smoking and diabetes mellitus were present in 27.3% and 30.0%, respectively. General complications occurred in 12.0%, with pulmonary embolism being the most common at 4.5%. Orthopedic complications included pin-track infections in 27.3% (30) and osteomyelitis in 1.8% (2). Pin site infections required medical treatment in 21 cases and external fixator changes in five. Two cases each needed several debridements for osteomyelitis and soft tissue. Full union occurred in 79.1% (87) over 23.1 ± 3.2 weeks and final alignment in 97.3% (107) over 34.8 ± 4.8 weeks. Malunions occurred in 1.8% (2), and one case had hypertrophic nonunion. Factors like rural residency, smoking, diabetes, open fractures, worst fracture grade (Gustilo and Anderson type C), and general complications occurrence significantly correlated with pin site infection (all p-values < 0.05).

Conclusion

A unilateral external fixator as a primary and definitive treatment is a viable, simple, and effective option for TDF with a high success rate even in a resource-limited setting. In this study, residents in rural areas, smoking, diabetes, open fracture, worst fracture grade, and general complication occurrence were associated with pin site infection occurrence.

Perinatal Birth Asphyxia Among Newborns at Jiblah Public Health Hospital in Ibb City, Yemen, During Six Years of Conflict and Its Predictive Factors: A Retrospective Cross-Sectional Study

BACKGROUND

Birth asphyxia is a major cause of infant death across the world, especially in developing countries, where the issue is significantly underreported and underestimated, particularly in fragile and conflict-affected states.

OBJECTIVE

The purpose of this study was to determine the prevalence and risk factors for birth asphyxia in women at Jiblah University Hospital in Ibb, Yemen, and its predictive factors throughout six years of conflict.

METHOD

We conducted a retrospective cross-sectional chart review and analysis of the birth database spanning from June 2013 to September 2019 at Jiblah University Hospital in Ibb, Yemen. We used APGAR (appearance, pulse, grimace, activity, and respiration) scores <7 at both the first- and fifth-minute post-delivery with umbilical cord arterial blood pH <7 (metabolic acidosis) and/or neurologic manifestations (seizures or an altered tone) within the first 24 hours of life to define birth asphyxia cases. Factors associated with birth asphyxia were analyzed using univariate and multivariate regression analysis with an odds ratio (OR) and 95% confidence interval (CI).

RESULTS

A total of 5,193 neonates were delivered during the study period. The prevalence of birth asphyxia in 309 (6%) neonates. In a multivariate analysis, illiteracy (OR: 2.90; 95% CI: 0.98-8.41), referred mothers (OR: 3.04; 95% CI: 1.42-6.40), advanced maternal age (OR: 1.05; 95% CI: 1.02-1.07), home delivery (OR: 6.50; 95% CI: 3.09-12.57), prematurity (OR: 1.43; 95% CI: 1.05-1.93), and low birth weight (OR: 3.09; 95% CI: 1.93-4.93) were predictors for birth asphyxia and were statistically significant (p<0.05).

CONCLUSION

In this study, the prevalence of birth asphyxia was equivalent to that of other underdeveloped nations. However, continual attention and treatments are required to lower the risk of birth asphyxia. Illiteracy, referred mothers, advanced maternal age, home delivery, prematurity, and low birth weight were all predictors of birth asphyxia in this research. Most birth asphyxia factors mentioned in this study can be managed through effective prenatal, intrapartum, and postpartum care, as well as a strict following of national obstetrics and neonatal guidelines.

Microsurgical Digits Replantation in Resource-Limited Setting: A Retrospective Study

Background

This article aims to share our experiences with microsurgical finger replantation in a resource-limited setting.

Methods

This multi-institutional, retrospective study included 21 cases of finger amputation that underwent microsurgical replantation, within 7 years period. Patient demographics, preoperative assessments, surgical approaches, and outcomes were documented and analyzed. A univariate analysis was performed to obtain factors associated with digit reimplantation failure.

Results

Out of 21 cases included, 8 (38.1%) had complete amputations and 13 (61.9%) had incomplete amputations. Crush injuries accounted for the majority (71.4%). On average, 2.2 ± 1.1 digits were affected, with the ring finger being the most commonly injured (71.4%). The mean operative time was 121.5 ± 26.8 minutes. The success rate of digit replantation was 76.2%. During a mean follow-up of 14.3 ± 3.7 months, 85.7% of successfully replanted digits considered their replantation results satisfactory. The majority of replanted digits demonstrated active and effective holding and grasping abilities without pain or instability (76.2%). Replantation failure was associated with a higher number of affected digits (p < 0.001), longer operative time (p = 0.004), complete avulsion (p = 0.003), current smoking (p = 0.025), diabetes (p = 0.006), hypertension (p = 0.047), procedure difficulty score (p= 0.004), and occurrence of complications (p < 0.001).

Conclusion

Microsurgical finger replantation can yield favorable outcomes and acceptable survival rates, even within resource-limited settings. However, this procedure requires specialized equipment and personnel that may not be available at all institutions. Influential factors in digit replantation failure, include an increased number of damaged digits, extended operative duration, complete avulsion, current smoking, diabetes, hypertension, procedure difficulty score, and postoperative complications occurrence.

Clinical Characteristics and Survival of Hepatocellular Carcinoma: Insights from Single-Centre Experience in Saudi Arabia

Background Hepatocellular carcinoma (HCC) represents the most common primary liver malignancy, with a high fatality rate. Relatively, Saudi Arabia has a high incidence of HCC, which is detected in later stages with a poor prognosis. This study aims to investigate the patterns, outcomes, and mortality predictors of HCC in Saudi Arabia. Method A retrospective study from April 2018 to June 2022 included patients with HCC who were diagnosed and managed at the Najran Oncology Center, Saudi Arabia. Through our cancer registry, the patients' clinical, laboratory, radiological, and survival profiles were extracted and analyzed to assess factors associated with mortality using a univariate analysis. The overall survival was calculated by the Kaplan-Meier method. Results The study involved 52 patients with an average age of 74.6 years, predominantly male (the male-to-female ratio is 2.25:1). Viral infections were the primary cause of liver disease in 40.3% (n=21) of patients. At diagnosis, the Child-Pugh class distribution included 23.1% (n=12) patients in class A, 36.5% (n=19) patients in class B, and 40.4% (n=21) patients in class C. Uninodular tumors with ≤50% liver extension were observed in 65.4% (n=34) of cases, and 30.8% (n=16) had portal vein thrombosis. Elevated alpha-fetoprotein (AFP) levels were noted in 48.1% (n=25) of patients, with 23.1% (n=12) exceeding 400 ng/mL. Curative resection was performed in 32.7% (n=17) of patients. The mean survival time was 23±11.8 months (median of 22.5 months, minimum of six, and maximum of 49 months). Relapse occurred in seven (13.5%) cases, while new metastasis occurred in 20 (38.5%) cases. During the study period, 26 (50.0%) patients died. The main cause of death was disease progression in 15 (28.8%) patients. Univariate analysis showed that AFP>400 ng/mL (OR: 4.68; 95% CI: 1.87-11.66, p=0.001), presence of relapse (OR: 0.16; 95% CI: 0.03-0.78, p=0.023), abdominal ascites (OR: 3.38; 95% CI: 1.25-9.14, p=0.016), advanced the Cancer of the Liver Italian Program (CLIP) score (OR: 0.60; 95% CI: 0.41-0.88, p=0.009) were associated with higher mortality rate and were statistically significant. Conclusion Most cases of HCC in our patients were attributed to viral hepatitis, with the majority having liver cirrhosis. Higher AFP (>400 ng/mL), relapse, abdominal ascites, and a higher cancer CLIP score were associated with poorer outcomes. Targeted screening and health education should be advocated; in addition, social determinants should be proactively addressed.

Small Bowel Obstruction in Virgin Abdomen: Predictors of Surgical Intervention Need in Resource-Limited Setting

Background

Limited evidence is available regarding the management of small bowel obstruction in the virgin abdomen (SBO-VA), with most studies excluding this entity. This study aims to assess the available data on the treatment outcomes and predictors of surgical intervention in SBO-VA.

Methods

A retrospective cross-sectional study was conducted between 2015 and 2021, including all diagnosed and managed cases of SBO-VA at Al-Nasar Hospital. Patients were divided according to the treatment approach into surgical or conservative groups. Preoperative laboratory and radiologic data were gathered and compared between groups.

Results

During the study period, 67 cases, primarily males (58.2%), with an average age of 52.2±14.4 years were assessed. Common comorbidities included diabetes (20.9%) and hypertension (16.4%). Key symptoms were rebound tenderness (82.1%) and abdominal tenderness (70.1%). The predominant etiology was adhesions (23.9%). About 46.2% received conservative treatment, 53.8% underwent urgent surgery. Conservative treatment failed in 9.4% of cases, and complications arose in 23.9%, with most being fever (17.9%). Factors necessitating surgical management included older age (58.8 ±11.7 vs 44.9 ±13.8 years, p<0.001), previous hospital admission (p<0.001), presence of abdominal tenderness (p=0.030), longer abdominal pain duration (4.0 ±0.9 vs 2.1 ±0.6 days, p<0.001), higher C- reactive protein (p= 0.033), higher white blood cell (p= 0.006), longer time to hospital presentation (75.3 ±17.2 vs 39.0 ±22.8 days, p= <0.001), small bowel thickness ≥3 cm (p=0.009), and reduced bowel enhancement (p <0.001) on computed tomography imaging. In surgical group, the need for ICU admission was higher and hospital stays were shorter than in conservative group and were statistically significant (p<0.05).

Conclusion

The main etiology of SBO-VA in our study was adhesions. Older age, previous hospital admission, longer abdominal pain duration, abdominal tenderness, increased inflammatory markers, and alarm signs on CT scans are the main factors for determining the need for urgent surgical exploration in patients with SBO-VA. To achieve prompt identification and intervention, it is crucial to maintain a high level of vigilance and awareness, even in individuals with no prior surgical history.

Permanent Complete Heart Block: A Rare Complication of Influenza Infection

The cardiovascular complications of viral illnesses are often underestimated in clinical practice. The influenza virus, one of the most prevalent viral infections, has been associated with a wide spectrum of arrhythmias that are typically transient and self-resolving. We present the case of a 60-year-old female with no prior cardiac comorbidities who developed a complete heart block after an influenza infection. She presented to the clinic with flu-like symptoms and was found to have a complete heart block with a junctional escape rhythm. Polymerase chain reaction testing subsequently confirmed an influenza A infection. She was initially placed on a temporary pacemaker. However, a permanent dual-chamber pacemaker was implanted as bradycardia persisted. Later follow-ups in the cardiology clinic showed that the patient remained dependent on the pacemaker. While there are a few descriptions of influenza-induced transient atrioventricular block, cases of influenza-induced permanent complete heart block are extremely rare, particularly in the absence of severe myocardial inflammation.

Idiopathic high-flow priapism in a 4-month-old infant: A case report and review of literature

Key Clinical Message

High-flow priapism in pediatric population is rare, yet comprehensive clinical evaluation, along with penile Doppler ultrasound, and cavernosal blood analysis are crucial for accurate diagnosis. Conservative therapy is effective as an initial treatment.

Abstract

High-flow priapism is considerably rare in the pediatric age group. We report a four-month-old infant presented with a prolonged penile erection. Diagnostic confirmation was achieved through the utilization of Doppler ultrasound and cavernous blood gas analysis. We also review published data on the management of this condition.

Open surgical retrieval of intra-uterine contraceptive device perforating the ileum: A case report

INTRODUCTION AND IMPORTANCE

Intra-uterine contraceptive devices (IUCDs) are globally acknowledged for their high utilization and tolerability as contraceptive techniques. However, the uncommon but critical complication of IUCD perforation and migration into the gastrointestinal (GI) system necessitates careful consideration.

CASE PRESENTATION

We present a case of IUCD migration culminating in ileal perforation in a 30-year-old female. The patient, with a history of IUCD insertion four years prior, manifested persistent abdominal discomfort lasting for a period of six months. Computed tomography (CT) scans of the abdomen disclosed the presence of an extraneous object perforating the uterine wall and penetrating the ileum. Surgical intervention substantiated the diagnosis, encompassing the removal of the IUCD and subsequent suturing to amend the bowel wall defect. The patient's post-operative recovery proceeded without additional complications.

CLINICAL DISCUSSION

Migration and GI perforation of the IUCD are uncommon complications, and require immediate attention and proper management. When there is a suspicion of a missing IUCD, obtaining radiologic confirmation and timely removal is crucial.

CONCLUSION

In females of reproductive age, persistent abdominopelvic pain warrants an evaluation of their IUCD placement history and a thorough examination. If the IUCD string is not visible, further radiological investigation is mandated. Any delay in diagnosis and the ensuing treatment may lead to significant, potentially catastrophic, organ damage.

Prognostic determinants and treatment outcomes of Fournier's Gangrene treatment in a resource-limited setting: A retrospective study

BACKGROUND

Fournier's gangrene (FG) is a destructive necrotizing infection with a generally poor prognosis. This study aims to share our experience in handling FG patients in a resource-limited setting and identify prognostic factors for FG mortality.

METHODS

A retrospective study of thirty-six patients diagnosed with FG and treated at our teaching hospital between Jun 2010 to Oct 2022 was conducted. Laboratory and nonlaboratory data and patients' outcomes were gathered. A univariate analysis was computed for identifying prognostic factors for FG mortality.

RESULT

The main age was 68.30 ± 5.61years and most (69.4%) were older than 65 years. The overall survival was 63.9% and the mortality rate was 36.1%. Univariate analysis showed that advanced age (p = 0.02), delayed in hospital presentation (p = 0.024), involvement of larger area (p = 0.001), a history of diabetes mellitus (p < 0.006), end-stage renal disease (p = 0.018), heart failure (p = 0.005), cerebrovascular accident (p = 0.003), liver cirrhosis (p = 0.001), presence of multiple comorbidities (p = 0.001), septic conditions at admission (p = 0.048), need for mechanical ventilation (p = 0.001), hypoalbuminemia (p < 0.001), and elevated blood urea nitrogen (p = 0.002) were found to be risk factors for mortality in patients with FG.

CONCLUSIONS

Fournier's gangrene is a fulminant condition with a high mortality rate, especially in resource-limited settings. In this study, the mortality rate was 36.1%. Advanced age, delayed in hospital presentation, involvement of larger area, a history of diabetes mellitus, end-stage renal disease, heart failure, cerebrovascular accident, liver cirrhosis, presence of multiple comorbidities, septic conditions at admission, need for mechanical ventilation, hypoalbuminemia, and elevated blood urea nitrogen were associated with FG mortality.

Pediatric Spinal Neuroschistosomiasis in Yemen: An Overlooked Dilemma in an Endemic Region

BACKGROUND

Neurological involvement in schistosomiasis presents a significant and serious complication. While the disease is generally considered treatable during the early stages, the rarity of this condition often leads to delays in diagnosis and treatment. This study aims to report the clinical characteristics of pediatric patients with spinal neuroschistosomiasis (NS) in an endemic area to the disease.

METHODS

A retrospective cross-sectional review was conducted at Althora General Hospital in Ibb, Yemen, from January 2016 to January 2021. The study examined confirmed pediatric cases of spinal NS, analyzing their clinical characteristics, laboratory and radiological data, treatment approaches, and complications.

RESULTS

The study identified 10 cases of spinal NS with a mean age of 10.1± 3.2 years. The majority (90%) were male and from rural areas, all with a history of freshwater exposure, a known risk factor for schistosomiasis. The average time from presentation to treatment was 33.4± 45.6 days (7-150 days). Common symptoms observed in all patients were bladder dysfunction and paresthesia (100%). Intestinal dysfunction was prevalent in 90% of cases, while 80% exhibited limb weakness or inability to walk. The diagnosis was confirmed through cerebrospinal fluid (CSF) serology in 80% of cases, and stool and urine exams yielded positive results in 90% and 30% of cases, respectively. Magnetic Resonance Imaging findings revealed medullary lesions in 50% of cases, cauda equina lesions in 20%, and multiple lesions in 30%. All patients received oral praziquantel and high-dose steroids for at least three days as part of their initial treatment. During the average follow-up period of 5.6±1.7 months, one patient experienced lower extremity paraplegia, while two cases (20%) showed partial improvement with residual deficits including urinary and fecal incontinence. Complete resolution of symptoms was achieved in seven cases (70%).

CONCLUSION

Schistosomiasis should be considered in pediatric patients with myeloradicular manifestations, especially in endemic areas. Early identification can be achieved through history, prompt imaging, and CSF serology. In the absence of immediate test results, expert-guided presumptive therapy should be considered to minimize neurological complications.

Treatment outcome of Fournier's gangrene and its associated factors: A retrospective study

INTRODUCTION

Fournier's gangrene (FG) is a rapidly progressive necrotizing infection that affects the perineal and abdominal regions and is known for its high mortality rate. This study aims to present the practical experience of managing FG patients and identify factors that may affect their clinical outcomes.

MATERIALS AND METHODS

A retrospective study was conducted from April 2009 to December 2020 at General Military Hospital in Sana'a, Yemen including 26 patients who were diagnosed with FG and treated on. Data on demographic characteristics, time to admission, surgical intervention, and treatment outcomes were collected. Univariate analysis was performed to determine factors that affect patient outcomes.

RESULT

The mean age of the patients was 65.77 ± 5.04 years, and 65.4% of them were over the age of 65. Most patients (57.7%) presented after five days of experiencing symptoms, and 65.4% were in septic conditions. Of the patients, 17 (65.4%) survived, and the total mortality rate was 34.6%. Univariate analysis showed that delayed presentation (p = 0.001), a history of diabetes mellitus (p < 0.001), end-stage renal disease (p < 0.001), heart failure (p < 0.001), cerebrovascular accident (p = 0.032), liver cirrhosis (p < 001), presence of multiple comorbidities (p < 001), involvement of lager area (p < 001), septic conditions (p = 0.009), advanced age (p = 0.018), and intensive care unit admission (p = 0.002) were found to be risk factors for mortality in patients with FG.

CONCLUSIONS

FG is a potentially life-threatening medical condition, even with aggressive and specialized treatment. Our study revealed a mortality rate of 34.6%. Factors such as older age, the presence of multiple comorbidities, septic conditions, the abdominal spread of the disease, intensive care unit admission, and delayed presentation contribute to higher mortality rates.

Traumatic herniation of buccal fat pad into the oral cavity in an infant: A case report

Buccal fat herniation is a rare traumatic disease that should be included in differential diagnosis of infants' oral cavity mass. History of proceeding trauma, careful evaluation of mucosal perforation aiding the diagnosis.

Congenital uterine arteriovenous malformation presenting as vaginal bleeding following vaginal delivery in a 23-year-old woman: A case report

Congenital uterine arteriovenous malformations (AVMs) are an uncommon cause of vaginal bleeding in women of reproductive age. In the medical literature, there are few reports of congenital uterine AVMs. This report describes a 23-year-old woman who presented with intermittent vaginal bleeding following a vaginal delivery two years prior. Initially, a molar pregnancy was suspected, but further assessment with magnetic resonance imaging revealed a diagnosis of right uterine AVM. The patient underwent uterine artery embolization, which was repeated three months later. At two-year follow-up, the patient remained free of symptoms. This case highlights the importance of considering congenital uterine AVM as a potential cause of vaginal bleeding and emphasizes the need for clinical examination and radiologic investigations to establish an accurate diagnosis. Treatment depends on disease severity, comorbidities, patient age, and fertility desires.

Thoraco-abdominal impalement injury with an iron rod: A case report

INTRODUCTION AND IMPORTANCE

Impalement thoracoabdominal injuries are potentially life-threatening due to the associated bleeding and multiple visceral injuries. They are uncommon and often result in severe surgical complications, requiring prompt treatment and extensive care.

CASE PRESENTATION

We present a 45-year-old male patient who fell from a 4.5-meter-high tree and landed on a Schulman iron rod stick, which pierced the patient's right midaxillary line, exiting from his epigastric region and leading to multiple intraabdominal injuries and right pneumothorax. The patient was resuscitated and immediately shifted to the operating theater. The main operative findings were moderate hemoperitoneum, gastric and jejunum perforations, and liver laceration. A right chest tube was inserted, and injuries were repaired with segmental resection, anastomosis, and colostomy procedure with uneventful post-operative recovery.

CLINICAL DISCUSSION

Providing efficient and prompt care is crucial for patient survival. This includes securing the airways, providing cardiopulmonary resuscitation, and aggressive shock therapy to stabilize the patient's hemodynamic status. The removal of impaled objects is strongly discouraged outside the operation theater.

CONCLUSION

Thoracoabdominal impalement injury is rarely reported in the literature; appropriate resuscitative care, prompt diagnosis, and early surgical intervention may minimize mortality and improve the patient's outcomes.

Surgical management of penoscrotal hypospadias in a child with Opitz G/BBB syndrome: a case report

Opitz G/BBB syndrome is a rare condition characterized by three significant anomalies; hypertelorism, cleft lip and palate, and hypospadias. However, other anomalies may be associated. Herein, we report a 4-year-old child presented with penoscrotal hypospadias. On examination, hypertelorism and cleft lip and palate were noticed, suggesting a diagnosis of Opitz G/BBB syndrome. The cleft lip was corrected in the first year, and a two-staged surgical approach was implemented for penoscrotal hypospadias. In the first stage, the chordee was corrected and urethral plate was reconstructed using a tabularized incised plate urethroplasty and testicular tunica vaginalis flap. In the second stage, the remanent hypospadias was corrected, and the meatal opening reached its normal location. In conclusion, a two-staged surgical approach for the treatment of penoscrotal hypospadias associated with Opitz G/BBB syndrome may provide excellent outcomes in early-recognized cases. The urologist should pay attention to abnormal facial characteristics in patients with hypospadias.

Metastasis of colorectal adenocarcinoma to the right ventricle in a young man: a case report

Cardiac cancers are exceedingly rare, mainly appearing as secondary cancers in patients with numerous systemic metastases, and are often detected by autopsies. Right ventricle (RV) metastasis from metastatic colorectal cancer (mCRC) is rarely reported in the literature. We report a 24-year-old man's case of mCRC, who developed positional variation in pulse rate while receiving the second cycle of chemotherapy. The echocardiography and chest computed tomography (CT) scan showed RV mass. The tumor was right-sided, and Kirsten rat sarcoma (KRAS) mutated based on that. He was treated with FOLFOX chemotherapy protocol plus bevacizumab and enoxaparin with an initial reduction in mass size. However, follow-up CT 9 months later demonstrated disease progression. For that, the chemotherapy was stopped, and the patient received palliative care. In conclusion, this case provides evidence that mCRC and RV location of metastasis can and do occur. In such a case, therapeutic intervention should be determined by weighing the benefits and risks.

Iatrogenic Ureteral and Colonic Injuries During Emergency Cesarean Section: A Lesson Learned from a Surgical Catastrophe - A Case Report

Introduction

Iatrogenic concomitant ureteral and colonic injury in emergency cesarean section (C-section) is an exceedingly rare, yet, catastrophic complication and has not been reported to our knowledge.

Case Report

A 30-year-old woman presented with decreased urination for 2 days after a C-section. Ultrasonography showed severe left hydronephrosis and moderate abdominal free fluid. A ureteroscopy revealed a total occlusion of the left ureter, and subsequently, a ureteroneocystostomy was performed. Two days later, the patient was complicated with abdominal distension that necessitated re-exploration. The exploration revealed colonic injury (rectosigmoid), peritonitis, endometritis, and ureteral anastomosis disruption. A colostomy, repair of colonic injury, hysterectomy, and ureterocutaneous diversion were performed. The patient's hospital stay was complicated, with stomal retraction requiring operative revision and wound dehiscence, which was treated conservatively. After 6 months, the colostomy was closed, and the ureter was anastomosed via the Boari-flap procedure.

Conclusion

Injuries to the urinary and gastrointestinal tracts are serious complications of a cesarean section; concurrent involvement is exceedingly rare; however, delayed recognition and intervention can worsen the prognosis.

Pancreatic Tumorigenesis: Precursors, Genetic Risk Factors and Screening

Pancreatic cancer (PC) is a highly malignant and aggressive tumor. Despite medical advancement, the silent nature of PC results in only 20% of all cases considered resectable at the time of diagnosis. It is projected to become the second leading cause in 2030. Most pancreatic cancer cases are diagnosed in the advanced stages. Such cases are typically unresectable and are associated with a 5-year survival of less than 10%. Although there is no guideline consensus regarding recommendations for screening for pancreatic cancer, early detection has been associated with better outcomes. In addition to continued utilization of imaging and conventional tumor markers, clinicians should be aware of novel testing modalities that may be effective for early detection of pancreatic cancer in individuals with high-risk factors. The pathogenesis of PC is not well understood; however, various modifiable and non-modifiable factors have been implicated in pancreatic oncogenesis. PC detection in the earlier stages is associated with better outcomes; nevertheless, most oncological societies do not recommend universal screening as it may result in a high false-positive rate. Therefore, targeted screening for high-risk individuals represents a reasonable option. In this review, we aimed to summarize the pathogenesis, genetic risk factors, high-risk population, and screening modalities for PC.

Transient urocolpos due to vesicovaginal reflux in a 37-year-old woman: a case report

Urocolpos is a urine collection in the vagina, possibly due to vesicovaginal reflux (VVR) or a fistula. Urocolpos is a rare phenomenon in adults, and it is commonly underrecognized by radiologists. The occurrence of urocolpos due to VVR after a Caesarean section in adult females is a rare phenomenon; failure to recognize it may lead to misdiagnosis as vesicovaginal fistula and often leads to unnecessary medical interventions. We report a 37-year-old female who complained of abdominal pain and intermittent daytime urinary incontinence for six months, starting after a Caesarean section for her third baby. An abdominal computed tomography scan revealed a large fluid-filled vagina on a full bladder without anatomical abnormality. A post-voiding scan showed a complete resolution. In conclusion, urocolpos is an underrecognized entity that rarely coexists with VVR. Post-voiding resolution and vaginal contrast reflux are important findings that can aid radiologists in identifying such cases.

Primary pulmonary leiomyosarcoma with coexistent pulmonary aspergillosis: a case report

Coexisting primary pulmonary leiomyosarcoma (PPL) with pulmonary Aspergillosis in immunocompetent patients is a rare occurrence. Here, we presented a 54-year-old woman presented with a dry cough for two months. Bronchoscopy revealed pulmonary aspergillosis. The patient was treated with antifungal therapy for one month without improvement. To evaluate further, a chest computed tomography (CT) scan showed a large heterogeneous enhancing mass in the lower lobe of the left lung with left atrium thrombosis. Computed tomography-guided biopsy was performed, and histopathology demonstrated the diagnosis of PPL. The metastasis workup staging showed multiple metastases in vertebrae, scapula, rib, and liver. The patient was treated with chemotherapy followed by tumor bed radiotherapy. Unfortunately, her general condition worsened, and she passed away with overall survival of fourteen months. In conclusion, clinicians should be alert to underlying malignant disease if airway Aspergillus infection is suspicious in patients without strong risk factors for invasive fungal infection.

Bladder rupture after pembrolizumab immunotherapy for bladder cancer: a case report

Pembrolizumab is a promising checkpoint inhibitor for advanced urothelial carcinoma. Like other immunotherapies, it can cause rare immune-related adverse events. The spontaneous rupture of the urinary bladder after the intravenous injection of pembrolizumab is rare and has not been reported. Here, we present a 74-year-old man patient case of locally advanced transitional cell carcinoma of the urinary bladder who presented severe abdominal pain the same day of the second dose of pembrolizumab administration. The exploratory laparotomy revealed intraperitoneal rupture of the urinary bladder associated with peritonitis. After surgical repair, the patient's condition improved. The purpose of this report is to discuss the possible association of bladder perforation in bladder cancer with pembrolizumab immunotherapy, its management, and the importance of early recognition to prevent more fatal complications.

Synchronous occurrence of papillary thyroid carcinoma and early esophageal squamous cell carcinoma in a 45-year-old female: a case report and review of the literature

Papillary thyroid cancer (PTC) coexistent with esophageal squamous cell carcinoma (SCC) is of rare occurrence. We report a 45-year-old female who presented with painless anterior neck swelling for the past year. Ultrasonography showed a left hypoechoic thyroid mass measured 20x13 mm without lymph node enlargement. The fine-needle aspiration cytology was suggestive of PTC. Consequently, total thyroidectomy with bilateral neck dissection was performed. Incidentally, a small mass measuring 4x2 cm arising from the esophageal wall was identified and resected. Postoperatively, the patient developed a small esophageal fistula which was treated conservatively. The histopathological examination confirmed the diagnosis of PTC and SCC of esophageal mass. The patient underwent radiotherapy, and radioactive iodine therapy, and had acceptable conditions within two years of follow-up. In conclusion, even though the coexistence of PTC and esophageal SCC is rare, the possibility of concurrence of both tumors should be considered if an incidental mass was identified intraoperatively.

Characteristics of patients undergoing thyroidectomy in a resource-limited setting in Ibb city of Yemen: a retrospective monocentric study

Thyroid disorders are prevalent among Yemenis. However, there is limited data regarding thyroid disease burden, surgical intervention outcomes, and predictive factors in our country. This study aims to review the indications, histopathology, and complications of thyroid surgery in a resource-limited setting where the management is provided primarily by general surgeons. A retrospective study between Jun 2010 and March 2019 included 246 cases who underwent thyroid operations for a thyroid disorder in Al-Nasr Hospital, Ibb, Yemen. The patient's demographic characteristics, operative findings, complications, fine needle aspiration biopsy (FNAB) results, final pathology, and outcomes were gathered and analyzed. The mean age was 41.60± 8.31 years. The prevalence was high (30.1%) in the age group of 31-40 years and females (87.8%) with a female-to-male ratio of 7.2: 1. The main indication for thyroidectomy was compressional symptoms (35%), and the main preoperative cytology findings were multimodular goiter (89%). There was thyroid cancer in 18(7.3%) patients, and the most type was follicular thyroid carcinoma (FTC) in 9 patients. The most typical type of surgery was near-total thyroidectomy in 186 (75.6%) patients. Complications were presented in 47 patients (19.1%), and total mortality was observed in 5(2.03%) patients. Intraoperative bleeding was the most typical complication in 36 (14.6%) patients. The sensitivity, specificity, and accuracy of FNAB were 96.34%, 44.44%, and 96.34%, respectively. Fine needle aspiration biopsy (FNAB) was not precise enough in diagnosing FTC with a sensitivity of 55%. Our result showed a considerable rate of postoperative complications of thyroid surgery, and thyroidectomy may be a viable option even in a resource-limited setting or performed by general surgeons.

Role of microsurgical free flap reconstruction in managing complex wound: a retrospective cross-sectional study

Introduction

while reconstruction of complex wounds with severe tissue defects has been a significant problem in plastic surgery, free flap microsurgical procedures could solve many of these problems. In Yemen, data regarding free flap microsurgery for complex wounds are scarce. This study aimed to share our microsurgery experiences in repairing complex wounds using different free flaps in a resource-limited setting.

Methods

a retrospective cross-sectional study between April 2019 and June 2022 conducted at 21 University-affiliated hospitals included 30 patients with complex wound defects that were not amenable for regional, pedicle procedures, or skin grafts and underwent microsurgical reconstructions with deferent free flap tissue transfer. The primary outcome was flap survival or failure, while the secondary outcome was postoperative complications.

Results

the main age was 34.76 ± 16.88 years, with 24 (80%) males and 6 (20%) females. Replacing extensive tissue loss caused by road traffic accidents was the most common indication (36.6%). The mean defects required to be reconstructed were 84.9 ± 44.70 cm². The lower extremities accounted for the majority of reconstructed defects (50%), and mostly (23.3%) involved the leg. Only 10 (33.3%) flaps were performed immediately within 48 hours of trauma. The fibulae osteo-cutaneous free flap (30.0%), radial forearms free flap (23.3%), and anterolateral thigh flap (23.3%) were used most commonly. All flaps were harvested and repaired under loupe magnification or operative microscope by a single surgeon. The overall flap success rate was 83.3%. The total complication rate was 23.3%, and postoperative infection and partial flap necrosis occurred in 3 (10.0%) and 2 (6.6%) patients, respectively. A total flap loss occurred in 5 (16.7%) patients.

Conclusion

reconstruction of complex wounds with microsurgical free flaps is a viable option even in a resource-limited setting. In our study, microsurgery with fibulae osteo-cutaneous free flap was the most commonly used. Despite many limitations, microsurgical free flaps were effective in treating individuals operated on in our setup with a limb salvage rate of 83.3%.