Large Right Atrial Myxoma: A Rare Presentation

We present a case of a 74-year-old female with a large right atrial myxoma who initially presented to her primary care physician with nonspecific constitutional and abdominal symptoms. Her presenting symptoms were initially thought to originate from her gastrointestinal tract, but her workup for a gastrointestinal disorder was nondiagnostic. It was not until this patient developed symptoms of overt right heart failure that a cardiac condition was suspected. Our case highlights the importance of understanding the potential of cardiac myxomas to mimic many diseases, including cardiac, infective, neurologic, immunologic, pulmonary, and malignant diseases. Therefore, clinicians must always maintain a high index of suspicion for cardiac myxomas when evaluating patients with cardiac and non-cardiac-related symptoms that may be due to these tumors.

The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial

Background

Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair.

Patients and methods

All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh.

Results

The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation.

Trial Registration

ClinicalTrials.gov, identification number NCT04179578.

An Incidental Myxoma Hidden in Chest Pain

Chest pain is a very common symptom in an emergency context. Its differential diagnosis is extensive and includes some conditions that require immediate recognition and intervention. It can also be a symptom associated with rarer diagnostic possibilities. Here, we report the case of a 53-year-old woman admitted to the emergency department due to chest pain and initially diagnosed with non-ST elevation acute myocardial infarction. A transthoracic echocardiogram revealed a large hyperechogenic round mass, suggestive of a left atrial cardiac myxoma. Coronary angiography showed no significant lesions. The patient underwent cardiac surgery with excision of the mass, whose histological diagnosis was atrial myxoma. The immediate postoperative period was uneventful, and the patient was discharged asymptomatic and without echocardiographic changes. Cardiac tumors are a rare finding, of which myxomas are the most common. Symptoms can typically result from embolism, obstruction, or constitutional symptoms. A myxoma presenting as acute chest pain and mimicking an acute coronary syndrome is an uncommon finding. This case reminds us of an extremely rare differential diagnosis of chest pain and awakens us to the usefulness and importance of using echocardiography as a diagnostic tool.

Case report: Hysteroscopy combined with a vaginal mold for severe recurrent vaginal adhesion and stenosis with pyocolpos after pelvic fracture in a 13-year-old female

Vaginal adhesions and stenosis are infrequent long-term sequelae following pediatric pelvic fractures. Patients may not present with signs and symptoms before menarche, leading to delayed diagnosis and treatment. We report an adolescent girl who presented with a post-abdominal trauma pelvic fracture and urethrovaginal fistula and subsequent severe vaginal adhesion, which resulted in infection and obstructive symptoms after menarche. Hysteroscopy-guided vaginal adhesion release using an epidural catheter and ultrasonography was performed, followed by vaginal dilation, to resolve obstructive symptoms. For girls with pelvic fractures, education on possible long-term sequelae is required, as is regular follow-up. Timely diagnosis and treatment are important, and hysteroscopic release of vaginal adhesion and postoperative regular vaginal dilation may be an effective treatment.

Forty-Year Experience Alleviating Postoperative Hirschsprung-Associated Enterocolitis by Complete Full-Thickness Posterior Rectal Cuff Excision. The Anorectal Line Eliminates Problematic Anastomoses

Introduction: A modified pull-through (PT) distinguished by complete full-thickness removal of the posterior rectal cuff, initially developed as an open procedure in 1980, has been performed with laparoscopic assistance since 1997. Postoperative bowel dysfunction improved when the anatomic landmark for PT surgery was revised from the dentate line (DL) to the anorectal (or Herrmann's) line (ARL) in 2007. A 40-year (1980-2019) review of 153 consecutive rectal/rectosigmoid type Hirschsprung's disease (HD) patients is presented. Methods: Data for postoperative bowel dysfunction and Hirschsprung-associated enterocolitis (HAEC) classified according to the American Pediatric Surgical Association (APSA) scale were obtained retrospectively. Results: PT was open (n = 43) and laparoscopic (n = 110). Dissection was DL (n = 57) and ARL (n = 96). Over 40 years, 5/153 patients (3.3%) had postoperative obstructive symptoms (POS), and 10/153 patients (6.5%) had 13 episodes of postoperative HAEC; APSA grades were: I (n = 4); II (n = 8); and III: (n = 1) presenting with explosive diarrhea (10/13; 76.9%), fever (10/13; 76.9%), abdominal distension (9/13; 69.2%), or bloody stools/shock (1/13 with grade III; 7.7%). The grade III case had histologically-proven transitional zone PT. Postoperative HAEC developed in 3/5 (60.0%) POS+ patients and 7/148 (4.7%) POS- patients (P = .002). Symptom duration and treatment were not correlated with APSA grades. Conclusions: Complete full-thickness posterior rectal cuff excision and using the ARL reduced postoperative HAEC significantly in this series. Despite being anatomically distinct, the DL is inadequate as a precise landmark for PT surgery because it lacks functional relevance. The APSA scale could benefit from timely review to improve its clinical and prognostic value.

Concentration-dependent alpha1-Adrenoceptor Antagonism and Inhibition of Neurogenic Smooth Muscle Contraction by Mirabegron in the Human Prostate

Introduction: Mirabegron is available for treatment of storage symptoms in overactive bladder, which may be improved by β₃-adrenoceptor-induced bladder smooth muscle relaxation. In addition to storage symptoms, lower urinary tract symptoms in men include obstructive symptoms attributed to benign prostatic hyperplasia, caused by increased prostate smooth muscle tone and prostate enlargement. In contrast to the bladder and storage symptoms, effects of mirabegron on prostate smooth muscle contraction and obstructive symptoms are poorly understood. Evidence from non-human smooth muscle suggested antagonism of α₁-adrenoceptors as an important off-target effect of mirabegron. As α₁-adrenergic contraction is crucial in pathophysiology and medical treatment of obstructive symptoms, we here examined effects of mirabegron on contractions of human prostate tissues and on proliferation of prostate stromal cells.

Methods: Contractions were induced in an organ bath. Effects of mirabegron on proliferation, viability, and cAMP levels in cultured stromal cells were examined by EdU assays, CCK-8 assays and enzyme-linked immunosorbent assay.

Results: Mirabegron in concentrations of 5 and 10 μM, but not 1 µM inhibited electric field stimulation-induced contractions of human prostate tissues. Mirabegron in concentrations of 5 and 10 µM shifted concentration response curves for noradrenaline-, methoxamine- and phenylephrine-induced contractions to the right, including recovery of contractions at high concentrations of α₁-adrenergic agonists, increased EC₅₀ values, but unchanged E_max values. Rightshifts of noradrenaline concentration response curves and inhibition of EFS-induced contractions were resistant to L-748,337, l-NAME, and BPIPP. 1 µM mirabegron was without effect on α₁-adrenergic contractions. Endothelin-1- and U46619-induced contractions were not affected or only inhibited to neglectable extent. Effects of mirabegron (0.5–10 µM) on proliferation and viability of stromal cells were neglectable or small, reaching maximum decreases of 8% in proliferation assays and 17% in viability assays. Mirabegron did not induce detectable increases of cAMP levels in cultured stromal cells.

Conclusion: Mirabegron inhibits neurogenic and α₁-adrenergic human prostate smooth muscle contractions. This inhibition may be based on antagonism of α₁-adrenoceptors by mirabegron, and does not include activation of β₃-adrenoceptors and requires concentrations ranging 50-100fold higher than plasma concentrations reported from normal dosing. Non-adrenergic contractions and proliferation of prostate stromal cells are not inhibited by mirabegron.

Magnetic resonance enterography: safe and effective imaging for stricturing Crohn's disease

BACKGROUND

Symptomatic Crohn's disease (CD) patients often undergo diagnostic imaging studies for evaluation of disease activity or complications including bowel strictures and obstruction. Magnetic resonance enterography (MRE) provides information regarding disease activity, chronicity, and stricture formation without using ionizing radiation.

AIM

Examine the use of MRE among CD patients presenting with symptoms suggesting obstruction in a tertiary care practice setting.

METHODS

We performed a retrospective study of all CD patients undergoing MRE at a tertiary IBD referral center over a 3-year study period including a subgroup analysis of patients presenting obstructive symptoms. Positive and negative findings from MRE were correlated with medical and surgical decision outcomes over the subsequent 90-day period.

RESULTS

In the study, 119 CD patients underwent 133 MRE scans, including 40 scans on individuals presenting with obstructive symptoms. Positive findings of CD including active inflammation, stricturing, and penetrating disease were more frequent in MREs ordered to evaluate obstructive symptoms (87.5%) compared other indications (58.1%, p = 0.001). In patients presenting with obstructive symptoms, MRE findings assisted in directing a change of clinical management towards escalation of medical therapy in 55% and surgery in 32.5%. Review of surgical resection specimens corroborated MRE findings of disease activity and fibrosis in 92% of cases going to surgery.

CONCLUSIONS

In practice-based use at a tertiary IBD referral center, MRE provided an effective, radiation-free alternative to computed tomography by providing valuable diagnostic information for evaluating and directing care in Crohn's disease, particularly for patients presenting with obstructive symptoms.

Is the Rehbein procedure obsolete in the treatment of Hirschsprung's disease?

PURPOSE

After 25 years of practice and positive results of the Rehbein-procedure (RB) for children with Hirschsprung Disease (HD), we changed to the less invasive transanal endorectal pull through (TERPT). The aim of this study was to compare short- and mid-term complications of these two procedures in our patients with HD.

METHODS

Retrospective data of 50 HD patients were analyzed. Of these patients, 25 underwent RB (2000-2006) and in 25 the TERPT was performed (2005-2009). Medical records were reviewed to score complications and outcomes. Differences were analyzed using Chi-Square and Mann-Whitney U tests.

RESULTS

All RB patients (100%) were given a colostomy compared with four patients (16%) in the TERPT group (p < 0.001). The average age at surgery in the RB group was 191 days whereas this was 72 days in the TERPT group (p < 0.01). The mean length of time of surgery in the RB group (158 min) was not significantly different from that in the TERPT group (183 min). Ganglion cells were located in all specimens at the proximal end of the specimens. The median time to first feeding significantly decreased from 2 days (range 1-11) in the RB group to 1 day (range 1-3) in the TERPT group (p < 0.01). The median length of hospital stay decreased in the TERPT group (8 days) compared with the RB group (10 days) (p < 0.001). There was a significant reduction in postoperative obstructive symptoms during the first 6 months in the TERPT group (48%) compared with the RB group (84%) (p = 0.016). Postoperative enterocolitis decreased from 40% in the RB group to 24% in the TERPT group although this was not statistically significant.

CONCLUSIONS

The introduction of TERPT reduced the need for colostomies; it shortened days to first feeding after surgery and reduced hospital stay. It also improved short-term outcome with less obstructive symptoms. We recommend TERPT surgery as a first choice in children with HD. we consider the RB now to be obsolete.