Spontaneous expulsion from rectum: a rare presentation of intestinal lipomas

Lipomas are rare, subserosal, usually solitary, pedunculated small lesions appearing mainly in the large intestine with a minimal malignancy potential. They usually run asymptomatic and become symptomatic when they become enlarged or complicated causing intestinal obstruction, perforation, intusucception or massive bleeding. In rare cases they can be self-detached and expulsed via the rectum as fleshy masses. This event mainly occurs in large, pendunculated lipomas which detach from their pedicle. The reason for this event remains in most of cases unclear although in some cases a predisposing factor does exist. Abdominal pain and obstructive ileus may be observed while in many cases bleeding occurs. The expulsed mass sets the diagnosis and in most of the cases all symptoms subside. Diagnosis is rarely established before surgery with the use of barium enema, computed tomography and colonoscopy which additionally provides measures of treatment and diagnosis. In atypical cases though, in cases where the malignancy can not be excluded or in complicated cases, surgery is recommended. Usually the resection of the affected intestinal part is adequate. If during surgery a lipoma is encountered simple lipomatectomy seems also to be adequate

Superior Mesenteric Artery Syndrome

A 63-year-old female presented to our department complaining of epigastric pain, nausea and vomiting. Symptoms started after a significant loss of weight and persisted despite treatment, leading to hospitalization for dehydration and renal failure due to protracted vomiting. During hospitalization, no pathology could be identified and the patient was discharged. Symptoms persisted and she was eventually readmitted. Superior mesenteric artery syndrome was diagnosed based upon clinical suspicion and barium studies. She was subjected to duodenojejunostomy after failure of conservative treatment. Her immediate postoperative course was uneventful and the patient was well during her two-year follow-up. Clinicians should be suspicious of superior mesenteric artery syndrome, albeit rare, and be aware of its treatment, which is either conservative or surgical

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

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

Abstract 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

Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy for the treatment of cholecysto-choledocholithiasis in a single time procedure

Background: Although the ideal management of cholecysto-choledocholithiasis is controversial, the two-stage approach (ERCP, sphincterotomy and common bile duct clearance followed by laparoscopic cholecystectomy) remains the standard way of management worldwide. One stage approach using the so-called laparoendoscopic rendez vous technique offers some advantages, mainly by reducing the hospital stay and the risk of post ERCP pancreatitis. Aim: To compare the laparoedoscopic rendez vous one stage approach with the standard two stage approach consisting of preoperative ERCP followed by laparoscopic cholecystectomy for the treatment of cholecysto-choledocholithiasis. Setting: Controlled randomized trial, University Hospital/Teaching Hospital Methods: Patients with cholecysto-choledocholithiasis were randomized either to the laparoendoscopic rendez vous (n: 50) or to the two stage approach (n: 50). Both elective and emergency cases are included. Primary endpoint was to detect difference in overall hospital stay, while secondary endpoints were to detect differences in morbidity (especially post-ERCP pancreatitis) and success of CBD clearance Results: Hospital stay was significantly shorter in the laparoendoscopic rendez vous group; median 4 (2-19) days vs 5.5 (3-22) days, p=0.0004. There was no difference in morbidity and success of CBD clearance between the two groups. Post ERCP amylase value was found significantly lower in the laparoendoscopic rendez vous group; median 65 (16-1159) vs 91 (30-1846), p= 0.02. Conclusion: Analysis of the results suggests the superiority of the laparoendoscopic rendez vous technique in terms of hospital stay and post ERCP hyperamylasemia.Πρόλογος: Αν και η ιδανική θεραπεία της χολολιθίασης–χοληδοχολιθίασης παραμένει αμφισβητούμενη, η θεραπεία δύο σταδίων [ενδοσκοπική παλίνδρομη χολαγγειοπαγρεατογραφία (ERCP), σφιγκτηροτομή, και καθαρισμός του χοληδόχου πόρου ακολουθούμενη από λαπαροσκοπική χολοκυστεκτομή], παραμένει η συνηθέστερη θεραπευτική αντιμετώπιση παγκοσμίως. Η θεραπεία σε ένα στάδιο με την τεχνική “rendezvous”προσφέρει ορισμένα πλεονεκτήματα, όπως η μικρότερη παραμονή των ασθενών στο νοσοκομείο και η μείωση των κινδύνων για ανάπτυξη μετά-ERCP παγκρεατίτιδας. Σκοπός: Η σύγκριση της ενός σταδίου αντιμετώπιση με την τεχνική “rendezvous” με τη θεραπεία δύο σταδίων η οποία περιλαμβάνει την προεγχειρητική ERCP και τη λαπαροσκοπική χολοκυστεκτομή, στη θεραπευτική αντιμετώπιση της χολολιθίασης-χοληδοχολιθίασης , που αντιμετωπίζεται είτε εκλεκτικά είτε με χαρακτήρα εκτάκτου / επείγοντος. Τύπος μελέτης: Προοπτική τυχαιοποιημένη μελέτη Μέθοδος: Ασθενείς με χολολιθίαση-χοληδοχολιθίαση τυχαιοποιήθηκαν να υποβληθούν σε θεραπεία ενός ή δύο σταδίων. Στη μελέτη συμπεριλήφθηκαν ασθενείς τόσο σε τακτική όσο και σε επείγουσα βάση. Πρωταρχικός στόχος της μελέτης ήταν η καταγραφή διαφορών στη συνολική παραμονή των ασθενών στο νοσοκομείο, ενώ δευτερεύοντες στόχοι ήταν καταγραφή πιθανών διαφορών στη νοσηρότητα, ειδικά στη μετα-ERCP παγκρεατίτιδα και στην υπεραμυλασαιμία, καθώς και στα ποσοστά επιτυχούς καθαρισμού του χοληδόχου πόρου. Αποτελέσματα: Η μέση παραμονή στο νοσοκομείο ήταν σημαντικά μικρότερη στην ομάδα που έλαβε θεραπεία σε ένα στάδιο: median 4 (2-19) ημέρες vs 5.5 (3-22) ημέρες, p=0.0004. Δεν υπήρξε διαφορά στη νοσηρότητα και στα ποσοστά επιτυχούς καθαρισμού του χοληδόχου πόρου μεταξύ των δύο ομάδων. Η μέση τιμή της αμυλάσης ορού μετά τη σφιγκτηροτομή ήταν σημαντικά χαμηλότερη στην πρώτη ομάδα ασθενών: median 65 (16-1159) vs 91 (30-1846), p= 0.02. Συμπεράσματα: Η ανάλυση των αποτελεσμάτων αναδεικνύει την υπεροχή της ενός σταδίου αντιμετώπισης με την τεχνική “rendezvous”, όσον αφορά στην παραμονή των ασθενών στο νοσοκομείο και στην μετα-ERCP υπεραμυλασαιμία

Ingested Fish Bone: An Unusual Mechanism of Duodenal Perforation and Pancreatic Trauma

Ingestion of gastrointestinal foreign bodies represents a challenging clinical scenario. Increased morbidity is the price for the delayed diagnosis of complications and timely treatment. We present a case of 57-year-old female patient which was admitted in the emergency room department complaining of a mid-epigastric pain over the last twenty-four hours. Based on the patient's history, physical examination and elevated serum amylase levels, a false diagnosis of pancreatitis, was initially adopted. However, a CT scan confirmed the presence of a radiopaque foreign body in the pancreatic head and the presence of air bubbles outside the intestinal lumen. The patient was unaware of the ingestion of the foreign body. At laparotomy, after an oblique duodenotomy, a fish bone pinned in the pancreatic head after the penetration of the medial aspect of the second portion of the duodenal wall was identified and successfully removed. The patient had an uneventful postoperative recovery. Wide variation in clinical presentation characterizes the complicated fish bone ingestions. The strategically located site of penetration in the visceral wall is responsible for the often extraordinary gastrointestinal tract injury patterns. Increased level of suspicion is of paramount importance for the timely diagnosis and treatment

Comparative evaluation of CT and MRI in the preoperative staging of colon cancer

Abstract The aim of this study is to compare the diagnostic performance of magnetic resonance imaging (MRI) against computed tomography (CT) in various aspects of local staging in colon cancer patients. This study was a prospective single arm diagnostic accuracy study. All consecutive adult patients with confirmed colon cancer that met the current criteria for surgical resection were considered as eligible. Diagnostic performance assessment included T (T1/T2 vs T3/T4 and  T3cd) and N (N positive) staging, serosa and retroperitoneal surgical margin (RSM) involvement and extramural vascular invasion (EMVI). Imaging was based on a 3 Tesla MRI system and the evaluation of all sequences (T1, T2 and diffusion-weighted imaging-DWI series) by two independent readers. CT scan was performed in a 128 row multidetector (MD) CT scanner (slice thickness: 1 mm) with intravenous contrast. Pathology report was considered as the gold standard for local staging. Sensitivity (SE), specificity (SP), and area under the curve (AUC) were calculated for both observers. MRI displayed a higher diagnostic performance over CT in terms of T1/T2 vs T3/T4 (SE: 100% vs 83.9%, SP: 96.6% vs 81%, AUC: 0.825 vs 0.983, p < 0.001), N positive (p < 0.001) and EMVI (p = 0.023) assessment. An excellent performance of MRI was noted in the T3ab vs T3cd (CT AUCReader1: 0.636, AUCReader2: 0.55 vs MRI AUCReader1: 0.829 AUCReader2 0.846, p = 0.01) and RSM invasion diagnosis. In contrast to these, MRI did not perform well in the identification of serosa invasion. MRI had a higher diagnostic yield than CT in several local staging parameters