Case Report Primary Amyloidosis Manifesting as Cholestatic Jaundice after Laparoscopic Cholecystectomy

A 71-year-old female patient with cholelithiasis who had undergone laparoscopic cholecystectomy was admitted with obstructive jaundice (total bilirubin ∼6 mg/dL) three months later. An ERCP was performed, in which a gallstone was found, followed by a sphincterotomy and cleansing of the bile duct. Due to deterioration of jaundice (>25 mg/dL), a new, unsuccessful ERCP and stent placement was carried out. Because of ongoing cardiac failure, she underwent an echocardiogram which revealed restrictive cardiomyopathy possibly due to amyloidosis. A liver biopsy was performed, which was positive for amyloid deposits in the liver, and the diagnosis was confirmed by the detection of monoclonal IgG protein in urine. The patient's jaundice gradually deteriorated and she died one week later from hepatic insufficiency

Great saphenous vein versus expanded polytetrafluoroethylene graft in patients undergoing elective treatment of popliteal artery aneurysm with posterior approach

Background: Aim of this study is to compare 30-day and 5-year outcomes of great saphenous vein (GSV) vs. expanded polytetrafluoroethylene (ePTFE) graft in patients undergoing elective treatment of popliteal artery aneurysm (PAA) using a posterior approach. Methods: Between January 2010 and December 2023, a retrospectively maintained dataset of all consecutive asymptomatic PAAs who underwent open repair with posterior approach or endovascular repair in 40 centers was investigated. Out of of 971 cases, 525 patients were included in the present analysis. These were further divided into: posterior approach with GSV graft (252, GSV Group), and posterior approach with ePTFE graft (273, ePTFE Group). Thirty-day outcomes were assessed and compared. During follow-up, survival, primary patency, secondary patency, freedom from reintervention(s), and amputation-free survival were compared between the two groups using log-rank tests. Uni- and multivariate Cox regression analyses were performed in ePTFE Group to find predictive factors of poor outcomes. Results: Two groups were homogeneous in terms of preoperative risk factors and morphological data. Median follow-up duration was similar [24 months (IQR 10 - 36) GSV Group vs. 21 months (IQR 7-47) ePTFE Group; p = .123]. At 5 years, there were no differences between the two groups in terms of survival (84.7% GSV Group vs. 86.1% ePTFE Group; p = .097, log-rank = 2.756), secondary patency (94.9% GSV Group vs. 89.4% ePTFE Group; p = .068, log-rank = 3.336), and amputation-free survival (99.1% GSV Group vs. 99.6% ePTFE Group; p = .567, log-rank = .328). Five-year primary patency (89.5% GSV Group vs. 76.2% ePTFE Group; p = .007, log-rank = 7.239), and freedom from reintervention(s) (92.8% GSV Group vs. 80.6% ePTFE Group; p = .011, log-rank = 6.449) were significantly higher in GSV Group. Using multivariate analysis in ePTFE Group, factors compromising primary patency were patients on dialysis (p = .054, OR = 3.641), and patients that were not on any preoperative antiplatelet therapy or anticoagulation (p = .019, OR = 5.532), whilst none of the perioperative factors affected freedom from reintervention(s). Conclusion: GSV as graft guaranteed better primary patency with less reinterventions rates at mid-term follow-up after treatment of PAAs via a posterior approach. Patients on dialysis and who were not on any preoperative antiplatelet therapy or anticoagulation had lower patency rates

Long-term risk prediction after major lower limb amputation: 1-year results of the PERCEIVE study

Background: Decision-making when considering major lower limb amputation is complex and requires individualized outcome estimation. It is unknown how accurate healthcare professionals or relevant outcome prediction tools are at predicting outcomes at 1-year after major lower limb amputation. Methods: An international, multicentre prospective observational study evaluating healthcare professional accuracy in predicting outcomes 1 year after major lower limb amputation and evaluation of relevant outcome prediction tools identified in a systematic search of the literature was undertaken. Observed outcomes at 1 year were compared with: healthcare professionals' preoperative predictions of death (surgeons and anaesthetists), major lower limb amputation revision (surgeons) and ambulation (surgeons, specialist physiotherapists and vascular nurse practitioners); and probabilities calculated from relevant outcome prediction tools. Results: A total of 537 patients and 2244 healthcare professional predictions of outcomes were included. Surgeons and anaesthetists had acceptable discrimination (C-statistic = 0.715), calibration and overall performance (Brier score = 0.200) when predicting 1-year death, but performed worse when predicting major lower limb amputation revision and ambulation (C-statistics = 0.627 and 0.662 respectively). Healthcare professionals overestimated the death and major lower limb amputation revision risks. Consultants outperformed trainees, especially when predicting ambulation. Allied healthcare professionals marginally outperformed surgeons in predicting ambulation. Two outcome prediction tools (C-statistics = 0.755 and 0.717, Brier scores = 0.158 and 0.178) outperformed healthcare professionals' discrimination, calibration and overall performance in predicting death. Two outcome prediction tools for ambulation (C-statistics = 0.688 and 0.667) marginally outperformed healthcare professionals. Conclusion: There is uncertainty in predicting 1-year outcomes following major lower limb amputation. Different professional groups performed comparably in this study. Two outcome prediction tools for death and two for ambulation outperformed healthcare professionals and may support shared decision-making

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

Multiple non-syndromic basal cell carcinoma with the chest as primary site and lung metastases: A rare case

Basal cell carcinoma (BCC) is the most commonly diagnosed cancer in humans, usually affecting elderly Caucasian men and skin regions mostly exposed to the sun, that rarely metastasizes. We report an unusual and aggressive case of multiple, non-syndromic metastatic BCC with an uncommon primary site in the chest and pulmonary metastases, treated successfully with surgery and vismodegib. A 51-year-old woman presented with a large pigmentary lesion of the chest, close to the sternum. She had the lesion for &gt; 25 years and lately noticed multiple facial lesions. The diagnosis of multiple BCC was suspected and a punch biopsy of the primary lesion was performed. Diagnosis was confirmed by immunohistochemistry (BerEp4+, EMA− phenotype). After excision, staging with a thorax computed tomography scan revealed metastatic micro-nodules in the left lung, confirmed histologically after video-assisted thoracic surgical biopsy. Adjuvant chemotherapy with vismodegib was proposed and administered. At 30 days follow-up, thorax computed tomography scan was unaltered and her facial lesions showed significant regression. Although prognosis remains poor, early diagnosis and prompt management complimented by novel biological agents, like vismodegib, targeting disease pathogenesis, seems to bring promising results.</jats:p