Recurrent laryngeal nerve palsy due to impacted dental plate in the thoracic oesophagus: case report

<p>Abstract</p> <p>Background</p> <p>Retained oesophageal foreign bodies must be urgently removed to prevent potentially serious complications. Recurrent laryngeal nerve palsy is rare and has not been reported in association with a foreign body in the thoracic oesophagus.</p> <p>Case presentation</p> <p>We present a case of a dental plate in the thoracic oesophagus that caused high dysphagia. Delayed diagnosis led to a recurrent laryngeal nerve palsy, which persisted despite successful surgical removal of the foreign body.</p> <p>Conclusion</p> <p>Oesophagoscopy is essential to fully assess patients with persistent symptoms after foreign body ingestion, irrespective of the level of dysphagia. Recurrent laryngeal nerve palsy may indicate impending perforation and should prompt urgent evaluation and treatment.</p

Pancreatic anastomosis training models:current status and future directions

Postoperative pancreatic fistula (POPF) is a major cause of morbidity and mortality after pancreatoduodenectomy (PD), and previous research has focused on patient-related risk factors and comparisons between anastomotic techniques. However, it is recognized that surgeon experience is an important factor in POPF outcomes, and that there is a significant learning curve for the pancreatic anastomosis. The aim of this study was to review the current literature on training models for the pancreatic anastomosis, and to explore areas for future research. It is concluded that research is needed to understand the mechanical properties of the human pancreas in an effort to develop a synthetic model that closely mimics its mechanical properties. Virtual reality (VR) is an attractive alternative to synthetic models for surgical training, and further work is needed to develop a VR pancreatic anastomosis training module that provides both high fidelity and haptic feedback

How severe is diabetes after total pancreatectomy?:A case-matched analysis

OBJECTIVES: Total pancreatectomy (TP) is associated with significant morbidity and mortality. The severity of postoperative diabetes and existence of ‘brittle diabetes’ are unclear. This study sought to identify quality of life (QoL) and diabetes-specific outcomes after TP. METHODS: Patients who underwent TP were matched for age, sex and duration of diabetes with patients with type 1 diabetes. General QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) core quality of life questionnaire QLQ-C30 and the PAN26 tool. Diabetes-specific outcomes were assessed using the Problem Areas in Diabetes (PAID) tool and an assessment of diabetes-specific complications and outcomes. RESULTS: A total of 123 patients underwent TP; 88 died (none of diabetic complications) and two were lost to follow-up. Of the remaining 33 patients, 28 returned questionnaires. Fourteen general and pancreas-specific QoL measurements were all significantly worse amongst the TP cohort (QLQ-C30 + PAN26). However, when diabetes-specific outcomes were compared using the PAID tool, only one of 20 was significantly worse. HbA1c values were comparable (P = 0.299), as were diabetes-related complications such as hypoglycaemic attacks and organ dysfunction. CONCLUSIONS: Total pancreatectomy is associated with impaired QoL on general measures compared with that in type 1 diabetes patients. Importantly, however, there was almost no significant difference in diabetes-specific outcomes as assessed by a diabetes-specific questionnaire, or in diabetes control. This study does not support the existence of ‘brittle diabetes’ after TP

The role of down staging treatment in the management of locally advanced intrahepatic cholangiocarcinoma : Review of literature and pooled analysis

Copyright © 2020 by The Korean Association of Hepato-Biliary-Pancreatic Surgery.Peer reviewedPublisher PD

Risk factors for failure to rescue after hepatectomy in a high-volume UK tertiary referral center

BACKGROUND: Mortality after severe complications after hepatectomy (failure to rescue) is strongly linked to center volume. The aim of this study was to evaluate the risk factors for failure to rescue after hepatectomy in a high-volume center.METHODS: Retrospective study of 1,826 consecutive patients who underwent hepatectomy from 2011 to 2018. The primary outcome was a 90-day failure to rescue, defined as death within 90 days posthepatectomy after a severe (Clavien-Dindo grade 3+) complication. Risk factors for 90-day failure to rescue were evaluated using a multivariable binary logistic regression model.RESULTS: The cohort had a median age of 65.3 years, and 56.6% of patients were male. The commonest indication for hepatectomy was colorectal metastasis (58.9%), and 46.9% of patients underwent major or extra-major hepatectomy. Severe complications developed in 209 patients (11.4%), for whom the 30- and 90-day failure to rescue rates were 17.0% and 35.4%, respectively. On multivariable analysis, increasing age (P = .006) and modified Frailty Index (P = .044), complication type (medical or combined medical/surgical versus surgical; P &lt; .001), and body mass index (P = .018) were found to be significant independent predictors of 90-day failure to rescue.CONCLUSION: Older and frail patients who experience medical complications are particularly at risk of failure to rescue after hepatectomy. These results may inform preoperative counseling and may help to identify candidates for prehabilitation. Further study is needed to assess whether failure to rescue rates could be reduced by perioperative interventions.</p

Monopole Dynamics in N=2 super Yang-Mills Theory From a Threebrane Probe

The BPS states of N=2 super Yang-Mills theory with gauge group SU(2) are constructed as non-trivial finite-energy solutions of the worldvolume theory of a threebrane probe in F theory. The solutions preserve 1/2 of N=2 supersymmetry and provide a worldvolume realization of strings stretching from the probe to a sevenbrane. The positions of the sevenbranes correspond to singularities in the field theory moduli space and to curvature singularities in the supergravity background. We explicitly show how the UV cut off of the effective field theory is mapped into an IR cut off in the supergravity. Finally, we discuss some features of the moduli spaces of these solutions.Comment: 26 pages, harvmac, some equations corrected in section 3. No conclusions changed, references added. Apologies to those not previously referenced, final version to appear in Nucl. Phys.

Primary Unilateral Macronodular Adrenal Hyperplasia With Concomitant Glucocorticoid And Androgen Excess And KDM1A Inactivation

Background: Primary bilateral macronodular adrenal hyperplasia (PBMAH) is a rare cause of Cushing’s syndrome. Individuals with PBMAH and foodGIP-dependent Cushing’s syndrome due to ectopic aberrant expression of the gastric inhibitory polypeptide receptor (GIPR) typically harbour inactivating KDM1A sequence variants. Primary unilateral macronodular adrenal hyperplasia (PUMAH) with concomitant glucocorticoid and androgen excess has never been encountered or studied.Methods: We investigated a woman with a large, heterogeneous adrenal mass and severe ACTH-independent glucocorticoid and androgen excess, a biochemical presentation typically suggestive of adrenocortical carcinoma. The patient presented during pregnancy (22nd week of gestation) and reported an 18-month history of oligomenorrhoea, hirsutism, and weight gain. We undertook an exploratory study with detailed histopathological and genetic analysis of the resected adrenal mass and leukocyte DNA collected from the patient and her parents.Results: Histopathology revealed benign macronodular adrenal hyperplasia. Imaging showed a persistently normal contralateral adrenal gland. Whole-exome sequencing of four representative nodules detected KDM1A germline variants p.G46S and likely pathogenic p.R269Dfs*7Whole-exome sequencing of four representative nodules detected inactivating KDM1A germline variants p.G46S and p.R269Dfs*7. Copy number variation analysis demonstrated an additional somatic loss of the KDM1A wild-type allele on chromosome 1p36.12 in all nodules. RNA-sequencing of a representative nodule showed low/absent KDM1A expression and increased GIPR expression compared to 52 unilateral sporadic adenomas and four normal adrenal glands. LH Receptor (LHCGR) expression was normal. Sanger sequencing confirmed heterozygous KDM1IA variants in both parents (father: p.R269Dfs*7; mother: p.G46S) who showed no clinical features of suggestive of glucocorticoid or androgen excessadrenal disease. Conclusions: We investigated the first PUMAH associated with severe Cushing’s syndrome and concomitant androgen excess, suggesting pathogenic mechanisms involving KDM1A.  SIGNIFICANCE STATEMENTAdrenal tumours, mostly benign and non-functioning, are detected in 5% of the general population. The detection of an adrenal mass with concomitant glucocorticoid and androgen excess is considered pathognomonic highly suggestive of adrenocortical carcinoma. Macronodular adrenal hyperplasia typically involves both adrenal glands with associated glucocorticoid excess. In an exploratory study, we investigated a previously unencountered case of primary unilateral macronodular adrenal hyperplasia (PUMAH) with concomitant glucocorticoid and androgen excess. We identified germline KDM1A variants as previously reported in primary bilateral macronodular adrenal hyperplasia (PBMAH) and foodGIP-dependent Cushing’s syndrome. This study expands the phenotypic spectrum of inactivating KDM1A variants by describing the first case of PUMAH with combined cortisol and androgen excess, associated with KDM1A variants. These findings are essential considerations in the workup of patients with adrenal masses.  <br/