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Management of an intraoperative tracheal injury during a Mckeown oesophagectomy: A case report

Introduction and importanceTracheobronchial injuries are uncommon complications during oesophagectomies adopting blind dissection or thoracoscopy. Neoadjuvant chemo-radiotherapy is considered a risk factor while double-lumen endotracheal tube insertion and direct surgical damage are other related causalities. Presentation of caseA 65-year-old male underwent a Mckeown oesophagectomy with a right thoracotomy for a mid-oesophageal carcinoma. During the latter stages of cervical dissection and oesophageal mobilization, a 2-cm tracheal injury was noted in the posterior membranous trachea. It was repaired with 2.0 prolene with interrupted sutures and local transposition muscle flap using prevertebral muscles. Post-operatively, he was ventilated in view of prolonged surgery and the probability of airway oedema with the double-lumen ET tube. A transient bubbling of the intercostal drain was managed conservatively and attributed to a secondary pneumothorax. He was extubated and made an uncomplicated recovery. At 2 years, he did not have any tracheal stenosis. Clinical discussionIf diagnosed intraoperatively and for sizes >2 cm, tracheobronchial injuries should be repaired. Various techniques exist with differing evidence. Repair with non-absorbable sutures, use of synthetic grafts, innate tissue such as intercostal and pectoral muscle flaps, and pericardial and pleural flaps are all being used. Early extubation might be useful provided other criteria for extubation are met. ConclusionTracheobronchial injuries during oesophagectomies present a surplus challenge to both the anaesthetist and the surgeon. Collective decision-making tailored to the patient and close monitoring during the postoperative phase would result in good outcomes.

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Acute abdomen following axial torsion of a Giant Meckel's diverticulum in a young male: A case report.

Introduction and importanceAmong Meckel's diverticulum (MD), the ‘Giant’ category is relatively rare. Most Giant MDs lead to complications such as torsion and diverticulitis.Presentation of caseA 20-year-old South Asian male presented with a three-day history of vomiting and left-sided abdominal pain. X-ray and ultrasound scan of the abdomen illustrated features of small bowel obstruction. He underwent laparotomy under general anaesthesia. A gangrenous, axially torsed 25-cm Giant MD with concurrent ileal compression by a mesodiverticular band was detected and diverticulectomy and segmental resection with end-to-end anastomosis of the ileum was performed. Histology revealed ectopic gastric and pancreatic tissue. He had an uneventful postoperative stay and was devoid of any surgery-related complications at one-year follow-up.Clinical discussionAdults mainly present with bowel obstruction following complicated MDs. Multiple mechanisms have been elaborated as causalities of bowel obstruction where the presence of bands of congenital or inflammatory origin, intussusception, and enteroliths are relatively common. The presence of ectopic tissue in MDs is associated with increased complications. Symptomatic MDs need resection to abate future complications such as haemorrhage and obstruction.ConclusionDespite the low diagnostic potential of clinical examination and radiological studies, a high degree of suspicion is warranted in cases of probable MD-resultant complications, where more common aetiologies have been ruled out, as delay in diagnosis and definitive surgical therapy are invariably associated with worsened morbidity and mortality. It is high time to elucidate related demographics and clinical data on Giant MDs to identify high-risk categories and develop safer follow-up protocols.

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Phylogenetic analyses of the mitochondrial, plastid, and nuclear genes of Babesia sp. Mymensingh and its naming as Babesia naoakii n. sp.

BackgroundThe recently discovered Babesia sp. Mymensingh, which causes clinical bovine babesiosis, has a wide geographical distribution. We investigated the phylogenetic position of Babesia sp. Mymensingh using its mitochondrial, plastid, and nuclear genes. Based on morphological and molecular data, Babesia sp. Mymensingh is a unique species and we named it as Babesia naoakii n. sp.MethodsA blood DNA sample from a Babesia sp. Mymensingh-infected cow was subjected to genome sequencing to obtain the sequences of mitochondrial, plastid, and nuclear genes. Six phylogenetic trees were then constructed with (1) concatenated amino acid sequences of cytochrome oxidase subunit I, cytochrome oxidase subunit III, and cytochrome b genes of the mitochondrial genome; (2) 16S rRNA of the plastid genome; (3) nucleotide sequences of the elongation factor Tu gene of the plastid genome; (4) ITS1-5.8S rRNA-ITS2; (5) concatenated nucleotide sequences of 89 nuclear genes; and (6) concatenated amino acid sequences translated from the 89 nuclear genes.ResultsIn all six phylogenetic trees, B. naoakii n. sp. formed a sister clade to the common ancestor of Babesia bigemina and B. ovata. The concatenated nuclear genes of B. naoakii n. sp. and their translated amino acid sequences shared lower identity scores with the sequences from B. bigemina (82.7% and 84.7%, respectively) and B. ovata (83.5% and 85.5%, respectively) compared with the identity scores shared between the B. bigemina and B. ovata sequences (86.3% and 87.9%, respectively).ConclusionsOur study showed that B. naoakii n. sp. occupies a unique phylogenetic position distinct from existing Babesia species. Our findings, together with morphological differences, identify B. naoakii n. sp. as a distinct parasite species.Graphical

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First detection of Theileria equi in free-roaming donkeys (Equus africanus asinus) in Sri Lanka.

Equine piroplasmosis (EP) is a tick-borne disease caused by Theileria equi and Babesia caballi in equids, including horses, donkeys, zebras, and mules. It is globally endemic with significant economic impact on the equine industry. Infected animals may serve as carriers, and they may be a source of infection for ticks, thereby posing a great challenge for disease management. Sri Lanka is a tropical country, where infections by various tick-borne parasites are common among livestock animals. However, infections by T. equi and B. caballi remain unstudied in Sri Lanka. Therefore, in the present study, we conducted an epidemiological survey to investigate the presence of T. equi and B. caballi in apparently healthy free-roaming donkeys. Blood samples were randomly taken from 111 donkeys in Mannar (n=100) and Kilinochchi (n=11) districts in Sri Lanka. Thin blood smears were prepared from the blood samples and subjected to microscopic examination. Additionally, blood DNA samples were prepared and screened for T. equi and B. caballi infections using species-specific PCR assays. Our results showed that 64 (57.7%) and 95 (85.6%) of the donkeys were positive for T. equi by microscopy and PCR, respectively. However, all samples were negative for B. caballi. Phylogenetic analysis of the T. equi 18S rRNA sequences detected two distinct genotypes, namely C and D. To our knowledge, this is the first report of T. equi in Sri Lanka and of genotype C in donkeys. The present study highlights the importance of monitoring the shrinking donkey population in Sri Lanka owing to EP caused by T. equi.

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