Altered Anatomy Research Articles

Impact of altered pulmonary vein anatomy on long-term outcomes after cryoablation of paroxysmal atrial fibrillation

Abstract Background Cryoballoon catheter treatment for pulmonary vein (PV) isolation is an effective method for treating paroxysmal atrial fibrillation (AF). Purpose Evaluation of the significance of certain anatomical features of pulmonary veins for predicting the development of arrhythmia recurrence after pulmonary vein cryoballoon ablation (PV CBA) in paroxysmal AF. Materials and Methods 465 consecutive patients (61% were male) with paroxysmal AF (57±11 years) were included and analyzed. All underwent CPVA between 2018 and 2022. PV and left atrial (LA) anatomy were evaluated in all patients using multi-slice computed tomography (MSCT) before the CPVA procedure. After the ablation procedure, all patients were followed up for 24-56 months to assess the impact of pathologic abnormalities in PV anatomy on recurrences in the long-term follow-up period. Results Complete PV isolation was achieved in all patients. LA and PV anatomy was normal in 298 patients (64%). Pathologic change of PV anatomy was present in 167 patients. (36%). During 24-56 months of follow-up, AF recurrence was registered in 178 patients (38%). Patients with recurrent AF had mainly enlarged right (RSPV) and left superior PVs (LSPV) (p<0.001). The presence of left common PVs (n=126, Log-rank p<0.001), as well as the presence of additional right pulmonary veins (n=67, Log-rank p<0.001), was associated with early development of sustained arrhythmia recurrences, compared to patients with typical PV characteristics. Conclusion Altered PV anatomy is a risk factor for arrhythmia recurrence after PV CBA. Mandatory visualization of the LA and PV with MSCT improves patient selection for effective catheter-based treatment of atrial fibrillation.

Pelvic Organ Prolapse Suspension (POPS) for Obstructive Defecation Syndrome (ODS) : Functional Outcome

Background: Genital apparatus represents the anatomical support for the bladder and rectum, therefore, inevitably the genital prolapse implies serious anatomical and functional alterations of these organs. Pelvic organ prolapse is one of the most common pathological conditions in postmenopausal women.Pelvic organ prolapse suspensions (POPS) is a recent surgical procedure for one-stage treatment of multiorgan female pelvic prolapse. Methods: This observational study evaluated the preliminary results of POPS of 42 women with a mean age of 50 within 4 years of period. Patients underwent posterior colpoperineorrhaphy to correct residual rectocele and hiatal enlargement at the same time. Results: We had no relapses and the preliminary results were excellent. We evaluated the patients after 6 months follow-up and confirmed the validity of our treatment. The technique is simpler than traditional treatments with an important reduction or completely disappearance of the pre-operative symptoms. Conclusions: Uterus-preserving pops operation was found to be safe and effective with high patient satisfaction rates and simultaneous correction of anterior prolapse. Significant improvements in patients quality of life. J Shaheed Suhrawardy Med Coll 2022; 14(2): 20-24

Important practical aspects in the management of patients with shot bowel syndrome and intestinal failure

Short bowel syndrome is a gastrointestinal disorder resulting from massive resection of the small intestine. The most common causes of resection are acute mesenteric ischemia, Crohn’s disease, abdominal trauma, adhesive intestinal obstruction, intestinal malignancies, and radiation enteritis. Short bowel syndrome with intestinal failure is characterized by severe malabsorption-m aldigestion accompanied by abdominal pain, diarrhea, dehydration, and progression of protein-energy malnutrition. Many patients with SBS develop long-term clinical complications over time due to altered bowel anatomy and physiology or various therapeutic interventions such as parenteral nutrition and central venous catheterization. This review focuses on the most important aspects of diagnosis, treatment, and prevention of several complications that can occur in this patient population, including macronutrient and micronutrient imbalances, diarrhea, fluid and electrolyte imbalances, metabolic bone disease, biliary disorders, bacterial overgrowth in the small intestine, and complications related to venous access. The main therapeutic strategies for SBS with intestinal failure are: special diet, enteral nutritional support with semi-elemental mixtures, parenteral nutrition, oral rehydration, antimicrobal and antidiarrheal drugs, enzymes. Administration of glucagon-like peptide 2 analog, teduglutide, is clinically effective in reducing dependence on parenteral nutrition and improving quality of life. Management of patients with SBS with intestinal failure is a complex long-term process which requires dynamic clinical and laboratory monitoring.

Cardiac arrest in pregnancy with successful stabilisation and delivery on veno-arterial extracorporeal membrane oxygenation: a case report

Abstract Background Cardiac arrest in pregnancy is rare. Clinicians need to adapt management to the altered anatomy and physiology of pregnancy and the wellbeing of two patients (mother and fetus) may come into consideration. The medical literature has limited reports on outcomes following extracorporeal membrane oxygenation (ECMO) in pregnancy. Case summary We report the evaluation, management and outcome of a woman with cardiac arrest and severe left ventricle dysfunction (LV) in mid-trimester of pregnancy. The previously well woman had tolerated two prior term pregnancies without complication. At 25 weeks of gestation she presented to hospital with breathlessness and vomiting after a pre-syncopal episode at home. She then had in-hospital cardiac arrest, managed initially with cardiopulmonary resuscitation (CPR). The LV was dilated, thin-walled and severely impaired (LV ejection fraction 14%) and there was a secundum atrial septal defect (ASD). She was supported with veno-arterial ECMO. Planned birth occurred five days post-arrest for maternal indication. Coronary angiography demonstrated 99% proximal left anterior descending artery stenosis and aneurysm, raising the possibility of previous subclinical Kawasaki disease. She underwent surgical revascularisation and ASD closure. Both mother and infant made a good recovery. Discussion We report a case of cardiac arrest in pregnancy as first presentation of severe LV dysfunction. The case highlights the role of ECMO for cardiac arrest in pregnancy and outlines specific interventions and management concepts in this setting.

Surgical anatomy of the cystic artery: A systematic review with meta-analysis

BackgroundThe current evidence-based systematic review with meta-analysis presents a detailed overview of the cystic artery (CA) surgical anatomy, including its origin, number, topography, and morphometry. Moreover, the surgical implications of these variants are further discussed. MethodsAccording to the Evidence-Based Anatomy Workgroup and PRISMA 2020 guidelines, the systematic review was performed using four online databases. The Anatomical Quality Assurance Tool was used to evaluate the risk of bias. Meta-analysis was performed with the R programming software. The pooled prevalence and pooled mean of different CA parameters were calculated. ResultsThe CA most commonly originated from the right hepatic artery (a pooled prevalence of 85.75 %). Other described origins (in order of frequency) were the aberrant right hepatic artery, the common hepatic, the left hepatic, the gastroduodenal, the superior mesenteric, and the middle hepatic arteries. The CA was single in 88.59 %, while it can be identified as double, triple, or absent. Most commonly, it was located inside the cystohepatic triangle in 83.83 %. Most commonly, it was superomedially to the cystic duct (77.80 %) and posteriorly to the common hepatic duct (35.08 %). The CA pooled mean length was 21.34 mm, and its diameter was more commonly over 1 mm. ConclusionThe CA surgical anatomy is paramount when operating on the gallbladder. The CA's altered anatomy and adjacent area could lead to confusion, iatrogenic injury, and prolonged surgical time. The CA depicts high morphological variability; therefore, surgeons should consider the typical anatomy and possible (usual and unusual) variants.

Glaucoma in Pathological Myopia, Diagnosis and Treatment Approaches

The rising global prevalence of myopia is contributing to an increase in pathological myopia (PM). Myopia has been extensively documented as a risk factor for primary open-angle glaucoma. However, glaucomatous changes in eyes with PM typically occur at normal intraocular pressures. Moreover, the unique anatomical alterations observed in PM result in distinctive differences in the clinical appearance of the optic nerve head and peripapillary region. Consequently, the evaluation of optic nerve cupping is more challenging in these cases than in those of normal eyes. Therefore, the diagnosis and treatment of glaucoma in this patient group is challenging. Furthermore, these patients may present with established visual field defects that can mimic glaucoma. On the other hand, optical coherence tomography is less useful for the detection and monitoring of disease due to the lack of normative data for these anatomically unique eyes. The most crucial factor in detecting early glaucomatous changes is the monitoring of the progression of retinal nerve fiber layer thinning over time. Consequently, the most effective method of monitoring glaucoma patients with PM is through longitudinal follow-up. Finally, the medical and surgical management of glaucoma in patients with pathologic myopic glaucoma presents its own unique challenges.

Iron Treatment in Patients with Iron Deficiency Before and After Metabolic and Bariatric Surgery: A Narrative Review.

Iron is an essential nutrient in living organisms with multiple vital functions. Iron deficiency (ID) can cause long term health consequences beyond iron deficiency anemia (IDA). The high prevalence of ID and its long-term effects in patients with obesity and after metabolic and bariatric surgery (MBS) is recognized. Nevertheless, there is limited knowledge of the optimal route or dose for treatment of patients with obesity and post-MBS, and an evidence-based universal guideline for prevention and treatment of ID in short- and long-term post-MBS (PMBS) is not yet available. ID in the general population is currently treated with oral or parenteral iron, where oral iron treatment is considered the preferred option with parenteral iron as a second-line treatment in case there is intolerance or lack of response to oral iron. In patients with obesity with chronic low-grade inflammation and PMBS patients with altered gut anatomy and function, there are also alterations in the bioavailability and higher risks of side effects of available oral irons. The conclusions of current studies exploring effective treatment of iron deficiency in this population have been inconsistent and further well-planned randomized and prospective studies are needed. This is a narrative review of the literature on the available treatment options and strategies for treatment of ID in PMBS patients to recognize the knowledge gaps and provides topics of future research.

THE INFLUENCE OF PULMONARY VEIN ANATOMY ON OUTCOMES AFTER ABLATION OF PAROXYSMAL ATRIAL FIBRILLATION

Background. Pulmonary vein isolation is the cornerstone of catheter-based treatment for atrial fibrillation. Cryoballoon ablation offers an effective and reproducible method for pulmonary vein isolation, yet recurrence of arrhythmias remains a challenge. Despite advances in catheter technologies, the role of altered pulmonary vein anatomy as a factor for atrial fibrillation recurrence is poorly studied. Materials and Methods. This prospective study included 465 patients with paroxysmal atrial fibrillation who underwent cryoballoon ablation. Pulmonary vein and left atrial anatomy were evaluated using multislice computed tomography. Patients were followed for 24–48 months to assess atrial fibrillation recurrence and anatomical risk factors. Cox proportional hazard modeling and Kaplan-Meier analysis were used to evaluate predictors of arrhythmia recurrence. Results. Complete Pulmonary vein isolation was achieved in all patients. During follow-up, 38% of patients experienced atrial fibrillation recurrence. Patients with altered pulmonary vein anatomy, particularly a left common pulmonary vein and additional pulmonary veins, showed a higher rate of recurrence. Cox regression analysis identified left atrial volume index >50 mL/m² and pathological pulmonary vein anatomy as independent risk factors for atrial fibrillation recurrence. Conclusion. Altered pulmonary vein anatomy is a significant risk factor for atrial fibrillation recurrence following cryoballoon ablation. Comprehensive imaging of the left atrial and pulmonary vein using multislice computed tomography can improve patient selection, reducing the recurrence risk and improving long-term outcomes.

Improving Successful Cannulation of External Ventricular Drain: 3D-Printed Surgical Guide for Inexperienced Neurosurgeons

ObjectiveExternal Ventricular Drain (EVD) is a fundamental neurosurgical procedure that is commonly performed by junior neurosurgeons. Expedient, successful cannulation of the ventricles can be lifesaving. Yet, the free-hand technique of EVD insertion is associated with significant mal-positioning rates. This study aims to improve EVD placement by junior neurosurgeons with the aid of a customized 3D printed surgical guide. MethodsA 3D printed surgical guide was developed and customized to our institution’s EVD insertion procedure. First year neurosurgical residents were taught how to perform pre-operative trajectory planning based on coronal brain images and how to use the surgical guide during standard EVD insertion procedure. Number of passes, accuracy of EVD placement, operative complications, need for revision, and surgeon’s experience with the guide were recorded. Results14 patients underwent guide-assisted EVD insertion by first year neurosurgical residents. Significantly, 6 (43%) patients had ventricular anatomy distorted by midline shift. All surgeons achieved successful ventricular cannulation using the EVD guide on first pass (100%). 13 out of 14 (93%) of the guide-assisted EVDs were optimally placed (Karkarla Grade 1). 1 (7%) guide-assisted EVD was suboptimally placed (Karkarla Grade 2). There was no intra or post-operative complication and there was no EVD revision. ConclusionsFor inexperienced surgeons, the 3D printed EVD guide can improve ventricular cannulation even in cases of altered ventricular anatomy. The benefit of 3D printing would also allow the guide to be widely adopted by other institutions worldwide.

S3192 Magnetic Balloon-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgical Altered Anatomy

S3192 Magnetic Balloon-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgical Altered Anatomy

Effect of hiatal hernia and esophagogastric junction morphology on esophageal motility: Evidence from high-resolution manometry studies.

High-resolution Manometry (HRM) is the most sensitive and specific test available for clinical assessment of hiatal hernia (HH), a common condition defined as the separation between the Lower Esophageal Sphincter (LES) and crural diaphragm (CD). While the link between HH and Gastroesophageal Reflux Disease (GERD) is established, the potential association of HH with esophageal dysmotility, independently from GERD, is uncertain. This study aimed to analyze if HH, with or without GERD, can associate with esophageal motility disorders. Consecutive patients without previous esophageal surgery who underwent HRM between 2018 and 2022 were enrolled. All patients with symptoms suggestive of GERD underwent impedance-pH testing off-therapy. HH was defined as a separation >1 cm between LES and CD, and esophagogastric junction (EGJ) morphology was classified as: Type I, when there was no separation between LES and CD; Type II, in case of minimal separation (>1 and <3 cm); Type III, when ≥3 cm of separation was present. Demographic and clinical characteristics were collected at baseline, including Age, Gender, Alcohol-, Coffee- and Smoke-habits, GERD diagnosis and symptoms' duration. Two cohorts of patients, with and without HH, were retrospectively individuated, and their association with Ineffective Peristalsis, Hypercontractile Esophagus and Outflow Obstruction was analyzed with univariate and multivariate Logistic regressions using the statistical software R. 848 consecutive patients were enrolled, and 295 cases of HH (34.8%), subdivided into 199 (23.5%) Type II- and 96 (11.3%) Type III-EGJ patients, were identified. Ineffective peristalsis was diagnosed in 162 (19.1%) subjects, Hypercontractile esophagus in 32 (3.8%), and Outflow Obstruction in 91 (10.7%), while GERD was present in 375 (44.2%) patients. HH was significantly associated with Ineffective Peristalsis (p < 0.001) and GERD (p < 0.001). Furthermore, HH resulted to be a risk factor for Ineffective peristalsis (OR 2.0, 95% CI 1.4-2.8, p < 0.001) both when the analysis was conducted in all the 848 subjects, independently from GERD, and when it was carried out in patients without GERD (OR 2.3, 95% CI 1.02-5.3, p = 0.04). The risk for Ineffective Peristalsis increased 1.3 times for every centimeter of HH. No statistically significant association was found between HH and Outflow obstruction or Hypercontractile Esophagus. An increasing separation between the LES and CD may lead to a gradual and significant elevation in the risk of Ineffective Peristalsis. Interestingly, this association with HH is true in patients with and in those without GERD, suggesting that the anatomical alteration seems to play a major role in motility change.

Contaminated well water driving d‐lactic acidosis in child with short bowel syndrome

Abstractd‐lactic acidosis is a rare type of lactic acidosis that typically presents in patients with short bowel syndrome (SBS). Clinical features include a high anion‐gap metabolic acidosis and acute onset of neurological impairment. The underlying pathology is thought to be due to altered gut flora and carbohydrate malabsorption in patients with altered gut anatomy. The treatment centers on correcting acid–base derangements, dietary modifications to decrease carbohydrate intake and antibiotics. We present a case of recurrent d‐lactic acidosis in a patient with SBS. In this unique case, we highlight the importance of considering the home environment when developing a treatment plan.

When the Going Gets Tough: A Review of Total Hip Arthroplasty in Patients with Ipsilateral Above- and Below-Knee Amputation.

Life expectancy and overall function of amputated patients have improved significantly over the last few decades; for this reason, amputees are more exposed to primary or secondary degenerative disease of the hip, requiring total hip arthroplasty (THA) surgery. However, during training, not all the surgeons acquire adequate skills to manage these patients, and only a few studies and case reports describe technical pearls and outcomes of THA in patients with ipsilateral lower limb amputation, either above or below the knee. The objective of this narrative review is to present current evidence and surgical tips for performing THA in ipsilateral amputated patients, with a focus on the differences between patients with above- (AKA) and below-knee amputation (BKA). We reviewed manuscripts in major scientific databases, cross-referencing to retrieve adjunctive manuscripts, and summarized all relevant cases. We found 17 manuscripts, spanning 70 years of literature, collecting a total of 39 patients who underwent THA on an ipsilateral amputated limb: 13 AKA, 23 BKA, and 3 through-knee-amputation (TKA). The cohort primarily consists of patients with post-traumatic hip arthritis, often associated with sequelae such as fractures to other bones, soft tissue compromise and heterotopic calcifications. Managing with amputated patients requires careful planning, which includes the study of the residual bone, muscle anatomy, and the level of femoral amputation, as these factors present significant surgical challenges, especially in patients without a knee joint. In dealing with the post-traumatic and multi-comorbidity patients, rehabilitation goals should be considered prior to surgery and should drive the surgical strategy. We found that BKA patients typically have high functional demands, necessitating precise positioning of the components and an aggressive post-operative physiotherapy regimen to avoid unsatisfactory outcomes. AKA patients, on the other hand, often present with altered anatomy, and typically require more surgical instruments and expertise to achieve intraoperative dislocation of the hip joint.

Pancreatoduodenectomy after Ivor-Lewis Santi oesophagectomy with gastric tube reconstruction. An European multicentre experience

BackgroundPancreaticoduodenectomy (PD) is the standard surgery to treat tumors and other conditions affecting the head of the pancreas. PD involves the division of the gastroduodenal artery (GDA) and its branches, to allow for complete dissection of lymph nodes. However, PD in patients with prior esophageal resection presents challenges due to altered anatomy and risks compromising gastric tube vascularization. GDA preservation becomes crucial to avoid ischemia, although this may pose oncological risks by potentially leaving behind regional lymph nodes. This article reviews European surgical center experiences and techniques for PD in patients with prior esophageal surgery, focusing on short-term outcomes. MethodsWe have collected all the experiences carried out in European surgical centers and evaluated the techniques applied for PD in patients who had prior esophageal surgery while analyzing short-term outcomes. ResultsEight patients from 5 European centers were identified. Six patients were diagnosed with pancreatic adenocarcinoma, including one borderline case. Intraoperatively, the gastroduodenal artery (GDA) was preserved in all cases, with portal vein reconstruction required in only one instance due to tumor invasion. No ischemia or venous congestion of the gastric tube was observed during the surgical procedure. Post-operative complications that occurred included POPF type C in 1 (12.5 %), PPH type C in 1 (12.5 %). The median number of harvested lymph nodes was 21 [14–24]. with a median of 1.5 positive lymph nodes. R1 resection was present in 62.5 % of cases. ConclusionPerforming pancreaticoduodenectomy subsequent to Ivor Lewis esophagectomy is a technical challenge, but seems feasiable and safe in selected patients. GDA-preserving pancreaticoduodenectomy emerges as a valuable and time-efficient variation of the conventional procedure, it can be considered oncologically appropriate, but studies confirming its long-term impact on radicality are still needed.

Ultrasound-guided radial vein cannulation for general anesthesia in cases with difficult peripheral venous access: a report of two cases

BackgroundDespite advancements in ultrasonography, locating peripheral veins for catheter placement remains a challenge in patients with altered anatomy owing to multiple surgeries. Herein, we highlight the potential of using the radial vein as an alternative site for ultrasound-guided peripheral venous catheterization.Case presentationWe present two cases of patients with extensive surgical histories, including multiple abdominal surgeries, leading to difficult peripheral venous access. Traditional sites for peripheral venous catheterization were unsuitable due to vein narrowing or lack of visibility. In both cases, ultrasonography helped identify the radial vein as the only viable site for catheter placement. The patients underwent successful ultrasonography-guided catheterization of the radial vein without complications, facilitating medical management, including anesthesia induction and intraoperative monitoring.ConclusionsThe radial vein is a feasible and safe alternative for ultrasound-guided peripheral venous access in patients where traditional venous access sites are compromised.

Study of Eye Movements Abnormalities in Epilepsy

ABSTRACT Idiopathic epilepsy (IE), is a group of epileptic syndromes with no structural brain lesion, but with microstructural changes in neuronal networks leading to neuropsychological consequences. Therefore, the assessment of saccadic eye movements can provide insight into the integrity of cerebral networks as it involves large cortical and subcortical brain areas and circuitries. Describe saccadic eye movement abnormalities in patients with IE and correlate them with disease characteristics and antiseizure medication. Case–control study including IE patients followed in the Neurology Department of Razi University Hospital and healthy controls matched. Participants underwent a recording of saccadic eye movements. Pursuit, prosaccade, and anti-saccade tasks were performed. 115 patients and 98 matched healthy controls were included. The gender ratio (male to female) was 0.6. The mean age at onset was 16.3 ± 12 years. Diagnosed epileptic syndromes were juvenile myoclonic epilepsy (JME), epilepsy with generalized tonic-clonic seizures, childhood absence epilepsy, temporal lobe epilepsy, frontal lobe epilepsy, and rolandic epilepsy. Saccadic eye movements were impaired in 52.2% of our patients and significantly more altered in those with JME (p = .021). Prolonged horizontal saccades latencies were the most frequent eye movement abnormalities (32.1%), followed by altered horizontal smooth pursuit (22.6%). A positive correlation was found between age at eye movements recording, age at onset, disease duration, global cognitive impairment, and saccadic eye movements. However, no definite relationship was identified. Saccadic eye movement illustrates extending anatomic alterations in IE including frontal and temporoparietal cortical areas and cortico-subcortical circuits. Eye movement recording is a useful and reproducible tool in the assessment of epileptic patients and provides a better understanding of neuronal mechanisms in epilepsy.

Effects of facial forms and midline deviations and rolls on female facial beauty according to laypeople, orthodontists, and prosthodontists or restorative dentists

No study has examined the simultaneous effect of facial forms, midline deviations and midline angulations on facial beauty. Therefore, this comprehensive study aimed to evaluate these and many other hypotheses. This psychometric study was performed on 15,042 observations. A female frontal photograph was edited to 45 perceptometric images with controlled anatomical alteration: 3 facial forms (euryprosopic [brachyfacial], mesoprosopic [mesofacial], leptoprosopic [dolichofacial]), each having either 9 bidirectional midline deviations (0, 1, 2, 3, and 4 mm deviated to the left and right) or 7 bidirectional midline angular deviations (0°, 5°, 10°, and 15° deviated to the left and right). One of the photographs were repeated. These 46 images were esthetically judged by 327 participants (243 laypeople, 49 orthodontists, and 35 ‘prosthodontists or restorative dentists’). Hierarchical mixed-model multiple linear regressions and post hoc tests were adopted to evaluate the simultaneous impacts of the photomodel’s facial forms, midline deviations to the right or left, and midline rolls to the right or left plus sex, age, experience, and dental specialty of the referees on their perception of facial beauty as well as the tolerable zones of midline alterations. These were also done separately for each specialty group, and also for each facial face. Ideal combinations of anatomic features were determined using repeated-measures ANOVAs. Differences between esthetic preferences of different groups in terms of each image were assessed using one-way ANOVAs and t-tests (α = 0.05, α = 0.008, α = 0.001). All 5 anatomical features significantly and independently influenced perception of facial beauty. The tolerance threshold for midline deviations was 1 mm deviations to the right and left sides. For midline rolls, the only tolerable form was the no-roll (‘on’) midline; the judges preferred right-oriented defects over left-sided ones. The most beautiful facial form was mesoprosopic, followed by leptoprosopic. Men perceived the female face slightly more attractive than did women. The viewers’ specialty (or lack of it), their age, or their experience did not affect their esthetic preferences. Predictors of esthetic preferences were all 5 anatomical features plus views’ sex, but not their dental specialty, age, or experience. Zones of acceptability and also the ideal range of anatomical features were determined.

787. THE CHALLENGE OF GASTRO-ESOPHAGEAL ONCOLOGICAL SURGERY AFTER BARIATRIC PROCEDURES: EXPERIENCE OF A REFERRAL HIGH-VOLUME UPPER GI SURGICAL CENTER

Abstract Background The effectiveness of bariatric surgery for weight loss in morbidly obese patients has been well established and it's becoming more common as many surgeons are trained to perform them safely, even in older patients. Obesity is associated with reflux and hormonal imbalances that increase the risk of Barrett's esophagus, esophageal adenocarcinoma and gastric cancer. Bariatric procedures alter gastric anatomy, vascularization and lymphatic drainage and render subsequent upper gastrointestinal surgery for malignancies a technical challenge, that will present more and more in the future. We present laparoscopic sleeve gastrectomy, gastric bypass and gastric banding conversion to oncological respective surgeries. Methods We retrospectively reviewed the medical records of our referral high-volume center for upper gastrointestinal surgery and identified patients who underwent upper gastrointestinal oncologic surgery from January 1998 to May 2024. We selected all patients who had previously undergone bariatric surgery (laparoscopic sleeve gastrectomy, laparoscopic gastric bypass, gastric banding, or other less common procedures). Three patients met our criteria, and we recorded: demographic characteristics, surgical technique, oncologic surgical outcome, postoperative complications, long-term complications, and oncologic follow-up. Results A hybrid IvorLewis esophagectomy was performed years after a sleeve gastrectomy for distal esophageal adenocarcinoma. The sleeve was used for gastric pull-up, adequately vascularized by the right gastroepiploic artery as demonstrated by intraoperative indocyanine green. A patient developed adenocarcinoma of the cardia after Roux-en-Y gastric bypass, infiltrating the gastric pouch, the gastric remnant and liver S2. After neoadjuvant chemotherapy, an open Ivor-Lewis esophagectomy was performed using the gastric remnant for a pull-up. In a third patient, a locally advanced adenocarcinoma of the stomach developed after gastric banding. After neoadjuvant chemotherapy, an open total gastrectomy with Roux-en-Y esophagojejunostomy was performed. Conclusion We report three cases of successful esophago-gastric oncological surgery in patients with altered anatomy and vascularization due to previous bariatric surgery, without major postoperative complications or mortality. Oncologic benchmarks for both esophageal and gastric surgery were met as a high lymph node yield and oncologic margins were maintained. Our heterogeneous series suggests that sleeve gastrectomy, gastric bypass, and gastric banding surgery can be successfully converted to resective surgeries after a metachronous neoplasia diagnosis in high-volume upper gastrointestinal centers. These and similar modified reconstructive techniques are likely to be used in the future as metabolic surgery and esophago-gastric cancer are increasing.

Regional differences in leaf evolution facilitate photosynthesis following severe drought.

Characterizing physiological and anatomical changes that underlie rapid evolution following climatic perturbation can broaden our understanding of how climate change is affecting biodiversity. It can also provide evidence of cryptic adaptation despite stasis at higher levels of biological organization. Here, we compared evolutionary changes in populations of Mimulus cardinalis from historically different climates in the north and south of the species' range following an exceptional drought. We grew seeds produced from predrought ancestral plants alongside peak-drought descendants in a common glasshouse and exposed them to wet and dry conditions. Before the drought, northern ancestral populations expressed traits contributing to drought escape, while southern ancestral populations expressed drought avoidance. Following the drought, both regions evolved to reduce water loss and maintain photosynthesis in dry treatments (drought avoidance), but via different anatomical alterations in stomata, trichomes, and palisade mesophyll. Additionally, southern populations lost the ability to take advantage of wet conditions. These results reveal rapid evolution towards drought avoidance at an anatomical level following an exceptional drought, but suggest that differences in the mechanisms between regions incur different trade-offs. This sheds light on the importance of characterizing underlying mechanisms for downstream life-history and macromorphological traits.

Prevalence of the Huschke Foramen in Colombian Population: An Important Anatomic Alteration for the Planning of TMJ Arthroscopy

Abstract Background Ignoring this anatomic structure would have implications for iatrogenic perforation with the trocar toward the FH during the initial blind drilling or due to the diffusion of the infusion liquid toward the middle ear. Purpose To analyze the prevalence of the FH in an institutional population with a high incidence of TMD to provide further guidelines in diagnosing this anomaly and the planification of TMJ arthroscopy. Materials and Methods A retrospective tomographic study was conducted at the ENT—Oral and Maxillofacial and Radiology Department of the Hospital Universitario la Samaritana in Bogotá, Colombia. Inclusion criteria were patients over 18 years of age who had complementary exams such as ear, face, paranasal sinus, and/or TMJ tomography. Exclusion criteria were history of direct trauma to the external auditory canal in the medical history, patients with craniofacial syndromes, congenital anomalies, and/or history of cranial, mandibular, or temporal fractures. Two radiologists were part of the evaluators of the CT images who conducted the measures in the axial tomographic section and established the presence of the tympanic defect. Results A sample size of 139 medical records of patients, where females represent n: 101 (72.6%) and males represent n: 38 (27.4%). The average age was 43 years ± 18 years. Among the studied population, a total of five FH were detected, corresponding to a prevalence of 3.6% (95% CI 1.5–8.1%). The average size of the defect was 3.52 mm ± 1.1 mm. All the patients had TMJ-related symptoms, but none of them reported otalgia. Conclusion The initial evaluation of each patient must be addressed to assess the integrity of the tympanic bone. In this study, the defects size was smaller than others previously reported. However, diffusion through the tympanic defect could spread the lavage substance into the middle ear during TMJ arthroscopic surgery.