History Of Multiple Surgeries Research Articles

Percutaneous Ventriculoatrial Shunting as a Salvage Method in the Pediatric Hydrocephalus Patients with Peritoneal Problems.

To evaluate the efficacy of percutaneous ventriculoatrial shunting as a salvage method for pediatric patients with abdominal complications. Data obtained from 9 patients with ventriculoperitoneal shunt dysfunctions owing to abdominal complications, who underwent ventriculoatrial shunting as salvage treatment at a single institution between January 2019 and September 2021 were retrospectively analyzed. All operations were conducted under the guidance of intraoperative fluoroscopy and ultrasound. The mean age of the enrolled patients was 8.1 ± 1.2 years (2-15 years). Six (67%) patients were male and 3 (33%) were female. The mean number of the patients? ventriculoperitoneal shunt revisions until atrial catheter placement was 7.5 times. The reasons for intraperitoneal catheter failure included peritoneal adhesions in 4 (44.5%) patients, pseudocyst formation in 3 (33.3%), and peritonitis in 2 (22.2%). Seven patients from the study cohort had no problem after ventriculoatrial shunt placement. Only 1 patient had shunt dysfunction related to the ventricular catheter, and ventricular catheter and shunt valve revision was performed 26 months after ventriculoatrial shunt placement. The atrial catheter of the patient was intact. One patient died from the progression of her primary disease (medulloblastoma in the 4 < sup > th < /sup > ventricle), which was unrelated to the ventriculoatrial shunt. Percutaneous ventriculoatrial shunting under the guidance of intraoperative fluoroscopy and ultrasound is a safe, effective, and easy alternative in patients with peritoneal complications and a history of multiple operations.

ALT Free Flap Coverage after Carotid Endarterectomy in the Setting of Severe Radiation Changes

Summary: Carotid endarterectomy with patch angioplasty is commonly performed for severe atherosclerotic disease to reduce stroke risk. After neck radiation, loss of tissue planes; reactive fibrosis of skin; contraction; and rarely, necrosis of skin may occur, leading to severe wound complications and possible exposure of carotid artery reconstruction. Historically, local myocutaneous flaps have been performed to provide soft tissue coverage; however, these procedures may be associated with increased donor site morbidity and can be affected by radiation changes. This report describes the novel use of a fasciocutaneous free flap for durable vascularized soft tissue, and the associated secondary benefit of improved suppleness and range of motion. Additionally, the distant location of the donor site allows for an efficient two-team approach. Here, we describe a patient with severe carotid artery disease with a history of multiple surgical procedures and radiation, which was successfully treated with a carotid endarterectomy and bovine patch angioplasty by vascular surgery and immediate free anterolateral thigh flap coverage by our team.

THU457 Variable Presentations Of Hypophosphatasia In Two Patients In The Outpatient Setting

Abstract Disclosure: A. Elmaaz: None. S. Batool: None. P. Dandona: None. Introduction: Hypophosphatasia is a rare disorder characterized by defective mineralization of bone and teeth which is caused by an autosomal inherited mutation in the tissue nonspecific alkaline phosphatase (ALP) encoding genes. Here we present two cases of multiple dental and bony defects secondary to low ALP enzyme activity due to hypophosphatasia. Case 1: A 27-year-old female with history of mitochondrial disease, gastroparesis, malabsorption syndrome, and autonomic dysfunction was referred to Endocrinology clinic because of persistently low serum ALP levels associated with recurrent muscle, joint, and bone pain since the age of 13. She had history of multiple tooth extractions because of dental developmental abnormalities and fractures. She also reported history of fractures of three of her fingers in both hands during her childhood and teenage years. The patient was adopted and was unaware of any biological family history. Physical examination was remarkable for short-statured female, 4'8". Notably, the middle phalanges in little fingers bilaterally were shorter than the other fingers. Workup showed vitamin D level of 21 (30-80) ng/ml, despite being on 50,000 IU twice a week for 6 months with normal PTH and ionized calcium levels. The repeated serum level of ALP was 24 (31-125) U/L with bone and liver isoenzymes levels of 42% and 58 % respectively. Vitamin B6 level was 13.2 (2.1-21.7) ng/ml. Bone mineral density was unremarkable. Case 2: A 53-year-old female with history of congenital left hip dysplasia, hypertension, and dyslipidemia was seen by Endocrinology service for evaluation of decreased ALP levels. She denied any history of falls or fractures. However, she reported chronic bone pain, especially in bilateral hip joints with history of multiple surgeries in her left hip joint. She had required teeth braces and multiple dental surgeries during her childhood due to dental maldevelopment. Her height was 4'8". Laboratory workup was remarkable for low serum ALP level of 30 U/L with bone isoenzyme of 24 %. Vitamin B6 level was 206.7 (2.1-21.7) ng/ml. She had elevated serum phosphorus levels with normal calcium, PTH, and vitamin D levels. Pyridoxal-5- Phosphate level was high. Bone mineral density revealed osteopenia. Conclusion: Hypophosphatasia is a rare disease, hence it could be easily missed due to high variability in clinical presentations and severity of symptoms. Low serum levels of ALP with history of bone pain, recurrent fractures, premature loss of deciduous teeth, or loss of adult dentition should raise the suspicion of hypophosphatasia. Resistance to vitamin D supplementation is another clue to the diagnosis. A multidisciplinary approach is required for appropriate management. Presentation: Thursday, June 15, 2023

Risk factors of massive blood transfusion in liver transplantation: consequences and a new index for prediction including the donor

BackgroundMassive blood transfusion (MBT) is a common occurrence in liver transplant (LT) patients. Recipient-related risk factors include cirrhosis, history of multiple surgeries and suboptimal donors. Despite advances in surgical techniques, anesthetic management and graft preservation have decreased the need for transfusions, this complication has not been completely eliminated. MethodsOne thousand four hundred and sixty-nine LT were performed at our institution between May 2003 and December 2020, and data was available regarding transfusion for 1198 of them. We divided the patients into two groups, with regards to transfusion of 6 or more units of packed red blood cells in the first 24 h posttransplant, and we analyzed the differences between the groups. ResultsOut of the 1198 patients, 607 (50.7%) met criteria for MBT. Survival was statistically lower at 1, 3, and 5 years when comparing the groups that had MBT to those that did not (92.6%, 85.2% and 79.7%, respectively, in the non MBT group, vs. 78.1%, 71.6% y 66.8%, respectively, in the MBT group). MBT was associated with a 1.5 mortality risk as opposed to non-MBT patients. Logistical regression analysis of our variables yielded the following results for a new model, including serum creatinine (OR 1.97), sodium (OR 1.73), hemoglobin (OR 1.99), platelets (OR 1.37), INR (OR 1.4), uDCD (OR 2.13) and split liver donation. ConclusionMassive blood transfusion impacts patient survival in a statistically significant way. The most significant risk factors are preoperative hemoglobin, INR and serum creatinine.

Vaginal Vault Infiltration With Bupivacaine for Postoperative Pain Control After Total Laparoscopic Hysterectomy: A Randomized Control Trial

ABSTRACT A viable alternative to total abdominal hysterectomy is total laparoscopic hysterectomy (TLH), which offers abdominal route advantages for women in need of total hysterectomy for benign diseases. Fewer complications, faster recovery, and less pain are ensured by laparoscopy, although this method is not entirely devoid of pain. Reports from various authors indicate that up to 80% of laparoscopic surgery patients require opioid analgesia, which could increase hospital-stay duration and delay mobilization/recovery. Because of these statistics, opioid analgesic usages ought to be minimized, for the aforementioned reasons and also to prevent additional adverse effects. This study was performed to evaluate efficacy of reducing postoperative pain by infiltration of bupivacaine, a long-acting anesthetic agent, into the vaginal vault after TLH. This study was a randomized control trial designed as a 2-arm double-blinded study conducted at a North-Indian Apical Center in the Department of Obstetrics and Gynecology. After written informed consent from all patients, computer-generated randomization software placed them in 1 of 2 groups: group 1, the intervention group (received the infiltration of bupivacaine in the vaginal vault following TLH), or group 2 (the control group). The inclusion criteria were a uterine size of ≤12 weeks' pregnancy and patients requiring TLH with or without bilateral salpingo-oophorectomy for uterine size and benign conditions. Exclusion criteria were contraindication to any medication used by the study, presence of malignancy, history of multiple surgeries, and history of inflammatory disease. Postoperative pain outcome measured in both groups at 1, 3, 6, 12, and 24 hours via a visual analog score was the primary outcome. The secondary outcome was the need for rescue analgesia. A complete profile of each patient was created, using eligibility criteria, body mass index, and demographic profile, and a complete gynecological and physical examination was performed, along with preoperative investigations for fitness to general anesthesia. Per standard protocol, general anesthesia was administered for all surgeries. After vault closure, a fine-tipped aspiration needle was used to administer 10 mL of bupivacaine, which was infiltrated laparoscopically at 2 different locations, approximately 2–4 cm apart. The control group omitted this step. In the first 24 hours after operation, pain was treated using 1 g intravenous paracetamol every 6 hours. For the next 5 days, patients were given nonsteroidal anti-inflammatory drugs (diclofenac) 3 times daily for 5 days. Participants scaled their pain using the visual analog scale (VAS) score at the 1, 2, 6, 12, and 24 hours intervals postsurgery. Scores greater than 4 initiated the distribution of tramadol 50 mg intramuscular. Also recorded were the uterine weight, the operative time, complications, and the amount of operative bleeding. Group 1 patients exhibited VAS scores of less than 4 at 1 hour postsurgery (100%), 3 hours postsurgery (100%), 6 hours postsurgery (97%), 12 hours postsurgery (96.7%), and 24 hours postsurgery (36.7%). The control group VAS scores of less than 4 for the respective times were as follows: 1 hour (93%), 3 hours (86.6%), 6 hours (30%), 12 hours (10%), and 24 hours (3.3%). From these data, it is clear that the infiltration with a local analgesia was effective in reducing postoperative pain. Overall, a feasible and safe option for postoperative pain relief is vaginal cuff infiltration with local anesthetic. A significant increase in the number of women experiencing minimal postoperative pain for 24 hours after laparoscopic hysterectomy took place due to infiltration of the vaginal vault with 10 mL of 0.25% bupivacaine (with no complications). Furthermore, this method reduces requirements of additional opioid/analgesia usage. The beneficial use of local vault infiltration with bupivacaine after TLH within the first 24 postoperative hours is highlighted by this study.

Parotid Metastasis in a Case of Papillary Thyroid Carcinoma: Case Report and Review of Literature.

Papillary thyroid carcinoma (PTC) is the most common differentiated thyroid neoplasm. Common sites of regional and distant metastasis includes lymph nodes, lungs and bone. 51year old female patient who was a known case of PTC with a history of multiple surgeries, radioactive iodine therapy (RAI) and oral chemotherapy presented with a painful right parotid mass. PET scan demonstrated FDG avid lesions in the right parotid gland, cervical lymph nodes and other distant sites. Cytology report showed features of metastatic PTC. Patient underwent extended total parotidectomy with facial nerve resection, skin and masseter muscle resection and extended radical neck dissection. Final histopathology (HPE) report showed metastatic papillary carcinoma thyroid. Patient is currently on oral chemotherapy and on regular follow up. PTC rarely metastasizes to parotid gland and such cases have to be treated with surgery alone or with a combination of surgery and RAI based on tumour burden.

Metagenomic next-generation sequencing assists the diagnosis treatment of fungal osteoarticular infections.

Fungal osteoarticular infection (FOI) is not commonly seen in clinical practice but proposes a great challenge to orthopedic surgeons. In this study, we aimed to investigate the risk factors, the clinical features, and surgical outcomes of FOI in our institution. Specifically, we aimed to explore the role of metagenomic next-generation sequencing (mNGS) in the diagnosis and treatment of FOI. All the patients who were diagnosed and managed with FOI in our institution from January 2007 to December 2020 were retrospectively reviewed, including primary fungal implant-related infection, primary fungal osteomyelitis or arthritis, and fungal infections secondary to bacterial osteomyelitis or implant-related bacterial infections. The potential risk factors and the clinical and surgical features were analyzed. The pathogen data were compared between culture and the mNGS test. A total of 25 patients were included, namely, 12 primary implant-related infections, 7 primary fungal osteomyelitis or arthritis, and 6 fungal infections secondary to bacterial osteomyelitis or implant-related bacterial infections. Most cases had undergone multiple surgeries or long-term antibiotic treatment. Diagnosis was mainly based on microbial culture and the mNGS test. Optimization of culture methods and the use of mNGS assisted the diagnosis. Specifically, mNGS was performed in 12 patients, 5 of whom were culture-negative. In the remaining seven cases, mNGS demonstrated the same results as culture. Management of FOI was complicated as most patients required multiple surgeries followed by long-term antifungal treatment. In selected cases, antifungal-impregnated cement spacer retention can be an optional choice. The overall success rate was 100% (25/25) for our cohort. We concluded that patients with comorbidities and a history of multiple surgeries or long-term antibiotics are under higher risk for FOI. Use of mNGS assists the diagnosis and treatment of FOI. Surgery combined with long-term antifungal treatment achieved satisfactory outcomes. In selected cases, antifungal-impregnated cement spacer retention can be an optional treatment choice.

P9.14: Massive Blood Transfusion: Risk Factors and Consequences

Introduction: Massive blood transfusion (MBT) is a common occurrence in liver transplant patients. Recipient-related risk factors include cirrhosis, history of multiple surgeries and suboptimal donors. And, while advances in surgical techniques, anaesthetic management and graft preservation have decreased the need for transfusions, this complication has not been completely eliminated. Materials and Methods: One thousand four hundred and sixty nine liver transplants were performed at our institution between May 1998 and December 2019, and data was available regarding transfusion for 1469 of them. We divided the patients into two groups, with regards to transfusion of 6 or more units of packed red blood cells in the first 24 hours post transplant, and we analyzed the differences between the groups. We analyzed the risk factors for massive transfusion, as well as factors that influence patient survival by using Cox regression. Results: Out of the 1198 patients, 607 (50.7%) met criteria for massive transfusion.Both groups were statistically different with regards to hepatocellular carcinoma, autoimmune cause, liver/kidney transplant, uDCD, retransplantation, albumin serum levels, creatinine, sodium, bilirubin, haemoglobin, platelets, INR, MELD, McCluskey and Child scores. Out of the variables from the McCluskey index, only the following were significant for massive bleeding: Haemoglobin <10, INR >2 and creatinine >1.2. We contrasted the efficiency of all of the previously mentioned scores for capacity to predict massive transfusion, but none reached an area below the curve above 0.7. Survival was statistically lower at 1, 3, and 5 years when comparing the groups that had MBT compared to those that did not (92,6%, 85,2% and 79,7% respectively in the non MBT group, vs. 78,1%, 71,6% y 66,8%, respectively, in the MBT group). Regarding survival analysis, MBT was associated with a 1.5 mortality risk as opposed to no MBT. Conclusion: Massive blood transfusion impacts patient survival in a statistically significant way. The most significant risk factors are preoperative haemoglobin, INR and creatinine.

Deep endometriosis: clinical and epidemiological findings of diagnosed women according to the criteria of the international deep endometriosis analysis group (IDEA)

Introduction: endometriosis occurs when tissue similar to the endometrium affects the peritoneum, which can infiltrate structures and organs such as the bowel, ureter, bladder or vagina and is usually accompanied by an inflammatory process. It is estimated that the disease affects 6 to 10% of women of reproductive age and more than 50% of infertile women. The clinical and epidemiological data of patients with DE come from studies whose women were selected by surgery, therefore subject to selection bias. Transvaginal pelvic ultrasound with bowel preparation (TVUBP) has high specificity and sensitivity values. Objective: analyze the clinical and epidemiological profile of patients with DE diagnosed through the TVUBP. Methods: a cross-sectional study that analyzed 227 patients with an ultrasound diagnosis of deep endometriosis. Results: infertility affected 43.8% of women. Painful symptoms considered as moderate or severe (visual analogue scale, VAS, &gt;3) had the following prevalence and mean values on the VAS scale, respectively: dysmenorrhea in 84.7% (6.9), dyspareunia in 69.1%, (4.2) menstrual dyschezia in 60.7% (4.3) and menstrual dysuria in 35.7% of patients. A history of multiple surgeries occurred in 10.4% and only 6.8% of patients had undergone physiotherapy for the pelvic floor. Conclusion: the DE population had a high prevalence of infertility and pain symptoms, findings that reflect the social impact on the quality of life and family planning of these women. The high frequency of history of multiple surgical approaches and the low incidence of history of pelvic physiotherapy in the population with DE, contrary to the currently established ideal treatment recommendations, indicate the difficulty of access for patients to specialized centers.

Corrective osteotomy for complex tibial deformity in a patient with hereditary vitamin D-resistant hypophosphatemic rickets (HVDRR) using CT-based navigation system and 3D printed osteotomy model

Planning a three-dimensional (3D) osteotomy using computed tomography (CT) data is useful especially in cases with complex deformities. Furthermore, CT-based navigation system allows the preoperative virtual planning to be replicated in actual surgery. However, one disadvantage when using navigation systems is that when osteotomies are performed on tracker-attached bone, the bone fragments on the side that were cut away cannot be tracked. This is especially problematic when performing multiple osteotomies on bones with complex deformities. We solved this problem by creating a 3D printed bone model that can be referenced intraoperatively and used in combination with the navigation system. We applied these techniques to perform segmental corrective osteotomy for a complex tibial deformity with intramedullary nail (IMN) fixation case of hereditary vitamin D-resistant hypophosphatemic rickets (HVDRR) in an adult man. Due to the patient’s history of multiple surgeries, the affected tibia had a narrow and partially closed medullary canal. Therefore, we planned to use an IMN for correction and fixation of tibial deformity to protect the thin and stretched skin around the deformed tibia. With the assistance of CT-based navigation, we could perform an accurate three-dimensional tibial osteotomy. Moreover, we could perform accurate preparation of closed medullary canal for the IMN placement by referring to the 3D printed bone models. Six months after the operation, the bone union at the osteotomy sites was confirmed and the patient was able to return to his normal life and work.

Pulmonary embolism following the third thoracic tuberculosis surgery: A case report and literature review

BackgroundThe study aimed to analyze the clinical effects of pulmonary embolism succeeding a third surgery conducted for multiple recurrences in thoracic tuberculosis (TB).Case reportA 74‐year‐old female patient developed thoracic tuberculosis and was subsequently treated in our hospital in March 2019, October 2020, and February 2021. The third surgical intervention included anterolateral thoracic lesion resection, internal fixation, posterior spinal tuberculous sinus resection, and debridement with suture. The operative time was 172 min resulting in a substantial intraoperative blood loss (2321 ml). Postoperative re‐examination of chest CTPA indicated a strip filling defect and pulmonary embolism in the external branch of the right middle lobe of the lung. After completing the active treatment, the D‐dimer quantification, WBC, CRP, and ESR values were 1261 ng/ml, 7.71 × 109/L, 74.66 mg/L, and 63 mm, respectively. Chest CTPA re‐examination after the treatment showed no signs of pulmonary embolism.ConclusionPatients with a long‐term history of multiple operations, high BMI, cerebral infarction, diabetes, and older age group were more likely to develop pulmonary embolism after spinal tuberculosis surgery. Thus, the possibility of postoperative pulmonary embolism should be thoroughly analyzed before any subsequent surgical treatment in patients with recurrent spinal tuberculosis.

Malignant Transformation of an Aneurysmal Bone Cyst to Huge Fibroblastic Osteosarcoma without Radiation Exposure: Proper Surgical Management is More than a Challenge

In this study, we present a case of aneurysmal bone cyst presenting as pathologic fracture of the left proximal femur. The patient, who had history of multiple surgeries, was referred to us with a giant mass. The patient was found to develop osteosarcoma without radiation exposure. External hemipelvectomy was performed.Appropriate surgical management of a huge tumor that repeatedly operated is more than a challenge like this case. Aneurysmal bone cysts rarely present as pathologic fractures initially. In addition, to the best of our knowledge, the number of aneurysmal bone cysts (ABCs) exhibiting malignant transformation to osteosarcoma without radiation exposure is less than ten in the literature.Keywords: aneurysmal bone cyst, osteosarcoma, malignant transformation, hemipelvectomy

Vascularized Second Metatarsal Joint Transfer with Concomitant Orthognathic Surgery for Reconstruction of the Temporomandibular Joint: Our Pilot Experience.

Temporomandibular joint ankylosis-associated deformity and dysfunction is a challenge to reconstruct. Alloplastic temporomandibular joints, both stock and custom-made, are used to replace the ankylotic mass with a functional joint. Still, the cost of these alloplastic joints is so expensive that it cannot be affordable to most of our population. A primary objective of achieving at least 35 mm of mouth opening was planned. Secondarily we planned to achieve a functional occlusion with acceptable facial balance and symmetry. Autologous TMJ reconstruction using vascularized second metatarsal joint transfer with concomitant orthognathic surgery. The surgery aims to achieve a significant functional rehabilitation with correction of maxillomandibular deformity in a single-stage surgery. As a result of this, we present our initial experience to rehabilitate the patient with temporomandibular joint ankylosis both functionally and aesthetically by performing simultaneously joint replacement using the patient's own vascularized second metatarsal joint and concomitantly performing the orthognathic surgery. By this, we could holistically treat the patient with minimal cost and make them socially acceptable. We do not propose a 2nd metatarsal vascularized flap as a substitute for a custom-made total TMJ prosthesis. Still, we suggest a viable option in a selected set of patients where TMJ prosthesis cannot be afforded or has failed with a history of multiple surgeries in the same region.

Transperineal total mesorectal excision for rectal cancer on the residual rectum after multiple abdominal surgeries in a patient with Crohn\u2019s disease: a case report

BackgroundThe improved prognosis of Crohn’s disease may increase the opportunities of surgical treatment for patients with Crohn’s disease and the risk of development of colorectal cancer. We herein describe a patient with Crohn’s disease and a history of multiple surgeries who developed rectal stump carcinoma that was treated laparoscopically and transperineally.Case presentationA 51-year-old man had been diagnosed with Crohn’s disease 35 years earlier and had undergone several operations for treatment of Crohn’s colitis. Colonoscopic examination was performed and revealed rectal cancer at the residual rectum. The patient was then referred to our department. The tumor was diagnosed as clinical T2N0M0, Stage I. We treated the tumor by combination of laparoscopic surgery and concomitant transperineal resection of the rectum. While the intra-abdominal adhesion was dissected laparoscopically, rectal dissection in the correct plane progressed by the transperineal approach. The rectal cancer was resected without involvement of the resection margin. The duration of the operation was 3 h 48 min, the blood loss volume was 50 mL, and no intraoperative complications occurred. The pathological diagnosis of the tumor was type 5 well- and moderately differentiated adenocarcinoma, pT2N0, Stage I. No recurrence was evident 3 months after the operation, and no adjuvant chemotherapy was performed.ConclusionThe transperineal approach might be useful in patients with Crohn’s disease who develop rectal cancer after multiple abdominal surgeries.

Zollinger ellison syndrome due to primary nodal gastrinoma located outside the limits of the conventional gastrinoma triangle: report of a case

Primary nodal gastrinoma is a rare entity and the diagnosis is often contemplative when no other non - nodal primary site can be identified despite thorough investigations and operative exploration. Here we report one such case wherein a primary nodal gastrinoma was diagnosed as an entity of exclusion. Additionally, the location of the disease outside the confines of the conventional gastrinoma triangle further contributes to the rarity of the presentation. A young male patient had presented to us with history of multiple operations in the past for recurrent upper abdominal pain presumably consequential to peptic ulcer disease viz a trucal vagotomy and gastrojejunostomy, duodenal ulcer perforation surgery and a cholecystectomy. CT scan and endoscopic USG showed a preaortic calcified node located outside the limits of the gastrinoma triangle. A raised serum gastrin level and an endoscopic guided FNAC confirmed the diagnosis of a gastrinoma. A 68 Ga-DOTANOC PET CT revealed an exclusive nodal uptake with no discenable primary lesion. Normalization of gastrin levels after removal of the involved pre-aortic node further pointed to the diagnosis of primary nodal gastrinoma. A high index of clinical suspicion is warranted especially in a history of multiple surgeries for recurrent upper abdominal pain and location of the lesion outside the confines of the ‘Gastrinoma Triangle’ should not be deterrent for the diagnosis.

Extragenital endometriosis with lesions of the small and large intestine, the formation of a pathological cavity draining to the anterior abdominal wall (case report)

Extragenital endometriosis is one of the most severe benign diseases of the female reproductive system, characterized by different site of target organs. This pathology is associated with the development of severe complications, the treatment of which requires a multidisciplinary approach. This case report is dedicated to the experience of treating a patient with a history of multiple surgical procedures and long-term undiagnosed deep infiltrative endometriosis, complicated by abdominocutaneus endometriotic fistula.

A case report of Gorham-Stout disease diagnosed during the course of recurrent meningitis and cholesteatoma

BackgroundGorham-Stout disease is a rare bone disorder. Here, we present a case of Gorham-Stout disease diagnosed during follow-up of a patient with cholesteatoma; the disease affected the temporal bone and other sites of the skull. To the best of our knowledge, this is the first report of Gorham-Stout disease diagnosed with recurrent cerebrospinal leakage after surgery to treat cholesteatoma.Case presentationA 25-year-old male patient re-presented to our department for the first time in 7 years with otorrhea in the right ear and recurrent meningitis. The patient had a history of multiple surgeries for cholesteatoma and suffered from recurrent cerebrospinal fluid leakage, which initially was thought to be caused by recurrence of cholesteatoma. Therefore, skull base reconstruction was planned. However, the underlying cause was identified eventually as defects in the temporal bone caused by massive osteolysis due to Gorham-Stout disease. Skull base reconstruction was abandoned because the osteolysis was considered to be progressive. Conservative treatment with infectious control was implemented as an alternative.ConclusionThis case describes unusual temporal bone osteolysis after cholesteatoma surgery and the importance of considering the possibility of multiple concurrent diseases in such individuals. The distinguishing features of this case are the fact that the temporal bone had disappeared, and deconstruction was complicated by infection and inflammation caused by cholesteatoma, surgical invasion, and Gorham-Stout disease. Appropriate diagnosis saved the patient from ineffective multiple surgeries for cerebrospinal fluid leakage or cholesteatoma, and improved his quality of life.

Magnetic compression anastomosis with atypical anastomosis for anastomotic stenosis of the sigmoid colon: a case report

BackgroundMagnetic compression anastomosis (MCA) is mainly applied in the gastrointestinal and biliary tracts through a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery.Magnets usually adsorb in the end-to-end direction (end-to-end anastomosis), exert a strong magnetic force and create an anastomosis according to the size of the magnets.Regular endoscopic dilation is required to prevent restenosis when the anastomotic size is small.We report a case in which MCA was successfully used to treat anastomotic stenosis of the sigmoid colon; the magnets adsorbed in the side-to-side direction rather than the end-to-end direction and generated a wide anastomosis in a short time that did not require endoscopic dilation.Case presentationAn 81-year-old woman was admitted to our hospital to treat anastomotic stenosis of the sigmoid colon for closure of transverse colostomy. Two years prior, the Hartmann operation and drainage were performed at other hospitals due to perforated diverticulitis of the sigmoid colon. Obstruction of the sigmoid colostomy occurred, and a transverse colostomy was performed. One year after the first surgery, high anterior resection was performed, but anastomotic stenosis occurred, causing obstruction. MCA was planned because the patient had a history of multiple operations and was expected to have strong adhesions postoperatively. MCA was safely performed, but two magnets were accidently adsorbed in the side-to-side direction. The magnet position could not be changed. The two magnets were expected to move and adsorb in an end-to-end direction naturally due to bowel movements. The magnets that adsorbed in the side-to-side direction dropped from the anus 5 days after treatment, and the anastomosis was observed by colonoscopy. Three ileus tubes were placed from the transverse colostomy beyond the anastomosis to prevent restenosis. Colonoscopy showed that the anastomosis diameter was wider than expected at 14 days after treatment, and endoscopic dilation was not necessary. No complications were observed in this patient’s postoperative course. Finally, closure of the patient’s colostomy was successfully performed.ConclusionsMCA with side-to-side anastomosis generated a wide anastomosis in a short time.

P619 Efficacy of zinc acetate hydrate administration for zinc deficiency in patients with inflammatory bowel disease: a multi-centre retrospective study

Abstract Background Zinc deficiency is common in patients with inflammatory bowel disease (IBD), and the frequency is about 42.1% in Crohn’s disease (CD) and 38.5% in ulcerative colitis (UC). Patients with IBD with serum zinc deficiency are more likely to have adverse disease-specific outcomes. However, there are few studies about the effect of administering zinc preparations in IBD patients with zinc deficiency. The purpose of this study was to investigate the efficacy of zinc acetate hydrate (Nobelzin®︎) preparation for patients with IBD with zinc deficiency. Methods 56 IBD patients who were treated with Nobelzin®︎ for zinc deficiency from March 2017 to November 2019 were analyzed. We conducted a multicenter retrospective observational study to investigate changes in serum zinc concentration or changes in disease activity before and after administration and their contributing factors. Results Among 56 cases, 4 cases were excluded due to self-interruption of internal use, and 52 cases (39 cases of CD, 13 cases of UC) were included. The median observation period was 27.5 (13–47) weeks, the median serum zinc concentration before administration was 58.5 (50.8–65.3) μg/dl, and the average of starting dose of Nobelzin®︎ was 67.8±31.1 mg/day. Nobelzin®︎ administration normalised serum zinc concentration(Zn ≥80 μg/dl) in 94.2 % (49/52) of patients. The median administration period required for normalisation of serum zinc concentration was 5 (3–8) weeks. In the group of CD patients who achieved zinc normalisation, the median CDAI score significantly improved after the normalisation from 171.5 to 129.5 (p &amp;lt; 0.001). Similarly, the partial Mayo score in the same group of UC significantly improved after the normalisation (p = 0.035). There were 77.6 % patients who did not have additional treatment without Nobelzin®︎ administration until zinc was normalised. In CD patients of this group, the median CDAI score significantly improved after the normalisation from 152 to 120 (p = 0.029). All 3 cases in which zinc normalisation was not achieved within the observation period were CD cases, and they had a history of multiple surgeries, changes in biologics, or a long medical history. In one patient, side effects of Nobelzin®︎ administration were observed and these were abdominal discomfort and nausea. During the observation period, serum copper concentration was measured in 27 patients after administration of Nobelzin®︎, and one patient presented with copper deficiency. Conclusion Our findings show that administration of zinc acetate hydrate preparations may be effective in improving zinc deficiency and contribute to improve disease activity in IBD patients with zinc deficiency.

Osificación heterotópica mesentérica precoz posabdomen abierto y su manejo quirúrgico. Presentación de un caso

Objective : Report the case of a patient with a history of multiple surgeries due to peritonitis and open abdomen, with intraoperative finding of mesenetrioc heterotopic ossification. Clinical case : A 59-year-old male patient with a history of complicated appendectomy 12 months ago, which requires the management of an open abdomen, right colectomy and terminal ileostomy. One year after appendectomy, is readmitted for transit reconstitution. Intraoperative finding were calcified mass in mesentery, of 15 x 10 x 6 cm, whose histological study reports mesenteric heterotopic ossification. This entity has low frequency, and is associated with a history of trauma and abdominal surgery, is described as a cause of morbidity and mortality. Resective surgical management is feasible for experienced teams. Conclusion : A case with antecedent of open abdomen is described, with later finding of mesenteric heterotopic ossification. This clinical case is representative for its classic risk factors and management used for its resolution.