Multidisciplinary Planning Research Articles

Perioperative Management of a Pregnant Patient With a Mechanical Heart Valve Undergoing Appendectomy: a Case Report

Introduction and importance: Managing pregnant patients with mechanical heart valves who require non-cardiac surgery presents unique challenges, particularly in balancing anticoagulation to prevent thromboembolic complications while minimizing bleeding risks. This case report discusses the perioperative management of a pregnant patient with a mechanical mitral valve undergoing emergency appendectomy. Case presentation: A 28-year-old pregnant woman at 22 weeks gestation with a history of rheumatic heart disease and a mechanical mitral valve presented with acute appendicitis. Anticoagulation therapy was shifted from warfarin to low-molecular-weight heparin (LMWH) to mitigate the risks of bleeding and teratogenicity. Intravenous unfractionated heparin (UFH) was used perioperatively to maintain adequate anticoagulation. A multidisciplinary team guided the patient’s care, and she underwent a successful laparoscopic appendectomy with stable maternal and fetal outcomes. Clinical discussion: Perioperative anticoagulation in pregnant women with mechanical heart valves is critical to avoiding valve thrombosis while minimizing the risk of bleeding. In this case, using LMWH as a bridging therapy and UFH during surgery proved effective in balancing these risks. The case underscores the importance of a coordinated multidisciplinary approach to optimize maternal and fetal outcomes during emergency surgery. Conclusion: This case highlights the complexities of managing anticoagulation in pregnant patients with mechanical valves requiring non-cardiac surgery. With appropriate anticoagulation adjustment, multidisciplinary planning, and vigilant perioperative monitoring, both maternal and fetal outcomes can be favorable in such high-risk situations.

Determining the Mental Health Literacy Level of University Students and Examining Their Attitudes Towards Seeking Psychological Help.

This descriptive study examined the mental health literacy levels and attitudes towards seeking psychological help among university students. The study was conducted with 317 students from a university in Türkiye. Data were collected via an online platform using a Personal Information Form, the Mental Health Literacy Scale (MHLS) and the Attitudes Toward Seeking Professional Psychological Help Scale-Short Form (ATSPPHS-SF). Participants, with an average age of 20 ± 1, were predominantly female (89%). Most had previously sought psychological support (75.1%) and believed the psychology information obtained online was accurate (61.2%). Significant differences were found between residential location (p = 0.034) and maternal education level (p = 0.017) with the Knowledge Subscale of MHLS, and between history of seeking psychological support (p = 0.010) with the Resource Subscale of MHLS. Additionally, there was a significant difference between seeking psychological support history and mean ATSPPHS-SF scores (p = 0.060). The scores on MHLS (13.15 ± 3.38) and ATSPPHS-SF (18.38 ± 3.77) indicated moderate levels, with a positive and significant relationship between the scales' total scores (p = 0.000). The study concluded that mental health literacy is crucial for increasing the rate of seeking psychological help. Addressing the lack of knowledge regarding mental health is essential for early diagnosis, prevention and maintenance of mental health. It is recommended incorporating mental health literacy content into university curricula, initiating efforts to provide information about psychological help resources and engaging psychiatric nurses in educational roles on campus through multidisciplinary planning.

Precision medicine and multidisciplinary care in gastric and gastroesophageal junction (G/GEJ) cancers: Challenges and practice gaps in community cancer clinics.

385 Background: The advent of biomarker-driven therapeutic strategies brings increasing precision to the treatment of G/GEJ cancer, placing biomarker testing at the forefront of patient management. The management of evolving logistics for testing and related decision-making can be challenging, especially in community clinics. As part of a multi-center quality improvement initiative, we evaluated current gaps in biomarker testing and practice patterns including multidisciplinary care for G/GEJ cancers in community oncology centers. Methods: Between 5/2024 and 8/2024, oncology team members (N = 60) from 5 US-based community oncology practices completed surveys assessing attitudes, knowledge, competence, practice patterns, challenges, and gaps regarding biomarker testing and multidisciplinary care in G/GEJ cancers. Results: Despite practice guidelines, many patients with G/GEJ cancer did not receive testing for recommended biomarkers. While most providers report that biomarkers HER2 (67%) and PD-L1 (62%) are routinely reported in pathology reports, less than half said testing for MSI/MMR, TMB, and BRAF p.V600E were reported, and less than 25% reported analysis of NTRK1/2/3 , RET , CLDN.18.2, and FGFR2 . Biomarkers most frequently requested if not included in the original pathology work-up were PD-L1 (48%), TMB (32%), and BRAF p.V600E (32%). Top challenges reported by providers in integrating biomarker testing into practice were prioritizing testing for limited tissue (38%), determining whether to begin treatment prior to receipt of molecular testing results (35%), and optimizing specimen collection for molecular testing (27%). Only 23% of providers reported feeling very or extremely comfortable (4/5 on 5-point Likert scale) with interpreting and applying biomarker testing results to treatment decision-making. Additional challenges included turnaround time for biomarker testing, uncertainty interpreting biomarker results, and inconsistent or infrequent multidisciplinary tumor boards. Indeed, some providers (12%) reported not participating in multidisciplinary tumor boards at all, while others reported participating weekly (16%), once or twice a month (21%), every other month (12%), or less frequently (23%). Providers believed improving test ordering process (47%), decreasing testing turnaround time (42%), and standardizing panels for biomarker testing (40%) would be most impactful in implementation of biomarker testing into clinical workflows. Conclusions: Although most oncology teams reported use of some form of biomarker testing in treatment of G/GEJ cancer, testing was inconsistent and not as comprehensive as currently recommended. These data will be leveraged to develop multidisciplinary action plans with participating clinics to improve biomarker testing for treatment selection in G/GEJ cancers.

Chronic Heart Failure and Coronary Artery Disease: Pharmacological Treatment and Cardiac Rehabilitation

Coronary artery disease is the leading cause of acute and chronic heart failure. Patients with heart failure and ischemic heart disease need a tailored assessment to define the appropriate treatment, while a specific multidisciplinary management plan should be followed. Indeed, several factors should be assessed before starting treatment, such as heart failure symptoms and/or signs, angina, electrocardiographic features, right and left ventricular systolic and diastolic function, serological abnormalities, cardiac structural and functional integrity, and pulmonary function. New scenarios and developments have emerged recently in this field, increasing our knowledge regarding pathophysiology, exercise, and pharmacology. Effective and appropriate management and treatment reduce the risk of death and hospitalization for heart failure. Herein, we provide an updated, state-of-the-art overview of pharmacological treatment and cardiac rehabilitation in patients with chronic heart failure and coronary artery disease. Furthermore, tailored and contemporary management in clinical practice will be proposed for this specific and fragile patient population.

Airway Management in A 9-Month-Old Infant with Congenital Oral Teratoma: A Case Report

Paediatric airway management in children under one year of age with congenital oral tumors poses significant challenges, particularly due to potential airway obstruction and postoperative mucosal oedema. This report details the anaesthetic management for the successful resection of a congenital oral teratoma in a 9-month-old child. Anticipating difficult intubation due to limited oral cavity size and restricted mouth opening, a multidisciplinary plan was implemented. This included the availability of a fibreoptic scope and surgical teams prepared for emergency tracheostomy. The patient was successfully intubated via conventional laryngoscopy under inhalational anaesthesia, intravenous ketamine, and periglottic lidocaine. The case underscores the importance of individualized precautions and a coordinated approach to optimize outcomes.

N16 Optimizing care for women of childbearing age with Inflammatory Bowel Disease: Developing a specific pathway utilizing European Crohn's and Colitis Organisation guidelines and the American Gastroenterology Association recommendations

Abstract Background Recent advances have greatly improved our understanding of the interaction between Inflammatory bowel disease (IBD) and reproductive health. The European Crohn's and Colitis Organisation (ECCO) and the American Gastroenterology Association (AGA) have both provided valuable guidelines to support best practices in this area.1,2 Translating these guidelines into a practical care pathway is useful for patients with a pregnancy wish or for those who are already pregnant, ensuring effective implementation in daily practice. Methods Our goal was to develop the IBD multIdiscipliNary Family plAnning uz leuveN care paThWay (IBD INFANT Wish) and to improve preconception counselling for IBD patients with a pregnancy wish. To develop, implement and evaluate this pathway, we applied a 7-phase model.3 Our structured approach aims to provide comprehensive, multidisciplinary care tailored to the unique challenges and needs of IBD patients during preconception, pregnancy and postpartum. Results After completing the first three phases of the 7-phase methodology, we went on to develop the IBD INFANT Wish. The development of this care pathway took into account different trajectories depending on patient type, expected risks and comorbidities. This approach ensures that each patient's unique circumstances are addressed, providing tailored and effective care throughout the pathway. The care pathway (see Figure) is structured as a time-task matrix, mapping the journey of a female IBD patient from (active) pregnancy wish through the postpartum period, outlining the necessary actions at each stage (preconception, pregnancy and postpartum). Besides the care pathway, other tools were developed. An information display was created for the infusion ward and outpatient clinic to highlight the importance of preconception counselling. A preconception counselling template was developed to ensure that general practitioners and peripheral obstetricians are aware of counselling their IBD patients. In addition, an information brochure has been created providing comprehensive information on preconception and supporting patients in a healthy pregnancy. A decision tree was developed to help the IBD team provide optimal care for patients who want to become pregnant or are pregnant already, with a focus on high-risk pregnancies. Finally, a sticker about vaccinations for the baby was made for the baby's vaccination booklet in case the mother received biological therapy during pregnancy. Conclusion The development of the IBD INFANT Wish marks a significant advancement in guiding IBD patients of childbearing age, providing multidisciplinary and evidence-based care tailored to improve both maternal and infant outcomes while setting a new standard for future practice.

Case management in Emergency Care: Impact Evaluation of the CARED Program.

Hospitals face mounting pressure to reduce unplanned utilization amid rising healthcare demands from an aging population. The Case management for At-Risk patients in the Emergency Department (CARED) program is among the first ED transitional care strategies to focus on both frail older adults and Emergency Department (ED) re-attenders to reduce acute hospital utilization. This study aims to evaluate the effectiveness of the CARED program in reducing hospital (re)admissions and ED re-attendances within 30- and 60-days post-discharge. A retrospective, propensity-matched study was conducted from April 2022 to July 2023 in the ED of Ng Teng Fong General Hospital in Singapore. The CARED program identifies and enrols at-risk patients i.e., frail older adults and patients who re-attend the ED within 30 days of hospital discharge, for a geriatric assessment. This is followed by multidisciplinary team care, discharge planning and right siting of care from the ED to community-based services by ED case managers. The primary outcomes were hospital (re)admissions and ED re-attendances within 30- and 60-days post-discharge. Secondary outcomes were cost avoidance and bed occupancy days from reduced acute hospital usage. Nearest-neighbour 1:1 propensity score matching matched 1,615 intervention group to 1,615 control group. Baseline characteristics of the intervention and control groups did not differ significantly. Difference-in-differences (DID) analyses showed significantly lower 30-day (3.96%; 95% CI 2.71% to 5.23%) and 60-day (6.69%; 95% CI 5.47% to 7.91%) hospital admissions, as well as 30-day (4.89%; 95% CI 3.83% to 5.95%) and 60-day (6.50%; 95% CI 5.28% to 7.72%) ED re-attendances in the intervention group compared to the control group. Additionally, the reduced admission and ED re-attendance rates resulted in 30-day and 60-day inpatient admission costs avoidance ($1,553,548.96 (69.86%); 95% CI $1,525,827.76 to $1,581,270.15; P = 0.006; and $1,400,047.07 (32.56%); 95% CI $1,365,484.79 to $1,434,609.37; P = 0.048 respectively), ED attendance costs avoidance ($25,849.92 (23.70%); 95% CI $25,091.93 to $26,607.89; P = 0.096; and $37,538.39 (18.09%); 95% CI $36,470.27 to $38,606.53; P = 0.086 respectively) and bed occupancy days saved (1,212 days; 95% CI 1,191.80 days to 1,232.20 days; P = 0.003; and 1,267 days; 95% CI 1,242.58 days to 1,291.42 days; P = 0.011 respectively). CARED program effectively reduced unplanned hospital use within 30- and 60-days post-ED discharge for at-risk patients. It also significantly lowered inpatient admission and ED attendance costs and hospital bed occupancy days, highlighting its potential to improve patient outcomes and reduce healthcare expenses.

Anesthetic Management of Renal Tumor with Level 3 Inferior Vena Cava Extension at a University Hospital in Vietnam: A Case Report

Background: Renal tumors with inferior vena cava (IVC) invasion pose significant challenges for surgical and anesthetic management. This report presents the anesthetic management of a patient with a level 3 IVC-invading renal tumor, emphasizing the complexity and multidisciplinary approach required. Case Presentation: A 55-year-old woman with a large left renal tumor causing complete obstruction of the left renal vein and near-total obstruction of the IVC was admitted for surgery. Multidisciplinary planning included a nephrectomy with removal of tumor from the IVC. The patient underwent general anesthesia with extensive hemodynamic monitoring and fluid management to mitigate potential blood loss and cardiovascular instability. The surgery, lasting 5 h, involved successful radical nephrectomy, tumor removal from the IVC, and resection of liver metastases. Postoperative recovery was without complications, and the patient was discharged 7 days. Conclusion: Managing anesthesia for renal tumors with IVC invasion requires careful preoperative planning, invasive monitoring, and multidisciplinary approach.

Organ Procurement From a Brain-Dead Pregnant Woman in Third Trimester With Nonviable Fetus in Utero: A Case Report.

Organ procurement from brain-dead pregnant women is rare and typically occurs postfetal delivery. In this case report, we describe organ procurement from a brain-dead woman in her third trimester of pregnancy with a nonviable fetus remaining in utero. We report a 33-year-old woman at 38 weeks gestation who suffered anoxic brain injury following cardiac arrest due to suspected opioid overdose. After confirming brain death and fetal demise, organ procurement was performed with the fetus in situ. Despite significant anatomical challenges, successful procurement of the liver and kidneys was achieved through innovative surgical strategies. This case highlights the feasibility of organ procurement in late-stage pregnancy with fetus in situ, emphasizing multidisciplinary planning and surgical adaptability.

Iatrogenic descending thoracic aorta perforation by pedicle screws as a delayed complication of scoliosis correction surgery. The anesthetic management and TEE role

A 29-year-old lady was referred to us with a rare complication of scoliosis correction surgery. She had two of the screws migrated and penetrated the descending thoracic aorta. She came to theater to have the screws removed and the aorta repaired endovascularly. The successful intervention needed a multidisciplinary team planning, coordinated work, and communication between the four involved teams: anesthesia, vascular surgery, interventional radiology, and spine surgery. There was a lot of anesthetic challenges that were new to us because of the rarity of that complication. In addition, it was another situation where the trans-esophageal echocardiography was found very useful and affected the decision making by visualizing the screws inside the aorta. The outcome was successful, and the patient was discharged home safely, hence, we would like to share our experience in managing this difficult case to help others who might find themselves in a similar situation.

A prospective study of methylated ctDNA in patients undergoing treatment for liver metastases from colorectal cancer.

Decision regarding local treatment of colorectal liver metastases (CRLM) is a multidisciplinary assessment, and liver intervention should be performed when the metastases are deemed resectable. There is no standard biomarker to aid neither this decision nor the postoperative treatment decisions. The present prospective, observational study aimed to investigate the potential clinical utility of a combined tumor-specific and organ-specific methylated circulating DNA assay in the perioperative setting of CRLM. The study included 56 cases with CRLM. Blood samples were drawn preoperatively and postoperatively. Multiplex methylation analysis of the markers NPY, KANK1, and GAL3ST3 (meth-ctDNA) was performed using droplet digital PCR. The assay detected preoperative and postoperative meth-ctDNA in 37% and 46% of patients, respectively. Patients with negative preoperative meth-ctDNA had a longer median PFS compared to those with positive preoperative meth-ctDNA (HR=2.2, 95% CI 1.2-3.9, p<0.01). In a multivariate analysis, preoperative negative meth-ctDNA was identified as a strong independent predictor of PFS (HR=3.3, 95% CI 1.5-7.2, p<0.01). Similarly, patients with negative postoperative meth-ctDNA had longer median PFS (HR=3.0, 95% CI=1.6-5.6, p<0.001) and OS (HR=4.1, 95% CI 1.9-9.1, p<0.001) compared to those with positive postoperative meth-ctDNA. Preoperative meth-ctDNA may serve as an important biomarker to inform the multidisciplinary assessment and treatment planning of CRLM. Negative meth-ctDNA may indicate the optimal timing for liver intervention, whereas positive meth-ctDNA may indicate initiation or re-orientation of chemotherapy, or immediate local intervention. Our results confirm postoperative negative meth-ctDNA as a strong prognostic marker of survival.

Early Care of Polytraumatized Patients: A Framework for Orthopaedic Surgeons.

The role of orthopaedic surgeons during trauma activations is vague and often underused. Advanced trauma life support (ATLS) is a training program and framework for performing initial life- and limb-threatening interventions. ATLS was created by Dr. James Styner, an orthopaedic surgeon, to systematically evaluate and treat trauma patients after his family received suboptimal initial care following a plane crash in 1976. There are numerous orthopaedic assessments done during the ATLS primary and secondary surveys. Understanding hierarchy and sequencing of these interventions may enhance orthopaedic integration into the broader resuscitation and surgical efforts. ATLS training is not standard in US orthopaedic residency programs. Fundamental understanding of ventilation parameters and resuscitative protocols enhance decision making for the extent of orthopaedic surgical intervention acutely. Defining indications for emergent interventions among other surgical specialties improves multidisciplinary surgical planning. This review aims to answer the question, "What needs to be done now using the ATLS survey framework and how can an orthopaedic surgeon contribute?" Furthermore, this review intends to introduce ATLS for orthopaedic surgeons in supportive roles with surgical and nonsurgical responsibilities by describing basic protocols and evidence of benefit.

Empowering professionals: a multidisciplinary approach to supporting people seeking asylum and refugees.

People seeking asylum and refugees living in initial accommodation in the UK can experience significant barriers to accessing care. They often have complex health and social needs and may experience fragmentation in the delivery of services. The Respond Integrated Refugee Health Service, hosted by University College London Hospital and operating across North Central London, has been created to address some of these challenges. In addition to offering in-person holistic health and well-being assessments, infection screening and onward care planning, Respond has developed an online multidisciplinary team (MDT) forum to support professionals working with the most complex of cases. Key professional groups from across the network are invited to contribute to multidisciplinary care planning, providing an efficient and streamlined multiagency model of care, improved access to interdisciplinary pathways and opportunities for interprofessional learning. Here, we describe the creation of the Respond Complex Refugee Health Advice and Guidance MDT and discuss the perceived benefits and limitations of the MDT approach in improving the care of people seeking asylum and refugees.

Esthetic and Functional Rehabilitation: Retreatment of Anterior Fixed Dental Prothesis With Biologically Oriented Preparation Technique and Digital Workflow.

This clinical case describes a multidisciplinary retreatment of a patient with anterior fixed dental prostheses (FDPs) using minimally invasive restorations and a biologically oriented preparation technique (BOPT). A 56-year-old female patient, treated 30 years ago with a metal-ceramic FDP due to dental agenesis, presented a misfit prosthesis at the gingival margin, black spaces, and food retention at the pontics. Notably, tooth number 2.6 was absent, and she exhibited a left crossbite. Her chief complaint was the compromised esthetics of her restorations. Given her coagulation disorder, von Willebrand disease, she declined mucogingival surgery. A diagnostic wax-up and mock-up was performed to establish treatment goals. The initial phase involved periodontal, orthodontic, and implant treatment. The orthodontic treatment with aligners to correct the crossbite. Subsequently, bleaching and a second mock-up were conducted to guide prosthetic treatment. In the prosthodontic treatment, the abutment teeth were prepared using a vertical BOPT to remodel the gingival tissues, achieving the esthetic goal of repositioning the gingival margin without surgery. The provisional phase was critical for soft tissue remodeling and ensured clinical success. After stabilization of the soft tissues, a monolithic zirconia FDP was delivered, with a follow-up of 2 years. A multidisciplinary treatment plan, utilizing a digital workflow, resulted in stable clinical and esthetic outcomes at the two-year follow-up, effectively retreating an anterior bridge using BOPT in a patient with a coagulation disorder that contraindicated complex surgical interventions.

Anaesthetic management of infant with occipital encephalocele associated with Arnold Chiari III malformation - A Case Report

Children with occipital meningoencephalocele associated with Arnold–Chiari III malformation present unique challenges to anesthesiologists. Meningoencephalocele is a congenital anomaly wherein meninges, brain, and cerebrospinal fluid (CSF) are herniated through defect in the skull. Challenges to anesthesiologists include difficult airway, latex allergy, bleeding, CSF loss, and autonomic disturbances. Here, we report a late case of a 9-month-old male child with occipital encephalocele associated with Arnold–Chiari III malformation. The child underwent surgical correction under general anesthesia without any adverse event. The anticipated difficult airway was secured with prior planning and teamwork. Multidisciplinary care and careful planning are essential to safeguard the perioperative outcomes for patients with meningoencephalocele wherein difficult airway, blood loss, autonomic dysfunction, and perioperative hypothermia are major concerns.

When the plan “A” does not work, there is an “O” in the alphabet: Orthotopic kidney transplant. A case report

Introduction: The prolonged wait for an organ can lead to depletion of vascular access in patients with chronic kidney disease. The lack of suitable vessels forces surgeons to explore alternative approaches for renal graft anastomosis, such as the orthotopic transplant procedure. The aim of this article is to present a case of a patient with exhaustion of vascular access and urgent need for kidney transplantation, which was successfully performed using orthotopic technique. Case Report: A 33-year-old man with stenosis of the iliac arteries underwent an orthotopic transplant with placement of the graft to the splenic vessels and pyeloureteral anastomosis. The patient had a very successful evolution and normal graft function. Conclusion: As surgical techniques evolve, increasingly complex patients require advanced, individualized approaches. This case exemplifies the multidisciplinary planning and execution needed to meet the growing challenges in transplantation. The report underscores the importance of innovative surgical strategies and comprehensive transplant protocols to address the future demands of the transplant community.

"Fournier": the eponym of a disastrous gangrene. Clinical case experience.

Fournier's gangrene is a relatively rare infectious necrotizing fasciitis that affects the superficial and deep tissues of the perineal, genital and perianal regions. Expressly known to be highly morbid, this condition can carry a staggering spectrum of mortality in the absence of a diligent multidisciplinary management plan. The disastrous and critical scale of the entity deserves particular attention to improve the results. We report the tragic case of a patient with a medical history of diabetes admitted with the diagnosis of Fournier's gangrene. Examination revealed multi-organ failure and laboratory findings marked leukocytosis, lactic acidosis and elevated inflammatory markers. Despite intensive medical treatment and emergency extensive surgical debridement, the patient died. The particularity of this documented report highlights the need for increased vigilance in the field of professional medical practice, emphasizing the interest in further awareness-raising to bridge the gap between the public and this disease, which could help optimize patient prognosis.

Perinatal Management of Hepatic Adenomas.

With a strong association between hepatic adenomas and estrogen established, understanding the risks, evaluation, and perinatal management of hepatic adenomas is necessary for obstetric clinicians. The aim of this study is to review the preconception counseling, perinatal management, and postpartum care of hepatic adenomas. A literature review identified relevant research, review articles, textbook chapters, databases, and societal guidelines. Hepatic adenomas require individualized recommendations based on their prepregnancy size and evolution over pregnancy. Hepatic adenomas measuring greater than 5 cm are associated with a significantly increased risk during pregnancy including rupture. Ideally, optimal management of hepatic adenoma includes accurate diagnosis, discontinuation of estrogen-containing contraception, and surgical resection of large masses prior to conception. Patients should undergo serial surveillance of the adenoma during the antenatal and postpartum periods, with surgical intervention as indicated with multidisciplinary planning. An individualized approach is necessary when managing hepatic adenomas in the patient who is pregnant or intends pregnancy. More contemporary data are required to guide management and patient counseling.

Adult Bladder Exstrophy Managed by Complete Primary Repair: A Case Report

Bladder Exstrophic diseases, referred to collectively as Bladder Exstrophy-Epispadiasis complex, are a spectrum of embryological anomalies with a rare prevalence of approximately 3.3 per 1,00,000 live births with a male gender predominance. An 18-year-old man presented to Urology Outpatient Department (OPD) with subumbilical abdominal wall defect, absent anterior bladder wall with epispadiasis and was diagnosed as a case of adult classic bladder exstrophy with Epispadiasis complex. There was no history of any fever, haematuria, dysuria or abdominal pain. His ultrasound abdomen and intravenous pyelography reported normal kidney function. He had a low Body Mass Index (BMI) (17.5 kg/m2 ) with serum creatinine of 0.6 mg/dL. The patient underwent a complete primary repair, including bladder template closure and bladder neck reconstruction using Young-Dees-Leadbetter technique. Epispadias was repaired with the Modified Cantwell-Ransley approach. Abdominal wall defect closure was done with the help of rectus abdominis muscle flap which was later grafted using Split Thickness Skin Graft (STSG). Postoperatively, a small vesicocutaneous fistula developed which healed spontaneously over two weeks period. On follow-up patient was on clean intermittent catheterisation with some incontinence episodes during night-time. Bladder exstrophy in adult patients is rare, as the condition is usually identified in the neonatal period and can be surgically corrected early on. Due to the complexity of the surgery, these cases require thorough multidisciplinary evaluation and careful planning for successful correction.

Congenital teratoma of the oral cavity - the largest personal series of cases.

The objective of this study is to present the largest personal series of oral teratomas already published in English literature and discuss the diagnosis, neonatal management, and surgical treatment of this disorder. The study included patients treated by the senior author (RSF) between 2004 and 2023. Data were collected regarding prenatal evaluation, perinatal approach, surgical management, evolution, and treatment of secondary deformities. In addition, we performed a literature review on the topic. Twelve patients with oral teratoma were included in this study. Seven cases did not have been submitted to any previous treatment, and five cases had already undergone some treatment in another institution. Four cases were diagnosed as epignathus (33.3%), two as true teratomas (16.6%), four as teratoid teratomas (33.3%), one as dermoid teratoma (8.3%) and one as fetus in fetus (8.3%). All patients, except for one, had the tumor surgically removed with good evolution. There was one case of recurrence, successfully operated. The most frequently associated comorbidity was 0-14 fissure, present in 66% of the cases. The experience of our twelve cases indicates that prenatal diagnosis, associated with good multidisciplinary planning of the delivery care, and complete resection of the masses reveal high success rates in the treatment of this pathology. This study was performed in line with the principles of the declaration of Helsinki. Approval was granted by the Ethics Committee of Federal University of Paraná - 47102421.2.0000.5225.