Severe Surgical Complications Research Articles

Severe cosmetic surgical complications of the labia minora

Study ObjectivesGynecologists need resources related to labia minora, severe cosmetic surgical complications currently unavailable in the medical literature. Women’s requests for genital cosmetic surgery significantly increased within the last two decades; however, the medical literature does not report severe complications and their causes. Therefore, the author hypothesizes that currently used surgical concepts for labia minora reduction are partially responsible for cosmetic surgical debilitating complications. This clinical research aims to present photo documentation of severe surgical complications associated with various cosmetic surgical interventions. DesignedA prospective case series study was conducted in a single gynecologic corrective surgical practice to show different debilitating symptoms associated with labia minora cosmetic surgery. Primary data sources were obtained from direct clinical examinations. Secondary data sources were acquired from scientific-clinical and psychological medical literature articles, websites, medical records, procedure reports, statistical data, and recommendations. Data collection was done prospectively, and data analysis performed retrospectively included variable clinical observations and the severity of symptoms related to different surgical technique concepts. InterventionPatients were exposed to medical interviews, examinations, discussions, and validated questionnaires. In addition, an analysis of commonly used surgical cosmetic intervention concepts scrutinized (labia minora amputation, central wedge resection, and labial delamination). SettingsThe single practice center for corrective cosmetic surgery. PatientsThe study’s sample size was 110 women with severe cosmetic surgical complications of labia minora. Measurements and main resultsThe primary outcome measures the prior cosmetic surgical intervention outcomes of the labia minora, and the secondary outcome measures the occurrence of symptoms. Procedure duration was measured from the initial incision to the last suture placement. The follow-up study was conducted at a one-year interval for three years. The labia minora cosmetic severe complications were associated in 76 % with labial amputation, 21% with central wedge resection, and 3% with modified delamination. The most common symptomatic complication in labia minora amputation was over-resection. In all subjects, debilitating physical pain, neurological pain, psychological disorders, and sexual dysfunction were observed. ConclusionsCurrent labia minora cosmetic surgical concepts contribute to severe surgical complications with debilitating physical, emotional, and sexual dysfunction.

Long-term weight loss outcomes after bariatric surgery: a propensity score study among patients with psychiatric disorders.

To analyze the safety and long-term result of bariatric surgery in patients with psychiatric disorders. From January 2009 to December 2018, n = 961 patients underwent bariatric surgery in a tertiary center. Among them, two groups of patients were created: a group of patients with psychiatric disorders (PG) and a group without psychiatric disorders (CG), using a propensity score matched (PSM). Primary endpoint was long-term outcomes and secondary endpoints were the postoperative morbidity 90 days after surgery, late morbidity, occurrence of psychiatric adverse events, and resolution of obesity-related comorbidities. Analysis with PSM permitted to compare 136 patients in each group, with a ratio 1:1. TWL% at 2 years in the PG was 32.7% versus 36.6% in the CG (p = 0.002). Overall surgical morbidity was higher in the PG than the CG (28% vs 17%, p = 0.01). Severe surgical complications were not statistically significant (4% vs 3%, p = 0.44). Psychiatric adverse events were significantly more frequent in the PG than in the CG. The resolution of obesity comorbidities was equivalent for both groups at 2 years. Substantial weigh loss was reported among patients with psychiatric disorders receiving bariatric surgery at the cost of more non-severe surgical complications. Further, a psychiatric postoperative follow-up visit may be warranted for patients with preoperative psychiatric disorders, given the incidence of psychiatric adverse events.

Systematic Ranking of NSQIP Surgical Risk Calculator Outputs

The National Surgical Quality Improvement Program (NSQIP) calculator is a risk-predicting calculator, that predicts the likelihood of postoperative complications. Card sorting methodology was used to capture feedback from expert and non-expert participants regarding the severity of surgical complications. The study result indicated ambiguity of postoperative complications. To overcome this barrier, a proposed order of postoperative complications was developed based on the Borda count ranking performed by surgeon.

C2 pedicle screw insertion assisted by mobilization of the vertebral artery in cases with high-riding vertebral artery

Objective: To examine the feasibility, safety, and efficacy of mobilization of the vertebral artery for C2 pedicle screws in cases with high-riding vertebral artery (HRVA). Methods: The clinical data of 12 patients with basilar invagination and atlantoaxial dislocation underwent atlantoaxial reduction and fixation in the Department of Neurosurgery, the First Affiliated Hospital of University of Science and Technology of China between January 2020 and November 2021 were retrospectively analyzed. All patients had high-riding vertebral artery on at least one side that prohibited the insertion of C2 pedicle screws. There were 2 males and 10 females aged (48.0±12.8) years (range: 17 to 67 years). After correction of vertical dislocation during the operation, the C2 pedicle screw insertion and occipitocervical fixation and fusion were performed using the vertebral artery mobilization technique. Neurological function was assessed using the Japanese Orthopedic Association (JOA) scale. The preoperative and postoperative JOA score and the main radiological measurements, including the anterior atlantodental interval (ADI), the distance of the odontoid tip above the Chamberlain line, the clivus-canal angle, were collected and compared by paired t-test. Results: Mobilization of the high-riding vertebral artery was successfully completed, and C2 pedicle screws were then fulfilled after the vertebral artery was protected. There was no injury to the vertebral artery during the operation. Meanwhile, no severe surgical complications such as cerebral infarction or aggravated neurological dysfunction occurred during the perioperative period. Satisfactory C2 pedicle screw placement and reduction were achieved in all 12 patients. All patients achieved bone fusion 6 months after surgery. No looseness and shift in internal fixation or reduction loss was observed during the follow-up period. Compared to the preoperative, the postoperative ADI decreased from (6.1±1.9) mm to (2.0±1.2) mm (t=6.73, P<0.01), the distance of the odontoid tip above Chamberlain line decreased from (10.4±2.5) mm to (5.5±2.3) mm (t=7.12, P<0.01), the clivus-canal angle increased from (123.4±11.1) ° to (134.7±9.6) ° (t=2.50, P=0.032), the JOA score increased from 13.3±2.1 to 15.6±1.2 (t=6.99, P<0.01). Conclusion: The C2 pedicle screw insertion assisted by mobilization of the vertebral artery is safe and considerably effective, providing a choice for internal fixation in cases with high-riding vertebral arteries.

Clinical evaluation of neoadjuvant tyrosine kinase inhibitor administration for mast cell tumours in eight dogs

AbstractComplete surgical removal of tumour cells is the first‐line treatment for canine cutaneous mast cell tumours. Surgical removal of mast cell tumours sometimes requires radical surgery. This may cause severe complications, loss of biological function or poor cosmetic outcomes. This report describes the clinical outcomes of preoperative administration of an effective tyrosine kinase inhibitor for mast cell tumours. Five of eight cases responded to tyrosine kinase inhibitors; complete removal was possible in three cases with narrower (&lt;1 cm) surgical margins than the conventional tumour margin estimated from the original tumour size. Mast cell tumours may not require wide resection if they are responsive to tyrosine kinase inhibitors before surgical removal. Preoperative administration of tyrosine kinase inhibitors could be a treatment option for dogs that have difficulty with complete removal causing severe surgical complications, or for owners who do not accept loss of biological function or poor cosmetic outcomes.

Intracorporeal versus extracorporeal anastomosis in segmental resections for colon cancer: a retrospective cohort study of 328 patients

PurposeThe intracorporeal anastomosis (IA) technique possibly results in enhanced recovery and reduced morbidity rates compared to the extracorporeal anastomosis (EA) technique. This study compared the short-term morbidity rates of IA versus EA in segmental resections for colon cancer.MethodWe performed a retrospective cohort study of consecutive patients from 2015 to 2020 using the IA or EA technique at a single Danish colorectal center. Comparative outcomes of interest were surgical efficacy and short-term morbidity rates. An inverse probability of treatment weighting (IPTW) analysis of clinically relevant outcomes was conducted to explore potential baseline confounding.ResultsWe included 328 patients, 129 in the EA and 199 in the IA groups. There was no significant difference in preoperative baseline characteristics between the two groups. The rate of overall surgical (16% in both groups, p = 1.000) and medical complications (EA: 25 (19%) vs. IA: 27 (14%), p = 0.167) was comparable for both groups. The IA technique did not cause a reduction in operative time (EA: 127.0 min [103.0–171.0] vs. IA: 134.0 min [110.0–164.0], p = 0.547). The IPTW analysis indicated that having an IA caused a reduction in the rate of major surgical complications (RRRadjusted = 0.45, 95%CI [0.29–0.69], p = 0.000).ConclusionAdopting IA for colon cancer resulted in similar overall morbidity rates without increasing the duration of the surgical procedure compared to EA. The IA technique had a probable protective effect against developing severe surgical complications. However, this must be interpreted cautiously, limited by the retrospective study design.

Potential Mechanisms of Multimodal Prehabilitation Effects on Surgical Complications: A Narrative Review.

Continuous advances in prehabilitation research over the past several decades have clarified its role in improving preoperative risk factors, yet the evidence demonstrating reduced surgical complications remains uncertain. Describing the potential mechanisms underlying prehabilitation and surgical complications represents an important opportunity to establish biological plausibility, develop targeted therapies, generate hypotheses for future research, and contribute to the rationale for implementation into the standard of care. In this narrative review, we discuss and synthesize the current evidence base for the biological plausibility of multimodal prehabilitation to reduce surgical complications. The goal of this review is to improve prehabilitation interventions and measurement by outlining biologically plausible mechanisms of benefit and generating hypotheses for future research. This is accomplished by synthesizing the available evidence for the mechanistic benefit of exercise, nutrition, and psychological interventions for reducing the incidence and severity of surgical complications reported by the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). This review was conducted and reported in accordance with a quality assessment scale for narrative reviews. Findings indicate that prehabilitation has biological plausibility to reduce all complications outlined by NSQIP. Mechanisms for prehabilitation to reduce surgical complications include anti-inflammation, enhanced innate immunity, and attenuation of sympathovagal imbalance. Mechanisms vary depending on the intervention protocol and baseline characteristics of the sample. This review highlights the need for more research in this space while proposing potential mechanisms to be included in future investigations.

Surgical efficacy and learning curves of laparoscopic complete mesocolic excision with intracorporeal anastomosis for right-sided colon cancer: A retrospective two-center cohort study.

There is a potential benefit on long-term outcomes following complete mesocolic excision (CME) for right-sided colon cancer when compared to conventional colectomy. This study aims to analyze the learning curve and short-term outcomes of laparoscopic CME with intracorporeal anastomosis (ICA) for right-sided colon cancer in the hands of experienced colorectal surgeons. A two-center cohort study of consecutive patients undergoing right-sided colectomy from September 2021 to May 2022 at two tertiary colorectal centers in Denmark. Learning curves of surgical time were estimated using a cumulative sum analysis (CUSUM). A total of 61 patients were included. According to the CUSUM analysis, 32 cases were needed to obtain a peak in operative time, resulting in a decrease in time consumption (group 1/learning phase: 217.2 min [SD 53.6] and group 2/plateau phase 191.6 min [SD 45.1], p = 0.05). There was a nonsignificant reduction in the rates of severe surgical complications (Clavien-Dindo > 3) (13% vs. 7%, p = 0.67) between the two groups, while the length of hospital stay remained constant (median 3.0 days, interquartile range, IQR [2.0; 4.0]). The learning curve of laparoscopic CME with ICA for right-sided colon cancer demonstrated that 32 cases were needed to obtain a plateau phase expressed by operative time.

Safety profile of a multimodal fail-safe model to minimize postoperative complications in oncologic colorectal resections—a cohort study

BackgroundDespite innovations in surgical techniques, major complications following colorectal surgery still lead to a significant morbidity and mortality. There is no standard protocol for perioperative management of patients with colorectal cancer. This study evaluates the effectiveness of a multimodal fail-safe model in minimizing severe surgical complications following colorectal resections.MethodsWe compared major complications in patients with colorectal cancers who underwent surgical resections with anastomosis during 2013–2014 (control group) with patients treated during 2015–2019 (fail-safe group). The fail-safe group had preoperative bowel preparation and a perioperative single dose of antibiotics, on-table bowel irrigation and early sigmoidoscopic assessment of anastomosis in rectal resections. A standard surgical technique for tension-free anastomosis was adapted in the fail-safe approach. The chi-square test measured relationships between categorical variables, t-test estimated the probability of differences, and the multivariate regression analysis determined the linear correlation among independent and dependent variables.ResultsA total of 924 patients underwent colorectal operations during the study period; however, 696 patients had surgical resections with primary anastomoses. There were 427 (61.4%) laparoscopic and 230 (33.0%) open operations, while 39 (5.6%) laparoscopic procedures were converted. Overall, the rate of major complications (Dindo-Clavien grade IIIb–V) significantly reduced from 22.6% for the control group to 9.8% for the fail-safe group (p < 0.0001). Major complications mainly occurred due to non-surgical reasons such as pneumonia, heart failure, or renal dysfunction. The rates of anastomotic leakage (AL) were 11.8% (22/186) and 3.7% (n = 19/510) for the control and fail-safe groups, respectively (p < 0.0001).ConclusionWe report an effective multimodal fail-safe protocol for colorectal cancer during the pre-, peri-, and postoperative period. The fail-safe model showed less postoperative complications even for low rectal anastomosis. This approach can be adapted as a structured protocol during the perioperative care of patients for colorectal surgery.Trial registrationThis study was registered in the German Clinical Trial Register (Study ID: DRKS00023804).

Single centre analysis of perioperative complications in trans-oral robotic surgery for oropharyngeal carcinomas.

Trans Oral Robotic Surgery (TORS) is a modality in the management of oropharyngeal squamous cell carcinoma(OPSCC). This study was conducted to show the rates of peri-operative complications after TORS for OPSCC in our experience. Single centre retrospective analysis of consecutive OPSCC treated with TORS. The surgical complication severity was recorded according to Clavien-Dindo criteria (CDC). Eighty-seven OPSCC were operated with TORS. According to CDC, grade I, grade II and IIIb were registered in 8%, 4.6% and 11.5% of cases, respectively. The postoperative pain, registered with visual-analogue scale (VAS) score, was 8 ± 1.2 for the secondary healing wounds and 6.2 ± 1.5 for the flap reconstructions (p < 0.01). The impact on swallowing function was not significant between secondary healing and flap reconstructions(p = 0.96). Any major or life-threatening intraoperative complications have not been recorded. Only one patient had postoperative bleeding into the neck whilst 13.3% of patients had postoperative bleeding from the primary tumor. No total local or free flap failure were registered. The mean duration of tracheostomy use was 7.4 ± 2.6days, and nasogastric tube 14.3 ± 6.9days. Only one patient, who had also reconstruction with flap, experienced a postoperative severe dysphagia with severe aspiration, needing a permanent tracheostomy tube and percutaneous endoscopic gastrostomy feeding. TORS for OPSCC showed less morbidity, lower risk of severe complication and mortality. Thus, this treatment modality could be offered as first line treatment in selected cases.

Body composition assessment in patients with gastric cancer.

460 Background: The number of overweight patients with gastric cancer who underwent gastrectomy has increased in Japan. In addition to obesity, sarcopenia is a risk factor of severe surgical complication. The study aimed to elucidate the relationship between body composition and surgical outcome of gastrectomy for gastric cancer. Methods: This study was a retrospective, cohort study that include 701 patients who underwent gastrectomy in our institution between May 2008 and July 2017. Using preoperative computed tomography (CT), body composition such as psoas muscle index (PMI) and visceral fat area (VFA) were measured in the third lumber section. The patients were divided into two groups according to PMI (cut-off value 5.2 cm2/m2 in male and 3.5 in female) or VFA (cut-off value 155 cm2 in male and 116 in female), respectively. Surgical outcomes and postoperative complications were compared between the low and high groups for each PMI and VFA value. Results: There were 53 severe complications (14 anastomotic leakage, 14 pancreatic fistula, 8 respiratory failure, and 7b intraabdominal abscess) in this cohort. Some 701 patients were included in the study, 528 of whom were classified as normal PMI and 173 were as low PMI. In addition, 528 of whom were classified as normal VFA and 173 were as low PMI. In multivariate analysis, age and gender were independent risk factor for severe postoperative complication, however, low PMI was not. Conclusions: Our analysis showed no relationship between preoperative low PMI and postoperative complications. [Table: see text]

Open Pyeloplasty in Infants under 1 Year—Proven or Meaningless?

The use of minimally invasive surgery (MIS) to treat ureteropelvic junction obstruction (UPJO) in children has significantly increased. Nowadays, open pyeloplasty (OP) seems to lose importance. The aim of this study is to evaluate the safety and efficacy of OP in infants < 1 year. Medical records of patients < 1 year with UPJO who had undergone retroperitoneal OP (January 2008-February 2022) at our institution were retrospectively analyzed. Included patients were operated on according to a modified Anderson-Hynes technique. All clinical, operative, and postoperative (1 month-5 years' follow-up) data were collected. Additionally, a nonvalidated questionnaire was sent to the patients/parents. A total of 162 infants (124 boys) met the inclusion criteria. The median age at surgery was 3 months (range: 0-11 months). The median operation time was 106 min (range: 63-198 min). None of the patients had severe surgical complication (Clavien-Dindo > 3). The nonvalidated questionnaire showed a high impact of quality of life. Follow-up was in median 30.5 months (0-162 months). OP is still a reliable procedure with good long-term results especially in infants < 1 year of age, which can be performed in a variety of centers.

OGC P41 Long term Outcomes after curative treatment of lower oesophageal squamous cell carcinoma: Single centre study

Abstract Background Over the past few decades the incidence of squamous cell carcinoma (SCC) of lower oesophagus has decreased slightly. While multimodal therapy for resectable oesophageal cancer has shown definite benefits in management of adenocarcinoma of oesophagus, the ideal therapeutic modality for management of lower oesophageal SCC remains unclear. Worldwide there are a wide variations in the management of lower oesophageal squamous cell carcinoma. Except for a small proportion of patients with early cancers confined to the mucosa, curative therapies for Oesophageal SCC entail either neoadjuvant chemo-radiotherapy (CTRT) followed by oncological resection or radical chemo/radiotherapy. However, there are no clear guidelines to support either modality. The purpose of this study was to assess various curative treatment modalities for lower oesophageal SCC and analyse the short and long term outcomes. Methods Data of patients with histologically proven distal oesophageal SCC treated at a single OG resection Centre in North East London between 2011 and 2021, was retrospectively collected from a prospectively maintained database. All patients were discussed in Upper GI MDT for management plan.The lower oesophagus was defined as distal third of oesophagus below the tracheal bifurcation. In the patients who underwent surgery, post operative complications were recorded according to Clavien Dindo classification. Results Between January 2011 to December 2021, 34 patients with lower oesophageal SCC were treated at our Centre. The median age of patients was 72 +/-2 years. 47.06% were females. The median Charlson Co morbidity index was 5. 25 (73.53%) patients received definitive chemo-radiotherapy. 20.58% received neoadjuvant treatment. Overall, 20.58% patients with lower oesophageal SCC underwent surgical resection (Five with neoadjuvant and two i.e. 5.89% went straight for surgery). Median age of patients received definitive radiotherapy was 72+/-9 years as compared to median age of 67+/- 9 years in those who underwent resection. Most patients had stage III disease (16 patients). Severe surgical complications defined as Clavein Dino Grade III/IV occurred in two patients. There were no post operative mortalities. Overall median survival was 24 months. 5-year survival 20.58%. Median survival in patients who received definitive CTRT was 13 +/- 21 months, while those who were operated had a median survival of 72 +/- 39 months. Conclusions We reported the management and outcomes of lower oesophageal SCC over a period of 10 years. These findings are limited due to the small number of cases. A multicentre study to assess the management and outcomes of this group of cancer will assist in the future development of guidelines.

Expanding the genetic and phenotypic spectrum of ACTA2-related vasculopathies in a Dutch cohort

Heterozygous pathogenic/likely pathogenic (P/LP) variants in the ACTA2 gene confer a high risk for thoracic aortic aneurysms and aortic dissections. This retrospective multicenter study elucidates the clinical outcome of ACTA2-related vasculopathies. Index patients and relatives with a P/LP variant in ACTA2 were included. Data were collected through retrospective review of medical records using a standardized questionnaire. A total of 49 individuals from 28 families participated in our study. In total, 20 different ACTA2 variants were detected. Aortic events occurred in 65% of the cases (78.6% index patients and 47.6% relatives). Male sex and hypertension emerged as significantly associated with aortic events. Of 20 individuals, 5 had an aortic diameter of <45 mm (1.77 inches) at the time of the type A dissection. Mean age at first aortic event was 49.0 ± 12.4 years. Severe surgical complications for type A and type B dissection occurred in 25% and 16.7% of the cases and in-hospital mortality rates were 9.5% and 0%, respectively. P/LP ACTA2 variants are associated with an increased risk for an aortic event and age-related penetrance, which emphasizes the importance of early recognition of the disease. Caregivers should be aware of the risk for aortic dissections, even in individuals with aortic diameters within the normal range.

Optimal Perioperative Fluid Therapy Associates with Fewer Complications After Pancreaticoduodenectomy

BackgroundOptimal fluid management in pancreaticoduodenectomy patients remains contested. We aimed to examine the association between perioperative fluid administration and postoperative complications. MethodsWe studied 168 pancreaticoduodenectomy patients operated in 2015 (n = 93) or 2017 (n = 75) at Helsinki University Hospital. In 2015, patients received intraoperative fluids following a goal-directed approach and, in 2017, according to anesthesiologist’s clinical practice (conventional fluid management). We analyzed the differences in perioperative fluid administration between the groups, specifically examining the occurrence of severe complications (Clavien–Dindo ≥ III), pancreatic fistulas, cardiovascular complications, and the length of hospital stay. ResultsThe goal-directed group received more intraoperative fluids than the conventional fluid management group (12.0 ml/kg/h vs. 8.3 ml/kg/h, p < 0.001). Urine output (770 ml vs. 575 ml, p = 0.004) and intraoperative fluid balance (9.4 ml/kg/h vs. 6.3 ml/kg/h, p < 0.001) were higher in the goal-directed group than in the conventional fluid management group. Severe surgical complications (19.4% vs. 38.7%, p = 0.009) as well as clinically relevant pancreatic fistulas (1.1% vs. 10.7%, p = 0.011) occurred more frequently in patients receiving conventional fluid management. Moreover, the conventional fluid management group experienced longer hospital stays (9.0 vs. 11.5 days, p = 0.02). Lower intraoperative fluid volume accompanying conventional fluid management was associated with a higher risk of severe postoperative complications compared with higher volume in the goal-directed group (odds ratio 2.58 (95% confidence interval 1.04–6.42), p = 0.041). ConclusionsThe goal-directed group experienced severe complications less frequently. Our findings indicate that optimizing the intraoperative fluid administration benefits patients, while adopting a too-restrictive approach represents an inferior choice.

Outcome of giant pituitary tumors requiring surgery.

ObjectiveThe management of giant pituitary tumors is complex, with few publications and recommendations. Consequently, patient’s care mainly relies on clinical experience. We report here a first large series of patients with giant pituitary tumors managed by a multidisciplinary expert team, focusing on treatments and outcome.MethodsA retrospective cohort study was conducted. Giant pituitary tumors were defined by a main diameter > 40mm. Macroprolactinomas sensitive to dopamine agonists were excluded. All patients were operated by a single neurosurgical team. After surgery, multimodal management was proposed, including hormone replacement, radiotherapy and anti-tumor medical therapies. Outcome was modeled using Kaplan-Meyer representation. A logistic regression model was built to identify the risk factors associated with surgical complications.Results63 consecutive patients presented a giant adenoma, most often with visual defects. Patients were operated once, twice or three times in 59%, 40% and 1% of cases respectively, mainly through endoscopic endonasal approach. Giant adenomas included gonadotroph, corticotroph, somatotroph, lactotroph and mixed GH-PRL subtypes in 67%, 14%, 11%, 6% and 2% of patients respectively. Vision improved in 89% of patients with prior visual defects. Severe surgical complications occurred in 11% of patients, mainly for tumors > 50 mm requiring microscopic transcranial approach. Additional radiotherapy was needed for 29% of patients, 3 to 56 months after first surgery. For 6% of patients, Temozolomide treatment was required, 19 to 66 months after first surgery.ConclusionsGiant pituitary tumors require multimodal management, with a central role of surgery. Most often, tumor control can be achieved by expert multidisciplinary teams.

Peritonitis Due to Appendicitis Related to Mercury Sequestration: An Unusual Peruvian Case Report

Elemental mercury ingestion caused by folk practices is rare and usually harmless. Nevertheless, some complications related to mercury ingestion have been reported such as appendicitis related to mercury sequestration and poisoning leading to systemic toxicity. Patients usually present with nausea, vomiting, and abdominal tenderness. Mercury sequestration in the appendix depends on its anatomy and mercury physical properties, both of which may lead to appendicitis, resulting in subsequent peritonitis leading to multiple and severe surgical complications. A 26-year-old Peruvian man complaining of vomiting and abdominal pain after ingestion of elemental mercury as part of a folk practice presented to the emergency department. Physical exam was remarkable for rigid abdomen and diffuse rebound sign. A clinical diagnosis of peritonitis was made. The patient was taken to the operating room where an open appendectomy and peritoneal lavage were performed. On gross inspection, a silver foreign body within the perforated appendix was seen by the surgical team. The patient developed multiple surgical complications leading to multiple organ failure and death. Clinicians should be aware that mercury ingestion is usually benign. However, severe complications may develop. Early surgical and medical intervention should be initiated promptly to achieve better outcomes. We present the first case of peritonitis due to appendicitis related to mercury sequestration in the appendix.

Complications and corrective surgery after ileal pouch-anal reconstruction?

Proctocolectomy with ileal J‑pouch-anal and rectal reconstruction is the standard surgical treatment for ulcerative colitis, selected cases of Crohn's disease, FAP and multilocular colon carcinoma. Although this treatment has been continuously developed over the last 40years, the long-term success rate is 80-90% of the treated patients. The reasons for this are manifold: chronic pouchitis, incontinence, secondary diagnosis of Crohn's disease, fistulas, severe surgical complications, rectal stump left for too long, chronic abscess and surgical technical errors. This article deals with the control of acute complications and with the management of long-term complications. Some of the triggering complications for pouch failure do not generally imply failure of the method. Acorrection, closure of the fistula and in individual cases also acompletely new pouch creation can restore agood pouch function in about 75% of cases. Various indications, techniques and results are presented.

Incidence and prognosis of patients with small intestinal neuroendocrine tumors in a population based nationwide study

Background & aimsSmall intestinal neuroendocrine tumours (SI-NETs) are the most frequent malignant tumours of the small intestine. Population based studies on SI-NETs are scarce. We aimed to examine the incidence, presentation of disease and prognosis of SI-NET and to determine patient prognosis in those undergoing emergency or elective surgery. MethodsThis was a retrospective population-based study. Information on all patients diagnosed with neuroendocrine tumours of the small intestine (excluding duodenum) from the beginning of the Icelandic Cancer Registry and the pathology departments in the country (1966–2017). Detailed phenotypic information was obtained from medical records on symptoms at diagnosis, treatment, recurrence and survival. ResultsA total of 113 patients with SI-NETs were identified, 3 patients were excluded due to lack of data and/or diagnostic error, leaving 110 patients for final analysis. The incidence of SI-NET was 0.78/100,000 and did not increase during the study period. A total of 42 % (n = 46) of patients were diagnosed incidentally. Long-term prognosis, after a landmark of 12 months, was better in patients who were diagnosed incidentally (HR 0.52; p = 0.03). Overall 89 % (n = 98) of cases underwent surgical resection of the primary tumor, 31 % (n = 30) patients acute or semi-acute surgery and 69 % (n = 68) elective surgery. Emergency surgery was associated with a 6-fold risk of death in the first 12 months after surgery (HR: 5.99; p = 0.01) and associated with more severe surgical complications. However, there was no difference in the long-term risk of death after the first 12 months (HR: 1.39; p = 0.27). ConclusionsThe incidence of SI-NETs has not changed significantly in the last decades. Incidentally diagnosed SI-NET was associated with a favorable long-term prognosis. Emergency surgery in patients with SI-NET was associated with a significantly worse short-term risk of mortality compared to those who underwent elective surgery.

The structure of intra- and postoperative complications after surgery for fibrous-cavernous pulmonary tuberculosis and their impact on the surgery outcome

The objective: to study the frequency, structure and impact on the surgery outcome of intra- and postoperative complications after lung resections for fibrous-cavernous tuberculosis.Subjects and Methods. A retrospective cohort analysis of intra- and postoperative complications was performed in 847 patients who underwent surgery for fibrous-cavernous pulmonary tuberculosis. Their influence on the surgery outcome was determined in accordance with the modified Russian classification of surgical errors assessment by R. M. Satava and the Accordion classification for severity of surgical complications. It has been established that the most dangerous complications that adversely affect the result of the operation are the following: injury to the cavity, vessels of the root of the lung and systemic circulation, empyema of the pleural cavity, exacerbation of tuberculosis, and pulmonary heart. These complications caused an unfavorable outcome in all 47 patients with such an outcome and led to a fatal outcome in 22 (78.6%) patients out of 28 deceased patients. Additions to the Accordion classification of postoperative complications are proposed taking into account the specific features of surgeries for tuberculosis.