Urgent Surgical Repair Research Articles

Apoptosis Occurs in the Anterior Talofibular Ligament of Patients With Chronic Lateral Ankle Instability: An In Vitro Study.

Chronic lateral ankle instability is treated operatively, whereas most acute ankle sprains associated with acute anterior talofibular ligament injury are usually treated nonoperatively. This treatment strategy is widely accepted and has been validated using a variety of clinical or radiological methods. We suspected that there may be biological differences between chronic and acutely injured ligaments, particularly with respect to apoptosis. Apoptosis is known to cause ligament degeneration. If it could be demonstrated that apoptosis occurs more in the anterior talofibular ligament tissues of patients with chronic lateral ankle instability compared with patients with acute anterior talofibular ligament injury, biological evidence could be supported. We sought to (1) elucidate the difference in the extent of apoptosis between patients with chronic lateral ankle instability and those with acute anterior talofibular ligament injury. In addition, we asked: (2) What is the expression level of apoptotic enzymes such as caspases 3, 7, 8, and 9 and cytochrome c in each patient group? (3) Is there a correlation between apoptotic activities and the symptom duration period of chronic lateral ankle instability? Between March 2019 and February 2021, 50 patients were prospectively enrolled in this study. Anterior talofibular ligament tissues were harvested from patients who were divided into two groups: the chronic lateral ankle instability group and the acute anterior talofibular ligament injury group. Patients with insufficient remaining ligaments were excluded from the chronic lateral ankle instability group, and cases in which the tissue was severely damaged or the quality of collected tissue was insufficient because of severe impingement into the fracture site were excluded from the acute anterior talofibular ligament injury group. Tissues were collected from 21 patients (11 males and 10 females) in the chronic lateral ankle instability group with a mean age of 37 ± 14 years and from 17 patients (6 males and 11 females) in the acute anterior talofibular ligament injury group with a mean age of 49 ± 17 years. To investigate our first purpose, apoptotic cells were counted using a TUNEL assay. To answer our second question, Western blotting for apoptotic enzymes such as caspases 3, 7, 8, and 9 and cytochrome c was performed to investigate apoptotic activity. Immunohistochemistry was also used to detect apoptotic enzymes. To answer our third question, the time elapsed after the first symptom related to chronic lateral ankle instability occurred and the expression level of each enzyme was investigated. More apoptotic cells were observed in the chronic lateral ankle instability group than in the acute anterior talofibular ligament injury group in the TUNEL assay. Western blotting revealed that the apoptotic activities of the chronic lateral ankle instability group were higher than those of the acute anterior talofibular ligament injury group: caspase 3 was 117 in the chronic lateral ankle instability group and 59 in the acute anterior talofibular ligament injury group (mean difference 58 [95% confidence interval (CI) 31 to 86]; p < 0.001), caspase 7 was 138 in the chronic lateral ankle instability group and 45 in the acute anterior talofibular ligament injury group (mean difference 93 [95% CI 58 to 128]; p < 0.001), caspase 8 was 126 in the chronic lateral ankle instability group and 68 in the acute anterior talofibular ligament injury group (mean difference 58 [95% CI 29 to 89]; p < 0.001), caspase 9 was 128 in the chronic lateral ankle instability group and 54 in the acute anterior talofibular ligament injury group (mean difference 74 [95% CI 44 to 104]; p < 0.001), and cytochrome c was 139 in the chronic lateral ankle instability group and 51 in the acute anterior talofibular ligament injury group (mean difference 88 [95% CI 46 to 129]; p < 0.001). Immunohistochemistry revealed higher expression of caspases 3, 7, 8, and 9 and cytochrome c in the chronic lateral ankle instability group compared with those in the acute anterior talofibular ligament injury group. Caspases 3, 7, and 9 showed no correlation with duration of chronic lateral ankle instability symptoms: the Pearson correlation coefficient was 0.22 [95% CI -0.25 to 0.69] for caspase 3 (p = 0.36), 0.29 [95% CI -0.16 to 0.74] for caspase 7 (p = 0.23), and 0.29 [95% CI -0.16 to 0.74] for caspase 9 (p = 0.23). In chronic lateral ankle instability, apoptotic activity in the anterior talofibular ligament was higher than in acute anterior talofibular ligament injury. Apoptosis occurs more in chronic injured ligaments than in acutely injured ligaments. Although urgent surgical repair is not required for acute anterior talofibular ligament injury, chronic lateral ankle instability may progress if the nonoperative treatment is not successful. Further research should focus not only on timing of apoptotic progression, but also on biological augmentation to reverse or prevent apoptosis within the anterior talofibular ligament.

Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample

ObjectiveAcute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes. MethodsThe National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified. ResultsWe identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups—female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P < .001), and patients aged >80 years had a 6.8-fold increased risk of mortality (P < .001). Sex was not significantly associated with mortality. ConclusionsSurgical repair of ATAAD continues to carry high risk of morbidity and mortality, with outcomes impacted significantly by patient age, regardless of patient comorbidity burden.

Impedance spike cut-off enhances safety of CLOSE-protocol guided ablation of atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation (CA) with radiofrequency (RF) energy using the CLOSE protocol has proven safety and efficacy in a large prospective multicenter study (1) with a rate of pericardial tamponade (PT) as low as 0.9%, thus with lower PT risk than reported by previous register data for PVI (2). PT may still become hazardous in the era of uninterrupted anticoagulation and may require urgent surgical repair. Steam pop is the major cause of PT during PVI with RF ablation and is usually preceded by steep impedance rise measured between tissue and tip of the RF catheter. The STOCKERT SMARTABLATE RF Generator as a core part of technology for CLOSE protocol guided PVI offers the opportunity to automatically stop RF energy delivery within 0.5 seconds if catheter impedance rises above a predefined value: impedance spike cut off (ISCO). The standard – manufacturer recommended – value for ISCO is 50 Ohms per 0.5 seconds. Purpose To investigate the effect of reduced ISCO during CLOSE protocol guided catheter ablation of AF on the occurrence of acute PT and pericardial effusion (PE) in a large single center series. Methods We performed CLOSE protocol guided PVI procedures using Biosense Webster CARTO PRIME 3D navigation system, Smarttouch SF ablation catheter, VIZIGO steerable sheath, invasive blood pressure measurement via radial artery. We changed the STOCKERT SMARTABLATE generator settings to ISCO of 25 Ohms per 0.5 seconds. Cut off during ablation by ISCO led the operator to reduce contact force, angulation/orientation of catheter/steerable sheath, changing to jet ventilation if mechanical ventilation was present. A retrospective analysis of all procedures was performed. Investigation for PT by echocardiography was performed for every drop &amp;lt; 90mmHg systolic blood pressure, immediately after and one day post ablation. Statistical analysis was performed on the evaluable population. Results During 31 months of observation we performed 627 CLOSE protocol guided procedures: 409 PVI only, 218 PVI with additional ablations (cavotricuspid isthmus, slow pathway, additional LA lines, ethanol ablation of vein of marshall). We observed 3 (0.5%) PT immediately at the end of the procedure and no additional relevant PE the day after CA. Of the 3 PT, one patient needed urgent surgical repair and two were managed conservatively with pericardiocentesis and retransfusion. Conclusions CLOSE protocol guided PVI is a very effective and safe intervention for treatment of AF. In the multicentre VISITAX trial, the rate of PT was reported with 3 events per 329 patients (0.9%). By reducing ISCO to 25 Ohms per 0.5 seconds, we could half the rate of PT found in the VISITAX trial. The generator cut off at ISCO of 25 Ohms per 0.5 seconds indicates a potentially dangerous position for ablation. Our data are limited due to the retrospective monocentric design and therefore the aformentioned approach should be evaluated prospectively.

Pediatric Orthopedic Emergencies

Proper care of orthopedic injuries and emergencies in children and adolescents requires knowledge of the altered bone and ligament characteristics, varying stages of skeletal development, and potential for congenital or developmental abnormalities. Pediatric fractures affecting the growth plate require unique management to maintain optimal growth. Whereas some specific fractures in these skeletally immature patients require urgent surgical repair, other fractures remodel extremely well and can be managed with a simple splint. Particular dislocations are common in this population and may have concomitant fractures. There are several overuse injuries seen primarily in children, and treatment aims to keep the patient active while allowing the injury to heal. Potentially devastating osteoarticular infections occur in the pediatric population and must be differentiated from more benign causes of joint pain, such as transient synovitis or congenital abnormalities. Children are also at risk for abnormalities such as slipped capital femoral epiphysis or Legg-Calvé-Perthes disease, which are rarely diagnosed in the adult population. It is imperative for a clinician to be aware of these and other nuances to optimally care for orthopedic injuries and emergencies in the pediatric population. This review contains 9 figures, 13 tables and 45 references Key words: bone, musculoskeletal, orthopedic, skeletal

Pediatric Orthopedic Emergencies

Proper care of orthopedic injuries and emergencies in children and adolescents requires knowledge of the altered bone and ligament characteristics, varying stages of skeletal development, and potential for congenital or developmental abnormalities. Pediatric fractures affecting the growth plate require unique management to maintain optimal growth. Whereas some specific fractures in these skeletally immature patients require urgent surgical repair, other fractures remodel extremely well and can be managed with a simple splint. Particular dislocations are common in this population and may have concomitant fractures. There are several overuse injuries seen primarily in children, and treatment aims to keep the patient active while allowing the injury to heal. Potentially devastating osteoarticular infections occur in the pediatric population and must be differentiated from more benign causes of joint pain, such as transient synovitis or congenital abnormalities. Children are also at risk for abnormalities such as slipped capital femoral epiphysis or Legg-Calvé-Perthes disease, which are rarely diagnosed in the adult population. It is imperative for a clinician to be aware of these and other nuances to optimally care for orthopedic injuries and emergencies in the pediatric population. Key words: bone, musculoskeletal, orthopedic, skeletal

Pediatric Orthopedic Emergencies

Proper care of orthopedic injuries and emergencies in children and adolescents requires knowledge of the altered bone and ligament characteristics, varying stages of skeletal development, and potential for congenital or developmental abnormalities. Pediatric fractures affecting the growth plate require unique management to maintain optimal growth. Whereas some specific fractures in these skeletally immature patients require urgent surgical repair, other fractures remodel extremely well and can be managed with a simple splint. Particular dislocations are common in this population and may have concomitant fractures. There are several overuse injuries seen primarily in children, and treatment aims to keep the patient active while allowing the injury to heal. Potentially devastating osteoarticular infections occur in the pediatric population and must be differentiated from more benign causes of joint pain, such as transient synovitis or congenital abnormalities. Children are also at risk for abnormalities such as slipped capital femoral epiphysis or Legg-Calvé-Perthes disease, which are rarely diagnosed in the adult population. It is imperative for a clinician to be aware of these and other nuances to optimally care for orthopedic injuries and emergencies in the pediatric population. Key words: bone, musculoskeletal, orthopedic, skeletal

Pediatric Orthopedic Emergencies

Proper care of orthopedic injuries and emergencies in children and adolescents requires knowledge of the altered bone and ligament characteristics, varying stages of skeletal development, and potential for congenital or developmental abnormalities. Pediatric fractures affecting the growth plate require unique management to maintain optimal growth. Whereas some specific fractures in these skeletally immature patients require urgent surgical repair, other fractures remodel extremely well and can be managed with a simple splint. Particular dislocations are common in this population and may have concomitant fractures. There are several overuse injuries seen primarily in children, and treatment aims to keep the patient active while allowing the injury to heal. Potentially devastating osteoarticular infections occur in the pediatric population and must be differentiated from more benign causes of joint pain, such as transient synovitis or congenital abnormalities. Children are also at risk for abnormalities such as slipped capital femoral epiphysis or Legg-Calvé-Perthes disease, which are rarely diagnosed in the adult population. It is imperative for a clinician to be aware of these and other nuances to optimally care for orthopedic injuries and emergencies in the pediatric population. This review contains 9 figures, 13 tables and 45 references Key words: bone, musculoskeletal, orthopedic, skeletal

Brachial artery injuries - the impact of the anatomical site of injury on postoperative outcomes

The start of the armed conflicts in Libyan society in 2011 led to a dramatic increase in the incidences of unusual types of brachial artery injuries, which were previously uncommon. In this study, the postoperative outcomes have been compared prospectively between patients who have had injuries at the proximal anatomical half of the brachial artery with those who suffered injuries at the distal anatomical half.A cohort study was undertaken to compare patients who had an injury at the proximal anatomical half of the brachial artery (considered as the first group) and patients who had an injury at the distal anatomical half of the brachial artery (considered as the second group). This was undertaken to analyse the influence of the anatomical site of injury on the postoperative outcomes in patients who underwent urgent surgical repair procedures at the hospital from February 2011 to December 2016.Out of fifty-one patients, 31 (60.8%) patients had gunshot injuries, 12 (23.5%) had explosive injuries, four (7.8%) had stab wounds and four (7.8%) were victims of road traffic accidents. There were 13 (25.5%) patients in the first group and 38 (74.5%) patients in the second group. Three patients (5.9%) had postoperative arterial occlusion due to thrombosis, while two (3.9%) had postoperative graft occlusion due to thrombosis; the other two (3.9%) had compartment syndrome.Based on the anatomical background, critical limb ischaemia and postoperative ischaemic complications, as well as delayed limb amputation, are more associated with the injuries to the proximal anatomical half of the brachial artery due to poor collateral circulation at this level.

Clinical Review of Weight Loss Surgery, Procedures, Complications and Post Procedure Complications Management

Introduction: Obesity is worldwide epidemic associated with serious complications both physical and psychological.Weight loss can be achieved with either medications or surgery, however the non-surgical options lacks durability more than two years. The weight loss surgical approaches classifies as: restrictive (adjustable gastric banding, vertical band gastroplasty), restrictive/resective (sleeve gastrectomy), restrictive/malabsorptive (Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch) and purely malabsorptive (duodenal switch) options. Aim: Clinical review of different weight loss surgeries, mechanism of achieving weight loss, and complications of each procedure. Management of possible complications for each procedure. Results: [I] Gastric bypass (open and laparoscopic): the most commonly performed operation for long-term weight control in United States. Provides longstanding weight loss, better control of comorbidities as well as post procedure nutritional sequelae. Complications are (1) anastomotic leak (1–5.6%) and management either relaproscopy if detected early or radiological guided drainage for contained collection (2) anastomotic stricture (3- 11%) which can be managed by endoscopic dilatation or surgery (3) internal hernia require reoperation and closure of the defect. [II] Laparoscopic adjustable gastric band: the commonest weight loss surgery procedure in UK, complications are: (1) Pouch enlargement, (2) band erosion and (3) Band slip. [III] Sleeve gastrectomy: It is restrictive procedure involve neither anastomosis nor malabsortion and it is irreversible. Produce its clinical effect by early satiety from stomach volume loss and low circulating ghrelin levels. Complications (1) gastric leak: From staple line with incidence of 0.7-5%. If detected early (&gt;4days) requires urgent surgical repair, however late presentation (5-10 day) for conservative management (2) bleeding. [IV] Biliopancreatic Diversion with Duodenal Switch (BPD/DS), components of the procedure are: (1) sleeve gastrectomy. (2) Division of duodenum between pylorus and sphincter of oddi. (3) Bypassing proximal small intestine through alimentary limb; distal 250 cm of the small intestine from ICV anastomosed end to end with post pyloric duodenum, while billiopancreatic limb has blind end proximal to sphincter of oddi anastomosed distally ileo-ileal about75 to 100 cm from ICV. Advantages are morbid obese patient can lose more weight and maintain it comparing with other bariatric procedures also it has a better control of comorbidities. Complications are: anastomotic leak, bleeding and nutritional deficiencies. Conclusion: Many surgical procedures have emerged as an acceptable bariatric surgical option for obese patients. Most of the bariatric procedures available nowadays offer beside weight loss, a better control of the obesity related comorbidities as Biliopancreatic Diversion with Duodenal Switch (BPD/DS), while others as adjustable gastric band have low complications rate which explains its popularity.

Inguinal hernia containing the uterus and both adnexa in a full-term infant

We report a case of inguinal hernia that contained the entire uterus and both adnexa, presenting with an irreducible soft mass in the left groin and asymmetric labia majora, in a 2-month-old, full-term girl who visited the emergency department. Ultrasonography was performed immediately, and urgent surgical repair was performed without complications. Although inguinal hernia is a common surgical disease, it is rare that the hernia contains the uterus with its adnexa, and presents as a mass of the labia majora. Unlike the bowel herniation, the entity can be complicated by strangulation of the ovary, leading to infertility. To preserve fertility, rapid and accurate diagnosis using ultrasonography should be considered in an infant with an irreducible inguinal mass and asymmetric labia majora.

Ventral hernia repair under neuraxial anesthesia

BackgroundAcute strangulated ventral hernia is associated with operative morbidity and mortality. General anesthesia may increase the operative risk, especially in morbidly obese and COVID-19-positive individuals.MethodsA 67-year-old woman with body mass index (BMI) 51 kg/m2, hospitalized for SARS-CoV-2-related interstitial pneumonia and renal failure, presented with acute abdominal pain, nausea, vomiting, and abdominal tenderness secondary to giant ventral hernia strangulation.ResultsDue to the suspicion of vascular bowel compromise at contrast-enhanced CT scan, urgent open surgical repair surgery was performed under spinal anesthesia and Venturi mask support. There was no need for an intensive care unit (ICU) stay. Postoperative course was uneventful, and the patient was transferred to a rehabilitation center on postoperative day 10.ConclusionAlthough some anesthetists and surgeons may be reluctant to use regional anesthesia for both emergent and elective ventral hernia repair, this may represent an excellent option in obese patients with a high respiratory risk.

Urgent surgical repair is pivotal in the management of major airway injury due to blunt trauma

BackgroundBlunt traumatic airway injury is a life-threatening injury in which urgent management is pivotal and this would come through improving our clinical management and diagnostic tools. Our objective was to emphasize the importance of early referral and urgent surgical repair of major airway injury.ResultsRecords of 42 patients with major airway injury out of 17,520 registered thoracic trauma cases were reviewed over the past 15 years. Twenty-eight cases documented to have major tracheobronchial injuries due to blunt trauma underwent surgical repair either urgent (21 cases) or late (7 cases). The age ranged from 8 to 43 years old with a mean age of 22.3 ± 0.8. The most common presenting symptom was shortness of breath in 22 (78.6%) cases and the most frequent sign was subcutaneous emphysema which was seen in 22 (78.6%) cases. The postoperative morbidity and mortality rates were significantly higher in the delayed repair group (p value < 0.001).ConclusionThe urgent surgical repair is the treatment of choice for major airway injury which is facilitated by early recognition and referral. It is pivotal to avoid respiratory and systemic complications and related mortality.

Late Presentation of Penetrating Ulcers at the Ascending Aorta Associated With Intra-Mural Haematoma

The combined pathology of intra-mural haematoma (IMH) and penetrating aortic ulcer (PAU) represents disease progression of the PAU with high risk for further progression to either rupture or pseudo-aneurysm formation, and hence surgical intervention should be offered once diagnosis is made regardless of the presentation. We present a 70-year-old fit lady with chronic type A IMH associated with multiple PAUs, diagnosed incidentally, the patient underwent urgent surgical repair with good outcome.

Interval Surgery for Unstable Traumatic Ventricular Septal Defect

Blunt or penetrating thoracic wall trauma can lead to formation of a traumatic ventricular septal defect. This is a serious cardiac complication that can have dire hemodynamic consequences in a setting of ongoing hemorrhage. This demands urgent surgical repair to cease further deterioration. We describe a patient with traumatic VSD who underwent successful interval repair after management of acute abdomen and stabilization of hemodynamics using vasopressors and Intra-Aortic Balloon Pump (IABP). Keywords: Traumatic VSD; patch repair; left ventricle

P251 Right ventricular free wall dissection clearly detected and recorded by echocardiography: a fatal complication after inferior myocardial infarction

Abstract An 81-year-old man was transferred to our institution by ambulance because of poor feeding, general fatigue and slight disorientation lasting for a week. On arrival, he was awake and able to speak, however, his blood pressure was low at 61/43 mmHg in spite of his medical history of hypertension. His ECG showed abnormal Q waves and ST elevation in II, III, aVF leads. The echo exam detected severe hypokinesis in the left ventricular inferior wall and reduced ejection fraction at 30%. Pericardial effusion was not observed in the first echo exam. The patient was diagnosed as cardiogenic shock due to recent inferior myocardial infarction. Coronary angiography was performed, which detected total occlusion of mid right coronary artery, followed by a successful percutaneous coronary intervention (PCI) with a drug-eluting stent under the support of intra-aortic balloon pumping. Nevertheless, his blood pressure remained low and intravenous adrenaline administration was necessary during and even after PCI. To detect the cause of prolonged low blood pressure, echo was performed again immediately after PCI. The echo exam detected new findings: right ventricular posterior free wall was dissected and abnormal shunt flows were obviously observed from left ventricle to right atrium through the dissection cavity during systole. An urgent surgical repair was considered as the only option for his survival, however, his family did not accept it because the operation itself was too risky. On the next day of his admission, he passed away. Right ventricular free wall dissection is a very rare but fatal complication after inferior myocardial infarction, nevertheless, we could detect it by echocardiography with clearly recorded images. Abstract P251 Figure.

P1322 Role of echocardiography in the assessment of mechanical complications of acute myocardial infarction: case report series

Abstract INTRODUCTION The incidence of the mechanical complications of acute myocardial infarction (AMI) has noticeably decreased throughout the world after the era of primary percutaneous coronary intervention (PCI); nonetheless, when they present, the mortality rate continues being high, requiring for their diagnosis an adequate clinical suspicion, followed by intensive care therapy and in most cases, surgical treatment. In the current report we present 4 cases of mechanical complications using transthoracic echocardiography (TTE) as diagnostic tool: a ventricular septal defect, a papillary muscle rupture, a left ventricular (LV) free wall rupture and a ventricular aneurysm. PATIENT 1: A 71-year-old male who presented with inferior AMI and no reperfusion therapy, complicated with transitory AV block, ventricular fibrillation and severe mitral regurgitation secondary to posteromedial papillary muscle rupture (Panel A). He followed surgery with biological mitral valve replacement and PCI of the right coronary artery (RCA). PATIENT 2: A 71-year-old male who presented with anterior AMI and no reperfusion therapy, suddenly showed signs of cardiogenic shock. The TTE demonstrated pericardial effusion associated with an image of thrombus fixed to the antero-apical wall of the LV of 21 mm in dimension, apical segments akinesia and left ventricular ejection fraction (LVEF) of 40% (Panel B). These findings concluded LV free wall rupture, that required urgent surgical repair of the apical region with sphacelated myocardium. PATIENT 3: A68-year-old male, with history of hospitalization 2 months prior for an event of acute coronary syndrome. Admitted again for chest pain, with a TTE that demonstrated a ventricular septal defect associated with intramyocardial dissection, apical thrombus of 17x11 mm in dimension, apical dyskinesis and LVEF of 30% (Panel C). Coronary angiography documented critical obstruction of proximal left anterior descending coronary artery (LAD) and chronic total occlusion of the RCA. He was taken to surgical repair of the defect and coronary artery bypass (CABG). PATIENT 4: A 77-year-old male, with a history of PCI in 2009 (unknown coronary vessel), presented with inferior AMI and no reperfusion therapy. TTE demonstrated an aneurysm in the basal inferior segment of 55x44 mm in dimension, partially thrombosed, with a neck of 23 mm, severe mitral regurgitation and LVEF of 45% (Panel D). Coronary angiography documented multivessel disease with unsuitable coronary anatomy for CABG. CONCLUSIONS The incidence of AMI mechanical complications has decreased noticeably to less than 1% in the era of primary PCI. These include free wall rupture (0.17%), papillary muscle rupture (0.26%) and LV free wall rupture (0.17%). Immediate echocardiographic assessment is needed when clinical findings suggest such complications; urgent treatment is fundamental to improve short term prognosis. Abstract P1322 Figure. Bidimensional TTE images.

Computed tomography-guided additive manufacturing of Personalized Absorbable Gastrointestinal Stents for intestinal fistulae and perforations

Small bowel perforations and obstructions are relatively frequent surgical emergencies, are potentially life-threatening, and have multiple etiologies. In general, treatment requires urgent surgical repair or resection and at times can lead to further complications. Stents may be used to help with healing intestinal perforations but use is limited as currently available stents are non-absorbable, are manufactured in a narrow size range, and/or are limited to usage in locations that are accessible for endoscopic removal post-healing. The use of 3D-printed bioresorbable polymeric stents will provide patients with a stent that can prevent leakage, is tailored specifically to their geometry, and will be usable within the small bowel, which is not amenable to endoscopic stent placement. This work focused on the rapid manufacturing of gastrointestinal stents composed of a polycaprolactone-polydioxanone (PCL-PDO) composite. Dynamic Mechanical Analysis (DMA) tests were conducted to separately analyze the effects of composition, the filament formation process, and physiological temperature on the PCL-PDO material properties. The proposed stent design was then modeled using computer-aided design, and Finite Element Analysis (FEA) was used to simulate the effects of physiologically relevant forces on stent integrity. The presence of hydrolysable ester bonds was confirmed using FT-IR spectroscopy. In vitro studies were used to evaluate the biocompatibility of the polymer composite. Further analyses were conducted through stent placement in ex vivo pig intestines. PCL-PDO stents were then 3D-printed and placed in vivo in a pig model.

Retinal detachment

Around 5% of GP consultations are said to be eye-related, with loss of sight being the most feared long-term health condition. In 2013 there were 4 500 000 GP consultations related to eye health. The RCGP has stated that 50% of sight loss could be avoided through earlier diagnosis and improved eye care. It is essential that retinal detachment is recognised as an ophthalmological emergency and referred for urgent surgical repair to prevent visual loss. This article outlines the causes, presentation and management of retinal detachment, emphasising risk factors and clinical features that facilitate early diagnosis and prompt referral.

Rare presentation of small bowel adenocarcinoma with neuroendocrine differentiation in the jejunum: A case report and summary of diagnostic and management options.

Cancer of the small bowel (SB) is rare. The most common SB malignancy is neuroendocrine, followed by adenocarcinoma. SB adenocarcinoma with overlapping neuroendocrine differentiation (NED) is very uncommon. The present case report discusses the case of a young African American female who presented with high-grade SB perforation and underwent urgent surgical repair. Histology of the tumor revealed jejunal adenocarcinoma with NED. To the best of our knowledge, this type of tumor has not yet been reported in the jejunum. Referring patients that present with insidious and nonspecific abdominal discomfort for imaging studies that are more sensitive to the SB could potentially identify tumors earlier, prevent the development of emergent gastrointestinal complications and offer a chance for cure. An overview of diagnostic tools for SB evaluation was provided.

Tension Pneumocephalus from Endoscopic Endonasal Surgery: A Case Series and Literature Review

Background: Tension pneumocephalus (TP) caused by endoscopic endonasal surgery is a serious complication. We report 4 cases of TP caused by endoscopic surgery and review other cases in the literature, with special attention given to the symptoms, imaging manifestations, therapeutic approaches. Methods: We performed a retrospective chart review of patients with TP caused by endoscopic surgery in our institution from 2015 to 2018. Additionally, the MEDLINE database was searched for all case series or reports of TP caused by endoscopic surgery. Findings: Seventeen articles were identified for review, including the 4 cases from the authors' institution. Ultimately, a total of 25 cases were included in this study. The main symptoms of TP were headache and change in mental status. Cerebrospinal fluid (CSF) leakage was reported in 21 patients (21/25, 84.0%). Eight patients (8/25, 32.0%) presented with the Mount Fuji sign imaging characteristic. Twenty-three patients were treated with surgical intervention for TP (endoscopic multilayer closure of skull base defect, cranial burr hole, bifrontal craniotomy). In addition, we first reported that 2 patients with TP were successfully given conservative treatment. Interpretation: The therapeutic method of TP should depend on the degree of the mass effect and clinical symptoms. When patients with TP presented with obvious symptoms of CSF leakage and intracranial hypertension, urgent surgical multilayer repair of the skull base defects or/and release of the intracranial pressure were the keys to treating these patients. However, conservative treatment under close observation was also feasible when the related symptoms were not obvious. Funding Statement: This work was financially supported by the National Natural Science Foundation of China (No. 81870703). Declaration of Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethical Approval Statement: This study was approved by the Institutional Review Board of AEENTH at Fudan University.