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  • ISSN: 2379-0911
    Early Online
    Volume 7, Issue 1
    Review Article
    E. Scott Sills* and Samuel H. Wood
    Prompt diagnosis of tubal ectopic pregnancy (EP) is now usually possible before rupture and catastrophic hemorrhage, yet if unrecognized, EP remains an obstetrical emergency with high maternal mortality. Long considered unsalvageable, the EP itself is incidentally terminated during treatment to save the life of the mother. Of note, the embryo ploidy error rate in EP is thought to be comparable to intrauterine gestations. As operative experience with EP has increased, rare cases have been documented where scattered trophectoderm foci occasionally escape and successfully migrate to secondary extrauterine sites following surgical removal of the primary lesion. From this sequence, the following insights are possible: 1) that trophectoderm developed well beyond the stage for in vitro culture retain the capacity to tolerate mechanical, thermal, and/or hypoxic stress of standard EP surgery, and 2) that the ectopic so dislodged is sufficiently tenacious for attachment to atypical surfaces never physiologically matched to support pregnancy (e.g., omentum, peritoneum, ovarian epithelium, etc). In this report, these features are exploited to outline an experimental surgical and laboratory protocol to facilitate ectopic-to-eutopic (E2E) pregnancy transposition. At least three relevant issues push against the limits of present technology: 1) Optimal atraumatic removal of the ectopic implant site is unsettled; 2) Once the gestational sac is exteriorized, temporary in vitro culture support will be needed with microsurgical modification to maximize subsequent graft uptake in the awaiting maternal endometrium; 3) The best method and equipment for fresh transfer of a relatively large, complex embryo is undefined. Recent progress in reviving tissue for heterologous heart transplant—even after confirmed cardiac death of the donor—suggests that estimating success with ectopic recovery, processing, and reimplantation could depend on factors besides embryo cardiac potential and gestational sac status. Parallel advances in layered tissue allografting, in utero microsurgery, and wound healing along with in vitro perfluorocarbon-based embryo oxygen support; endometrial preparation and embryo transfer techniques borrowed from IVF promote consideration for how selected EPs may be relocated to the womb. The E2E procedure thus explores the shared terrain of tissue harvest/resuscitation, organ transplant, vascular engraftment and advanced reproductive technology domains. Rescue will not be possible for every EP case, and extensive investigational work in animal models will be required to establish inclusion criteria before the concept is ready for clinical use.
    Case Report
    Pablo Weber Alvarez*, Alejandro Weber Sanchez, Carlos Ricardo Rueda Alvarado, Maria Josefina Marín y Dorado
    Congenital deformities that cause limb overgrowth in childhood have multiple genetic and environmental etiologies. One of them is the Klippel-Trenauney-Weber syndrome (SKT), a rare condition characterized by blood vessel, soft tissue and bones abnormalities, which may affect structures like fingers toes or the hole limb, and may worsen preexisting deformities such as clubfoot. We present the case of a 9-year-old patient with SKT and congenital cubfoot.
    Short Communication
    Rhys George*, Richard John Lyon, and Philip Ng Cheng Hin
    Background: Acute appendicitis is the most common abdominal surgical emergency, yet its diagnosis remains difficult with high negative appendicectomy rates (NAR) reported throughout the United Kingdom (UK). High NARs are associated with increased risk of morbidity. Recently guidelines have suggested the use of preoperative imaging modalities to reduce this; however these are not routinely followed in the UK. Our aim was to assess the effects of preoperative imaging on the NAR.
    Methods: Retrospective cohort study of all appendicectomies at a London District General Hospital over a one-year period. Examining histological data taken from tissue intraoperatively and examining reports of imaging conducted prior to operation.
    Results: The total NAR was calculated at 25.54%. Females had a higher NAR. (35.82% Vs 15.97%) (p<0.05). No significant difference in the NAR was seen between patients who underwent preoperative imaging and those who did not (21.53% Vs 26.12% (p=0.8908)).
    Conclusion: The use of preoperative imaging in our centre does not alter the NAR. The high rate of inconclusive ultrasound reports could contribute to this. UK guidelines for the secondary care management of suspected appendicitis are needed to reduce the NAR; careful consideration for the use of preoperative imaging should be used whilst conducting these guidelines.
    Fatih Can Karaca*
    Background and aim: The tissue undergoes wound healing processes following the surgery, with various cell populations serving during different processes. The aim of the current study was to analyze the cell populations present in the drainage fluid collected from the patients who underwent laparoscopic sleeve gastrectomy (SG) and analyze cell subsets using a flow cytometry-based approach.
    Materials and methods: The study subjects were patients who operated for laparoscopic SG, with a BMI of =35 kg/m2 and without any known comorbidities that might lead to intra- and postoperative complications. Draining fluid from the plastic chamber was collected in a 200 mL sterile plastic container for two days during the postoperative period. The monoclonal antibodies were utilized for the determination of cell sub-populations in the flow cytometry.
    Results: The patient population consisted of 8 male and 8 female patients with a mean age of 38.6±14.2 years. The neutrophils were the predominant cell type in the postoperative period. The percentage of the monocytes and lymphocytes significantly decreased on postoperative day 2 (p<0.01 and p<0.05, respectively). T lymphocytes were the predominant lymphocyte population in the drain fluid samples during the postoperative period.
    Conclusion: There is a strong presence of neutrophils on the surgery site, and the monocyte concentration significantly decreased on the postoperative second day. We suggest that the transformation of monocytes to the tissue macrophages during the wound healing process affected the monocyte ratio. T lymphocytes were the predominant population in the among the lymphocytes during the postoperative period.
    Mohammed Abdullah Alawad Abdullah*, Mugtaba Elsheikh Ibrahim, Reem Mohammed Hassan, and Nesreen Khidir
    Desmoid tumors are benign neoplasms that can often arise from the abdominal wall. We report the case of an abdominal wall desmoid tumor in a female patient with a history of one cesarean section. Surgical resection of the mass was done with wide excision and safe margins. Histopathology confirmed the diagnosis of desmoid tumor.
    Case Report
    Mohammed Abdullah Alawad Abdullah* and Nesreen Khidir
    Trichobezoar occurs in patients with psychological irresistible urge to pull and ingest hair from different parts of the body. Extension of trichobezoar to the duodenum and small bowel is called Rapunzel Syndrome. An18-year-old patient presented with mild abdominal symptoms and no clinical signs of peritonitis. Radiological investigations revealed huge pneumoperitoneum on CT scan but no free intraperitoneal fluid. Hybrid laparoscopic excision and closure were done. The case was complicated by dumping syndrome and leak. Re-operated with primary re-suturing of the leak. In conclusion, Rapunzel Syndrome can present with massive pneumoperitoneum only. Dumping syndrome can complicate the surgical treatment of Rapunzel Syndrome. Our patient had complications of wound infection, leakage and burst abdomen. Psychiatrist’s involvement is mandatory.
    Olga Haakman, George A. Vilos, Angelos G. Vilos, Tina Liang, Nancy G. Chan, and Basim Abu-Rafea*
    Struma ovarii is a rare, monodermal variant of mature ovarian teratoma predominately composed of mature thyroid tissue. It is usually diagnosed on histopathology following removal of an adnexal mass. Co-occurrence of endometriosis and Struma ovarii has been described in two case reports with no cases described of this entity co-existing with endometrioma in the same ovary in the absence of a dermoid cyst. A 47-year-old patient presented with a history of Stage IV endometriosis. Following laparoscopic oophoro-cystectomy, on histopathology assessment, Struma ovarii was diagnosed within an endometrioma. The patient had a normal TSH and CA-125. She recovered well post operatively and is seeking further fertility treatments using donor oocytes. This case presents the unique finding of Struma ovarii co-existing with endometrioma in the same ovary.
    Research Article
    Thamer A. Hamdan*, Nazar Haddad, and Ahmad A. Akbar
    Background: Preoperative nutritional status reflects a patient’s ability to successfully undergo physically demanding surgical procedures, resist infections and heal of surgical incisions. Serum albumin, transferrin and total lymphocyte count are all nutritional biomarkers that are used to assess overall nutritional status. Malnutrition is frequently not identified during preoperative preparation of individuals who will undergo spine surgery.
    Patients and methods: The prospective study which was conducted in the department of orthopedic surgery from March 2018–September 2019. A total of 48 patients that presented to the orthopedic department in Basra Teaching Hospital and Ibn-Albaitar private hospital had spinal lumbar surgery .The patients were investigated in form of total lymphocyte count, serum albumin, and serum transferrin preoperatively and at postoperative days 3, and 16th. The results and post-operative complications were recorded, and compared with pre-operative results.
    Results: The patients was divided into two groups : Group(A) whom developed complications labeled as symptomatic patients were 5 (10.5%), 2 patients with spinal infection (discitis), 1 patient with delay wound healing, 1 patient with seroma formation and 1 patient with surgical site infection and group (B) labeled as asymptomatic whom not developed complications. From the total patients (48), preoperative investigations showed 8(16.6%) had low S. Albumin, 7 (14.5%) had low S. Transferrin, and 3 (6.2%) had low total lymphocyte count. In the symptomatic patients (n=5) 4 (80%) had low S. Albumin, 2 (40%) had low S.Transferrin and 1 (20%) had low total lymphocyte count.
    Conclusions: Hypoalbuminemia is a risk factor for postoperative surgical site infection and wound healing problems.
    Research Article
    Michinobu Ohno*, Yasushi Fuchimoto, Akihiro Fujino, Yutaka Kanamori, Takako Yoshioka and Tomoro Hishiki
    Purpose: Complete resection of the primary lesion and lung metastases is important for the treatment of hepatoblastoma in children. Surgical navigation using Indocyanine green (ICG) is effective in identifying micro-lung metastatic lesions.
    Method: We examined eight procedures performed on six cases of hepatoblastoma lung metastases. In all cases, ICG (0.5 mg/kg) was intravenously administered 24 hours before surgery to identify the lesion.
    Results: Our cases included five males and one female, and the age at surgery ranged from 6 months to 12 years, and the affected side was the right side for five cases, the left side for one case, and both sides (including recurrent surgery) for two cases. The number of excised specimens was 34. Of those, 23 had tumor cells and 33 were ICG-positive. Of the 33 specimens, 23 were ICG-positive and had tumor cells, while 10 specimens were ICG-positive with no tumor cells. In addition, 18 out of 34 specimens were positive on preoperative computed tomography, and tumor cells were observed in all of them. There were 16 specimens that were negative on computed tomography but positive for ICG, of which six specimens showed tumor cells.
    Conclusion: Fluorescence-guided surgery is useful for visualizing micro-lung metastases that cannot be detected by imaging modalities. However, there are some false positives. Therefore, it is necessary to develop a technique for recognizing true micro-lung metastases.
    Ali Basim Almahfoodh*, Darren F Lui, Thamer Ahmed Hamdan
    Tranexamic acid (TXA) was first made in 1962 by Japanese researchers Shosuke and Utako Okamoto. [1].
    Case Report
    Feras Allagany, Angelos G Vilos, Nabigah Alzawawi, Olga Haakman, Basim Abu-Rafea and George A Vilos*
    Background: Mammary-type myofibroblastomas (MTMF) have been reported to occur at extramammary sites throughout the body of men and women of all ages, including the vulvovaginal and perianal area where they can pose diagnostic and therapeutic challenge due to indistinguishable clinical features from malignant tumors.
    Case: A 35-year-old woman, para 1, gravida 3, presented with an asymptomatic 5 cm by 3 cm tumor located along the anterior half of the left labia majora near the clitoris. Following excisional biopsy under general anesthesia, histopathological and immunohistochemical studies showed features consistent with a diagnosis of MTMF.
    Conclusion: Vulvar MTMF is a rare benign soft tissue neoplasm but it warrants appropriate marginal excisional diagnosis since it is indistinguishable from benign and/or malignant lesions of the vulva.
    Original Research
    Michinobu Ohno*, Yasushi Fuchimoto, Masataka Higuchi, Tetsuji Yamaoka, Makoto Komura, Akihiro Umezawa, Huai-Che Hsu, Shin Enosawa, Tatsuo Kuroda
    Purpose: Tracheal restoration is an essential treatment for tracheal congenital abnormalities, cancer or injury. We explored the potential of decellularized trachea to restore the trachea in swine, aiming on pediatric application.
    Method: We compared pigs with the allogeneic decellularized tracheal graft patch and those with the autotransplanted tracheal patch.
    Result: Distortion of the tracheal lumen was observed in both cases. No respiratory symptoms appeared during observation. Histologically, the foci of cartilage regeneration from the recipient trachea was demonstrated in the specimens, suggesting the induction of tracheal reconstitution.
    Conclusion: Allogeneic decellularized tracheal grafts could serve as a feasible tracheal restoration, especially for pediatric patients.
    Bianca Prado Patrús, Bianca Prado Patrús, Gustavo Lustosa Neves, Flavia Santos, Larissa Batista Pegorin Ribeiro dos Santos, Marcelo Vicente de Andrade Sobrinho
    Among transplants, the corneal is the most numerically expressive. This is due to the immunological privilege of the cornea which presents reduced rejection rates. In addition, capture, conservation and surgical techniques also contribute to this success.
    Keratoconus, leukoma, corneal dystrophy and post-facectomy decompensation are the main causes of optical transplants, having the latter a relationship with the number of preoperative cells and the skill of the surgeon. In hospitals where there are surgeons in training, there is an increase in corneal decompensation after facectomy.
    In terms of tectonic transplants in which the purpose is the preservation of the ocular structure, the main etiology is perforation due to trauma.
    From the observational and retrospective analysis of about 61 medical records of patients submitted to keratoplasty in the years 2015 to 2020, it is possible to understand the patients’ profile and main pathologies that evolve to transplantation in order to have an early diagnosis and to optimize their treatment.
    Original Research
    Luă Cunha, Diego Sobrinho, Laila Mota, Gabriela Yale, Edcleia Santos, Alessandro Prudente
    Objectives: The aim is to compare techniques of storage organs for transplantation. The ideal range of temperature is between 2 and 6 oC.
    Methods: Six storage techniques were tested: 1- Standard: set of plastic bags filled with preservation solution and immersed in a thermal box (34 liters) filled with cubed ice; 2- Standard + plastic pot: plastic pot wrapping bags before immersion in ice; 3- Standard + metal box: metal box involving bags before immersion in ice; 4- Standard + crushed ice: Crushed ice instead of cubes; 5- Standard + ice bar: Ice bars instead of cubes; 6- High volume box: Standard in a 50 liter cooler. Variables: a) Temperature inside de plastic bags, the box and the room; b) time to reach the lower temperature; c) time of the temperature within the ideal range. One-way ANOVA was used to compare means, with Tukey’s post hoc test and 5% of significance.
    Results: Each assay was repeated ten times. All groups presented mean temperature inside the bags bellow the expected range, although the group 5 was higher than 2 (p=0.014) and 6 (p=0.006). The group 5 also presented higher temperature inside the box than group 1 (p=0.03), 2 (p=0.007), 4 (p=0.016) and 6 (p=0.001). There was no difference between the groups regarding to neither room temperatures (p=0.106) nor the time to reach the nadir of temperature (p=0.395). The time within the ideal range of temperature were higher in group 5 when compared to group 2 (p=0.027) and 6 (p=0.026).
    Conclusions: Storage in thermal box, regardless of the technique, results in temperatures below the ideal range most of the time. Technical variations do not significantly impact on temperature inside the organ packaging, although using of bar ice leads to a closer approximation of the ideal range.
    Original Research
    Yugal Limbu*, Sujan Regmee, Roshan Ghimire, Dhiresh Kumar Maharjan, Prabin Bikram Thapa
    Introduction: The prognosis of pancreatic adenocarcinoma has improved with the advent of neoadjuvant therapy. The only chance of long-term disease-free survival in pancreatic cancer is achieved with complete tumor resection, and artery involvement by the tumor is one of the major determinants in its resectability. A novel technique, namely the periarterial divestment, has allowed surgeons to clear the tumor tissues off the visceral arteries without the need for arterial reconstruction.
    Methods: This study was a retrospective single series cohort of seven consecutive patients with histologically confirmed pancreatic ductal adenocarcinoma (PDAC) treated at Kathmandu Medical College Teaching Hospital from August 2019 to July 2021. Arterial divestment was performed in six of seven patients, and one patient underwent arterial reconstruction. The data on perioperative and the early oncological outcome was collected.
    Results: The mean age of the patients in this series was 54.4 years. Five patients underwent periarterial divestment, one underwent sub-adventitial divestment, and one underwent arterial (SMA) reconstruction due to deeper tumor infiltration into the arterial wall. The final histopathological specimen showed a positive margin in two of the cases. Four patients, all of whom underwent periarterial divestment, experienced postoperative diarrhea.
    Conclusion: The need for arterial reconstruction in borderline and locally advanced pancreatic cancer can be avoided by using the periarterial divestment technique. Divestment of arteries is technically feasible and can be carried out safely without compromising the patient’s oncological outcome. However, further validation of this technique must be done by well-designed studies with greater sample size.
    Case Report
    ABDI EL Moustapha*, DIBINGUE Clehaude, AL AFIFI Mahmoud, GALLOUO Messian, MOATAZ Amine, DAKIR Mohamed, DEBBAGH Adil, ABOUTAIEB Rachid
    Bladder rupture is a rare pathology that usually occurs after an abdominopelvic trauma. Extraperitoneal bladder injuries are most commonly related with pelvic fractures. We present a case of intraperitoneal bladder rupture detected by oliguria and haematuria. On palpation, a painful hypogastric voussure was discovered during the clinical evaluation.
    The patient underwent a CT urogram, which revealed a parietal defect at the level of the bladder dome measuring 3 cm with late stage intraperitoneal leaking of contrast medium, grade 4 according to the AAST classification. A 3cm bladder break at the level of the bladder dome was discovered during surgical exploration, along with a medium-sized peritoneal effusion (uroperitoneum). After aspiration and intensive cleaning of the uroperitoneum, the bladder damage was sutured in two planes using Vicryl 0 suture.
    Bladder hypertension caused by a severe impact on the abdomen, with a favoured position in the peritoneal region of the bladder, and embrochage of the bladder wall by a bone fragment or splinter can both contribute to a bladder injury following blunt trauma.
    Although bladder rupture is uncommon, it presents a considerable risk of morbidity and mortality if it is not recognised.
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