Musculoskeletal Echinococcus infection as a rare first presentation of hydatid disease: case report

Background

Hydatid disease (HD) is a cosmopolitan parasitosis caused by Echinococcus granulosus that can potentially affect any part of the human body. Liver and lungs are the most frequent localizations. Primary musculoskeletal hydatidosis are seldom reported in literature and their incidence is unknown.

Case presentation

We deem interesting to report a case of a primary hydatid cyst in a 25-year-old patient who presented with a painful swelling of the right elbow. Meticulous examination and preoperative imaging did not reveal other localizations. Patient was admitted for surgery where total excision of cyst was done without intraoperative spillage and a cutaneous skin flap was subsequently required to make up for soft tissue loss.

Conclusion

Primary hydatid cysts are sometimes difficult to diagnose preoperatively. It should be considered in the differential diagnosis of subcutaneous cystic lesions in regions where hydatid cysts are endemic. Currently, surgical excision is deemed first choice treatment for solitary cysts and antihelminthic treatment should be initiated preoperatively in the case of risk of rupture or in the event of complications.

     

Pre-expanded epigastric flap cover for ventral hernia following fungal necrotizing fascitis of caesarian section wound: An unusual complication

Introduction

Reconstruction of anterior abdominal wall after necrotizing abdominal wall infections is a challenge.

Material and methods

A 35-year-old lady presented with 20 × 18 cm sized defect of the anterior abdominal wall following fungal necrotizing fascitis. The defect was covered by an overlay prolene mesh and the soft tissue deficit was corrected by pre-expanded epigastric flap based on the superior epigastric artery.

Conclusion

A concerted multi-specialty effort is needed to correct these defects.

     

Duplication of gallbladder — Rare entity treated laparoscopically

Introduction

Gall bladder (GB) duplication is a rare condition that is often found incidentally. Its laparoscopic management has seldom been described. We report the case of a symptomatic duplicated gallbladder, successfully treated by laparoscopic cholecystectomy.

Case Profile

A 29-year-old woman was seen after several attacks of epigastric and right upper quadrant abdominal pain which radiated to the right upper back. Ultrasonography of the abdomen showed two pear-shaped structures in the GB fossa, which were confirmed on magnetic resonance imaging. She successfully underwent a laparoscopic cholecystectomy with an uneventful post operative course.

Conclusion

It is important that surgeons be aware of this rare anomaly because of the associated anatomical variations of main bile duct, hepatic artery and increased risk of common bile duct injury.

     

Magnetic resonance imaging as an adjunct diagnostic tool in computed tomography defined Bosniak IIF–III renal cysts: a multicenter study

Introduction

CT imaging is the standard examination for renal cystic lesions and defines the Bosniak category, which dictates further management. Given that Bosniak II/IIF/III renal cystic lesions can potentially harbor renal cell carcinoma (RCC), additional diagnostic modalities may be required in management decision making.

Aim

To determine the value of additional magnetic resonance imaging in CT-defined Bosniak IIF–III renal cystic lesions.

Materials and methods

This a multicenter retrospective study of 46 consecutive patients, diagnosed with cystic renal lesions between 2009 and 2016. The inclusion criteria were: (1) cystic renal lesion classified as Bosniak IIF–III on CT, (2) a subsequent MRI examination, and (3) documented outcome via surgery for cystic renal mass or follow-up.

Results

46 patients (35 males, 11 females) were included. The mean size of the cystic lesion was 3.92 cm (0.7–10 cm). According to the CT findings, Bosniak IIF and III were found in 12 (26.1%) and 34 (73.9%) cases. Reclassification of Bosniak category was done after MRI examination in 31 cases (67.4%). An upgrade rate of 58.7% (27 cases) to a higher category was made, while the downgrade rate to a lower category was achieved in 4 cases (8.7%). As a result, significant therapeutic management change was made in 12/31 patients (38.7%), of whom 8 underwent subsequent surgery.

Conclusion

MRI study may reduce the use of Bosniak IIF category (in comparison with CT), which has a direct impact on therapeutic management (surgery vs. surveillance) in a significant proportion of patients.

     

Giant cystic sacral schwannoma mimicking tarlov cyst: a case report

Purpose

To present a rare case of a giant schwannoma of the sacrum mimicking a Tarlov cyst.

Methods

A 58-year-old woman had a 1-year history of low back pain. MRI revealed a large cystic mass in the sacral canal with bony erosion. Radiological diagnosis of Tarlov cyst was made.

Results

The patient underwent surgical treatment for the lesion, which revealed a solid mass. Histopathological examination of the tumor confirmed the diagnosis of schwannoma. The postoperative course was uneventful and the patient has had significant improvement in her pain 1 month postoperatively.

Conclusion

Giant cystic schwannoma of the sacrum is a very rare diagnosis overlooked by practitioners for more common cystic etiologies, but its treatment is significantly different. Care should be taken to include this diagnosis in a differential for a cystic sacral mass.

     

Non-lethal Right Liver Atrophy After TIPS Occlusion in A Cirrhotic Patient: Introducing The Hepatic Biembolization

Background

Transjugular intrahepatic portosystemic shunt (TIPS) is the standard procedure in the treatment of refractory ascites and variceal bleeding in the setting of portal hypertension. Secondary obstruction of the shunt is a classic but potentially lethal complication.

Methods

We present here the case of a cirrhotic patient that underwent a TIPS for refractory ascites, with early complete thrombosis without lethal complication.

Results

Obstruction of the TIPS led to thrombosis of both the right hepatic and the right portal veins with progressive total atrophy of the right liver and marked hypertrophy of the left liver. Despite initial poor liver function, biological hepatic markers improved slowly until complete recovery.

Conclusion

Hence, we suggest the concept of combined right portal and hepatic vein embolization as a new procedure to induce partial liver hypertrophy before major liver resection, even in cirrhotic patients.

     

Epicardial infrared ablation to create a linear conduction block on a beating right atrium

Background

It is still difficult to create a secure linear conduction block on a beating heart from the epicardial side. To overcome this drawback we developed an infrared coagulator equipped with a cuboid light-guiding quartz rod. This study was designed to electrophysiologically confirm the efficacy of a new ablation probe using infrared energy in a clinical case.

Methods

The infrared light from a lamp is focused into the newly developed cuboid quartz rod, which has a rectangular distal exit-plane that allows 30 mm?×?10 mm linear photocoagulation. Two pairs of electrodes were attached to the right atrium of a patient who was undergoing surgery. Each pair of electrodes was placed 10 mm from an ablation line. The change in conduction time between the two pairs of electrodes was measured during ablation. The predicted conduction time delay ratio was 1.54.

Results

The actual conduction time after ablation was 1.38–1.43 times longer than the pre-ablation conduction time.

Conclusions

The infrared ablation using a newly developed cuboid probe made it possible to create a linear conduction block on the beating right atrial free wall clinically.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

Trans-oral robotic surgical excision of an ectopic parathyroid adenoma

Background

The pyriform sinus is a potential location for ectopic parathyroid tissue and we describe the use of trans-oral robotic to excise the ectopic tissue.

Methods

A 55-year-old female presented with primary hyperparathyroidism. 4D computed tomography and Sestimibi scan revealed a 1.2 × 0.7 cm mass in the left pyriform sinus. Using the da Vinci SI robot, a 1 cm hypopharyngeal incision was made with electrocautery in the left pyriform sinus and used to excise the mass.

Results

Ectopic mass was removed via trans-oral robotic approach and final pathology confirmed parathyroid tissue. Parathyroid hormone level dropped from 135.8 to 13.3 pg/ml 15 min after excision of the mass.

Conclusion

Ectopic parathyroid tissue can present in many different areas of the neck, with the pyriform sinus being a potential location. The trans-oral robotic parathyroidectomy confers the advantage of the lack of an external incision for removal of ectopic parathyroid adenoma.

     

MRI of female urethra and periurethral pathologies

Introduction and hypothesis

Accurate diagnosis of a wide spectrum of urethral/periurethral pathologies in women remains challenging due to its anatomical location and nonspecific clinical presentations. Magnetic resonance imaging (MRI) has emerged as the modality of choice for diagnosing female urethral and periurethral pathologies due to its multiplanar scanning capability, superior soft tissue differentiation, noninvasive nature, and overall excellent contrast resolution.

Methods

In this narrative review, we describe the use of MRI to visualize the female urethra and periurethral pathologies.

Results

MRI can confidently characterize lesions into cystic or solid, provide a more succinct differential diagnosis, and in some cases provide a specific and accurate diagnosis, enabling surgeons to prepare a roadmap before operative procedure. Moreover, functional MRI can be useful to assess dynamic disorders such as urethral hypermobility.

Conclusions

We provide a comprehensive review of normal MR anatomy of the female urethra, as well as the MR features of practically important urethral and periurethral lesions.

     

Two occurrences of delayed epidural hematoma in different areas following decompressive craniectomy for acute subdural hematoma in a single patient: a case report

Background

Delayed epidural hematoma (DEH) following evacuation of traumatic acute subdural hematoma (ASDH) or acute epidural hematoma (EDH) is a rare but devastating complication, especially when it occurs sequentially in a single patient.

Case presentation

A 19-year-old man who developed contralateral DEH following craniotomy for evacuation of a traumatic right-side ASDH and then developed a left-side DEH of the posterior cranial fossa after craniotomy for evacuation of the contralateral DEH. He was immediately returned to the operating room for additional surgeries and his neurological outcome was satisfactory.

Conclusions

Although DEH occurring after evacuation of ASDH or acute EDH is a rare event, timely recognition is critical to prognosis.

     

Axillary lymphadenectomy for breast cancer in elderly patients and fibrin glue

Background

Axillary lymphadenectomy or sentinel biopsy is integral part of breast cancer treatment, yet seroma formation occurs in 15-85% of cases. Among methods employed to reduce seroma magnitude and duration, fibrin glue has been proposed in numerous studies with controversial results.

Methods

Thirty patients over 60 years underwent quadrantectomy or mastectomy with level I/II axillary lymphadenectomy; a suction drain was fitted in all patients. Fibrin glue spray were applied to the axillary fossa in 15 patients; the other 15 patients were treated with harmonic scalpel.

Results

Suction drainage was removed between post-operative Days 3 and 4. Seroma magnitude and duration were not significant in patients receiving fibrin glue compared with the harmonic scalpel group.

Conclusions

Use of fibrin glue does not always prevent seroma formation, but can reduce seroma magnitude, duration and necessary evacuative punctures.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Is a “dragging sensation” a symptom of female pelvic organ prolapse?

Introduction and hypothesis

Pelvic organ prolapse (POP) commonly presents with a “vaginal lump or bulge” and/or a “dragging sensation.” The first symptom correlates strongly with clinical and imaging data. However, a “dragging sensation” may be less specific. Hence, we investigated the predictive value of both symptoms for POP.

Methods

This was a retrospective study involving archived data sets of women seen between November 2013 and May 2014. All underwent a clinical interview, POPQ examination, and 4D translabial ultrasound (TLUS). The main outcome measure was organ descent on clinical examination and TLUS. Offline analysis for organ descent was undertaken blinded against all other data.

Results

A total of 224 women were assessed. Mean age was 57 (23–84) years. Median parity was 3 (0–7). Ninety-three percent (n=208) were vaginally parous. Fifty-eight percent (n=129) complained of symptoms of prolapse: 49% (n=110) of a vaginal lump, 27% (n=61) of a dragging sensation. Clinically, mean point B anterior (Ba) was ?0.86 (?3 to +7.5) cm, mean cervical station (C) was ?4.1 (?9 to +8) cm, mean point B posterior (Bp) was ?1.1 (?3 to +5) cm. On imaging, mean bladder, uterine, and rectal descent were ?8.3 (?68.0 to 34) mm, +18.6 (?56.4 to 46.3) mm, and ?5.3 (?39.8 to 36) mm respectively. On univariate analysis, both symptoms were strongly associated with objective prolapse clinically and on TLUS, with “vaginal lump” consistently the stronger predictor.

Conclusions

The symptom of a “vaginal lump or bulge” was consistently a stronger predictor of objective POP than “dragging sensation.” This finding was insensitive to adjustments for potential confounders. However, a “dragging sensation” is clearly a symptom of prolapse.

     

Beinachsen- und Fußfehlstellung

Background

Varus and valgus malalignment as well as foot malalignment can change the load applied to the knee.

Methods

PubMed literature search

Results

Inconsistent results for leg axis and the incidence of osteoarthritis of the knee are reported in the literature.

Conclusion

Leg axis and foot malpositioning are not causative factors.

     

Entzündlich-rheumatische Erkrankungen

Background

Inflammatory rheumatic diseases can lead to cartilage changes.

Methods

PubMed literature search

Results

The rheumatoid arthritis can produce degrading enzymes and cause cartilage damage; longitudinal studies do not exist.

Conclusion

There are no high level studies. The expert opinion is that infammatory rheumatic diseases can lead to osteoarthritis of the knee.

     

Use of hyaluronidase cream to prevent peritoneal adhesions in laparoscopic ventral hernia repair by means of intraperitoneal mesh fixation using spiral tacks

Background

The aim of this study was to investigate the effects of hyaluronidase gel on the prevention of post-operative peritoneal adhesions to prosthetic materials used in laparosopic ventral hernia repair.

Methods

Ten pigs were included in this study. The animals were anesthtetized using Na-penthotal for induction and isofluorane for maiteneance. The abdomen was opened and, using helical fasteners, four implantantions were perfomed (squares of 4 × 4 cm). Two of the implants, placed in an upper location, were in polypropylene mesh, and two of the implants, placed in a lower aera, were in polytetrafluoroethylene (PTFE-e, Dualmesh^® Plus Corduroy). The implants located in the right side of animals were painted with hyaluronidase gel. Two helical fasteners, painted and unpainted, were implanted in a medial location. After a five-week period the pigs were operated on again, intraperitoneal adhesion ratios and grades were determined, and the pigs later sacrificed. Specimens having abdominal wall implants were taken for histological studies.

Results

Intraperitoneal adhesions decreased in implants painted with hyaluronidase gel in a comparative study with implants located in the left side of animals (not painted). On the other hand the polypropylene mesh, said typically to produce intraperitoneal adhesions, produced almost no adhesion in many animals.

Conclusions

Hyaluronidase gel reduces post-operative peritoneal adhesions ratio and grades including in the presence of polypropylene mesh.

     

Ultrasound-Guided Placement of Central Venous Port Systems via the Right Internal Jugular Vein: Are Chest X-Ray and/or Fluoroscopy Needed to Confirm the Correct Placement of the Device?

Background

Percutaneous central venous port (CVP) placement using ultrasound-guidance (USG) via right internal jugular vein is described as a safe and effective procedure. The aim of this study is to determine whether intraoperative fluoroscopy (IF) and/or postoperative chest X-ray (CXR) are required to confirm the correct position of the catheter.

Methods

Between January 2012 and December 2014, 302 adult patients underwent elective CVP system placement under USG. The standard venous access site was the right internal jugular vein. The length of catheter was calculated based on the height of the patient. IF was always performed to confirm US findings.

Results

176 patients were men and 126 were women and average height was 176.2 cm (range 154–193 cm). The average length of the catheter was 16.4 cm (range 14–18). Catheter malposition and pneumothorax were observed in 4 (1.3 %) and 3 (1 %) patients, respectively. IF confirmed the correct position of the catheter in all cases. Catheter misplacement (4 cases) was previously identified and corrected on USG. Our rates of pneumothorax are in accordance with those of the literature (0.5–3 %).

Conclusion

Ultrasonography has resulted in improved safety and effectiveness of port system implantation. The routine use of CXR and IF should be considered unnecessary.

     

Early postoperative complications after middle lobe-preserving surgery for secondary lung cancer

Purpose

Preservation of the middle lobe during lung surgery is traditionally avoided, because its presence in the hemithoracic cavity is considered a cause of complications. We report a series of lung cancer patients who underwent a secondary pulmonary resection with the preservation of the middle lobe to explore the complications and feasibility of these procedures.

Methods

We reviewed the clinical courses of six patients who underwent surgery for metachronous lung cancers. Five patients underwent right upper lobectomy, including one sleeve lobectomy, after having undergone prior right lower lobectomy. The remaining patient underwent a right lower lobectomy after having undergone a prior right upper lobectomy.

Results

There were no treatment-related deaths. One patient was readmitted for surgery to treat delayed air leakage progressing to pyothorax. One patient was treated for persistent air leakage. Two patients required intermittent drainage of pulmonary effusion, because of middle lobe atelectasis. The postoperative forced vital capacity and forced expiratory volume in 1 s were greater than the values predicted post-pneumonectomy in four evaluable patients.

Conclusions

While postoperative complications after middle lobe-preserving surgery are manageable, their high incidence should be considered when performing this surgery.