BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE ...BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE in patients with GOO.METHODS This study was a retrospective,observational,multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected.We analyzed technical success,clinical success,adverse events,and survival.Technical success was defined as adequate positioning and deployment of the stent.Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure.Postprocedural adverse events were recorded.RESULTS Eleven procedures in 10 patients with GOO were included.The mean age of the patients was 67.5 years(range:56-77 years).Malignant GOO was present in 9 patients.Technical success was achieved in 9/11 procedures(82%).Among them,clinical success was achieved in 9 patients(100%).Adverse events occurred in 1 patient(9%).The median survival was 3 months(n=7;range:1-8 months).CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.展开更多
BACKGROUND The majority of published reports on foreign bodies(FBs)involve the rectum and applied a transanal retrieval.Usually,patients with FB above the rectum are subjected to laparotomy for removal.Here,we illustr...BACKGROUND The majority of published reports on foreign bodies(FBs)involve the rectum and applied a transanal retrieval.Usually,patients with FB above the rectum are subjected to laparotomy for removal.Here,we illustrate the case of a man with an FB that had migrated into the descending colon,and its successful removal via a laparoscopic approach.CASE SUMMARY A 43-year-old man,who had the habit of FB insertion into his anus to aid defe-cation,presented upon experience of such an FB slipping through and migrating upward to the distal colon.Plain abdominal radiograph revealed a bottle-shaped FB,positioned in the left iliac fossa region.The FB was successfully removed via a laparoscopic-assisted procedure in which we combined diagnostic laparoscopic and endoscopic techniques during surgery.The patient was monitored for 2 d postoperatively and subsequently discharged home.CONCLUSION A minimally invasive approach should be adopted to aid extraction of colorectal FB as it is effective and safe.展开更多
BACKGROUND The management of tongue carcinoma is excision and radical neck dissection followed with reconstruction.This is a case report of a patient with tongue squamous cell carcinoma(SCC)who underwent the procedure...BACKGROUND The management of tongue carcinoma is excision and radical neck dissection followed with reconstruction.This is a case report of a patient with tongue squamous cell carcinoma(SCC)who underwent the procedure with sternocleidomastoid(SCM)flap reconstruction.CASE SUMMARY A 52-year-old woman without smoking history complained tongue ulcer since 3 years ago.Based on the histopathological examination,the patient was diagnosed with T2N2M0 right tongue SCC and underwent wide excision of tumor;right mandibular;neck dissection and were reconstructed with SCM flap.CONCLUSION SCC of the tongue requires wide excision and dissection of the neck and mandible if infiltration into the surrounding lymph nodes has been found.The SCM flap reconstruction could be used post-surgery.展开更多
BACKGROUND Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections,adhesions,seromas,fistula formation and significant postoperative pain.The modified rectus muscl...BACKGROUND Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections,adhesions,seromas,fistula formation and significant postoperative pain.The modified rectus muscle repair(RMR)is as an option to repair midline ventral hernias without mesh.AIM To evaluate the short term outcomes when the modified RMR was used to repair ventral hernias.METHODS This was a 5-year prospective study that examined the outcome of all consecutive patients with ventral abdominal wall hernias>5 cm in maximal diameter who underwent repair using the modified RMR technique in a single surgeon unit.Patients were reviewed in an outpatient clinic at 3,6 and 12 mo and evaluated for hernia recurrence on clinical examination.Each patient’s abdominal wall was also assessed with using ultrasonography at 24 mo to detect recurrences.All data were examined with SPSS ver 18.0.RESULTS Over the 5-year study period,there were 52 patients treated for ventral hernias at this institution.Four patients were excluded and there were 48 in the final study sample,at a mean age of 56 years(range 28-80).The mean maximal diameter of the hernia defect was 7 cm(range 5-12 cm).There were 5(10.4%)seromas and 1 recurrence(2.1%)at a mean of 36 mo follow-up.CONCLUSION The authors recommend the modified RMR as an acceptable alternative to mesh repair of ventral hernias.The seroma rate can be further reduced with routine use of drains.The modified RMR also has the benefit of eliminating all mesh-specific complications.展开更多
BACKGROUND Endoscopic submucosal dissection is considered curative for patients with early rectal cancer when level of submucosal invasion is<1000 microns with favourable histopathological features.Recent data sugg...BACKGROUND Endoscopic submucosal dissection is considered curative for patients with early rectal cancer when level of submucosal invasion is<1000 microns with favourable histopathological features.Recent data suggests even deeper submucosal invasion can potentially be curative if R0 resection can be achieved and when no high-risk histopathological features are seen in the resected specimen.To achieve R0 resection,deeper dissection is required.CASE SUMMARY A 66 year old New Zealand European male presented with 3 mo history of per rectal bleeding.He was referred for a colonoscopy test to investigate this further.This revealed a malignant appearing lesion in the rectum.Biopsies however showed high grade dysplasia only.Given endoscopic appearances suspicious for deep submucosal invasion,patient was consented for endoscopic intermuscular dissection(EID).The case was successfully performed,and the presence of muscularis propria was confirmed in the resected specimen.There were no complications and total procedure time was 124 min.Lesion was clear of radial margins however deep margins were positive confirming it was at least a pT2 cancer.Patient was recommended to have further treatment but could not have radical surgery due to comorbidities and instead was referred for long course chemoradiotherapy.CONCLUSION EID is a safe and feasible option for management of rectal cancer in highly selected patients.展开更多
BACKGROUND Simple lateral elbow dislocation(SLED)is a rare type of elbow dislocation;however,its treatment may be complicated by accompanying soft tissue or neurovascular damage.Herein,we report a rare case of SLED ma...BACKGROUND Simple lateral elbow dislocation(SLED)is a rare type of elbow dislocation;however,its treatment may be complicated by accompanying soft tissue or neurovascular damage.Herein,we report a rare case of SLED managed secondarily with open reduction and soft tissue repair following failure of closed reduction.CASE SUMMARY A 67-year-old woman suffered SLED after falling on her outstretched left hand with her elbow extended.She developed pain,swelling,and movement restriction in the elbow;there were no neurovascular symptoms,except for numbness in the 4th and 5th digits.Radiologic investigation confirmed the SLED,and a closed reduction under anesthesia was performed.The follow-up radiographs at 1-wk revealed failure of reduction;accordingly,open reduction with lateral collateral ligament and common extensor origin repair were carried out.The patient regained full elbow range of motion by six weeks.CONCLUSION Adequate concentric reduction for SLED,conservatively or surgically,reduces complications and provides a more functional joint.展开更多
BACKGROUND Ossifying fibroma is a type of benign fibro-osseous lesion.Most lesions affect the mandible region,particularly the molar and pre-molar areas.It predominantly affects females between the second to fourth de...BACKGROUND Ossifying fibroma is a type of benign fibro-osseous lesion.Most lesions affect the mandible region,particularly the molar and pre-molar areas.It predominantly affects females between the second to fourth decades of life.Larger ossifying fibroma tumors require more extensive resection.CASE SUMMARY A 39-year-old female complained of occasional pain and tumor enlargement on her left jaw for the 3 years prior to presentation.Intraoral examination revealed a firm swelling on her left lower gum.Extraoral examination revealed swelling on the left mandible body with no erythema and superficial ulcer.Computed tomography scan revealed a circular-shaped lesion on the patient’s left mandible body with a well-defined radiolucent border,sized 3.2 cm×2.8 cm×0.9 cm.The tumor was removed by marginal mandibulectomy.Biopsy from the resected tumor suggested cemento-ossifying fibroma(COF).CONCLUSION COF is often unnoticed,but this slow-growing tumor can cause significant symptoms regarding its distortion into adjacent structures.展开更多
Acute type B aortic dissection(TBAD) occurs as a result of an intimal tear within the proximal thoracic aorta. Patients are typically managed acutely with aggressive antihypertensive therapy. Surgical repair is reserv...Acute type B aortic dissection(TBAD) occurs as a result of an intimal tear within the proximal thoracic aorta. Patients are typically managed acutely with aggressive antihypertensive therapy. Surgical repair is reserved for those who develop complications such as rupture or malperfusion. The surgical management of acute TBAD has changed considerably in the last decade secondary to the advent of thoracic stent grafting. Thoracic endovascular aortic repair(TEVAR) has improved early mortality and morbidity rates for patients presenting with complicated TBAD. The role of TEVAR in patients presenting with acute and subacute uncomplicated TBAD is less clear. TEVAR has been associated with increased late survival and better aortic remodeling, with low perioperative morbidity in selected patients. Recent literature suggests certain radiographic criteria may be used to predict patients developing late aortic events who would benefit from early TEVAR. The purpose of this article is to review the contemporary management of acute TBAD, discuss controversies in management and evaluate the latest research findings.展开更多
Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a ...Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a prolapsed lump, painless bleeding, discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease; however, it is also associated with hyper-vascularity, and, recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. A comprehensive search in published English-language literature till 2013 involving hemorrhoids was performed to construct this review article, which discusses advances in the management of hemorrhoids. This includes conservative treatment(life style modification, oral medications, and topical treatment), office procedures(rubber band ligation, injection sclerotherapy, infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy, cryosurgery, and laser therapy), as well as surgical procedures including diathermy hemorrhoidectomy, Liga Sure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy(SH), and double SH. Results, merits and demerits of the different modalities of treatment of hemorrhoids are presented, in addition to the cost of the recent innovations.展开更多
Clinical testing of patients for hereditary breast and ovarian cancer syndromes began in the mid-1990s with the identification of the BRCA1 and BRCA2 genes.Since then,mutations in dozens of other genes have been corre...Clinical testing of patients for hereditary breast and ovarian cancer syndromes began in the mid-1990s with the identification of the BRCA1 and BRCA2 genes.Since then,mutations in dozens of other genes have been correlated to increased breast,ovarian,and other cancer risk.The following decades of data collection and patient advocacy allowed for improvements in medical,legal,social,and ethical advances in genetic testing.Technological advances have made it possible to sequence multiple genes at once in a panel to give patients a more thorough evaluation of their personal cancer risk.Panel testing increases the detection of mutations that lead to increased risk of breast,ovarian,and other cancers and can better guide individualized screening measures compared to limited BRCA testing alone.At the same time,multi-gene panel testing is more time-and cost-efficient.While the clinical application of panel testing is in its infancy,many problems arise such as lack of guidelines for management of newly identified gene mutations,high rates of variants of uncertain significance,and limited ability to screen for some cancers.Through on-going concerted efforts of pooled data collection and analysis,it is likely that the benefits of multi-gene panel testing will outweigh the risks in the near future.展开更多
More than 20 years have passed since the first report of laparoscopic colectomy in 1991. Thereafter, laparoscopic surgery for the management of colorectal diseases has been widely accepted as a prevailing option becau...More than 20 years have passed since the first report of laparoscopic colectomy in 1991. Thereafter, laparoscopic surgery for the management of colorectal diseases has been widely accepted as a prevailing option because of improved cosmetic outcomes, less postoperative pain, and shorter hospital stay in comparison with open surgery. To further the principle of minimally invasive surgery, two new approaches have been developed in this rapidly evolving field. The first is the totally laparoscopic approach. Currently most of standard techniques inevitably involve an abdominalincision for retrieval of the specimen and preparation for anastomosis, which might compromise the benefits of laparoscopic surgery. The totally laparoscopic approach dispenses with this incision by combining completely intraperitoneal anastomosis with retrieval of the specimen via a natural orifice, such as the anus or the vagina. Our new and reliable technique for intraperitoneal anastomosis is also described in detail in this article. The second is the single-incision approach. While three to six ports are needed in standard laparoscopic surgery, the single-incision approach uses the umbilicus as the sole access to the abdominal cavity. All of the laparoscopic procedures are performed entirely through the umbilicus, in which the surgical scar eventually becomes hidden, achieving virtually scarless surgery. This article reviews the current status of these two approaches and discusses the future of minimally invasive surgery for colorectal diseases.展开更多
The best approach to achieve cure in esophageal cancer is a combination of chemo-radiation and surgery. However, complications occur in half of patients. The current report, reports a rare but severe complication: Com...The best approach to achieve cure in esophageal cancer is a combination of chemo-radiation and surgery. However, complications occur in half of patients. The current report, reports a rare but severe complication: Complete obstruction of the esophagus, induced by preoperative chemo-radiation therapy. Normally, strictures are treated by repeated dilatations, however, in case of complete obstruction, the perforation rate of standard blind anterograde wire access and dilation is severely increased. In order to minimize the risk of perforations, the rendezvous technique was introduced. This technique involves an anterograde approach in combination with a retrograde approach in order to open and dilatate the esophagus. While technical success rates between 83% and 100% have been reported in literature, data on clinical outcomes are scarcer. The limited amount of studies available claim that success was achieved in almost half of patients. The patient in our case currently has an oral diet without restrictions and rates his quality of life with a VAS-score ten out of ten.展开更多
Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term...Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.展开更多
Papillary thyroid carcinoma(PTC) is the most common thyroid malignancy, accounting for approximatley 90% of thyroid malignancies in areas of the world without deficit of Iodine. It's universally accepted that tota...Papillary thyroid carcinoma(PTC) is the most common thyroid malignancy, accounting for approximatley 90% of thyroid malignancies in areas of the world without deficit of Iodine. It's universally accepted that total thyroidectomy is the minimal surgical treatment for patients with PTC higher than 1 cm. When a quality surgery is performed, the prognosis for PTC is excellent with 10 and 20-year overall survival rates around 90% and 85%, respectively. Lymph node metastases are very frequent in PTC, occurring in 50%-80% of PTC patients, the most of them being located in the central compartment of the neck(CCN) and with a high rate of occult or clinically undetectable disease. A lot of controversy exists regarding how to treat the central nodal compartment disease of PTC. The first problem is the lack of standardization of the terminology and concepts related to the CCN, which are clearly established and defined in this paper according to the most recent consensus documents of endocrine societies. This uniformity will provide a more consistent and clear communicaction between all the specialist involved in the treatment of PTC. CCN can be performed to treat patients with clinically detectable, radiologically suspected of intraoperative visualized nodal disease(this is defined as therapeutic) or when these findings are absent(also called prophylactic). Indicactions, advantages and disadvantages of both therapeutic and prophylactic CCN dissection are widely discussed and clear recommendations provided.展开更多
Recently, a novel comprehensive treatment consisting of cytoreductive surgery(CRS) and perioperative chemotherapy(POC) was developed for the treatment of peritoneal metastasis(PM) with a curative intent. In the treatm...Recently, a novel comprehensive treatment consisting of cytoreductive surgery(CRS) and perioperative chemotherapy(POC) was developed for the treatment of peritoneal metastasis(PM) with a curative intent. In the treatment, the macroscopic disease is completely removed by the peritonectomy techniques in combination with POC. This article reviews the results of the comprehensive treatment for PM from gastric cancer, and verifies the effects of CRS and POC, including neoadjuvant chemotherapy(NAC) and hyperthermic intraoperative intraperitoneal chemotherapy(HIPEC). Completeness of cytoreduction, peritoneal carcinomatosis index(PCI) less than the threshold levels after NAC,absence of ascites, cytologic status, pathologic response after NAC are the independent prognostic factors. Among these prognostic factors, PCI threshold level is the most valuable independent prognostic factor. After staging laparoscopy, patients with PM from gastric cancer are recommended to treat with NAC before CRS. After NAC, indication for CRS is determined by laparoscopy. The indications of the comprehensive treatment are patients with PCI less than the threshold levels, negative cytology, and responders after NAC. Patients satisfy these factors are the candidates for the CRS and HIPEC.展开更多
BACKGROUND Superior mesenteric artery syndrome(SMAS)is a rare condition,characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery(SMA).Most cases of SMAS are assoc...BACKGROUND Superior mesenteric artery syndrome(SMAS)is a rare condition,characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery(SMA).Most cases of SMAS are associated with weight loss,and the most frequent clinical manifestations are nausea,vomiting,postprandial fullness,and abdominal pain.Treatment of SMAS is usually conservative,consisting mainly of adequate nutritional support,but in refractory cases surgery may be necessary,with gastrojejunostomy and duodenojejunostomy being the most commonly performed procedures.CASE SUMMARY We describe the case of a man in his forties with a pre-existing diagnosis of esophageal stricture due to sodium hydroxide ingestion,who suffered significant weight loss after replacement of his jejunostomy tube.He was admitted to the hospital due to pain and abdominal distension.A computerized tomography scan showed significant distension of the stomach and duodenum with narrowing of the duodenum at the point at which it is crossed by the superior mesenteric artery,thus establishing the diagnosis of SMAS.Due to the presence of the esophageal stricture,the patient was incapable of emesis;however,passage of a nasogastric tube for decompression was not possible.Considering the risk of gastric perforation due to distention,we opted for surgical treatment in the form of a surgical gastrojejunostomy after which he showed complete resolution of all symptoms and was discharged from the hospital 5 d after the procedure.CONCLUSION Diagnosis of SMAS can be challenging in patients with esophageal stenosis,and risk of gastric perforation may preclude conservative treatment.展开更多
BACKGROUND Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean,having been first performed in the region in the year 2011.We report the initial outcomes using a robot camera holder to assis...BACKGROUND Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean,having been first performed in the region in the year 2011.We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.AIM To report our initial experience using the FreeHand®robotic camera holder(Freehand 2010 Ltd.,Guildford,Surrey,United Kingdom)for laparoscopic colorectal surgery in Trinidad&Tobago.METHODS We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand®(Freehand 2010 Ltd.,Guildford,Surrey,United Kingdom)robotic camera holder between September 30,2021 and April 30,2022.The following data were recorded:patient demographics,robotic arm setup time,operating time,conversions to open surgery,conversions to a human camera operator,number and duration of intra-operative lens cleaning.At the termination of the operation,before operating notes were completed,the surgeons were administered a questionnaire recording information on ergonomics,user difficulty,requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.RESULTS Nine patients at a mean age of 58.9±7.1 years underwent colorectal operations using the FreeHand robot:Right hemicolectomies(5),left hemicolectomy(1),sigmoid colectomies(2)and anterior resection(1).The mean robot docking time was 6.33 minutes(Median 6;Range 4-10;SD±1.8).The mean duration of operation was 122.33±78.5 min and estimated blood loss was 113.33±151.08 mL.There were no conversions to a human camera holder.The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6±0.88 times per case,with cumulative mean interruption time of 4.2±2.15 minutes per case.The mean duration of hospitalization was 3.2±1.30 days and there were no complications recorded.When the surgeons were interviewed after operation,the surgeons reported that there were good ergonomics(100%),with no limitatio展开更多
BACKGROUND Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate.The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of bot...BACKGROUND Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate.The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of both the sympathetic and parasympathetic pathways.We present a case of perforated giant gastric ulcer with concurrent thyroid storm who underwent damage control surgery with emergency patch repair with falciform ligament and recovered well.CASE SUMMARY A 53-year-old male chronic smoker,with no previous medical history,presented with severe generalized abdominal pain and vomiting for one day duration.Further history revealed weight loss,diarrhea,and anxiety over the past three months.On clinical examination,patient was febrile with temperature of 38.6 Degrees Celsius and tachycardic at 130-140 beats per minute,his blood pressure was low at 90/50mmHg.His abdomen was tender with generalized peritonism.In view of his clinical history,a thyroid screen was ordered which showed raised thyroxine(T4)levels of 90.3 pmol/L and low thyroxine stimulating hormone(TSH)levels of 0.005μU/mL.Chest X-ray showed no sub-diaphragmatic free air,but contrasted CT scan revealed pneumoperitoneum with large amount of intraabdominal free fluid.The working diagnosis was perforated peptic ulcer complicated by thyroid storm.An urgent endocrinologist consult was made,and patient was started on beta blocker and intravenous steroids pre-operatively.The patient underwent emergency laparotomy with washout and patch repair of the perforated gastric ulcer.Patient was monitored post-operatively in intensive care unit and required IV hydrocortisone and Lugol’s iodine.Histology of the ulcer edges showed no malignancy.On post-operative day seven,T4 decreased to 20.4 pmol/L,TSH was 0.005 mLU/L.His thyroid function test subsequently normalized 3 mo post-operatively with T418.1 pmol/L,TSH 1.91 mLU/L.Patient’s recovery was otherwise uneventful.Thyroid receptor antibody subsequently was positive,and patient was managed for Grave’s disease by 展开更多
AIM: To study the feasibility and oncological outcomesfollowing laparoscopic total mesorectal excision(LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy(LCRT). METHODS: A protocol driven ...AIM: To study the feasibility and oncological outcomesfollowing laparoscopic total mesorectal excision(LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy(LCRT). METHODS: A protocol driven systematic review of published literature was undertaken to assess the feasibility and oncological outcomes following LTME in patients receiving LCRT. The feasibility was assessed using peri-operative outcomes and short term results. The oncological outcomes were assessed using local recurrence, disease free survival and overall survival.RESULTS: Only 8 studies-1 randomized controlled trial, 4 Case Matched/Controlled Studies and 3 Case Series were identified matching the search criteria. The conversion rate was low(1.2% to 28.1%), anastomotic leak rates were similar to open total mesorectal excision(0%-4.1% vs 0%-8.3%). Only 3 studies reported on local recurrence rates(5.2%-7.6%) at median 34 mo follow-up. A single study described disease free survival and overall survival at 3 years as 78.8% and 92.1% respectively. CONCLUSION: LTME following LCRT is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.展开更多
AIM: To appraise the current evidence for prophylactic oophorectomy in patients undergoing primary curative colorectal cancer resection.METHODS: Occult ovarian metastases may lead to increased mortality, therefore pro...AIM: To appraise the current evidence for prophylactic oophorectomy in patients undergoing primary curative colorectal cancer resection.METHODS: Occult ovarian metastases may lead to increased mortality, therefore prophylactic oophorectomy may be considered for women undergoing colorectal resection. A systematic review and meta-analysis wasperformed for English language studies from 1994 to 2014(PROSPERO Registry number: CRD42014009340), comparing outcomes following prophylactic oophorectomy(no known ovarian or other metastatic disease at time of surgery) vs no ovarian surgery, synchronous with colorectal resection for malignancy. Outcomes assessed: local recurrence, 5-year mortality, immediate post-operative morbidity and mortality, and rate of distant metastases.RESULTS: Final analysis included 4 studies from the United States, Europe and China, which included 627 patients(210 prophylactic oophorectomy and 417 non-oophorectomy). There was one randomized controlled trials, the remainder being non-randomised cohort studies. The studies were all at high risk of bias according to the Cochrane Collaboration's assessment tool for randomised studies and the NewcastleOttawa Score for the cohort studies. The mean age of patients amongst the studies ranged from 56.5 to 67 years. There were no significant differences between the patients having prophylactic oophorectomy at time of primary colorectal resection compared with patients who did not with respect to local recurrence, 5-year survival and distant metastases. There was no difference in post-operative complications or immediate post-operative mortality between the groups.CONCLUSION: Current evidence does not favour prophylactic oophorectomy for patients without known genetic predisposition. Prophylactic surgery is not associated with additional risk of post-operative complications or death.展开更多
文摘BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE in patients with GOO.METHODS This study was a retrospective,observational,multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected.We analyzed technical success,clinical success,adverse events,and survival.Technical success was defined as adequate positioning and deployment of the stent.Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure.Postprocedural adverse events were recorded.RESULTS Eleven procedures in 10 patients with GOO were included.The mean age of the patients was 67.5 years(range:56-77 years).Malignant GOO was present in 9 patients.Technical success was achieved in 9/11 procedures(82%).Among them,clinical success was achieved in 9 patients(100%).Adverse events occurred in 1 patient(9%).The median survival was 3 months(n=7;range:1-8 months).CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.
文摘BACKGROUND The majority of published reports on foreign bodies(FBs)involve the rectum and applied a transanal retrieval.Usually,patients with FB above the rectum are subjected to laparotomy for removal.Here,we illustrate the case of a man with an FB that had migrated into the descending colon,and its successful removal via a laparoscopic approach.CASE SUMMARY A 43-year-old man,who had the habit of FB insertion into his anus to aid defe-cation,presented upon experience of such an FB slipping through and migrating upward to the distal colon.Plain abdominal radiograph revealed a bottle-shaped FB,positioned in the left iliac fossa region.The FB was successfully removed via a laparoscopic-assisted procedure in which we combined diagnostic laparoscopic and endoscopic techniques during surgery.The patient was monitored for 2 d postoperatively and subsequently discharged home.CONCLUSION A minimally invasive approach should be adopted to aid extraction of colorectal FB as it is effective and safe.
文摘BACKGROUND The management of tongue carcinoma is excision and radical neck dissection followed with reconstruction.This is a case report of a patient with tongue squamous cell carcinoma(SCC)who underwent the procedure with sternocleidomastoid(SCM)flap reconstruction.CASE SUMMARY A 52-year-old woman without smoking history complained tongue ulcer since 3 years ago.Based on the histopathological examination,the patient was diagnosed with T2N2M0 right tongue SCC and underwent wide excision of tumor;right mandibular;neck dissection and were reconstructed with SCM flap.CONCLUSION SCC of the tongue requires wide excision and dissection of the neck and mandible if infiltration into the surrounding lymph nodes has been found.The SCM flap reconstruction could be used post-surgery.
文摘BACKGROUND Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections,adhesions,seromas,fistula formation and significant postoperative pain.The modified rectus muscle repair(RMR)is as an option to repair midline ventral hernias without mesh.AIM To evaluate the short term outcomes when the modified RMR was used to repair ventral hernias.METHODS This was a 5-year prospective study that examined the outcome of all consecutive patients with ventral abdominal wall hernias>5 cm in maximal diameter who underwent repair using the modified RMR technique in a single surgeon unit.Patients were reviewed in an outpatient clinic at 3,6 and 12 mo and evaluated for hernia recurrence on clinical examination.Each patient’s abdominal wall was also assessed with using ultrasonography at 24 mo to detect recurrences.All data were examined with SPSS ver 18.0.RESULTS Over the 5-year study period,there were 52 patients treated for ventral hernias at this institution.Four patients were excluded and there were 48 in the final study sample,at a mean age of 56 years(range 28-80).The mean maximal diameter of the hernia defect was 7 cm(range 5-12 cm).There were 5(10.4%)seromas and 1 recurrence(2.1%)at a mean of 36 mo follow-up.CONCLUSION The authors recommend the modified RMR as an acceptable alternative to mesh repair of ventral hernias.The seroma rate can be further reduced with routine use of drains.The modified RMR also has the benefit of eliminating all mesh-specific complications.
文摘BACKGROUND Endoscopic submucosal dissection is considered curative for patients with early rectal cancer when level of submucosal invasion is<1000 microns with favourable histopathological features.Recent data suggests even deeper submucosal invasion can potentially be curative if R0 resection can be achieved and when no high-risk histopathological features are seen in the resected specimen.To achieve R0 resection,deeper dissection is required.CASE SUMMARY A 66 year old New Zealand European male presented with 3 mo history of per rectal bleeding.He was referred for a colonoscopy test to investigate this further.This revealed a malignant appearing lesion in the rectum.Biopsies however showed high grade dysplasia only.Given endoscopic appearances suspicious for deep submucosal invasion,patient was consented for endoscopic intermuscular dissection(EID).The case was successfully performed,and the presence of muscularis propria was confirmed in the resected specimen.There were no complications and total procedure time was 124 min.Lesion was clear of radial margins however deep margins were positive confirming it was at least a pT2 cancer.Patient was recommended to have further treatment but could not have radical surgery due to comorbidities and instead was referred for long course chemoradiotherapy.CONCLUSION EID is a safe and feasible option for management of rectal cancer in highly selected patients.
文摘BACKGROUND Simple lateral elbow dislocation(SLED)is a rare type of elbow dislocation;however,its treatment may be complicated by accompanying soft tissue or neurovascular damage.Herein,we report a rare case of SLED managed secondarily with open reduction and soft tissue repair following failure of closed reduction.CASE SUMMARY A 67-year-old woman suffered SLED after falling on her outstretched left hand with her elbow extended.She developed pain,swelling,and movement restriction in the elbow;there were no neurovascular symptoms,except for numbness in the 4th and 5th digits.Radiologic investigation confirmed the SLED,and a closed reduction under anesthesia was performed.The follow-up radiographs at 1-wk revealed failure of reduction;accordingly,open reduction with lateral collateral ligament and common extensor origin repair were carried out.The patient regained full elbow range of motion by six weeks.CONCLUSION Adequate concentric reduction for SLED,conservatively or surgically,reduces complications and provides a more functional joint.
文摘BACKGROUND Ossifying fibroma is a type of benign fibro-osseous lesion.Most lesions affect the mandible region,particularly the molar and pre-molar areas.It predominantly affects females between the second to fourth decades of life.Larger ossifying fibroma tumors require more extensive resection.CASE SUMMARY A 39-year-old female complained of occasional pain and tumor enlargement on her left jaw for the 3 years prior to presentation.Intraoral examination revealed a firm swelling on her left lower gum.Extraoral examination revealed swelling on the left mandible body with no erythema and superficial ulcer.Computed tomography scan revealed a circular-shaped lesion on the patient’s left mandible body with a well-defined radiolucent border,sized 3.2 cm×2.8 cm×0.9 cm.The tumor was removed by marginal mandibulectomy.Biopsy from the resected tumor suggested cemento-ossifying fibroma(COF).CONCLUSION COF is often unnoticed,but this slow-growing tumor can cause significant symptoms regarding its distortion into adjacent structures.
文摘Acute type B aortic dissection(TBAD) occurs as a result of an intimal tear within the proximal thoracic aorta. Patients are typically managed acutely with aggressive antihypertensive therapy. Surgical repair is reserved for those who develop complications such as rupture or malperfusion. The surgical management of acute TBAD has changed considerably in the last decade secondary to the advent of thoracic stent grafting. Thoracic endovascular aortic repair(TEVAR) has improved early mortality and morbidity rates for patients presenting with complicated TBAD. The role of TEVAR in patients presenting with acute and subacute uncomplicated TBAD is less clear. TEVAR has been associated with increased late survival and better aortic remodeling, with low perioperative morbidity in selected patients. Recent literature suggests certain radiographic criteria may be used to predict patients developing late aortic events who would benefit from early TEVAR. The purpose of this article is to review the contemporary management of acute TBAD, discuss controversies in management and evaluate the latest research findings.
文摘Hemorrhoids are considered one of the most common anorectal diseases with a prevalence of 4.4% up to 36.4% of the general population, and a peak incidence between 45 and 65 years. Hemorrhoidal disease presents with a prolapsed lump, painless bleeding, discomfort, discharge, hygiene problems, soiling, and pruritus. Sliding anal canal lining theory is the most accepted theory as a cause of hemorrhoidal disease; however, it is also associated with hyper-vascularity, and, recently, with several enzymes or mediators involved in the disintegration of the tissues supporting the anal cushions, such as matrix metalloproteinase. A comprehensive search in published English-language literature till 2013 involving hemorrhoids was performed to construct this review article, which discusses advances in the management of hemorrhoids. This includes conservative treatment(life style modification, oral medications, and topical treatment), office procedures(rubber band ligation, injection sclerotherapy, infrared and radiofrequency coagulation, bipolar diathermy and direct-current electrotherapy, cryosurgery, and laser therapy), as well as surgical procedures including diathermy hemorrhoidectomy, Liga Sure hemorrhoidectomy, Harmonic scalpel hemorrhoidectomy, hemorrhoidal artery ligation, stapled hemorrhoidopexy(SH), and double SH. Results, merits and demerits of the different modalities of treatment of hemorrhoids are presented, in addition to the cost of the recent innovations.
文摘Clinical testing of patients for hereditary breast and ovarian cancer syndromes began in the mid-1990s with the identification of the BRCA1 and BRCA2 genes.Since then,mutations in dozens of other genes have been correlated to increased breast,ovarian,and other cancer risk.The following decades of data collection and patient advocacy allowed for improvements in medical,legal,social,and ethical advances in genetic testing.Technological advances have made it possible to sequence multiple genes at once in a panel to give patients a more thorough evaluation of their personal cancer risk.Panel testing increases the detection of mutations that lead to increased risk of breast,ovarian,and other cancers and can better guide individualized screening measures compared to limited BRCA testing alone.At the same time,multi-gene panel testing is more time-and cost-efficient.While the clinical application of panel testing is in its infancy,many problems arise such as lack of guidelines for management of newly identified gene mutations,high rates of variants of uncertain significance,and limited ability to screen for some cancers.Through on-going concerted efforts of pooled data collection and analysis,it is likely that the benefits of multi-gene panel testing will outweigh the risks in the near future.
文摘More than 20 years have passed since the first report of laparoscopic colectomy in 1991. Thereafter, laparoscopic surgery for the management of colorectal diseases has been widely accepted as a prevailing option because of improved cosmetic outcomes, less postoperative pain, and shorter hospital stay in comparison with open surgery. To further the principle of minimally invasive surgery, two new approaches have been developed in this rapidly evolving field. The first is the totally laparoscopic approach. Currently most of standard techniques inevitably involve an abdominalincision for retrieval of the specimen and preparation for anastomosis, which might compromise the benefits of laparoscopic surgery. The totally laparoscopic approach dispenses with this incision by combining completely intraperitoneal anastomosis with retrieval of the specimen via a natural orifice, such as the anus or the vagina. Our new and reliable technique for intraperitoneal anastomosis is also described in detail in this article. The second is the single-incision approach. While three to six ports are needed in standard laparoscopic surgery, the single-incision approach uses the umbilicus as the sole access to the abdominal cavity. All of the laparoscopic procedures are performed entirely through the umbilicus, in which the surgical scar eventually becomes hidden, achieving virtually scarless surgery. This article reviews the current status of these two approaches and discusses the future of minimally invasive surgery for colorectal diseases.
文摘The best approach to achieve cure in esophageal cancer is a combination of chemo-radiation and surgery. However, complications occur in half of patients. The current report, reports a rare but severe complication: Complete obstruction of the esophagus, induced by preoperative chemo-radiation therapy. Normally, strictures are treated by repeated dilatations, however, in case of complete obstruction, the perforation rate of standard blind anterograde wire access and dilation is severely increased. In order to minimize the risk of perforations, the rendezvous technique was introduced. This technique involves an anterograde approach in combination with a retrograde approach in order to open and dilatate the esophagus. While technical success rates between 83% and 100% have been reported in literature, data on clinical outcomes are scarcer. The limited amount of studies available claim that success was achieved in almost half of patients. The patient in our case currently has an oral diet without restrictions and rates his quality of life with a VAS-score ten out of ten.
文摘Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.
文摘Papillary thyroid carcinoma(PTC) is the most common thyroid malignancy, accounting for approximatley 90% of thyroid malignancies in areas of the world without deficit of Iodine. It's universally accepted that total thyroidectomy is the minimal surgical treatment for patients with PTC higher than 1 cm. When a quality surgery is performed, the prognosis for PTC is excellent with 10 and 20-year overall survival rates around 90% and 85%, respectively. Lymph node metastases are very frequent in PTC, occurring in 50%-80% of PTC patients, the most of them being located in the central compartment of the neck(CCN) and with a high rate of occult or clinically undetectable disease. A lot of controversy exists regarding how to treat the central nodal compartment disease of PTC. The first problem is the lack of standardization of the terminology and concepts related to the CCN, which are clearly established and defined in this paper according to the most recent consensus documents of endocrine societies. This uniformity will provide a more consistent and clear communicaction between all the specialist involved in the treatment of PTC. CCN can be performed to treat patients with clinically detectable, radiologically suspected of intraoperative visualized nodal disease(this is defined as therapeutic) or when these findings are absent(also called prophylactic). Indicactions, advantages and disadvantages of both therapeutic and prophylactic CCN dissection are widely discussed and clear recommendations provided.
文摘Recently, a novel comprehensive treatment consisting of cytoreductive surgery(CRS) and perioperative chemotherapy(POC) was developed for the treatment of peritoneal metastasis(PM) with a curative intent. In the treatment, the macroscopic disease is completely removed by the peritonectomy techniques in combination with POC. This article reviews the results of the comprehensive treatment for PM from gastric cancer, and verifies the effects of CRS and POC, including neoadjuvant chemotherapy(NAC) and hyperthermic intraoperative intraperitoneal chemotherapy(HIPEC). Completeness of cytoreduction, peritoneal carcinomatosis index(PCI) less than the threshold levels after NAC,absence of ascites, cytologic status, pathologic response after NAC are the independent prognostic factors. Among these prognostic factors, PCI threshold level is the most valuable independent prognostic factor. After staging laparoscopy, patients with PM from gastric cancer are recommended to treat with NAC before CRS. After NAC, indication for CRS is determined by laparoscopy. The indications of the comprehensive treatment are patients with PCI less than the threshold levels, negative cytology, and responders after NAC. Patients satisfy these factors are the candidates for the CRS and HIPEC.
文摘BACKGROUND Superior mesenteric artery syndrome(SMAS)is a rare condition,characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery(SMA).Most cases of SMAS are associated with weight loss,and the most frequent clinical manifestations are nausea,vomiting,postprandial fullness,and abdominal pain.Treatment of SMAS is usually conservative,consisting mainly of adequate nutritional support,but in refractory cases surgery may be necessary,with gastrojejunostomy and duodenojejunostomy being the most commonly performed procedures.CASE SUMMARY We describe the case of a man in his forties with a pre-existing diagnosis of esophageal stricture due to sodium hydroxide ingestion,who suffered significant weight loss after replacement of his jejunostomy tube.He was admitted to the hospital due to pain and abdominal distension.A computerized tomography scan showed significant distension of the stomach and duodenum with narrowing of the duodenum at the point at which it is crossed by the superior mesenteric artery,thus establishing the diagnosis of SMAS.Due to the presence of the esophageal stricture,the patient was incapable of emesis;however,passage of a nasogastric tube for decompression was not possible.Considering the risk of gastric perforation due to distention,we opted for surgical treatment in the form of a surgical gastrojejunostomy after which he showed complete resolution of all symptoms and was discharged from the hospital 5 d after the procedure.CONCLUSION Diagnosis of SMAS can be challenging in patients with esophageal stenosis,and risk of gastric perforation may preclude conservative treatment.
文摘BACKGROUND Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean,having been first performed in the region in the year 2011.We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.AIM To report our initial experience using the FreeHand®robotic camera holder(Freehand 2010 Ltd.,Guildford,Surrey,United Kingdom)for laparoscopic colorectal surgery in Trinidad&Tobago.METHODS We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand®(Freehand 2010 Ltd.,Guildford,Surrey,United Kingdom)robotic camera holder between September 30,2021 and April 30,2022.The following data were recorded:patient demographics,robotic arm setup time,operating time,conversions to open surgery,conversions to a human camera operator,number and duration of intra-operative lens cleaning.At the termination of the operation,before operating notes were completed,the surgeons were administered a questionnaire recording information on ergonomics,user difficulty,requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.RESULTS Nine patients at a mean age of 58.9±7.1 years underwent colorectal operations using the FreeHand robot:Right hemicolectomies(5),left hemicolectomy(1),sigmoid colectomies(2)and anterior resection(1).The mean robot docking time was 6.33 minutes(Median 6;Range 4-10;SD±1.8).The mean duration of operation was 122.33±78.5 min and estimated blood loss was 113.33±151.08 mL.There were no conversions to a human camera holder.The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6±0.88 times per case,with cumulative mean interruption time of 4.2±2.15 minutes per case.The mean duration of hospitalization was 3.2±1.30 days and there were no complications recorded.When the surgeons were interviewed after operation,the surgeons reported that there were good ergonomics(100%),with no limitatio
文摘BACKGROUND Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate.The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of both the sympathetic and parasympathetic pathways.We present a case of perforated giant gastric ulcer with concurrent thyroid storm who underwent damage control surgery with emergency patch repair with falciform ligament and recovered well.CASE SUMMARY A 53-year-old male chronic smoker,with no previous medical history,presented with severe generalized abdominal pain and vomiting for one day duration.Further history revealed weight loss,diarrhea,and anxiety over the past three months.On clinical examination,patient was febrile with temperature of 38.6 Degrees Celsius and tachycardic at 130-140 beats per minute,his blood pressure was low at 90/50mmHg.His abdomen was tender with generalized peritonism.In view of his clinical history,a thyroid screen was ordered which showed raised thyroxine(T4)levels of 90.3 pmol/L and low thyroxine stimulating hormone(TSH)levels of 0.005μU/mL.Chest X-ray showed no sub-diaphragmatic free air,but contrasted CT scan revealed pneumoperitoneum with large amount of intraabdominal free fluid.The working diagnosis was perforated peptic ulcer complicated by thyroid storm.An urgent endocrinologist consult was made,and patient was started on beta blocker and intravenous steroids pre-operatively.The patient underwent emergency laparotomy with washout and patch repair of the perforated gastric ulcer.Patient was monitored post-operatively in intensive care unit and required IV hydrocortisone and Lugol’s iodine.Histology of the ulcer edges showed no malignancy.On post-operative day seven,T4 decreased to 20.4 pmol/L,TSH was 0.005 mLU/L.His thyroid function test subsequently normalized 3 mo post-operatively with T418.1 pmol/L,TSH 1.91 mLU/L.Patient’s recovery was otherwise uneventful.Thyroid receptor antibody subsequently was positive,and patient was managed for Grave’s disease by
文摘AIM: To study the feasibility and oncological outcomesfollowing laparoscopic total mesorectal excision(LTME) in patients who have received Neo-adjuvant long course chemo-radiotherapy(LCRT). METHODS: A protocol driven systematic review of published literature was undertaken to assess the feasibility and oncological outcomes following LTME in patients receiving LCRT. The feasibility was assessed using peri-operative outcomes and short term results. The oncological outcomes were assessed using local recurrence, disease free survival and overall survival.RESULTS: Only 8 studies-1 randomized controlled trial, 4 Case Matched/Controlled Studies and 3 Case Series were identified matching the search criteria. The conversion rate was low(1.2% to 28.1%), anastomotic leak rates were similar to open total mesorectal excision(0%-4.1% vs 0%-8.3%). Only 3 studies reported on local recurrence rates(5.2%-7.6%) at median 34 mo follow-up. A single study described disease free survival and overall survival at 3 years as 78.8% and 92.1% respectively. CONCLUSION: LTME following LCRT is feasible in experienced hands, with acceptable short term surgical outcomes and with the usual benefits associated with minimally invasive procedures. The long term oncological outcomes of LTME after LCRT appear to be comparable to open procedures but need further investigation.
文摘AIM: To appraise the current evidence for prophylactic oophorectomy in patients undergoing primary curative colorectal cancer resection.METHODS: Occult ovarian metastases may lead to increased mortality, therefore prophylactic oophorectomy may be considered for women undergoing colorectal resection. A systematic review and meta-analysis wasperformed for English language studies from 1994 to 2014(PROSPERO Registry number: CRD42014009340), comparing outcomes following prophylactic oophorectomy(no known ovarian or other metastatic disease at time of surgery) vs no ovarian surgery, synchronous with colorectal resection for malignancy. Outcomes assessed: local recurrence, 5-year mortality, immediate post-operative morbidity and mortality, and rate of distant metastases.RESULTS: Final analysis included 4 studies from the United States, Europe and China, which included 627 patients(210 prophylactic oophorectomy and 417 non-oophorectomy). There was one randomized controlled trials, the remainder being non-randomised cohort studies. The studies were all at high risk of bias according to the Cochrane Collaboration's assessment tool for randomised studies and the NewcastleOttawa Score for the cohort studies. The mean age of patients amongst the studies ranged from 56.5 to 67 years. There were no significant differences between the patients having prophylactic oophorectomy at time of primary colorectal resection compared with patients who did not with respect to local recurrence, 5-year survival and distant metastases. There was no difference in post-operative complications or immediate post-operative mortality between the groups.CONCLUSION: Current evidence does not favour prophylactic oophorectomy for patients without known genetic predisposition. Prophylactic surgery is not associated with additional risk of post-operative complications or death.
