Visual Abstracts

Complications after a screening-colonoscopy are well known, such as intestinal bleeding and perforation. However, other organ injuries are not frequently identified and could lead to a life-threatening prognosis.

The aim of this work is to highlight splenic rupture as an unknown and serious complication of colonoscopy, its diagnostic method and treatment.

In this study, the case of a splenic rupture after a screening colonoscopy and polypectomy will be illustrated as accurately as possible, from diagnosis to surgical treatment. It will then be discussed along with a systemic review of the literature.

A screening colonoscopy with multiple polypectomies was performed on a 63-year-old female patient with no known health condition. Despite a difficult examination, a full colonoscopy was achieved.

One hour later, the patient presented diffuse and intense abdominal pain with hypotension and was immediately addressed to the emergency department.

On arrival, vital signs showed persistent hypotension with 76/48 mmHg, hemoglobin level at 120 g/L and lactates at 1.3 mmol/L. A point-of-care ultrasound showed free intra-abdominal liquid within the four quadrants, and the CT-scan revealed active bleeding with splenic hematoma with grade IV rupture.

With hypotension and free intra-abdominal liquid, criteria for surgical management were met. The patient was brought to the operating room for a median laparotomy and splenectomy. Approximately three liters of fresh blood and blood clots were among the findings. Regarding the spleen, active bleeding from the splenic artery and from a veinous tear in the gastrosplenic ligament were identified.

The patient was discharged on the 8^th day post-surgery with post-splenectomy recommendations such as vaccinations.

Splenic trauma after a screening colonoscopy and polypectomy is an unknown and therefore underestimated complication, but also life-threatening. In this aspect, early recognition and surgical management are essential.

Perforated peptic ulcer disease is a surgical emergency. Timely diagnosis and prompt surgical intervention can prevent morbidity and mortality, however underestimation of the extent of an ulcer is linked with a complicated course.

Persistent bilious discharge after primary closure of a peptic duodenal ulcer may not only be result of suture failure but also raise suspicion for a misinterpretation of the extent of the ulcer.

We present a case of a complicated postoperative course due to misinterpretation of the extent of a duodenal peptic ulcer.

74-year-old female with a history of chronic alcohol abuse (1/2 litre wine per day), smoking (58 py) and weight loss of 15 kg within 3 months (BMI 16 kg/m2) presented to our emergency department with acute epigastric pain.

A CT-abdomen demonstrated air below the diaphragm with reasonable suspicions of duodenal perforation and subsequent laparoscopic exploration was performed. A perforated peptic duodenal ulcer could be confirmed and was closed with running sutures, a drain was placed.  Intraoperative gastro-duodenoscopy showed no sign of malignancy. 

Postoperative day 1 the drain revealed bilious discharge and an open surgical revision was undertaken. A clear allocation could not be identified but suspecting the sutures as most reasonable cause  a redo of the sutures was done with placement of omental patch for support.

Two days later, again bilious discharge was observed and decision was made for another surgical revision. During open exploration an ulcer extended to the dorsal wall was identified and a distal gastrectomy with roux-en-y reconstruction was carried out. Thereafter no further surgical intervention was needed.

Precise surgical exploration is mandatory in order to correctly assess the extent of a peptic ulcer and prevent morbidity and mortality. Persistent bilious discharge after primary closure may raise suspicion for an extended peptic ulcer.

Appendiceal diverticulosis (AD) is a rare condition found at 0.004-2% of appendiceal specimens, associated with high risk of perforation, bleeding and almost a 50% probability of appendiceal neoplasm. Due to the latter, appendectomy is indicated even when AD is found coincidentally. Infected AD is the most frequent disease mimicking acute appendicitis (AA).

To raise awareness of this rare surgical entity and its challenging diagnosis.

A 41-year-old male patient with no previous medical history presented to our emergency department with right lower quadrant abdominal pain associated with elevated biological inflammatory markers. CT-scan revealed a 13mm-collection associated to AA (Fig.1). Additionally, the patient reported to have repeatedly blood in his stool for about 1 year raising the suspicion of inflammatory bowel disease (IBD). Therefore, we opted for an initial conservative treatment with intravenous antibiotics (Ceftriaxone 2g 1x/d and Metronidazole 500mg 3x/d). The patient was discharged home on day 2 with oral antibiotics for two weeks. An intermediately performed colonoscopy (day 5) was negative for IBD and a control CT scan (day 20) demonstrated that the previously described peri-appendiceal collection turned out to be a diverticulum (Fig.2). Planned surgery was performed 6 weeks after the initial admission.

Laparoscopy confirmed a voluminous diverticulum of the appendix, filled with mucus (Fig.3). Appendectomy was uneventful and the patient was discharged home the next day. Cytology revealed extra-cellular mucus in the context of a serositis and histopathology showed a complicated diverticulum with focal mesothelial hyperplasia, without malignancy.

Infected AD is a rare condition mimicking AA mostly found postoperatively in histopathological analyses; hence, its diagnosis is challenging. Due to high risk of malignancy, preoperative workout is mandatory and appendectomy should be performed within safe resection margins. In our case, AD was detected preoperatively, permitting an orchestrated surgical strategy.

We present a case of a 52-year-old active man in good health, who experienced severe abdominal pain and food vomiting after a marathon. The patient exhibited abdominal tenderness and distension upon examination, leading to diagnostic investigations. A CT scan revealed a volvulus DD internal hernia, causing gastric distension.

The aim of this study is to emphasize the importance of recognizing congenital intestinal malrotation as a potential cause of acute abdominal distress in adults. Additionally, the study underscores the necessity of prompt diagnosis, achievable through CT imaging and distinctive signs, and appropriate surgical intervention to prevent serious complications and avoid inadequate interventions.

The patient's case involved an emergency presentation to the hospital. Diagnostic investigations, including a CT scan, were performed to identify the cause of abdominal distress. Emergency laparoscopy and subsequent laparotomy were conducted to confirm the diagnosis, assess the anatomy of the small intestine and colon, and address the internal hernia and congenital intestinal malrotation.

The diagnostic investigations revealed a volvulus DD internal hernia, and emergency laparoscopy confirmed ileus, exposing a complete anomalous anatomy of the small intestine and colon. A second reintervention with a laparotomy approach was required to perform definitive treatment and address the structural anomaly known as congenital intestinal malrotation.

This case highlights the importance of recognizing mesenteric malrotation as a potential cause of acute abdominal distress in adults. It underscores the necessity of prompt diagnosis through CT imaging and distinctive signs, followed by appropriate surgical intervention to prevent serious complications and avoid inadequate interventions. The findings emphasize the significance of considering congenital intestinal malrotation in cases of acute abdominal pain, particularly in active adults.

Appendicitis and abdominal wall hernias are common pathologies in general surgery. A combination of both can be challenging to diagnose in the emergency setting.

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Case Report

An 87-year-old male was admitted to the emergency department with abdominal pain for one week. On physical examination, a painful mass could be palpated in the right lower quadrant, accompanied by local signs of inflammation. Blood tests showed elevated CRP and WBC levels. Due to cardiovascular comorbidities, the patient was on oral anticoagulant therapy. CT revealed a large fluid collection in the abdominal wall, primarily interpreted as infected hematoma. Surgical drainage was performed, unexpectedly releasing pus. The patient was put on antibiotics. During the following days, purulent discharge from the wound continued and the patient showed signs of sepsis. Abdominal CT was repeated, revealing acute appendicitis inside a Spigelian hernia. The patient was taken back to the operating room. After reduction of the hernia, laparoscopic appendectomy was performed uneventfully. Additionally, open debridement of the abdominal wall was carried out, leading to secondary closure of the wound after one week.

Discussion

Spigelian hernias account for merely 1–2% of all ventral hernias. They are exceptionally hard to diagnose due to their ambiguous presentation and a lack of clinical findings at an early stage. Risk of incarceration is high, caused by a typically small orifice in the Spigelian fascia. However, only a few cases of incarcerated appendices have been reported so far, making this combination an extremely rare cause of abdominal wall abscess.

Appendicitis inside a hernia can lead to exotic clinical and radiological presentations that are easy to misdiagnose. Incarcerated Spigelian hernias should always be considered as a differential diagnosis in patients with treatment-resistant abdominal wall abscesses.

Spontaneous rupture of urinary bladder (SRUB) is a rare condition with no standard of care and significant related morbidity and mortality. Although multiple causes (tumors, cystitis, excessive alcohol consumption, bladder outlet obstruction) including connective tissue disorders have been described, we report the rare association of SRUB and Osler-Weber-Rendu disease.

A 60-year-old woman, known for Osler-Weber-Rendu disease, 3 previous C-sections and a hystero-annexectomy for benign disease, complains of lower abdominal pain for 4 hours earlier associated with mild dysuria. Blood tests detect no inflammation. Urinalysis shows moderate leukocyturia (24 M/l) without clear erythrocyturia. Free intra-peritoneal fluid is detected on the contrast enhanced CT scan. Exploratory laparoscopy is therefore deemed.

Exploration reveals moderate clear ascites. A fluid sample found elevated creatinine (1101 µmol/l). After minimal adhesiolysis a perforation of about 1.5 cm of the bladder dome was found. After margin resection, defect was closed using 3.0 interrupted absorbable suture. Pathology report describes partially abraded squamous mucosa with fibrous changes in the chorion and underlying musculature. A Foley catheter and a surgical drain were left, the latter removed on the third postoperative day, and the patient discharged the same day.

Foley's catheter was removed at day 12, after cystography control. A six-week later cystoscopy found an inflammatory lesion of the bladder dome, compatible with the healing process, associated with 3 other inflammatory lesions.

SRUB is a rare disease asssociated with morbidiy and mortality. Diagnosis is often challenging because signs and symptoms are non specific, particulary at urinary tract. To our knowledge, although association with connective tissue disorders has been described, this represents the first report of an association of spontaneous bladder perforation and Osler-Weber-Rendu disease.

Paraduodenal hernias (PdH) are rare congenital internal hernias caused by abnormal rotation of the midgut during fetal development. Paradoxically, they are the most common type of internal hernia. They are a major contributor to small bowel obstruction in adults and have the potential for serious complications such as volvulus with ischemia or complete small bowel occlusion.

This report not only presents a case of a strangulated small bowel volvulus within a right PdH, but also provides a comprehensive literature review to highlight the clinical presentation, diagnostic challenges and management. This dual approach aims to enhance clinicians' awareness of this rare entity and emphasize the need to consider PdH in the differential diagnoses of intestinal obstructions.

We describe a case of 46-years-old male with symptoms suggestive of small bowel obstruction. Initial imaging was inadequate to identify the cause. Subsequent CT-imaging revealed a small bowel volvulus within a right PdH. The review analyzes the existing literature on PhD and compares diagnostic and management strategies.

Surgical exploration by laparotomy confirmed the PhD with strangulated small bowel volvulus. The hernia was repaired without the need of small bowel resection. The patient recovered well, underlining the efficacy of prompt and appropriate surgical intervention. The literature review highlights the critical diagnostic and therapeutic challenges in the management of small bowel volvulus within a right PhD and highlights the need for increased clinical awareness and timely intervention. Most cases are treated by laparotomy, however, some authors recommend a laparoscopic approach in selected cases.

Paraduodenal hernias are crucial in small bowel obstructions. This case in conjunction with a literature review emphasizes the importance of high clinical suspicion and thorough diagnostic procedures in atypical intestinal obstructions.

Acute venous mesenteric ischemia (AVMI) secondary to porto-mesenteric thrombosis is a rare yet life-threatening condition. Owing to its lack of specific symptoms and subtle clinical signs, a high level of suspicion is required. Enhanced-computed tomography (E-CT) of the abdomen is highly accurate for the diagnose.

We aim to describe two case report of AVMI and raise awareness of possible late perforation.

The first case is a 76-years-old female patient who presented with a 3-day history of abdominal, with multiples episodes of vomiting and bloody diarrhea. E-CT revealed a jejunal venous ischemia with lack of bowel wall enhancement and free fluid, due to extended porto-mesenteric thrombosis.

The second patient is a 45-years-old male who presented with a 10-day history of abdominal pain. E-CT demonstrated an ileal ischemia due to porto-mesenteric thrombosis.

In both patient, conservative treatment was started with therapeutic anticoagulation, intravenous antibiotic therapy and bowel rest. They were monitored in the intensive care unit for 48h.

The first patient improved and had no further complication. The second patient came back in the emergency department twenty days after the first admission, due to the sudden onset of pain. E-CT revealed a covered perforation concerning the previous ischemic small bowel loop. He was immediately brought to the operating room for an exploratory laparotomy where a segmental bowel resection was performed. He had a favorable outcome and was discharged at day 4 post-operative.

AVMI is a rare and unknown diagnosis. Early recognition is essential to initiate prompt treatment. In contrast to arterial mesenteric ischemia, which requires an immediate surgical or interventional radiology interventions, conservative management is a feasible option for this condition but need a close follow up. Unfortunately, late perforation can occur and should be immediately reconized.

Chylous ascites, characterized by the accumulation of lymphatic fluid in the peritoneal cavity, presents significant management challenges due to the lack of standardized treatment protocols.

This retrospective study aims to evaluate the efficiency and safety of Lipiodol® lymphangiography as percutaneous minimal-invasive intervention in the management of post-operative development of chylous ascites, offering insights into potential standardized treatment protocols.

We conducted a retrospective review of medical records of four patients developing post-operative chylous ascites at our institution between 2017 and 2023. Three patients had oncological pancreaticoduodenectomy and one had right hemicolectomy with complete mesocolic excision (CME). All patients developed significant post-operative chylous ascites due to radical lymphadenectomy, confirmed by triglyceride dosage and refractory to conservative treatment. The study focused on various aspects: the etiology of chylous ascites, previous conservative management attempts, detailed procedural techniques, and the outcomes of the interventions.

All patients underwent finally percutaneous interventional management with Lipiodol® injection into inguinal lymph nodes. Glue embolization would have been provided in cases where a visible leak was discovered. However, no visible leaks were detected during procedure. Therefore, lymphangiography alone was successful to stop leaking chyle in all patients after first attempt. This may be explained by the viscosity of Lipiodol® contributing already to embolization of the leaks. Furthermore, no complications were reported within 30 days post-procedure.

Our findings suggest that Lipiodol® lymphangiography is safe and effective in treating post-operative refractory chylous ascites. This offers an effective minimal-invasive alternative to traditional surgical approaches. Nonetheless, complex cases may require referral to specialized centers equipped with advanced resources and expertise. This study contributes to the growing body of knowledge of a minimal-invasive intervention in refractory chylous ascites and underscores the need for standardized treatment guidelines.

Paraduodenal hernias (PdH) are rare congenital internal hernias caused by abnormal rotation of the midgut during fetal development. Paradoxically, they are the most common type of internal hernia. They are a major contributor to small bowel obstruction in adults and have the potential for serious complications such as volvulus with ischemia or complete small bowel occlusion.

This report not only presents a case of a strangulated small bowel volvulus within a right PdH, but also provides a comprehensive literature review to highlight the clinical presentation, diagnostic challenges and management. This dual approach aims to enhance clinicians' awareness of this rare entity and emphasize the need to consider PdH in the differential diagnoses of intestinal obstructions.

We describe a case of 46-years-old male with symptoms suggestive of small bowel obstruction. Initial imaging was inadequate to identify the cause. Subsequent CT-imaging revealed a small bowel volvulus within a right PdH. The review analyzes the existing literature on PdH and compares diagnostic and management strategies.

Surgical exploration by laparotomy confirmed the PdH with strangulated small bowel volvulus. The hernia was repaired without the need of small bowel resection. The patient recovered well, underlining the efficacy of prompt and appropriate surgical intervention. The literature review highlights the critical diagnostic and therapeutic challenges in the management of small bowel volvulus within a right PdH and highlights the need for increased clinical awareness and timely intervention. Most cases are treated by laparotomy, however, some authors recommend a laparoscopic approach in selected cases.

Paraduodenal hernias are crucial in small bowel obstructions. This case in conjunction with a literature review emphasizes the importance of high clinical suspicion and thorough diagnostic procedures in atypical intestinal obstructions.

The sigmoid colon is the most frequent colonic site for volvulus formation, found in 60% -75% of volvulus cases. Common etiologies include chronic constipation, routine use of laxatives, dolicho-sigmoid and psychiatric disorders. Trauma remains an extremely rare cause of sigmoid volvulus, only described once in the literature.

To report a still asymptomatic trauma-related sigmoid volvulus and its management.

A healthy 48-years old male patient was admitted to our emergency department after a 4-meter ladder-fall. Clinical assessment revealed a lumbar point tenderness but no abdominal pain, tenderness or distension. Focused Assessment with Sonography for Trauma (FAST) was negative, complete blood count and biochemistry values were completely normal. A whole-body trauma CT-scan did not show any other lesions than a complete sigmoid volvulus based on a dolicho-sigmoid. The patient underwent successful colonoscopic decompression and contrast enema demonstrated complete devolvulation.

In-hospital follow-up was uneventful and since the asymptomatic-remaining volvulus was trauma-related, together with no previous history, no indication were found to proceed to a sigmoidectomy. Additional complete colonoscopy 6 weeks after the event did not show any signs of a persisting volvulus or other pathology. During a 11-months follow-up no signs of recurrence were present.

For anatomical reasons, the sigmoid colon is the most frequent colonic site for colonic volvulus formation. Mostly, it becomes apparent in frail and chronically-constipated patients, often suffering from concomitant psychiatric or neurologic disorders. In order to prevent recurrence in such patients, sigmoidectomy is usually offered. However, a still asymptomatic trauma-related sigmoid volvulus, which can immediately be decompressed, might be another entity, which is probably not an indication to proceed to surgery. The clinical course of our patient up to now – 11 months without recurrence - proves us right.

Colonic volvulus represents a rare cause of intestinal obstruction in adults, and caecum is involved in one quarter of cases. In patients with spinal cord injuries (SCI), its incidence is higher (2.6 %) and its diagnosis often delays due to mimicking coexisting conditions, like obstipation or Ogilvie syndrome, inconclusive clinical findings and lack of subjective complaints. Typical clinical signs of peritonitis can be completely absent in tetraplegic patients. The fibres responsible for the visceral pain origin at the level T1-L3 and the vagus nerve serve primarily for the transmission of reflexes.

To highlight the difficulties to diagnose an acute abdominal condition in patients with SCI due to impaired sensation and concomitant co-morbidities, which can mislead the exact diagnosis.

We report a case of ceacal volvulus in a tetraplegic patient.

A 60-year-old female patient with an 11-year-history of incomplete tetraplegia (sub C4) who presented on the emergency department with progressive abdominal distension, loss of appetite and slight abdominal pain since one week. Diminished faeces noticed during the regularly performed manual emptying over the last days. Clinically, the patient presented with a massive abdominal distension without signs of peritonitis. Laboratory findings showed leucopoenia (2.6 G/l), elevated CRP (83 mg/l) and hyperlactatemia (6.0 mmol/l).  The computerized tomography of the abdomen revealed a colonic volvulus with a coffee been sign (figure 1).  An urgent laparotomy was performed and confirmed a ceacal volvulus with necrosis (figure 2). A right hemicolectomy with primary anastomosis was completed. Apart from paralytic ileus, the postoperative course was uneventful and the patient was discharged home after 10 days.

Spinal cord injuries represent a risk factor to develop colonic volvulus. Due to unreliable clinical signs and symptoms, early use of computerized tomography or magnetic resonance imaging is advocated in unclear abdominal conditions.

Gastro-gastric fistula (GGF) occurs in 1–6% of patients who undergo Roux-en-Y gastric bypass (RYGB) for morbid obesity. The pathophysiology may be related to gastric ischemia and/or marginal ulcer. Epigastric pain, dysphagia, anemia and weight regain are most common signs of GGF. Combining upper endoscopy and contrast studies is the best method to confirm the diagnosis. Although GGF may be treated conservatively, symptomatic patients will require technically challenging revisional procedures.

We present a case-report video of a 51 years-old lady with a type II gastro-gastric fistula post RYGB, treated by laparoscopic approach.

Since the RYGB performed 6 months earlier, the patient has been suffering from significant increasing dysphagia, sometimes associated with vomiting, inability to feed and a loss of about 30 kg. A CT scan of the abdomen with oral and endovenous contrast revealed a gastro-gastric fistula due to anastomotic ulcer, that was confirmed by endoscopy. A laparoscopic surgical revision was then planned.

The patient was placed in a standard foregut position. Four trocars and a liver retractor were used. The alimentary loop was identified and released from the excluded stomach. Because of tenacious adhesions between the gastrojejunal anastomosis (GJA) and the excluded stomach, a resection en bloc of the excluded portion of the stomach, the GJA and the distal part of the pouch was performed. A new GJA was then created with a linear stapler and closed with continuous barbed absorbable 3-0 suture. An intraoperative endoscopy confirmed the patency of the anastomosis. Postoperative course was uneventful and the patient discharged on postoperative day two with no complications. At two months follow-up the patient reported being asymptomatic.

Laparoscopic revisional surgery after GGF post RYGB can be a real challenging operation. Type II GGF must be treated with en bloc resection and redo GJA.

Herpes-associated infections after cardiac surgery go along with an increased mortality and morbidity. Especially Herpes-associated pneumonia leads to prolonged mechanical ventilation periods and longer ICU treatment.

All patients undergoing cardiac surgery in our institution from December 2011-November 2022 that showed positive PCR of bronchoalveolar lavage for Herpes-simplex-Virus and clinical signs of pneumonia, were recorded.

A retrospective analysis of pre-, peri- and postoperative data was performed in accordance with the local ethics board.

A total of 168 Patients were tested positive for Herpes-simplex-virus and presented with clinical signs of pneumonia after receiving cardiac surgery performed at our institution.

Mean age was 65.3±14.7years and 29.9% of the patients were female. Aortic- or mitral valve replacement or reconstruction was performed in 30.5%(n=51) of patients, 22.7%(n=38) underwent CABG-surgery. Aortic surgery was performed in 12.5%(n=21) patients, the remaining received others.

Elective surgery was performed in 24.5%(n=41) patients, whereas 26.9%(n=45) underwent urgent surgery. Most patients underwent emergency cardiac surgery (48.2%(n=81). As result, 13.1%(n=22) patients were on mechanical ventilation prior to surgery.

Mean cardiopulmonary bypass time was 188.5±93.7min, mean cross clamp time in this cohort was 99.1±62.4min. In n=19 patients, circulatory arrest in deep hypothermia was performed.

Herpes-simplex positive PCR results were obtained after a median of 13(8; 19)days following surgery, antiviral treatment was performed for a median of 15(10; 20.3)days until negative PCR result.

Median length of ICU stay in this cohort was 24(15; 42)days, median length of mechanical ventilation in these patients were 17.1(8.9;27.8) days. Survival in this cohort was 82.3% at 30 days after surgery, 6-months survival was 55.6%

Herpes-simplex pneumonia following cardiac surgery is associated with prolonged mechanical ventilation and ICU stay as well as elevated mortality. Emergency surgery appears to be a major risk factor for a Herpes re-activation, suggesting early diagnostics and treatment in patients undergoing emergency surgery on ICU.

Degloving soft tissue injuries typically arise from severe injuries. It creates separation of skin and soft tissue from the underlying muscle and bone. Treatment is often prolonged and complex with a significant challenge for surgeons. As an innovative skin substitute, a novel acellular fish skin graft (Kerecis®) has demonstrated his potential to stimulate wound granulation and epithelialization in various animal and clinical studies.

We present the case of an effective and complete granulation and acceleration of skin healing after application of Kerecis® Omega-3 wound patch as a dermal substitute in a degloving post-traumatic foot wound.

A 15-year-old boy was admitted in the paediatric emergency room due to a severe polytrauma resulting from a public road accident (train). The full-body scan revealed a displaced transverse diaphyseal fracture of the left femur and multiple open fractures, including degloving of the right foot. During the initial surgery, devascularized regions were observed on the entire plantar foot surface, with direct visualization of the plantar fascia. Following several sessions of dry dressing and the onset of necrosis, the patient underwent a thorough debridement at the operating room. The application of Kerecis® on the plantar surface and Thiersch Graft fifteen days later on the dorsal portion of the foot were performed.

The definitive outcome was satisfactory with no retraction, no hypertrophic scar and complete wound coverage.

Kerecis® is a therapeutic alternative in the treatment of loss of substance in children.

Our previously published anatomy study describes different variations in the origin of the piriformis muscle around the second and third anterior foramen of the sacrum. The most common variation is located medially to the foramen. Whereby, the ventral branches of the sacral spinal nerves may be entrapped, potentially leading to corresponding piriformis and pelvic pain syndromes.

The present study investigates the use of ultrasound and magnetic resonance imaging (MRI) to visualize the origin of the piriformis muscle and associated structures. Subsequently, the study compares the imaging findings obtained with those derived from anatomical dissection.

For this study, Thiel-embalmed bodies (3 female and 1 male) were used. Ultrasound and MRI were employed as imaging techniques. Additionally, anatomical dissection was conducted to facilitate a comparative analysis.

Ultrasound imaging proved unfeasible as the structures of interest are located too deep within the pelvis. Thiel-embalming makes MRI investigation difficult because of different ion-water distribution in the body. However, despite these challenges, good resolution of the structures of interest was achieved, making it possible to compare the MRI images with the results of the dissection. This approach facilitated the identification of the relationship between the sacral nerves and the piriformis muscle, particularly in reference to the ventral origin of the piriformis muscle.

MRI is a recommendable approach for investigating the potential entrapment of the ventral branches of the sacral spinal nerves in cases involving the piriformis muscle in pelvic pain syndrome.

The use of primary cells cultivated from fresh patient material for research approaches, especially for in vitro drug testing, can overcome the drawbacks of long-term cultures of cell lines. 

Here we aim to fully characterize 196 pleural mesothelioma (PM) low passage primary cell lines generated over the past 16 years at our hospital.

For the identification of tumor cells, we performed a stepwise characterization. To exclude fibroblasts, we evaluated epithelial cell origin by immunohistochemical staining (IHC) of pan-Cytokeratin (pan-CK) in FFPE cellblocks. Pan-CK staining intensity was scored as weak (1), moderate (2) and strong (3). Finally, histo (H)-score (sum of intensity multiplied with % positive cells, range 0-300) was calculated. We performed cell growth characterization using colorimetric assay for cell metabolic activity (MTT assay).

We have taken all the frozen stock cell lines to grow in culture using our established workflow. 117 cell lines (60%) grew after thawing and we could generate more frozen aliquots. Median pan-CK H-score analyzed from 67 cell lines was 49 and ranged from 0-300 (figure 1a). Among them, 23 cell lines have an H-score over 100. The doubling time, analyzed from 14 cell lines so far, ranged from 37-292 hours (median 83.6 hours) (figure 1b).

We have successfully re-cultured a large number of primary cell stocks, and shown that the doubling time of those of epithelial origin is within a good range for future experiments. Only pan-CK high expressing cell lines (H-score >100) will be selected for further staining with additional PM tumor markers by IHC compared to the original tumor tissues. The cell lines with concordant marker expression compared to the original will be further selected for assessment of copy number variation assay for the final validation. These primary cells represent an invaluable tool for the future use as translational research model for PM.

Prolonged cold static preservation (CSP) of lungs is known to induce a programmed cell death named necroptosis. The cGAS/STING system recognizes cytosolic DNA released in stressed or damaged cells, like mitochondrial DNA, and triggers inflammatory responses.

Using rat lung epithelial cells and lungs exposed to a 4°C temperature in preservation solution, we assessed the activation of cGAS-STING and its potential role on necroptosis induced by prolonged CSP.

Rat lung epithelial cell line and primary macrophages were incubated in preservation solution at 4°C for 4 to 18 hours to mimic lung CSP in the presence of drugs blocking the cGAS/STING/TBK1 axis or calcium fluxes. Rat lungs were preserved at 4°C for 18h directly after procurement. cGAS-STING activation was analyzed by western blot and confocal microscopy for the phosphorylation of TBK1, a marker of cGAS-STING activation. IFN-β production, a signature of cGAS-STING activation, was monitored by ELISA. Necroptosis was detected by western blot of phosphorylated MLKL which is responsible for the formation of pores and membranes rupture during necroptosis. Cell damage was measured by LDH activity in cell supernatants and BALF.

TBK1 phosphorylation, a kinase downstream of STING, happened after 4 hours of cold preservation and persisted after 18 hours in cells and lungs. The addition of cGAS or STING inhibitors in the preservation solution blunted TBK1 phosphorylation and reduced LDH activity in cell supernatants and BAL. Cold preservation promoted a phosphorylation of MLKL and LDH release, hallmarks of necroptosis. Remarkably, inhibitors of cGAS and STING drastically reduced phosphorylation of MLKL. Chelation of intracellular calcium or depletion of calcium in the preservation solution reduced both necroptosis and cGAS/STING activation.

A previously undescribed crosstalk is engaged between cGAS-STING signaling and necroptosis during lung cold static preservation. Our results suggest that calcium could be the common trigger of these two processes.

Ex-vivo lung perfusion (EVLP) is a validated technique allowing evaluation and reconditioning of lung graft before transplantation (LTx). Moderate hyperthermia is recognized to induces cytoprotective effect, by increased production of specific proteins, well known as heat shock proteins (HSPs). 

We hypothesized that moderate heat stress applied during EVLP could improve lung graft function in a prolonged ex-vivo perfusion model via protection of lung endothelial function.

Rats were assigned into two groups: Control (n=5) or Heat stress (n=5). In both group, lungs were kept in situ for 1h at room temperature, warm ischemia, then heart-lung blocks were flashed with cold Perfadex® and kept for 1h at 4°C. Heart-lung blocks were mounted on the EVLP system for 6h. In Ctrl group, the temperature of perfusion solution was kept at 37°C during EVLP. In the HS group, perfusion solution was warmed to 41.5 °C for 30 min, (HS) then cooled dawn to 37°C to the end of EVLP. At the end of EVLP Perfusates and lung tissues were collected and frozen at -80°C for further analysis.

Lungs exposed to HS displayed improved lung function with reduced edema, associated with increased production of HSPs, less oxidative stress and preserved lung endothelial function confirmed by protection of endothelial junctions (Claudin-5, VE-Cad), decreased release of endothelial markers (vWF, SDC-1, sPECAM-1). Moreover, perfusate level of cell damaged markers (HMGB1 and S100A8) and cytokines (IL-1β, and TNF-α) were decreased in the HS group.

The application of mild heat stress improved functional outcomes of damaged donor lungs in an extended EVLP model via protection of lung vascular endothelium, decreased cell death and lung inflammation. These findings demonstrated that HS application during EVLP could be a promising therapeutic tool targeting lung endothelium, known to play important role in induction of primary graft disfunction following lung transplantation.

In most cases pediatric burns are domestic accidents and occur in the presence of the parents. In 2020, schools were closed from March 13 to May 11 due to COVID-19 pandemic. Parents also spent more time home due to telecommuting and travel restrictions. 

The purpose of this study is to determine whether this period of school closure and, consequently, the increase in children's home time with their parents, had an influence on the occurrence of pediatric burns.

Patients under 18 years old who visited the CHUV for burns during the period between March 13 and May 11 of 2020, 2019, 2018 and 2017 were included. They were separated into a COVID-19 group (2020) and a pre-COVID-19 group (2017-2018-2019) for comparison. We collected the children's age and sex, the mechanism, localization and depth of the burn, the percentage of body surface area burned, the need for hospitalization or skin graft, the place of occurrence, whether an adult was present, and the time from burn to consultation.

97 patients aged from 4 months to 17 years were included. Statistical analyses showed no significant differences. However, in the COVID-19 group, there was a higher proportion of boys, contact burns and lower limb burns, and a lower proportion of hospitalizations and burns involving the face and neck. Patient ages and burn severity were similar. We highlighted that some information was often missing in the consultations report, such as the place of occurrence, the presence of an adult and the time from burn to consultation.

Other studies that have looked at the impact of the lockdown on the epidemiology of childhood burns show highly variable results. We wanted to insist on the importance of fully documenting the report of a burned child and of systematically looking for signs that may raise suspicion of abuse.

Meckel’s diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract. Gastrointestinal bleeding is the most common presentation in children, followed by intestinal obstruction and diverticulitis. Intestinal obstruction caused by a volvulus or an intussusception of the Meckel’s diverticulum into the bowel is well described. Contrastingly, obstruction related to an inflamed diverticulum’s pedicle strangulating the small bowel has rarely been described. 

This case report aims at describing an unusual presentation and treatment of a complicated Meckel’s diverticulum in a child.

We report a case of a 5-year-old girl with signs of intestinal obstruction and fever with a non-peritoneal abdomen. Laboratory findings showed strongly elevated inflammatory markers. Computed tomography scan revealed small bowel obstruction with signs of bowel suffering in the right upper quadrant and the inability to visualize the appendix (Figure 1). Moderate left pleural effusion was observed in the absence of underlying pulmonary affection. Signs of internal hernia in the right upper quadrant were found on magnetic resonance imaging (Figure 2). Upon laparotomy, an inflamed, necrotic Meckel’s diverticulum was found, which distal extremity was enlarged and adherent to the transverse colon (Figure 3). The small bowel underneath was obstructed by the thin pedicle of the diverticulum, although without signs of suffering. A wedge resection of the diverticulum was performed.

The postoperative course was uneventful.

Although acute appendicitis is the most common cause of small bowel obstruction of infectious origin in a child, Meckel’s diverticulitis should be considered as an alternative diagnosis in the presence of atypical presentation and/or imaging of a febrile intestinal obstruction. The responsible mechanism can be a mesodiverticularband arising from an inflamed diverticulum or less commonly, in our case, a band formed by the pedicle of the inflamed diverticulum itself. Wedge resection of the diverticulum is a safe option.

This case report describes a large thyroid carcinoma with multiple bleeding skin ulcers in a 63-year-old patient. 

The patient first reported a diagnosis of a thyroid nodule in 1986. She refused further investigations until 2011. Symptomatic hyperthyroidism led to a biopsy in 2011, which diagnosed a papillary thyroid carcinoma (4.3x2.3x5 cm); the patient was informed, although she refused surgical discussion of the case, and she never visited a general practitioner again.  

The 63-year-old woman with a history of untreated papillary thyroid cancer was admitted in May 2023 to the emergency department of our hospital with multiple bleeding ulcers within a palpable large mass in the neck (Figure 1) and without any other symptoms. The CT scan (Figure 2) revealed a 9.2x8.7x11.2 cm inhomogeneous mass with muscle (sternocleidomastoid muscle) and vascular infiltration (left internal jugular vein). After an interdisciplinary discussion of the case, another fine needle aspiration was performed, showing a papillary carcinoma, Bethesda VI. The patient decided to undergo surgical treatment. 

We were able to perform a complex total thyroidectomy with partial resection of the injured and excess skin to ensure a better aesthetic result. There were no vascular or nerve injuries. The final pathological result showed a papillary thyroid carcinoma without any sign of degeneration into anaplastic, with microscopic evidence of infiltration into the underlying muscle tissue. A further interdisciplinary discussion followed and radioiodine therapy was recommended.

Papillary thyroid carcinoma is a typical non-aggressive tumour with, in literature, possible transformation into an anaplastic form. Furthermore, well-differentiated papillary thyroid carcinoma may precede or coexist with anaplastic carcinoma in about 50% of cases.  Our case represents a rare case of papillary thyroid cancer that hasn't mutated to a non-differentiated form in 37 years and hasn't given any symptoms except for ulcerations.  

Adrenocortical Oncocytic Neoplasms (ACONs) constitue approximately 10% of AdrenoCortical Carcinomas (ACC), which is a rare disease with an estimated incidence of 0.7 to 2 cases per million per year. Traditionally perceived as non-functioning, recent data indicate that nearly 30% of ACONs exhibit hormone production, giving rise to manifestations such as Cushing's syndrome, virilization, and various other symptoms. This poses a significant challenge for the medical community in accurately diagnosing these cases.

This case report delineates a unique manifestation of ACONs in a 67-year-old woman with a decompensated metabolic syndrome and psychotic outbreak. The patient's clinical profile encompassed refractory hypertensive crisis, weight gain, and psychotic symptoms, necessitating a comprehensive medical investigation. Despite an initially inconclusive medical workup, the patient later reported abdominal symptoms conducting to abdominal computed tomography (CT). This showed a bilobed left adrenal mass measuring 8.5x1.8x2.2cm. The hormonal workup indicated only marginally elevated urinary catecholamines, prompting suspicion of a pheochromocytoma. This led to the decision for laparoscopic left adrenalectomy. Histological analysis revealed an oncocytic adrenocortical carcinoma, with a subsequent complete resolution of the patient's clinical symptoms.

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This case report highlights an oncocytic adrenocortical carcinoma characterized by a fully decompensated metabolic syndrome and psychotic symptoms, emphasizing the potential diverse hormonal secretions associated with this entity. In the backdrop of limited literature on ACONs, it underscores the necessity of a multidisciplinary approach in their management. Physiological normal hormonal panels may not definitively exclude the secretory nature of an adrenal mass, necessitating complementary assessments in cases of clinical suspicion.

In conclusion, ACONs present a substantial challenge for clinicians due to their varied clinical manifestations and the limitations of preoperative diagnostic modalities. A comprehensive biological workup is essential for establishing an optimal treatment plan. Emphasizing the efficacy demonstrated in this case, complete resection remains the primary approach to managing ACONs.

Acute cholecystitis is due to an obstruction of the cystic duct, usually by a gallstone, followed by distension and subsequent inflammation of the gallbladder. The modern-day gold standard treatment of acute cholecystitis is laparoscopic surgery. It is, however, associated with a higher risk of bile duct injury (0.1%-1.5%) when compared to the open approach (0.1%-0.2%). Factors predisposing to bile duct or vasculo-biliary injuries are related to anatomy, disease-related pathology, structural misidentification and improper techniques.

We report a case of a patient with an acute cholecystitis with a destabilizing anatomy with what looked like the gallbladder and an unidentified mass,

We report a case of a patient with an acute cholecystitis in which we performed a laparoscopic cholecystectomy. We faced a destabilizing anatomy with what looked like the gallbladder and an unidentified mass, interpreted as a possible common bile duct cyst. Careful dissection allowed us to determine that what looked like a common bile duct cyst was actually a dilatation of “Hartmann’s pouch” due to a large gallstone.

Laparoscopic cholecystectomy reduces length of hospitalization and enhance intra-operative and postoperative morbidity compared with open cholecystectomy. It may increase the risk of bile duct injury, notably in an acute setting due to inflammation and an unclear anatomy. Hartmann’s pouch with the infundibulum can sometimes unexpectedly be present beneath the common hepatic duct. In order to avoid bile duct injury, notably in an acute setting, a surgical technique was developed, the Critical View of Safety. It is a method whose sole aim is to secure identification of the cystic structures

Understanding the anatomy allowed for an ultimately safe laparoscopic cholecystectomy. It is strongly advised that, in the event of atypical anatomy, a second opinion is asked of another and/or more experimented surgeon.

Pancreatic ductal adenocarcinoma (PDCA) still carries a poor prognosis, with only 10-30% of patients being surgically resectable and recurrences after surgery generally not amenable to operative treatment.

We report two cases of unusual solitary recurrences of PDAC, i.e. ovary (Krukenberg tumor) and rectal wall, following a previous R0 Whipple resection. Very few similar cases are described in the literature.

Patient 1: 51-year female (RS) was diagnosed with pancreatic head PDCA, underwent 6-cycle neo-adjuvant mFOLFIRINOX, a Whipple procedure and simultaneous resection of left ovary for a solitary synchronous 0.5 cm mass.

Patient 2: 52-year female (MMR) was diagnosed with pancreatic head PDAC, underwent 6-cycle neo-adjuvant FOLFIRINOX, and a Whipple resection, followed by 3-month Gemcitabine administration. Tumor staging was ypT3, ypN0, L0/V0, Pn1, R0, KRAS and P53 mutations.

Patient 1: The ovarian mass was found to be metastatic only on final pathology, revealing ypT2, ypN0, L1/V0, Pn1, R0, M1, RET mutation, no germ-line mutations. Peritoneal lavage cytology was negative. After 6-cycle adjuvant mFOLFIRINOX and 1-year disease-free-interval (DFI), a solitary right ovarian metastasis was found on follow-up PET and removed surgically, peritoneal lavage cytology was positive for malignant cells. The patient has now re-started 6-month systemic chemotherapy, in view of PIPAC administration.

Patient 2: After 2.5 years of DFI, isolated ovarian metastases were diagnosed and resected, followed by 5-cycle adjuvant CAPOX. After two further years of DFI (4.5 years total), another secondary lesion in the rectal wall was found while performing a colonoscopy for chronic diarrhea. The lesion was removed with a full-thickness anterior rectum resection and the patient is currently undergoing a new chemotherapy regimen.

Isolated ovarian (in women) and rectal metastases from primary PDAC can occur and may not necessarily be manifestations of advanced systemic disease. Surgical treatment, combined with systemic chemotherapy, can offer worthwhile DFIs.

Situs inversus totalis is a rare condition with incidence of < 1:10’000, characterized by a mirror-image of the normal configuration of major thoracic and abdominal organs. Polysplenia is another rare congenital disease defined by the presence of two or more spleens. Patients with this condition are more prone to develop splenic torsion due to a narrower pedicle. The association of both pathologies is very rare. 

Diagnosis and treatment of splenic torsion in this context can be challenging. 

We report a case of a 18-year-old-woman known since birth for situs inversus totalis, who consulted the emergency department of a regional hospital with sudden right abdominal pain associated with vomiting.

Biological examination showed leukocytosis and elevated C-reactivated protein. Abdominal CT confirmed the situs inversus totalis and revealed a polysplenia (fig. 1) with multiple accessory spleens and a well delimited hypodense mass suspected to be an infarction of the main spleen due to a splenic vessels’ torsion (fig. 2). In this context, the patient was transferred to our tertiary hospital for surgical management.

Hand assisted laparoscopic splenectomy was performed in an emergency setting. Post-operative course was uneventful and patient was discharged in the third post-operative day.

The diagnosis of splenic torsion is challenging due to the unusual incidence and unspecific symptoms. This problem has to be suspected in patients with polysplenia. Abdominal CT is mandatory to obtain a prompt diagnosis and to avoid a delay in surgical treatment. Splenectomy remains the gold standard and laparoscopic approach appears to be a safe option in the context of associated situs inversus totalis.

Acinar cystic transformations of the pancreas (ACT) are rare, benign, cystic lesions of the pancreas. They are often discovered in the context of non-specific abdominal pain or incidentally during imaging for another reason. Diagnosis is difficult by imaging only because of the lack of typical radiological criteria and most diagnoses are made by histopathological examination after surgical resection. Because no risk of malignant transformation is described in the literature, a conservative approach is the treatment of choice for ACT once the diagnosis has been made. 

We report two cases of ACT diagnosed by Magnetic Resonance Imaging (MRI) with typical radiological features for which conservative treatment was proposed.

The first case is a 65 year-old woman presenting with non-specific abdominal pain. An abdominal MRI was performed and showed multiple cystic lesions throughout the pancreas compatible with the diagnosis of ACT. The second case is a 74 year-old man presenting with diarrhea and weight loss. Abdominal imaging also showed multiple cystic lesions throughout the pancreas with atrophy of the surrounding pancreatic parenchyma. No malignant features were visualized. Both cases were discussed at our multidisciplinary hepatobiliary and pancreatic tumour board. Due to the typical imaging features and lack of malignant characteristics, conservative treatment with radiological follow-up was opted for, therefore avoiding potentially unnecessary surgical resection. Radiological follow-up showed stability of the lesions.

Pre-operative diagnosis of ACT is of great benefit as it can lead to more conservative treatment by radiological follow up instead of extensive surgical resection with its associated mortality and morbidity. This is especially true for asymptomatic patients. Unfortunately, the lack of cases and sufficient data remain an obstacle to establishing guidelines for diagnosis, management and treatment of ACT.

We wanted to share our experience to allow the establishment of radiological diagnostic criteria, which would lead to better management of these patients.

Hepatic hemangioma (HH) represents the most common benign tumour of the liver, and is most frequently localized in the right lobe. It is formed by clusters of vascular malformations and receives its blood supply from the hepatic artery. The prevalence of HH is estimated between 0,4-20% in autopsy studies. When the tumour exceeds 10cm, in some studies 5cm, it is considered as a giant hemangioma, accounting for 10% of all hemangiomas arising from the liver. The diagnosis is often made fortuitously in asymptomatic patients. Rarely patients are symptomatic and present with right upper quadrant (RUQ) pain and, in very rare cases, can present with complications in the form of BTBS, associated with chronic fever, abdominal pain, weight loss and asthenia. Sclerosing HH, in particular, is an exceedingly rare subtype of hemangioma characterized by the presence of degenerative changes histologically. The ongoing inflammatory process within the hemangioma cavity is the cause of the clinical features of BTBS that require surgical intervention.

To contribute to the literature by documenting a case of diagnosis and surgical management of a giant sclerosing hemangioma presenting with BTBS, diagnosed in a 43 year old woman, along with a brief review of the literature.

Case report, and short review of the literature, of HH and BTBS with a description on how to make this challenging diagnosis and the surgical management.

BTBS is one of the complications of a HH that has been rarely addressed in the literature. The current case report documents rare clinical and histological features of a complicated HH along with its surgical management. Diagnostic imaging is carried out by an abdominal CT for the HH, and can be completed by hepatic MRI if a BTBS is suspected.   Histologically features of sclerosis are found. 

Knowledge about the uncommon complications of HH and BTBS permits the implementation of appropriate investigation, diagnostic imaging and intervention in a timely manner and greatly improves the management and quality of life of patients presenting with this syndrome.

Heterotopic pancreas is a rare finding defined as pancreatic tissue without any anatomic or vascular connection to the normally localized pancreas. Most frequently found in the stomach, duodenum or proximal jejunum, it is usually asymptomatic but can cause abdominal pain, gastrointestinal bleeding, ulceration, pancreatitis, and gastric outlet obstruction. Diagnosis and distinction from neoplasms can be challenging. Therapeutic management should consider existing symptoms as well as potential malignancy. Endoscopic removal of heterotopic pancreas is feasible, but surgical resection is advisable in individual cases to achieve complete resection.

To raise awareness on an infrequent pathology and discuss its clinical significance and therapeutic options.

We report a case of incidental gastric heterotopic pancreas in the context of recurrent episodes of acute pancreatitis.

A 41-year-old female patient suffering from recurrent epigastric pain was treated at our institution for three episodes of acute interstitial pancreatitis within one year. She had a history of daily alcohol consumption currently suspended for 6 months. After the second episode, diagnostics showed an acute calculous cholecystitis and a laparoscopic cholecystectomy was performed, yet three months later a third episode of pancreatitis occurred. The patient underwent endosonographic follow-up for peripancreatic cystic formations, which confirmed early signs of chronic pancreatitis and incidentally revealed a polypoid tumor in the antrum (Figure 1). After an unsuccessful attempt of endoscopic removal, it was resected by gastroscopy-guided laparoscopic wedge-resection of the antrum with an uneventful postoperative course (Figure 2). Histopathologic analysis revealed heterotopic pancreas with dilated pancreatic ducts containing concrements and erosive inflammation (Figure 3). Despite complete resection of the heterotopic pancreatic tissue, the patient continued to suffer from recurrent episodes of pancreatitis.

Although rare, heterotopic pancreas belongs to the differential diagnosis of gastric tumors. It can develop the same diseases as the main pancreas, including pancreatitis, abscesses, lithiasis, cystic changes, and adenocarcinoma.

Mirizzi syndrome (MS) occurs when a gallstone lodged in the cystic duct or Hartmann pouch causes extrinsic compression of the common bile duct (CBD) or common hepatic duct. Due to the risk of intraoperative complications, high conversion rates, and biliary duct injury, surgical management is challenging.

This case report aims to explore the multidisciplinary management and therapeutic challenges of a type 1 Mirizzi syndrome, discussing the decision-making process and outcomes following complex endoscopic and surgical treatments.

A retrospective analysis of a single patient case was performed, including clinical data, imaging and invasive procedures. A literature review was conducted using Pubmed and Scopus databases with specific keywords focusing on cystic duct stones leading on Mirizzi type 1.

A patient with obstructive jaundice and elevated hepatic enzymes underwent a Magnetic resonance cholangiopancreatography (MRCP) detected a CBD stone with MS features, including an elongated cystic duct (image 1).
An Endoscopic retrograde cholangiopancreatography (ERCP) with biliary drain placement initially cleared the biliary tract, but post-procedural pancreatitis ensued.
Deteriorating symptoms led to a CT scan, uncovering a residual gallstone.
Another ERCP was conducted, it was not technically possible to remove the stone, a biliary stent was placed, clinical conditions improved.
The patient was then transferred to a specialized center for hepatobiliary surgery. A laparoscopic cholecystectomy with the rendez- vous technique was planned.
The procedure was complicated due to stone migration into the left intrahepatic biliary system, which was managed with a biliar stent. After three weeks, endoscopic removal of the intrahepatic stones was successfully performed (image 2 and 3). A follow-up MRI at two months confirmed the absence of residual stones and a normal biliary tree, with full recovery.

MS may require a multidisciplinary approach and individualized treatment. The complexity of this case highlights the importance of specialized hepatobiliary centers for achieving optimal outcomes.

Diaphragmatic hernia is defined by a protrusion of a hernia sac and abdominal organs into the chest through a diaphragmatic defect. Congenital diaphragmatic hernia are believed to be caused by a developmental impaired closure of the pleuroperitoneal folds. Currently, nearly all are diagnosed during the perinatal period or childhood. Clinical presentation ranges from asymptomatic patients to serious respiratory, cardiac and gastrointestinal symptoms depending on the size of the hernia. The most common location of congenital diaphragmatic hernia is posterolateral (Bochdalek hernia, 70-75%), followed by anterior (Morgagni hernia, (23-28%) and central (2-7%).

To discuss the diagnosis and repair of a rare diaphragmatic hernia.

We report a case of Morgagni hernia.

A 44-year-old female patient with trisomy 21 presented on the emergency department with a 4 day history of cough and progressive dyspnoea. Clinically, the patient presented with obstructive inspiratory and expiratory breath sounds. Laboratory findings showed an elevated CRP (184 mg/l). The computed tomography of the chest revealed a herniation of the right colonic flexure and small bowel into the right hemithorax with compression of the lung and shifting of the mediastinum (Figure 1). A bilateral pneumonia was concomitantly diagnosed. Antibiotic therapy was immediately started and the patient was intubated due to respiratory insufficiency. One day later surgery was performed. Through an open abdominal access, the content of the hernia was replaced into the abdomen, the complete hernia sac was resected, and the diaphragmatic defect closed with a non-absorbable suture reinforced by a large preperitoneal mesh. After surgery the right lung showed full expansion and the patient had an uneventful course.

Late presenting congenital diaphragmatic hernia in adulthood can be a life-threatening condition and is treated by surgical repair.

Background

Lumbar hernias are a rare form of posterior abdominal wall hernia, most common in patients aged 50 to 70 years, with a male predominance. Barbette was the first that suggested the Existence of lumbar hernias in 1672. In 1731, Garangeot reported the first case. The aetiology include congenital (20%) as well as primary acquired (55%) and secondary acquired (25%) lumbar hernias. There are two types of lumbar hernias described, according to the anatomical location of the hernial neck: the superior lumbar hernia also known as Grynfeltt-Lesshaft hernia and the inferior lumbar hernia also known as Petit hernia. Literature review showed that the most common type is the superior lumbar hernia.

Aims

We report the case of a 66-year-old, overweight male presenting with a small inferior lumbar hernia, initially misdiagnosed as a subcutaneous lipoma. The patient presented with an exacerbated and immobilizing paravertebral lumbar pain as well as a recurrence of deep vein thrombosis despite ongoing oral anticoagulation. The patient initially received pain killer treatment and physiotherapy as well as a change of oral anticoagulant.

Methods

Radiologically, a spinal fracture was ruled out. The lack of treatment response prompted an ultrasound examination, the results of which suggested a diagnosis of subcutaneous lipoma. An outpatient follow-up CT-graphic examination resulted in the diagnosis of a small, symptomatic inferior lumbar hernia with a fascial gap under 1 cm and the decision for a surgical intervention was made.

Results

Due to the recurrence of deep vein thrombosis, the surgical intervention was postponed for 3 months. Then he underwent open approach surgery with a simple and effective mesh plug hernioplasty of inferior lumbar hernia. Subsequently, the patient recovered well without any complications. 

Conclusion

A laparoscopic approach was discussed but rejected due to the small fascial gap. This case demonstrates the need to tailor the surgical approach to the individual patient.

Hernias are the most common surgical condition encountered by primary care physicians. However, giant inguinoscrotal hernias are rare and pose a challenging postoperative problem because reduction of the hernia contents inside the abdominal cavity may increase intra-abdominal and thoracic pressures. We describe a simple reduction with orchiectomy and mesh repair, without bowel resection, as a viable technique in a giant left inguinoscrotal hernia that extended to the patient´s knees with complete loss of Domain containing entire omentum, small and large bowel, and the appendix.

 A  57-year old patient presented with a symptomatic, irreducible, giant left inguinoscrotal hernia for 30 years. Computed tomography revealed a large-volume inguinoscrotal hernia containing a large part of the colon and small intestine. A preoperative cardiac and pulmonary evaluation was unremarkable. The primary method that we sought was the Lichtenstein's hernia repair. However a Consent including left orchiectomy and laparotomy with bowel resection was obtained.

Intraoperatively a large incision over the left inguinal ligament was made. Blunt mobilization of the hernial sac along the entire circumference and distally towards the scrotum. Because of strong adhesions between the spermatic cord and the hernial sac, a orchiectomy was performed. A sliding indirect hernia was identified. In Trendelenburg Position it was possible to reduce the entire abdominal content. The posterior wall of the inguinal canal was reconstructed and a tension-free mesh was inserted. A drain was placed. The remained scrotal skin was not resected.

The postoperative course was unremarkable and the patient was discharged on the third postoperative day.

Giant inguinoscrotal hernias are rare with challenging postoperative complications due to increase intra-abdominal and thoracic pressure. Therefore, patients undergoing elective herniorrhaphy should go to a thorough preoperatively cardiorespiratory evaluation. 

Amyand hernia (AH) is a rare condition where the appendix protrudes through an inguinal hernia (IH). Clinical manifestations can vary from hernia complications to acute appendicitis, intestinal obstruction or peritonitis. When AH is found during elective IH repair, less than 40% of patients undergo appendectomy. However, in case of emergency onset, appendectomy is more frequent and IH repair with mesh is usually avoided.  Hereby, we present the case of an acute appendicitis, where AH was coincidentally discovered.

To raise awareness of this rare surgical entity and its challenging surgical decision making.

We present the case of a 40-year-old male patient with no previous surgical history who presented to our emergency department with right lower quadrant pain associated with diarrhea and nausea. Clinical assessment revealed a positive McBurney’s sign. Blood tests showed an elevated CRP (22 mg/L) without increase in white cell count. A CT scan demonstrated uncomplicated acute appendicitis protruding into a right inguinal hernia sac (Figure 1).

Intravenous antibiotics were administered (Ceftriaxone 2g, Metronidazole 500mg) and the diagnostic laparoscopy confirmed the diagnosis (Figure 2). A left IH was also found intra-operatively. Appendectomy was uneventful, antibiotics were discontinued postoperatively and the patient discharged home on day 1. Histopathology confirmed acute ulcero-hemorrhagic appendicitis with focal fibrinous serositis. In view of the fortuitous discovery of bilateral IH in an asymptomatic patient, we did not proceed with immediate repair. The patient was therefore addressed to our outpatient’s clinic 6 weeks postoperatively and planned for elective repair.

Decision making in AH with appendicitis is not easy. We suggest to perform first the appendectomy and later on the hernia repair. This also allows to perform the hernia mesh repair utilizing the total extraperitoneal patch plastic (TEPP) technique.

The cyst of the canal of Nuck is an infrequent cause of inguino-labial swelling. Given its rarity in female adults and limited clinician awareness, misdiagnosis and mistreatment are common.

To raise surgeons' awareness and emphasize diagnostic considerations for this rare pathology necessitating surgical intervention.

A 21-year-old female patient presented with a two-month history of painful inguino-labial swelling on the right side, leading to multiple doctors’ consultations. Radiological investigations, including ultrasound, computed tomography, and Magnetic Resonance Imaging (MRI), unveiled a 4x2.6x1.7cm multiloculated cystic lesion not connected to the peritoneal cavity (Figure 1). The patient was subsequently referred to our outpatient’s clinic. Due to our suspicion of a cyst of the canal of Nuck, we proceeded to a surgical groin exploration.

Surgical exploration revealed a cystic lesion in the round ligament without an associated hernia (Figure 2). Histological analysis confirmed a multi-locular cyst with a mesothelial lining, consistent with a Nuck’s canal cyst (Figure 3). The postoperative follow-up was completely uneventful.

The cyst of the canal of Nuck results from an anomalous closure of the processus vaginalis along the round ligament, situated between the uterus and the labia majora. Anton Nuck documented this pathology already in 1691. The processus vaginalis typically closes within the first 5 years of life. Canal of Nuck cysts are rare, predominantly discovered within the first years of life. Since its occurrence in adulthood is rare, misdiagnoses are frequent due to lack of clinician’s awareness. Accurate diagnosis mandates a comprehensive clinical examination and appropriate radiological imaging, with ultrasonography as the primary diagnostic tool and MRI reserved for complex cases. Treatment involves surgical exploration with complete excision, possibly combined with repair of a concomitant hernia. Awareness of clinical characteristics and diagnostic approaches is essential for timely and accurate management in both pediatric and adult populations.

Richter’s hernia is defined as an abdominal hernia in which only a portion of the circumference of the bowel is entrapped in the hernial orifice. It occurs most often in the sixth and seventh decade and is more frequently in females. The most common site is the femoral ring followed by the inguinal ring. Richter’s femoral hernia represents 15% of all strangulated hernias with a mortality rate of 17% - 62%.

We present here the case of a perforated femoral Richter’s hernia of the small bowel, which was treated with segmental small bowel resection and primary mesh repair through an inguinal approach.

A 73-years old patient presented at our emergency department with acute abdominal pain associated with nausea and vomiting for the last 4 days. Physical examination revealed a slightly distended abdomen with a small, round and painful right inguinal mass. Performed CT-scan showed a mechanical small bowel ileus due to an incarcerated right femoral hernia. The patient underwent surgery by a direct inguinal approach. On opening the hernia sac, a Richter&#39;s hernia was found, showing necrosis of the incarcerated anti-mesenteric small bowel wall with a small perforation. Segmental small bowel resection with latero-lateral 2-layer anastomosis was performed. After closure of the peritoneum, a trans inguinal repair with pre-peritoneal placement of a Parietex™ Hydrophilic Anatomical mesh was done.

Recovery was uneventful and the patient discharged home 3 days later. At a 6-weeks outpatient’s control the patient was asymptomatic with no evidence of recurrence.

Perforated Richter’s hernia is a rare but misleading entity with a high mortality rate, which might be reduced by quick diagnosis and early surgery. In cases of clean or little contaminated wounds, primary repair with mesh implantation should be considered during the same operation.

Jejunal intussusception, a rare cause of chronic abdominal pain in adults, is often misdiagnosed. Benign tumors are the most common cause. Conventional endoscopy may not reach the lesion, CT scan or MRI may be required for diagnosis if suspected. There is a single case report dealing with a jejunal intussusception, caused by jejunal lipoma, successfully fixed by laparoscopy and bowel resection.

We present the case of a 50-year-old male patient with chronic left abdominal pain caused by a jejunal submucosal lipoma causing intermittent intussusception.

This is a video presentation of the laparoscopic jejunal lipoma with intracorporeal resection.

Three ports were used with an umbilical access. An intussusception was identified 20 cm from the Treitz ligament. The proximal bowel segment was suspended onto the anterior abdominal wall to verticalize the interested loop and the lipoma was extroflected and removed through enterotomy, followed by closure using Heineke-Mikulicz technique. The patient presented some post-operative lower GI bleeding that was treated conservatively and he was discharged on post-operative day five. Histopathology showed a submucosal lipoma of 4.5 cm.

In conclusion, small bowel intussusception, though rare, should be considered in chronic abdominal pain differential diagnosis. This case demonstrates successful treatment of a rare jejunojejunal  intussusception with a mini-invasive approach.

Bowel injuries commonly occur following blunt abdominal trauma, typically in high-speed accidents. However, there are limited cases in the literature where bowel injury is caused by a minimally displaced pelvic fracture resulting from minor trauma.

Our objective is to present a case of small bowel and sigmoid injuries secondary to a pelvic fracture with a fistula extending to the thigh.

Litterature review was conducted to assess the existence of similar cases.

An 86-year-old woman experienced a home fall resulting in fractures of the left ischiopubic and iliopubic branches, managed conservatively.

Two days post-fall, the patient complained of left inguinal pain with functional impairment. A CT scan indicated the presence of a fluid collection in the left tight, which was initially suspected to be an infected hematoma, and a dehiscence of the small bowel wall adjacent to the fracture without any free abdominal fluid. A subsequent CT scan using oral contrast confirmed the perforation of the sigmoid and small bowel, resulting in a bowel fistula extending to the left thigh.

Laparotomy was performed to suture the sigmoid and bowel. The sigmoid suture was protected with a double barrel colostomy, while the orthopedic team managed the drainage of the thigh.

Five days later, an additional thigh drainage is performed. Given the unfavorable clinical course, the next day a follow-up scan revealed an ongoing small bowel leakage with peritonitis. A laparotomy was performed, followed by a 7 cm small bowel resection and epiploplasty to cover a pubic symphysis bony fragment.

After 28 days of hospitalization, the patient was able to be discharged from the hospital and transferred to rehabilitation.

Intestinal injuries secondary to a minimally displaced pelvic fracture are rare but crucial to recognize and promptly manage to reduce morbidity and mortality.

It is well known that a large excisional haemorrhoidectomy could be certain cause of post-operative severe complications like incontinence, ectropion or anal stenosis.

Our main objective is to reduce post-operative complications avoiding large haemorrhoidectomy in patients suffering
of a circumferential 4th degree prolapsed haemorrhoids associated to external piles.

Prospective, single institution study between january 2017 to december 2019, applying the propensity score matching during a combined stapled excisional mucopexy followed at the same operative time by a classic Milligan-Morgan's technique using LigaSure Precise Triad system. (Figure No.1)

Universe of the study = fiftty patients, 32 presenting haemorrhoido-mucosal prolapse+piles were included prospectively & consecutively (20 men, 12 women), mean age 51.9 y (range 21-84). 18 patients (33.4%) were excluded because of  anatomical prolapse variations (10), associated anal fissures (2), HPV condylomata+piles (2), non-stoppable anticoagulation treatment (2), immunity treated disease (1), absence of haemorrhoidal piles (1). No inmediate postoperative complications were registerd. Surgery length 48, 05 min +/- 5, 30 min. Six patients (18,8%) required supplementary haemostasis due to persistent bleeding treated by single sutures (12 men, 5%, 6 women, 3%). The combined procedure allowed faster functional recovery with shorter time off work (weighted mean difference 9.45 d. p < 0.00001), earlier return to normal activities (weighted mean difference, 15.85 d. p < 0.03), better wound healing (odds ratio, 0.1; p< 0.0006). No stenosis, neither ectropion. (Table No.1)

Despite of a single limited study including a single operative group, results definetly confirm the strategy, demonstrating that the combined technique drastically reduces the risk of anal stenosis, ectropion, incontinence or recurrence of the prolapse. By the restoration of the anal canal anatomy under visual control & preservation of the required mucosal cutaneous bridges, results are replicable & safe.

Gallstone colonic obstruction resulting from a cholecystocolonic fistula is an infrequent late complication of recurrent cholecystitis. It typically occurs when the gallbladder comes into contact with the hepatic flexure of the colon, allowing gallstones to pass through the fistula. Involvement of the sigmoid colon is exceedingly rare and is often linked to pre-existing colon conditions.

This study aims to present and analyze a rare case of gallstone ileus, emphasizing the uncommon occurrence of spontaneous resolution and shedding light on the diagnostic and therapeutic challenges associated with this atypical presentation.

A 78-year-old female patient was admitted with a 5-day history of bowel obstruction, accompanied by nausea. Following initial assessment, a computed tomography scan was performed, revealing a 2 cm gallstone lodged in the sigmoid colon, attributed to a cholecystocolonic fistula.

Spontaneous resolution of the obstruction took place during the first night of hospitalization following antibiotic treatment, leading to the expulsion of the gallstone. A subsequent colonoscopy was performed to confirm the size of the fistula and to identify a substenosis resulting from post-diverticulitis as the root cause of the gallstone blockage.

There are limited documented cases of spontaneous resolution of gallstone colonic ileus in the sigmoid colon. Usually, surgical or endoscopic procedures are necessary for managing such occurrences. The discovery of a cholecystocolonic fistula and its connection to a post-diverticulitis substenosis provides valuable insights into the complex nature of this unusual presentation.

Neuroendocrine tumors of the small bowel (SB-NET) have an increasing incidence of up to 1.3 cases/100’000 worldwide. SB-NET’s are usually small and slowly growing tumors, leading often to delayed diagnosis. Regional lymph node (LN) and/or distant metastases are frequent. Treatment consists mainly of radical resection of the primary tumor together with mesenteric LN dissection (MLND). Specific management guidelines in emergency situations are lacking.

To describe the feasibility and safety of MLND with resection of SB-NET in an emergency setting.

A 61-year-old male patient presented with vomiting and clinical signs of an acute abdomen. CT scan revealed a SB bowel ileus with a hyper-vascularized mass in the ileum, suggestive for an occlusive SB-NET.

Exploratory laparotomy confirmed a large obstructing nodule in the middle ileum together with another 7 nodules within a 140cm long proximal SB-segment. No other lesions were detected. A 140cm segmental SB-resection with central MLND up to the superior mesenteric vessel root was performed together with prophylactic cholecystectomy and appendectomy. Adequate perfusion of the remaining SB was assessed by indocyanine green fluoroscopy. Histopathology confirmed 14 nodules of a well differentiated SB-NET in the SB together with 2 LN-metastases out of 18 resected LN. Somatostatin receptor subtyp 2A was expressed in 40% of tumor cells on immunohistochemistry. Complementary ⁶⁸Ga-DOTATATE PET-CT did not prove any other lesions. The postoperative follow-up was uneventful.

If SB-NET is suspected, MLND should be performed at the initial intervention, even in an emergency setting. Careful palpation of the entire SB is mandatory since multifocal SB-NET occur in up to 50% of patients. In cases where the diagnosis is not at all clear and no quick cut diagnosis is possible, early re-operation with MLND has to be performed after diagnosis, even when ⁶⁸Ga-DOTATATE PET-CT is negative (micro-metastases). 

Hemorrhoids, a prevalent colorectal condition, have traditionally been managed with surgical interventions like Milligan-Morgan and Recto Anal Repair (RAR). With advancements in medical technology, laser hemorrhoidectomy has emerged as a potential alternative for stages I to III, promising reduced operative times and improved patient outcomes

This longitudinal study, spanning from June 2021 to December 2023, was designed to systematically evaluate the efficacy of laser hemorrhoidectomy compared to the established Milligan-Morgan and Recto Anal Repair (RAR) surgical techniques in managing stages I-III hemorrhoids

In this comprehensive analysis, various outpatient hemorrhoidal interventions were considered, including laser therapy, Milligan-Morgan, RAR, and their combinations. The surgical approach for each of the 149 patients was determined based on the individual's hemorrhoidal status, ensuring an appropriate treatment corresponding to hemorrhoid stages I to IV. This methodology included both exclusive laser procedures and combined surgical treatments, allowing for a thorough evaluation across a broad spectrum of hemorrhoidal conditions

The data revealed a significant difference in median operative time, with laser-only procedures averaging 20 ± 10 minutes, compared to the 50 ± 10 minutes typically required for Milligan-Morgan, RAR, or their combinations. Additionally, patients treated with laser reported notably lower levels of immediate post-operative pain. This observation was further supported by lower pain scores on the Visual Analogue Scale (VAS) at one and four weeks post-operation, suggesting a more rapid recovery and earlier resumption of daily activities

The study corroborates the superior efficacy of laser hemorrhoidectomy for stages I-III hemorrhoids, particularly in terms of reduced operational time, pain management, and recovery speed, compared to traditional Milligan-Morgan and RAR procedures. While traditional methods remain the preferred surgeries for higher-grade hemorrhoids, the extended recovery periods and increased pain associated with these techniques emphasize the advantages of laser treatment as a more suitable alternative for lower-grade hemorrhoidal conditions

Crohn's disease (CD) is an inflammatory bowel disease often causing fistulous tracts between the gastrointestinal tract and other organs. Hepato-colic fistulas, which are pathological connections between the liver and colon, represent a rare but significant complication in CD.

We report a rare case of a hepato-colic fistula in a CD patient. It highlights the successful combination of conservative treatment in the acute phase followed by elective surgery.

A 59-year-old female patient with a known history of CD presented to our emergency department with right-sided abdominal pain for the last ten days. The pain persisted despite antibiotic treatment, administered by her gastroenterologist. Her personal history included CD-related ileo-ileal and ileo-sigmoid fistulas treated by ileo-cecal resection with ileo-colic anastomosis in 2017. At presentation, the patient was undergoing prednisone tapering. Our diagnostic investigations, including contrast-enhanced computed tomography (CT), revealed a hepato-colic fistula with a 3-4 cm hepatic abscess in segment V of the liver. (Figure 1-2)

The patient's initial management involved conservative treatment with radiological drainage, leading to improvement in clinical symptoms. A follow-up CT-scan four days post-drainage confirmed abscess disappearance. However, fistulography through the drainage catheter revealed a fistulous connection between the liver and the former ileo-colic anastomosis. The patient was discharged home on day 10 with the catheter in place and re-admitted for elective laparotomy one month later. She underwent resection of the ileo-colic anastomosis with an ileo-transverse re-anastomosis and catheter removal. The post-operative management included treatment for paralytic ileus, and she was finally discharged home in good condition 11 days after the intervention.

Hepato-colic fistulas are an exceptional yet critical complication of CD. This case emphasizes the importance of early diagnosis and the successful combination of multidisciplinary conservative and surgical treatment leading to favorable outcome.

Background

The main indications for oncologic pelvic exenteration (PE) with curative intention are locally advanced and recurrent malignant pelvic tumours. These complex and often multivisceral resections require surgical expertise as well as an interdisciplinary approach and are often associated with a high postoperative morbidity and mortality rate.

Aims

The aim of this study was to identify potential predictors for postoperative complications.

Methods

This is a monocentric, retrospective study of consecutive patients (n=412) undergoing PE due to pelvic malignancies between 2008 and 2022. Patient-, disease-, and surgery-related factors were investigated. The primary endpoint was major complications during the hospital stay (Clavien-Dindo≥3b). The secondary endpoint was 90-day postoperative mortality. Statistical analyses were conducted using Chi-Square test and binary logistic regression model.

Results

A total of 412 patients were included in the analysis, with colorectal cancer as the most common tumour site (n=299). The majority of patients underwent posterior PE (n=341), while 71 were treated with total PE. The mean age was 62.6 (±12) years. Major complications occurred in 149 patients (36.2%); 90-day mortality rate was 4.6%. Patient age (p=0.038, OR1.021), ASA score ≥3 (p=0.012, OR1.823), preoperative CRP>16mg/dl (p=0.007, OR1.945) and blood loss during surgery (p=0.001, OR1.340) were identified as independent risk factors for major complications in regression model. Predictors associated with increased 90-day mortality were patient age (p=0.002, OR1.126), preoperative CRP>16mg/dl (p=0.019, OR4.096) and long operation time (p<0.001, OR1.509).

Conclusion

The present study revealed preoperative CRP>16mg/dl as an independent risk factor for an inferior postoperative outcome after pelvic exenteration, despite the already known predictors such as patient age, ASA score, and blood loss. CRP is known to be a marker for malignant potential and co-morbidities. It might be valuable to consider preoperative CRP level as part of the preoperative risk assessment for patients treated with PE.

Background

There is ongoing debate wether length of the posterior rib remnant after first rib resection for thoracic outlet syndrome (TOS) affects outcome of surgery.

Aims

To assess the impact of length of posterior rib remnant on outcome of supraclavicular first rib resection for TOS using patient rated outcome measures (PROMs) and patients‘ self assessment.

Methods

In a prospective study all patients undergoing supraclavicular first rib resection for TOS since 2016 have been enrolled. Patients had to complete CBSQ (Cervical Brachial Symptom Questionnaire) before and 4 to 24 months after operation and report the percentage of improvement after operation. Length of rib remnant was measured on postoperative routine thorax x-ray from costovertebral joint to resection margin in mm.

Results

From 2016 to 2023 a total of 124 supraclavicular first rib resections for TOS have been perfomed in 103 patients (17% bilateral). 76% were female, average age was 38 years (18-69). Mean observation period was 12 months postoperatively (4-24 months). In 115 cases (93%) patients rated the postoperative outcome as 75% improvement. 3 patients were unable to rate the postoperative outcome, 6 were lost to follow-up. CBSQ scores showed an average improvement of 66% (87 preoperative vs. 30 postoperative). Average length of rib remnant was 21 mm (8 to 38mm). Analysis of subgroups revealed no correlation of length of rib remnant with postoperative CBSQ scores but good correlation of self assessed improvement in percent and percentage of improvement of postoperative scores respectively.

Conclusion

CBSQ is a reliable tool in evaluating outcome after surgery for TOS. Subgroup analysis revealed no correlation of length of posterior rib remnant with postoperative outcome but good correlation of patients‘ self assessment and improvement of CBSQ scores. More important factors for postoperative outcome than length of rib remnant are pre-existing chronic pain conditions, multiple crush situations, and preexisting peripheral atrophy with functional loss.

Postoperative empyema due to bronchopleural fistula may need a Clagett open-window thoracostomy. We describe how such a window was closed using a pedicled omental flap and how indocyanine green (ICG) fluorescence allowed control of perfusion.

This didactic video demonstrates the harvesting of the flap, the transdiaphragmatic mobilization and the control of adequate perfusion in the thorax using ICG fluorescence.

A 72 years old woman suffering from rheumatoid arthritis underwent thoracoscopic wedge resection of the right lower lobe for metachronous metastasis of a previously operated non-small cell lung cancer of the right upper lobe. A prolonged air leak due to non-healing of the stapling suture led to an empyema, which finally necessitated a Clagett thoracostomy. An endobronchial unidirectional valve was placed in the segmental bronchus leading to the pleural cavity without improvement. Due to the patient’s burden, we finally proposed a surgical closure of the thoracostomy.

The patient was hospitalized for intravenous antibiotic treatment and the thoracic cavity was debrided several times with the use of a negative pressure wound dressing. Once the thoracic cavity was clean and microbiology probes became negative, definitive closure of the thoracostomy was scheduled. We harvested a pedicled omental flap by laparoscopy. Under manual guidance from the thoracic side, the diaphragm was opened and the omental flap slipped through. ICG fluorescence showed a well perfused omentum which filled the airspace well. It was sutured into the thoracic cavity. The thoracostomy was finally closed leaving one chest drain.

An omental flap is probably the best autologous tissue to fill a chronically contaminated pleural airspace. ICG fluorescence adds additional security with direct highlighting of the good perfusion of this voluminous flap.

Anterior mediastinal masses can have various causes, including thymoma, lymphoma, germ cell tumor, neurogenic tumor and some less common etiologies. Accurate diagnosis relies on advanced imaging and histopathological examination. A multidisciplinary approach is essential for tailored interventions based on the specific histological subtype. Here, we present a case of a patient with an exceptionally large mediastinal mass.

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A 44-year-old patient was referred to our department following the incidental discovery of a substantial mediastinal mass. Remarkably, the patient was entirely asymptomatic despite a history of recurrent lipomas, including a sizable 300g lipoma on the thigh that necessitated surgical resection. Antibody tests (Anti-Musk, Anti-Ach, Anti-Titin) yielded negative results. The chest CT revealed a tent-shaped fatty mass extending from the anterior mediastinum into the basal and anterior bilateral hemithoraces. Fine needle aspiration indicated fatty tissue with focal chronic inflammation, ruling out thymic tissue, thymoma, or malignancy. In our multidisciplinary tumor board discussion, given the extensive size of the mass, a surgical approach was favored. We opted for a robot-assisted thoracoscopic surgery with three access ports, initiated from the right side. Following careful dissection and mobilization of the tumor mass from the anonymous vein and the pericardium, we converted to an anterolateral thoracotomy to completely remove the mass. Histopathological examination proofed beingn lipoma.

The approach to the presentation and treatment of anterior mediastinal masses is highly individualized and necessitates thorough discussion in a multidisciplinary tumor board, tailored to meet the unique needs of each patient. This case study highlights the successful resection of a giant anterior mediastinal mass using a combined robotic and open approach within our department.

Surgical decision-making in non-small-cell lung cancer (NSCLC) relies on balancing operative risks with oncologic benefits. Recent data have emerged demonstrating survival advantages following pulmonary resection as local consolidative therapy in stage IV NSCLC, yet operative risks for these potentially more challenging surgical procedures are not well-described.

We sought to characterize perioperative outcomes within a multicenter cohort of patients with resected stage IV NSCLC.

We retrospectively reviewed patients with metastatic NSCLC who underwent resection of primary lung tumors from 1996-2023 from 2 large academic institutions. Clinicopathologic, operative, and perioperative details were obtained from patient records. Predictors of pulmonary, cardiac, renal, and wound complications were assessed and multivariable regression model performed.

179 patients were included, at median age of 59.0 (51.8-66.5) years. Neoadjuvant therapy was received by 116 (64.8%), including chemotherapy 73 (40.8%), immunotherapy in 4 (2.2%), and targeted therapy in 48 (26.8%). Most patients underwent thoracotomy (141, 78.8%). Operations included 130 (72.6%) lobectomies, 24 (13.4%) wedges, 7 (3.9%) segmentectomies, 12 (6.7%) bilobectomies, and 6 (3.4%) pneumonectomies. Median blood loss was 150 (62.5-300) mL, and median operative duration was 236 (183-286) minutes. Typical length of stay was 5.0 (3.0-8.0) days. Postoperative complications occurred in 46 (25.7%), including 18 (10.1%) pulmonary, 19 (10.6%) cardiac, 5 (2.8%) renal, and 4 (2.2%) wound-related. MVA did not identify intrathoracic stage, extent of resection, nor neoadjuvant treatment as independent predictors of postoperative complication. All patients survived 30 days, and 2 deaths (1.1%) occurred within 90 days. Complications did not impact 90-day survival (p=0.36).

Surgery for stage IV NSCLC is well-tolerated, regardless of receipt of neoadjuvant therapy, intrathoracic stage, or extent of lung resection. Most complications are cardiopulmonary, without downstream impact on survival. These findings inform multidisciplinary and informed consent discussions, setting a baseline for future assessments of outcomes in this patient population.

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are commonly prescribed for diabetes. However, a recent concern involves a serious adverse effect in vulnerable post-operative patients: SGLT2i-induced euglycemic diabetic ketoacidosis (eu-DKA). In these cases, symptoms such as nausea, vomiting, hyperventilation, and abdominal pain are masked by post-operative effects. The SGLT2i further complicates the presentation with reduced polyuria and polydipsia. Recognizing SGLT2i as the hidden culprit is crucial for treatment, given the 2-5% mortality rate associated with eu-DKA in developed countries.

This case report aims to discuss SGLT2i-induced eu-DKA in post-operative patients, suggest management strategies, and offer recommendations on the ideal timing for withholding SGLT2i in surgical patients. 

We outline the post-lobectomy clinical course of a patient with type 1 diabetes mellitus on dapagliflozin therapy.

Our patient, a 76-year-old multimorbid woman, underwent an uneventful robot-assisted lung lobectomy due to adenocarcinoma. During monitoring, she developed severe treatment-resistant nausea and tachypnea. Arterial blood gas analysis showed progressive acidosis, peaking at a pH of 7.138 after 12 hours, low bicarbonate (8.8 mmol/l) and a base excess of -21.9 mmol/l. While blood analysis showed normal glucose levels, urine analysis showed elevated ketone levels (>5mmol/l) resulting in admission to the intensive care unit with the diagnosis of SGLT2i-induced eu-DKA. Homeostasis was achieved with glucose, magnesium, phosphate, and sodium-bicarbonate infusions. The patient transitioned to the regular ward on post-operative day 3 and was discharged from the hospital on day 11. The recovery of the lung remained uncomplicated throughout.

Given the half-life of SGLT2i as 11-13 hours, a prudent preventative approach would involve withholding SGLT2i administration 2-3 days before surgery. Substituting SGLT2i with insulin during this period, along with ensuring sufficient fluid replacement, would be a sensible strategy to mitigate the risk of eu-DKA. 

After anatomical lung resections, routine postoperative chest X-rays are common. Advances in chest drain monitoring and enhanced recovery programs in thoracic surgery (ERAS) raise questions about the necessity of these routine X-rays.

We hypothesize that, for non-small cell lung cancer (NSCLC) patients, chest drains connected to a digital system can be safely removed without consulting prior X-ray findings following anatomical lung resections.

Patients undergoing anatomical lung resections for NSCLC, excluding wedge resection or pneumonectomy, have been retrospectively analyzed between June 2020 and June 2023. Unless there was a clinical concern, such as prolonged air leak>7days, ICU admission, abnormal pleural effusion, and hypoxia or the decision of consultants, routine post-operative chest X-rays prior to drain removal were intentionally no longer performed.

The cohort consisted of 270 consecutive patients undergoing anatomical lung resections for NSCLC. Twenty-eight patients were excluded, most patients left the theatre with 2 drains (n=24). The remaining 242 patients underwent lung resections mostly via minimal invasive approaches, VATS/RATS (94%). Patients were grouped into three categories. Group 1: No pre-pull X-ray (n=125), Group 2: Pre-pull X-ray routine check (n=71), and Group 3: Pre-pull X-ray due to clinical concern (n=46). Central venous catheter insertion (n=42) and postoperative follow-up (n=29) were the two main indications for pre-pull X-ray in Group 2. The incidence of reoperation, including re-tube and re-VATS was comparable between the groups (Group 1: n=6 (4.8%), Group 2: n=4 (5.6%), Group 3: n=7 (15.2%); p=0.053. The mean duration of chest tube and hospital stay were markedly lower in Group 1 (2+2.7 vs 4.9+4.7 days; p<0.001) than in Group 2 (3.1+3.4 vs 5.8+3.8 days; p=0.011), respectively.

Chest drains can be removed safely without pre-pull X-ray after uneventful anatomical lung resections. Together with other ERAS measures, this practice change helped us to reduce the length of hospital stay significantly.

There's a recent shift from video-assisted thoracoscopy (VATS) to robot-assisted thoracoscopy (RATS) in anatomical lung resections.

We conducted a retrospective analysis of our center's experience with both modalities, examining intra- and postoperative outcomes.

We compared 116 patients undergoing VATS resection (2019-2021) with 103 patients undergoing RATS procedure (2022-2023) at our center. Multivariate Cox regression assessed factors affecting intraoperative blood loss, operation duration, postoperative chest tube duration, and hospital stay. To minimize potential confounders, the models were adjusted for Charlson Comorbidity Index, neoadjuvant therapy, re-operation, active smoking, and COPD grade.

Out of the 219 anatomical resections, the distribution was as follows: 22.4% upper lobe (18 vs. 31), 6.4% middle lobe (5 vs. 9), and 15.1% lower lobe (26 vs. 7). Additionally, there were 31.1% apical segments (37 vs. 31), 4.1% lingula (4 vs. 5), 8.2% segment-VI (9 vs. 9), and 12.8% basal segments (17 vs. 11). The distribution of these lobes/segments was comparable between VATS and RATS, respectively.

In intraoperative blood loss, RATS emerged as a protective factor (0.7; 0.6-1.0, p=0.04), while adhesions posed a risk (2.1; 1.6-2.9, p<0.001) according to Cox regression.

For operation duration, VATS versus RATS had no significant impact. However, radical lymph node resection (1.7; 1.3-2.2, p<0.001) and an elevated COPD grade (1.2; 1.0-1.4, p=0.04) prolonged the duration significantly.

RATS significantly increased the chance of early chest tube removal (0.4; 0.3-0.6, p<0.001), as did segment-IV resection (0.5; 0.3-0.9, p=0.01). Conversely, increased comorbidities (1.4; 1.0-2.7, p=0.008) and active smoking (1.5; 1.1-2.1, p=0.007) were associated with prolonged chest tube duration, similarly impacting hospital stay.

RATS, with enhanced exposure, enables precise surgery, reducing intraoperative blood loss, promoting earlier chest tube removal, and shortening hospital stays. Limited sample size prevented identification of additional impacts for different segments and lobes.

Partial pericardial agenesis is an extremely rare congenital condition, thus far only reported 32 times as an incidental intra-operative finding. It can manifest without symptoms, as observed in our case, or exhibit vague symptoms such as chest pain, palpitations, or shortness of breath. The absence of clear symptoms, the presence of ambiguous ones, and the absence of distinctive radiological findings collectively contribute to the complexity of diagnosing this condition

We present a case of left partial pericardial agenesis, supported by intraoperative video evidence.

In the course of investigating a 42-year-old woman presenting symptoms such as sweating, tachycardia, episodes of weakness, and unexplained weight loss, autoimmune thyroiditis was diagnosed. Subsequent imaging revealed the presence of a mediastinal soft tissue mass measuring 21 x 26 mm. Despite the mass showing minimal growth over time and displaying limited metabolic activity in the PET-CT scan, surgical removal of the mediastinal mass was recommended. Notably, there is no historical, clinical, or electrophysiological evidence of myasthenia gravis in this case.

While conducting the robot-assisted thymectomy, partial agenesis of the ventral left pericardium was observed in the overview (Figure 1). Of note, the posterior side remained completely intact. The thymectomy was executed without complications and post-operative histological examination indicated thymoma hyperplasia. The postoperative course was also smooth and uneventful. Given the incidental findings during the surgery, additional cardiac investigations were conducted postoperatively. Fortunately, no significant electrocardiographic abnormalities were detected.

To our knowledge, our case stands as the 33rd documented instance of an intraoperative incidental discovery of pericardial agenesis. The decision to pursue closure of the defect depends on its size. However, in situations where the defect is substantial, as observed in our case, it is not deemed obligatory.

The relation between HLA epitope mismatched load and outcomes of transplants such as heart, liver, and kidney has been proven. The Predicted Indirectly Recognizable HLA Epitopes (PIRCHE) score has been proposed to quantify the HLA disparity between donor and recipient.

We aim to analyze the effect of the PIRCHE model on the development of chronic allograft dysfunction (CLAD) and long-term survival in LTx.

Patients who underwent LTx between January 2010 and December 2019 with available calculated PIRCHE scores were included in this retrospective multivariante analysis using a prospectively collected database. The primary outcome measures of this study were the incidence of CLAD and long-term survival

 

244 LTx were performed in this period. 119 (48.7%) developed CLAD during follow-up. Patient characteristics are summarized in Table 1. Mostly bilateral LTx (97%), the primary indication was Cystic Fibrosis (29%) and COPD (27%). Primary graft dysfunction Grade 3 incidence at 72 hours was 15%. While 30- and 90-day mortality was 3,6% and 7,3%, respectively. Multivariante analysis showed that even though there was a strong correlation between high HLA mismatch and high PIRCHE score (p=0,00248), this would neither translate into a higher rate of PGD (p-0.803), nor earlier (< 2 years) or late-onset onset of CLAD (p 0.544) Furthermore, there was no correlation with one year or overall survival (p-0.971).

 

While the PIRCHE score displayed a robust correlation with HLA mismatch pre-transplant, this did not manifest in varying incidences of PGD, CLAD, or one-year mortality.

Catamenial pneumothorax is a rare finding among menstruating women. It is characterized by pneumothorax occurring 72 hours before or after onset of menses. Pathogenesis remains elusive. One proposed hypothesis is menstrual cycle dependent transfallopian air passing into the pleura by acquired diaphragmatic defects caused by endometriosis. 

A case of catamenial pneumothorax is presented.

A 48-year-old woman (non-smoker) was referred to our clinic with the third occurrence of a right-sided spontaneous pneumothorax in just 3 months approximately every 4 weeks. CT scan revealed no lung parenchyma abnormalities. During the last pneumothorax-episode a thoracoscopic apical wedge resection was performed in another hospital with the intention to seal a proposed pulmonary leak. Nevertheless, pneumothorax remained for 5 postoperative days. 
 

During explorative thoracoscopy several holes of 2 to 3 mm in diameter were found in the tendinous part of the right diaphragm, bordered by a few brownish deposits (Figure 1). A partial diaphragmatic resection with insertion of Veriset™ hemostasis patch was performed, as well as a pleural abrasion. Post-operatively, asymptomatic accumulation of intraabdominal free air was observed for 3 days. The patient was discharged at POD 7. The diaphragmatic biopsy showed granulating fibrosing and macrophage-rich inflammations with fresh and older residuals of hemorrhage. The findings are in accordance with endometriosis. The final follow-up 4 weeks postoperatively showed no signs of a re-pneumothorax. 

Our case supports the theory of a trans-diaphragmatic air passage as pathogenesis. Recurrent spontaneous pneumothorax in menstruating woman should raise suspicion for catamenial pneumothorax. In such cases, it is imperative to pursue surgical exploration along with inspection of the diaphragm. Defect closure should then be the goal to prevent recurrence.

Several studies have shown that dysregulation of microRNA expression contributes to pleural mesothelioma (PM), including its resistance to chemotherapy. While the majority of studies focused on well-annotated microRNAs, in 2019 previously unknown microRNAs were identified, which distinguished TCGA-MESO from TCGA lung cancer samples with high accuracy.

In the present study, we aim to evaluate these microRNAs in PM, non-PM and lung cancer tissue using PCR as alternative detection approach.

We used archived FFPE tissue from a cohort of 51 PM (39 epithelioid, 9 biphasic, 3 sarcomatoid) collected before chemotherapy, 16 non-PM pleural biopsies (9 benign inflammatory reaction, 7 pleural metastases), and 14 lung cancer cases (9 adenocarcinomas). Novel microRNAs were measured using self-designed PCR primers. Independent samples t-test was used to assess expression differences between groups.

We found significantly elevated expression of mpm-miRs-72, -18 and -58 in PM compared to both non-PM and lung cancer (Fig. 1A). Further subdividing the non-PM cases, showed that expression differences remained significant between PM and benign tissue with the highest difference found for mpm-miR-72 (5.4-fold, p=0.01). Expression of all three microRNAs was highest in biphasic PM, reaching statistical significance for mpm-miR-18 (1.9-fold, p=0.036; Fig. 1B). Since microRNAs have been shown to influence response to chemotherapy, we also compared expression differences based on chemotherapy response for the 33 PM patients for whom mRECIST data was available. Indeed, all three microRNAs showed highest expression in patients with progressive disease, with an expression difference compared to partial responders of 2.8-fold for mpm-miR-58 reaching statistical significance (p<0.001).

Our current findings support a diagnostic potential of novel microRNAs in PM for differentiation from benign lesions and lung cancer. Furthermore, higher expression of all three microRNAs in patients with progressive disease suggests a contribution of these microRNAs to chemoresponse, which warrants further investigation.

Thoracic surgery is considered a painful procedure.

The purpose of this study was to examine the short- and long-term effects of intercostal cryoanalgesia after thoracic surgery in adults, focusing on opioid consumption and neuropathic pain.

We conducted a single-center prospective analysis of 9 patients who underwent unilateral thoracic surgery in December 2022. Patients received intercostal nerve cryoanalgesia during the intervention involving five intercostal nerves. Visual analog scale (VAS) for pain, opioid consumption, and DN4 score for neuropathic pain were assessed during the early post-operative period and at 1-, 3- and 6-months post-surgery.

Eight patients underwent a video-assisted thoracic surgery procedure for lobectomy (N=5), wedge resection (N=2) or apicectomy and pleurodesis (N=1). One patient underwent thoracotomy and pleurectomy/decortication for mesothelioma.  The median drainage duration was 3 days (IQR: 1-4 days) and the median length of hospital stay was 3 days (IQR: 2-5 days). One patient died after lobectomy due to pneumonia and ARDS.

A maximal VAS ≤3 was found in 4/9 patients at postoperative day 1 and in 8/9 patients at day 2. An opioid-free management was possible in 6/9 patients at day 1 and in 7/9 patients at day 2. The deceased patient and the one who had thoracotomy needed opioids. At 1 month, 7/8 patients had VAS between 4-5 and 3 patients required opioids treatment. At 3 months, 7/8 patients had DN4 score ≥ 4, but only 1 patient required Pregabalin and opioid treatment. At 6 month, 2/6 patients had a DN4 score ≥ 4 and no patient had analgesic treatment.     

Our study highlights the potential benefits of intercostal cryoanalgesia in reducing opioid use and pain during the postoperative period after thoracic surgery. However, the observed neuropathic pain raises concerns and suggests the call for a clinical trial with patient-reported outcome measures to consider the benefit-risk ratio of this approach.     

Novel therapeutic approaches are needed for patients with pleural mesothelioma (PM). Our phase I and II clinical trials for localized chemotherapy with cisplatin-fibrin after surgery investigated safety and efficacy of this novel approach.

Here, we aimed to identify biomarkers associated with disease outcomes.

Tissues collected at diagnosis (pre-CTX) were available from 5 patients. We collected tumor tissues at surgery (post-CTX), before start of localized treatment, from all patients enrolled (n=25). FFPE tissues were immunohistochemically stained for p21 (cisplatin resistance), and Ki-67 (proliferation)¹. Using Qupath software, we classified tumor cells from stroma. Number of positive cells (%) were automatically counted. For p21, we also acquired H-score (sum of intensity x % positive cells) for p21. The association of marker expression with disease outcomes including progression free survival (PFS) and overall survival (OS) from surgery was analysed by SPSS software.

Ki-67 staining index (%) ranged from 1.2 – 60.8 (median 12.8). p21 staining index and H–score (range (median)) are 0 - 96 (21) and 0 - 225 (32), respectively. High Ki-67 labelling index was significantly associated with shorter PFS (p=<0.001, median (95% CI): 25.1 (11.3 – 39) vs 8.5 (6.8 -10.2) months) and OS (p<0.001, 37.8 (26.7 – 48.8) vs 16 (12.6 – 19.3) months) (figure 1). There was no association between clinical parameters with Ki-67 or p21 staining. p21 staining index and H-score showed no association with disease outcomes. For 5 patients of whom pre- and post-CTX tissues were available, we observed reduction of Ki-67 index after CTX in 3 cases. Whether the change in Ki-67 was associated with response to CTX and intracavitary treatment is still under investigation.

Although a small patient cohort, Ki-67 showed significant association with disease outcomes for patients receiving localized cisplatin-fibrin. Ki-67 may be useful for the selection of patients for this treatment regimen.

Pulmonary artery sarcomas (PAS) are rare and carry a poor prognosis. We present the case of salvage surgery for PAS recurrence with symptomatic outflow track near occlusion after multimodality treatment.

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A 48 year old female patient was admitted for PAS recurrence. Two years prior, she had a bilateral pulmonary tumor endarterectomy, under moderate hypothermia and circulatory arrest, followed by adjuvant chemotherapy. Due to an intracerebral metastasis the patient then underwent a craniotomy for intracerebral tumor resection. Following the surgery the patient underwent radiotherapy of the resection cavity. Due to multiple recurrent metastasis in the left medial frontal gyrus two more resections had to be performed through re-craniotomies. Two-year follow-up PET-CT showed a significant stenosis of the pulmonary artery trunk by a recurrent tumor mass which extended to the right ventricle, causing significant outflow obstruction. Multidisciplinary tumor board opted for salvage surgery. An extensive tumor resection including the pulmonary artery trunk and the pulmonary valve was followed by replacement using an allograft composed of a pulmonary valve with a pulmonary artery conduit. Postoperative course was uneventful and the patient was discharged 9 days after surgery to a rehabilitation center. Four months follow-up found no recurrence on the pulmonary artery trunk: but palliative care was initiated because of progressive cerebral metastasis. The patient later on died at the age of 49 in hospice care.

Salvage surgery for PAS recurrence is feasible in expert centers where close collaborations between thoracic and cardiac surgeons is possible. Potential benefits of such extensive surgery needs to be balanced with the patients’ life expectancy and quality of life, which are conditioned by presence of metastases.

In the posterior mediastinum, schwannomas are the most common nerve sheath tumors. While the majority of all patients are asymptomatic, symptoms usually occur in large lesions and greatly depend on the location. The resection of schwannoma is generally recommended since they can lead to a relevant mass effect and due to the potential for malignant transformation.

We aim to report the case of a large intrathoracic schwannoma that was resected by robotic-assisted thoracic surgery (RATS).

We report the case of a 45-year-old male patient presented to his general practitioner with clinical features of Horner’s syndrome. Upon magnetic resonance imaging, a large (7.0 x 6.5 cm), heterogeneously enhancing mass with neuroforaminal extension (Th1/2 and Th2/3) was discovered in the left upper hemithorax. A computed-tomography guided biopsy was performed and showed a S100-positive spindle cell neoplasm with no features of malignancy, favoring schwannoma. After multidisciplinary sarcoma board discussion, resection was recommended.

We performed a robotic-assisted thoracoscopic resection of the schwannoma using a 5-port access. The tumor’s capsule was densely adherent to the parietal pleura and the tumor resection was performed extrapleurally. For the complete resection, the subclavian and carotid arteries were dissected. The tumor was found to be originating from the sympathetic chain and was excised along with part of the nerve. Upon pathological evaluation, a 7.8 cm measuring schwannoma with no features of malignancy was reported. The patient made an uneventful postoperative recovery and was discharged at the third postoperative day. The Horner’s syndrome persisted during clinical follow-up.

The sympathetic chain is a rare origin of intrathoracic schwannomas. Their resection by robotic-assisted thoracic surgery is safe and feasible.

In non-small cell lung cancer (NSCLC), spread through air spaces (STAS) is a relatively novel concept describing an infiltration of cancer cells within air spaces beyond the borders of the main tumor. Previous studies have demonstrated a significantly increased risk of locoregional recurrence in STAS-positive NSCLC and lobectomy is therefore recommended over sublobar resection also in T1 tumors.

We aim to report the challenge in the management of STAS-positive early-stage NSCLC based on two clinical cases.

We report the cases of two patients who underwent sublobar resection for clinical T1 N0 M0 NSCLC. Patient 1 is an 80-year-old female patient with good performance status and sufficient functional reserve who underwent robotic-assisted left S6 segmentectomy and systematic mediastinal lymphadenectomy.

Patient 2 is a 57-year-old male patient with chronic obstructive pulmonary disease who underwent video-assisted thoracoscopic S1+3 segmentectomy and mediastinal lymphadenectomy.

In both patients, the intraoperative frozen section revealed an adenocarcinoma, but STAS was not detected. Due to the size of the primary tumor and the absence of signs of hilar or mediastinal lymph node metastases, we decided not to proceed to lobectomy. 

In both patients, the definitive pathological analysis revealed a poorly differentiated early stage adenocarcinoma (TNM stage, 8^th edition: pT1b pN0 cM0) without signs of angioinvasion. However, STAS was present in both specimens. After discussion at the multidisciplinary tumor board, a completion lobectomy was recommended for both patients.

During intraoperative frozen section, STAS is often underdiagnosed in early-stage NSCLC. Thoracic surgeons should therefore be aware of this clinical challenge and explicitly ask for signs of STAS when receiving the frozen section report. In addition, further research is required for a fast and intraoperative detection of STAS to increase the learning curve.

Lung cancer constitutes the leading cause of cancer-related deaths in Switzerland. There is evidence, that early detection trough screening programs could reduce morality. Since 2019, a study evaluating the feasibility and efficacy of low-dose CT lung cancer screening (LCS) program in Switzerland is ongoing. 

One potential risk associated with screening programs, is the psychological burden of the participants. 

204 Subjects (125 males, median age: 62 years) smokers or ex-smokers were included in the lung cancer screening consisting of a interview and a low-dose CT. CTs were assessed according to the LungRAD 1.1. In a subset of 59 participants (38 males, median age: 61 years) psychological distress was assessed using a visual analog scale (Range: 0-10) and the Impact of Event Scale (Score: 0-120).

Negative screening (LungRADs 1) results were seen in 46.04% of participants (n=93). Benign (LungRADs 2) or probably begnin (LungRADs 3) nodules occurred in 38.61% and 12.38% of participants (n = 78 and 25). Suspicious (LungRADs 4A) or very suspicious nodules (LungRADs 4B) were observed in 3.96% (n = 8) of participants. Seven patients (3.43 %) had malignancies (four adenocarcinomas, one squamous cell carcinoma, one thymoma, one thyroid cancer).

In the visual analogue scale, a psychological distress of 1.7 ± 2.14 was reported. In the Impact of Event Scale a value of 10.14 ± 15.93 was observed. Higher psychological distress values were occasionally reported, see Figure 1. A significant correlation between both scales was observed (p < 0.001, R²= 0.53, Figure 1).

In this investigation, it was observed that employing low-dose CT scans as a screening modality led to the detection of multiple malignancies. A majority of the subjects experienced minor psychological distress. Nonetheless, instances of significant stress were reported. Additional studies are warranted to quantify the magnitude and determinants of psychological distress associated with this screening process.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and debilitating disease, marked by diagnostic complexities leading to delays in diagnosis and treatment. The need for a national multidisciplinary evaluation board was recognized given the disease rarity and the mid-size population of Switzerland. The Swiss CTEPH board was inaugurated in January 2018, supported by the Swiss Society of Pulmonary Hypertension. The board comprises an interdisciplinary team uniting their expertise to deliberate on cases involving potential CTEPH and ensure comprehensive patient care.

We aimed to evaluate the impact of the multidisciplinary national CTEPH Board on a monocentric surgical endarterectomy program.

The patients discussed in the national CTEPH Board were retrospectively analyzed for the diagnosis of CTEPH and subsequent treatment allocation with focus on pulmonary endarterectomy (PEA).

From January 2018 to May 2023, our national CTEPH board received a total of 198 referrals. Among these, diagnosis of CTEPH was confirmed in 160 (81%) patients. Out of these patients, 73 (46%) were directed to PEA, while 56 (35%) were referred for BPA. Notably, 8 patients (11%) underwent both PEA and BPA. The annual median number of PEA procedures performed was 12, with a range of 10 to 17. Among the patients undergoing PEA, there was a significant improvement in their median mean pulmonary artery pressure (mPAP) from 43mmHg (preoperatively, range: 19 – 76mmHg) to 23mmHg at 6 months postoperatively (range: 12 – 51mmHg) (p<0.05). Additionally, the median 6-Minute Walking Distance showed improvement, increasing from 481m (preoperatively, range: 60 – 696m) to 517m postoperatively (range: 237 – 780m) (p<0.05).

Establishing an interdisciplinary CTEPH board is essential for addressing the unique diagnostic and management challenges in CTEPH. The Swiss national CTEPH board has played a crucial role in accurately diagnosing and identifying operable patients who benefit from surgical interventions leading to a considerable increase in PEA procedures since its establishment.

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a rare and severe form of pulmonary hypertension marked by persistent obstruction in pulmonary arteries (PA) caused by fibroobstructive tissue (FO), which may originate from unresolved thromboembolic material. The precise triggers for inadequate resolution of pulmonary emboli in CTEPH are not understood. The only curative treatment is the removal of FO and diseased intima by Pulmonary Endarterectomy (PEA). The FO in CTEPH may result from intimal damage, prompting mesenchymal transition and fibroblast proliferation. Understanding CTEPH development necessitates a focused exploration and characterization of the involved cell types was the aim of the present project.

We aim to stratify the cellular composition and determine the presence of ECs in the fully organized FO and diseased intima, in CTEPH patients.

The fully organized FO and diseased intima, were resected in PEA. Thereafter, tissues were macerated, digested, and obtained cell suspensions were cultured in a medium sustaining the growth of ECs. Propagated cell populations were analyzed for their cyto-morphological properties (shape size, morphology) by light microscopy.

Analysis of the obtained cultured primary cell populations from FO identified four different morphologies solely or in combination: fibroblast-, cobblestone-, squamous- and dendritic-like cells. Interestingly, on a limited number of resected intimal tissues we could identify a mixture of mainly cobblestone- and squamous cell-like cells.

As expected, cells isolated from intimal tissue contained more epithelioid cell types, while FO tissue predominantly contained fibroblast-like cells. These data imply that different cells populations are contributing to development of FO in CTEPH pathogenesis, pointing to their complex interactions being a key for deciphering the development of CTEPH. Further studies in this direction are warranted, in which the obtained cell types will be characterized, with an ultimate goal of establishing primary cell lines for further therapy studies either solely or in co-culture.

A 66-year old patient with a diagnosis of cT4N0M0 left central squamous cell carcinoma invading the descending aortic wall without any signs of lymph node involvement. His personal history includes a COPD Class I Group A, yet with a sufficient pulmonary function for an extensive resection or even pneumonectomy. The multidisciplinary tumor board recommended induction immunochemotherapy treatment due to the unique nature of the case.

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The patient demonstrated a partial response after the induction immunochemotherapy treatment so we proceeded to surgical intervention. For protection of the aortic wall we followed our protocol in these situations to insert upfront an aortic stent graft - GORE cTAG 28x28x150mm (landing zone 4-5) with a day before surgery – an extended left pneumonectomy including lymphadenectomy using the Robotic-Assisted Thoracic Surgery (RATS) approach. Notably, during the procedure, a meticulous separation of the tumor from the aorta was achieved (Figure 1). The patient's postoperative course was uneventful, with a hospital stay of six days. The final pathology revealed a Stage IIIA disease, characterized by ypT2a ypN2 cM0. The first CT scan 3 months after surgery revealed regular postoperative changes with no evidence of local recurrence, lymph node or distant thoraco-abdominal metastases.

This successful management highlights the effectiveness of a multimodal approach, combining innovative induction treatments, precise surgical techniques, and meticulous postoperative care. The presented case demonstrates the importance of collaborative decision-making within a tumor board setting and the successful application of advanced surgical interventions to achieve optimal outcomes in complex oncological cases.

Real-time imaging is a powerful approach allowing longitudinal observation of tumors and their microenvironment, providing cancer progression insights. In the context of NSCLC, understanding changes in tumor immune content is crucial for evaluating its response to immunotherapies. However, intravital imaging studies on NSCLC are infrequent and impeded by technical challenges.

We present here a novel murine thoracic window model combined with a breathing artifact correction method, enabling high-resolution real-time imaging of immune, vascular, and tumor compartments of orthotopic NSCLC.

Two lung adenocarcinoma (LAD) cell lines, CMT167-GFP (KRAS^G12V mutant, syngeneic to C57BL/6 mice) or 344SQ-GFP (Kras^G12D; p53^R172HΔG mutant, syngeneic to 129/Sv mice), were orthotopically injected into the lungs of 17 C57BL/6 mice, and tumor growth was monitored using micro-CT. The thoracic window was permanently implanted on the chest 10 days post-injection allowing repeated observation using an upright 2-photon microscope. The combination of a frame stabilizer and a respiratory gating monitoring pad integrated with the imaging system minimized breathing artifacts enabled high-resolution imaging of tumor cells (GFP), vasculature (Pacific Blue-Dextran angiography), and leukocytes (Rhodamine-6G) over a three-week period.

The surgical window implantation protocol was successfully performed within 60 minutes with a 95% success rate (n=18). Micro-CT data guided accurate window placement, and the frame design combined with stabilization enabled repeated high-resolution imaging of a surface area measuring 800 um² and 300 um depth of tumor bulk, vasculature, and leukocytes with limited breathing artifacts. Finally, the monitoring of LAD three times weekly over three weeks revealed increased vascular density (9%), tumor progression (55%), and leukocyte recruitment (13%) at the tumor site.

We successfully established a reproducible NSCLC permanent thoracic window model with an orthotopic approach. Longitudinal assessment of treatment-induced modulation of the TME and particularly on the immune cell homing may bring valuable information in the future.

With the advent of enhanced recovery programs (ERP) length of hospital stay (LoS) were shortened substantially. However, program refinements may have additional impact. Patients participating with periOPTIME are motivated to stay active during the preoperative period and profit from streamlined referrals to specialist counselling.

The program aims for minimal invasive approaches and strict reduction of unneeded examinations with emphasis on enhancing patient experience and QoL

Patients undergoing anatomical lung resection between May 2022 - December 2024 are treated within a modified ERP and compared to a historical control group (2018-2020).
To study prospectively the effect of a modified enhanced recovery program within a patient population undergoing anatomic lung resection. The primary objective is to assess LoS. Preliminary data from May - November 2022 was analysed.

The preliminary analysis included 19 patients with 58% male and 42% female participants and median age of 65 years. Most participants suffered from NSCLC (N=16) including UICC stage I-IV, followed by patients with Metastasis from other primary tumors (N=2) and one case with Cryptogenic Organising Pneumonia. Resections were scheduled as RATS (42%) or VATS (58%). Two VATS UL resections were converted to open surgery. Median LoS was 4 days (2-17) compared to 9 days in the historical group for VATS/RATS lobectomy. Open surgery was related to higher LoS. No major complications related to the study protocol occurred. Main reasons for prolonged LoS was airleak (N=5), chylothorax (N=1), pleural effusion (N=1) and social reasons (N=2). Median time to first mobilisation in the ERP group was 7 hours (3-24; sd=7.4). Median time for thoracic drainage was 23 hours (17-360; sd=90)

Preliminary data showed a shorter LoS in the ERP group, without the occurrence of major complications. The sample is too small to detect significant change in LoS. However, the results are promising.

Azygos vein aneurysms are rare and most of the time asymptomatic. They are typically discovered incidentally during imaging studies conducted for unrelated reasons. Since they can mimic more severe diseases, they need definitive diagnosis.

We aim to present a case of an azygos vein aneurysm and to highlight the importance of accurate diagnosis and appropriate management.

We present the case of a 50-year-old male who was referred after a paratracheal lesion was incidentally discovered on a computed tomography (CT) of the chest performed for an episode of shortness of breath. Subsequent CT confirmed the persistence of the lesion, raising suspicion of a paraganglioma or an enhancing lymphnode without excluding a beginning lymphoma. Following multidisciplinary discussions, a combined endo-esophageal and endo-bronchial ultrasonography was performed. However, this yielded inconclusive results : at ultrasonography a saccular lesion was seen and the biopsy showed an organized thrombus. After novel discussion in the multidisciplinary board, we decided to go ahead with more invasive diagnostic measures.

A multi-port exploratory thoracoscopy was performed : a lesion firmly attached to the azygos vein was identified. After mobilization from the esophagus and trachea, successful removal was achieved through resection of the azygos arch. The postoperative course was uneventful. Pathology confirmed the venous malformation in form of a saccular aneurysm of the azygos vein, containing organized thrombus.

Azygos vein aneurysm is a rare condition that can mimic a chest neoplasm, necessitating thorough investigations to rule out alternative diagnoses. Endoscopic ultrasound provided a strong diagnostic suspicion that was finally confirmed by thoracoscopy.

Doege-Potter syndrome constitutes a rare entity induced by a paraneoplastic production of Big-IGF2 causing hypoglycemia mainly due to a solitary fibrous tumor (SFT) of the pleura. The disease onset occurs in most people between 40 and 60 years old. Complete excision of the tumor is the treatment of choice. For larger tumors, preoperative embolization may be useful to minimize blood loss. The microscopic features for malignant potential are high mitotic activity, high cellularity, pleomorphism and presence of necrosis.

We present the case of a patient with Doege–Potter syndrome with concomitant SFT of the pleura resected en bloc with a diaphragmatic patch and a lung wedge resection.

A 44 years old woman with no prior medical history presented few months earlier with severe hypoglycemia. Outpatient workup showed suppressed insulin secretion and a thoracic CT-scanner revealed a large tumor of the right chest suggesting SFT. We decided for embolization followed next day by surgery through a hemi-clamshell. The en bloc resection with diaphragmatic patch and lung wedge resection was followed by reconstruction of the diaphragm with a Prolene mesh.

Pathological examination showed a SFT of 17.5cm in diameter with sound margins. No further features of malignancy was found, especially in the immunohistochemical examination (Mitotic activity, ki67, CD34 , S100 and CK116). Recovery from hypoglycemia was observed slightly after the embolization and then clearly postoperatively. Big-IGF2 results are still in process.

Surgical management preceded by embolization allowed a safe removal of the tumor through a hemi-clamshell. Histology confirmed the suspicion of SFT with no malignant features and return to normal glycemic levels was consistent with Doege-Potter syndrome.  

Direct visual control and 2D-fluoroscopy is widely used to achieve an anatomic syndesmotic reduction in ankle fractures with syndesmotic instability. However, significant malreduction rates are reported.

It was the aim of this study to evaluate the accuracy of conventional syndesmotic reduction and to assess the impact of intraoperative 3D-imaging to improve the quality of syndesmotic reduction.

Single institution consecutive case series (02/2021 – 12/2023) including all patients undergoing operative treatment for ankle fractures with syndesmotic instability. Syndesmotic reduction was performed following open reduction and internal fixation of the malleolar fractures. Provisional tibiofibular alignment was obtained under visual control and 2D-fluoroscopy. With the ankle held in a neutral position, temporary fibulotibial transfixation was performed with 2 K-wires. 3D-imaging was obtained (Cios Spin, Siemens Healthineers, Forchheim-Germany). Non-anatomical positions of the fibula were divided into anterior, posterior, or rotational malreductions. If reduction was not satisfactory, the reduction was improved and 3D-imaging repeated. Once adequate reduction was obtained, definitive syndesmotic fixation was performed and the K-wires were removed.

A total of 73 patients (mean age 45±16 years, m/f 43/30) were operated for ankle fractures with syndesmotic instability. Intraoperative 3D-imaging confirmed anatomic syndesmotic reduction in 45 patients (62%). In 24 patients (33%) reduction was repeated once, in 4 patients (5%) two additional reduction manoeuvers were necessary to obtain an anatomic result. Thus, a total of 32 malreductions were recorded in a total of 96 105 reduction manoeuvers (3330%). Of these, we observed 22 anterior (69%), 2 posterior (6%) and 8 rotational malreductions (25%).

Syndesmotic reduction under visual control and 2D-fluoroscopy proved to be unreliable with a syndesmotic malreduction in almost one-third of all reduction manoeuvers. With the help of intraoperative 3D-imaging incorrect tibiofibular alignment before definite fixation was identified, reduction corrected and thereby the rate of malreductions reduced.

Temporary external fixation is an established procedure in damage control surgery to adapt to the patient`s physiology. Yet, external fixation is also performed in patients that could also be cleared for early definitive fixation. MUST (MusculoSkeletal Temporary Surgery) describes injury patterns that should be considered for temporary fixation also in isolated musculoskeletal injuries.

The impetus of our study was to identify patient characteristics that are predictive for external fixation in physiologically compensated patients.

A retrospective database of patients admitted via trauma bay followed by surgical treatment from 2015 -2022 was analyzed. Only physiological compensated patients were included for further analysis. Statistical comparison was performed to test for significant differences in between the groups and logistic regression was performed to identify independent predictive factors for external fixation. Subgroup analysis for patients with and without cerebral injuries was performed.

From 355 initial patients, 204 patients were considered as physiological compensated. 78 patients received temporary external fixation and 126 did not. Patients in the external fixation group presented significant more open fractures, a higher overall ISS and AIS of the lower extremities. Adjusted logistic regression yielded the presence open fractures, elevated AIS of the lower extremities, non-intra-articular fractures and presence of cerebral injuries as independent predictors for external fixation.

The presence of intracranial injuries seems to influence the surgical decision making towards external fixation regardless of the injury severity and morphology. In addition, an open fracture constellation as well as the severity of lower extremity injuries seem to be able to predict external fixation. Further research regarding (temporary) fracture fixation within patients with intracranial lesions should be undertaken.

Musculoskeletal injuries are frequently observed in patients with multiple trauma. Determining the appropriate treatment strategy and timing definitive fracture fixation is crucial for systemic outcomes.

In this regard, this study aimed to provide recommendations for timing and sequence of fracture fixation in multiple injured patients, with an emphasis on concurrent injuries, to the head, chest, abdomen, spine (including spinal cord), vasculature and multiple extremity fractures.

We formed an international multidisciplinary expert panel consisting of 17 members from 4 continents and 10 countries and developed consensus statements using the Delphi-method. Starting in March 2023, statements were drafted to define conditions for each type of concomitant injury under which fracture fixation can be recommended based on the current literature and underwent repeated modifications until the in-person meeting in September 2023. During this meeting, the statements were discussed and adjusted by the expert panel until greatest possible consensus was reached. The process was supported with a systematic literature review to identify relevant literature.

A total of 20 consensus statements were prepared. Of these, 5 focused on traumatic brain injury; 3 on thoracic trauma; 4 on abdominal trauma; 3 on multiple extremity fractures; 3 on spinal injuries and 2 statements on vascular injuries. Overall, 78 publications were reviewed on whose basis an overwhelming consensus was achieved for all 20 statements.

The panel discussed the conditions and exceptions of definitive fracture fixation. A total of 20 statements were developed on the timing of fracture fixation in patients with concomitant injuries. All statements agree that fracture fixation for major extremity injuries should be initiated within 24 hours of admission and completed within that timeframe, unless physiological or severe concomitant issues prevent the patient from going to the operating room.

Displaced femoral neck fractures (FNFs) in patients under 65 years are relatively rare, accounting for less than 5% of hip fractures. This study examines controversies in the surgical approach for high-energy FNFs, specifically focusing on the feasibility of a closed reduction technique. 

Emphasizing the importance of reduction quality, which significantly influences outcomes, the aim of this study is to explore the correlation between closed reduction and primary bone healing.

A retrospective cohort study at a level one trauma center included 54 patients (median age 57.5) with FNFs treated between 2012 and 2021. Closed reduction and internal fixation were performed, and outcomes were assessed using various classification systems. Bone union, major complications, conversion to hip arthroplasty, and the relationship between reduction quality and outcomes were analyzed.

Closed reduction demonstrated satisfactory outcomes in over 85% of cases. Major complications occurred in 19%, with 17% requiring conversion to total hip arthroplasty. Unacceptable/borderline acceptable reduction quality correlated significantly with the need for later conversion. Regarding the quality of reduction, the surgeon's overall impression demonstrated the highest inter-rater reliability, whereas the Lowell’s criteria and the Garden alignment index only achieved a fair and slight level of agreement, respectively.

The study supports the safety and feasibility of closed reduction for acute FNFs in patients under 65, achieving favorable clinical and radiological outcomes with a low complication rate. Furthermore, it underscored the significance of the surgeon's overall impression in evaluating reduction quality. Enhanced reduction quality achieved through closed methods correlates with a reduced conversion rate to total hip arthroplasty.

Fixed-angle implants allow volar plating of dorsally displaced and comminuted distal radius fractures by buttressing the subchondral bone which prevents dorsal displacement. As the stability relies on buttressing rather than fixation, some implants use smooth fixed-angle locking pegs instead of locking screws. Biomechanical studies comparing these options have shown contradictory results.

The aim of this study was to compare the short-term radiological outcome of patients with distal radius fractures, stabilized with a volar plate using either locking screws or pegs.

Adult patients who received volar plating of a distal radius fracture at a trauma center in Switzerland between 06/2019 and 06/2022 were eligible for inclusion. Only patients who received an implant allowing both locking pegs and screws were included. Primary outcome was radiological loss of reduction. This was defined as a difference in radial inclination >5°, volar tilt >10° or ulnar variance >2mm measured on the standardized intraoperative images and at the 6-week follow-up. Secondary outcome was duration of surgery.

Out of the 521 patients who underwent surgical treatment for a distal radius fracture at the study hospital, 88 were included in this study. Of these 49 were treated with pegs and 39 with screws. Patient demographics between the groups were comparable, however there were more complex fractures in the peg group. There was no significant difference in the occurrence of radiological loss of reduction between the groups (13 vs 11 patients, p = 0.2). The duration of surgery was longer for patients who received screws (104 vs 81 minutes, p = 0.003).

Regarding secondary loss of reduction at the six-week follow-up both locking pegs and screws show similar results. Considering the potential benefits of pegs, such the smooth surface which may reduce the risk of joint penetration, pegs are a viable alternative to screws.

Routine outpatient visits and X-rays six weeks after surgery for upper extremity fractures is an example of an established healthcare standard. Is part of our daily business, but, its usufulness has never been investigated. 

To investigate the usefulness of the routinely planned six week outpatient visit and X-ray in patients treated surgically for the most common upper extremity fractures including clavicula, proximal humerus, humerus shaft, olecranon, radial shaft and distal radius.

This was a retrospective analysis of all patients treated surgically for upper extremity fractures between 2019 and 2022. The first outcome of interest was the incidence of abnormalities found on the X-ray made at the 6-weeks outpatient visit. In case an abnormality was detected, the hospital records were screened to determine its clinical consequence. The clinical consequences were categorized into requiring either additional diagnostics, additional interventions, change of standard postoperative immobilization, weightbearing or allowed range of motion (ROM). The second outcome of interest was the incidence of deviations from the local standard post operative treatment and follow-up protocol based on the 6-weeks outpatient visit as a whole. Deviations were also categorized in the same manner.

A total of 267 patients were included. Abnormalities on X-ray at 6-weeks were found in only 10 (3.7%) patients of which only 4 (1.5%) had clinical implications (in three patients extra imaging was required and in one patient it was necessary to deviate from standard weightbearing/ROM limitation regime). The clinical/radiological findings during the 6-weeks outpatient visit led to a deviation from standard in only 8 (3.0%) patients. Notably, the majority of these patients experienced symptoms suggestive for complications.

The routine 6-weeks outpatient visit and X-ray, after surgery for common upper extremity fractures, rarely has clinical consequences. It should be questioned whether these routine visits are necessary and whether a more selective approach should be considered.

Although rare, fractures may occur after an episode of seizures in absence of a direct trauma. Forceful muscular contractions as a result of convulsive seizures contributing to various types of fractures and dislocations have been reported.

This report explores the complexities surrounding fractures arising from epileptic seizures, a rare but consequential phenomenon.

We present the case of a 30-year-old male with grand-mal epilepsy and autism who sustained a proximal humerus fracture without direct trauma. The CT scan showed a complex 4-part humeral head fracture including a head-split component with anteroinferior displacement of the surface-bearing articular fragment (Fig. 1).

Surgical intervention comprised of open reduction and internal fixation with an anatomical locking compression plate, addressing the nuanced fracture pattern. The reduction of the dislocated head-split fragment proved to be the critical step in the operation after which the procedure was successfully completed without any further challenges. The patient's early discharge due to social and psychological reasons and a subsequent seizure on the opposite side added a layer of complexity to the case, prompting rigorous clinical and radiological follow-ups (Fig. 2). Despite setbacks, the postoperative phase demonstrated a gradual regression of humeral head depression, fostering the potential for recovery.

This case underlines the imperative for clinicians to consider the biomechanical impact of convulsive seizures and the risk of severe musculoskeletal injuries. Beyond the immediate medical intervention, it highlights the need for comprehensive care and vigilant follow-ups to ensure the optimal recovery of both, neurological and musculoskeletal aspects in patients at the intersection of epilepsy and traumatic fractures.

A trimalleolar fracture involves the lateral malleolus, medial malleolus and the distal posterior aspect of the tibia. The trauma is often accompanied by syndesmotic injury. Surgical repair using ORIF is generally required because the ankle cannot bear any weight while the bone knits. Postoperative full weight bearing usually begins after the fractures have started to heal and a cast has been removed. This process typically takes six weeks for a healthy person.

This case aims to show that an immediately protected full weight bearing due to noncompliance by a severely compromised patient after double plate ORIF is possible.

We present a 73-year-old male with chronic alcohol consumption, diabetes mellitus type II, advanced atherosclerosis and cardiac surgery two years ago. A two-level injury; a dislocated trimalleolar fracture with a syndesmotic injury and insufficient fracture of the medial tibial plateau, states poor clinical outcome with the nonsurgical therapy. The traditional surgical treatment would be single plate lateral malleolus ORIF with two threaded screws for the medial malleolus with one or two syndesmotic screws. However, due to the malcompliance, we performed the double plate ORIF on the lateral malleolus, single plate ORIF plus tension-band wiring on the medial malleolus with four tibiofibular positioning screws. The medial tibial plateau fracture was fixed with a single locking compression plate. IWB in a walking boot immediately after the surgery was implemented.

Despite the low pre-operative odds such as malnourishment, noncompliance and reduced bone stock the clinical and radiological follow-ups are showing very satisfactory results. A radiological scan 6 weeks after the operation confirmed a persisting anatomical reconstruction.

Our case showed that the double plate ORIF with more than the two tibiofibular positioning screws and IWB by polymorbid patients could be a viable option. Randomized controlled trials comparing single vs. double plate ORIF with IWB are needed.

Compartment syndrome (CS) is a serious, potentially limb-threatening condition characterized by increased pressure within a closed muscle compartment, leading to decreased tissue perfusion. In cases of tibial shaft fractures, there is a significant risk of developing CS, typically marked by pain out of proportion. In this case report we present an atypical manifestation of CS in a competent, sensate patient. The diagnosis of silent compartment syndrome (SCS) is scarcely covered in literature, with only a few case reports available.

Our aim is to deepen the understanding of SCS, highlighting its rarity and diagnostic challenges, and stressing the importance of awareness among clinicians.

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A 16-year-old patient, with a non-displaced spiral tibial fracture (AO/OTA 42A1), underwent uneventful intramedullary nail osteosynthesis without pre- or postoperative CS symptoms. The patient's pain was well monitored and -managed (max. NRS 5/10) with oral analgesics. On the second postoperative day, the patient was unable to contract the tibialis anterior and extensor hallucis longus muscles and experienced decreased sensation in the dermatome of the deep peroneal nerve. Despite the absence of severe pain, an elevated intracompartmental pressure of 65mmHg was detected, leading to an urgent lateral fasciotomy. This revealed necrotic muscle tissue in the anterior compartment. Postoperatively, the patient showed improved sensitivity but remained unable to contract the muscles.

In our hospital, we have recorded 1377 cases of tibial fracture osteosynthesis over the past 10 years, with 60 (4.4%) cases necessitating a fasciotomy. All patients undergoing this procedure reported significant pain with typically no relief from analgesics.

SCS can occur without pain in sensate, cooperative, and otherwise healthy patients, causing delayed CS diagnosis and therefore requiring heightened vigilance, emphasizing the clinical examination as a crucial component. The exact cause of absent pain, be it nerve damage, low subjective pain perception, or another factor, remains unclear.

In approximately 10% of cases, fracture extensions occur in femoral neck fractures, reaching up to the per- or subtrochanteric region. These fractures are not listed in the classification developed by AO/OTA, as they represent a combination of 31A and 31B fractures. Typically, hip arthroplasty is considered as the primary surgical strategy for femoral neck fractures. However, for these combined fractures, we have developed an alternative and new strategy. In order to enable early full weight-bearing and mobilization of patients, we treated such combined fractures with a Gamma nail osteosynthesis, which is considered the strategy of choice for per-subtrochanteric fractures. Additionally, to achieve adequate rotational stability in combined femoral neck fractures, we employ an additional anti-rotation screw.

For this specific combination of fractures, as far as we know, no uniform operative methods have been described in the literature. We recommend the use of an additional anti-rotation screw to prevent failure of the gamma nail osteosynthesis in these combined fractures. Additionally, in pertrochanteric fractures, a medial femoral neck component should always be sought with extended imaging using CT-scan.

We have examined five cases of these rare fractures. The data were collected from the Hospital Herisau and the Cantonal Hospital Zug. Postoperative follow-up assessments at 6 weeks have been conducted for all patients.

In all 5 cases, correct alignments are observed 6 weeks post-operation. There has been no dislocation of the fractures in relation to the postoperative radiological assessments during full weight-bearing. The achieved stability of the osteosynthesis, coupled with significantly reduced operative time and reduced intraoperativ blood lost compared to hip arthroplasty, presents a clear benefit for older patients. This, in turn, helps reduce perioperative mortality, especially in higher ASA (American Society of Anesthesiologists) stages.

An additional femoral neck screw for gamma nail osteosynthesis in combined femoral neck fractures and pertrochanteric fractures is a good option for maintaining a rotationally stable osteosynthesis which would otherwise not be given with a medial femoral neck fracture component.

Management of transmediastinal penetrating injuries (TMI) is challenging, and outcome is associated with mortality rates up to 60%.

Herein, we report a case with a complex TMI caused by a long flagpole.

A 61-year-old woman was helicoptered to our trauma center with a transthoracic impalement injury after a boating accident in which she fell on a flagpole. The rescue team brought in a stable patient. Primary survey revealed no further injuries. Initial chest x-ray showed an approximately 30-centimeter radiopaque foreign body penetrating the left thorax. Based on the trajectory, we assumed involvement of mediastinal organs in addition to injury of the lungs.

CT confirmed that the flagpole entered the left thorax through the 3^rd ICS, pierced the left upper lobe, and penetrated the mediastinum just above the aortic arch. The flagpole then passed between the trachea and esophagus before settling in the apex of the right lung. In order to perform the CT, the flagpole had to be shortened on the entrance side with a cold welder. We performed bronchoscopy and esophagoscopy before surgery. Despite extrinsic compression on the ventral esophageal wall and minor tracheal deviation, no evidence of an endoluminal lesion was found. The flagpole was manually stabilized throughout the management. We performed a clamshell incision in the 4^th ICS. As suspected, the flagpole penetrated both upper lobes and the mediastinum just above the aortic arch. The flagpole was carefully withdrawn, after which the aortic arch was found to be uninjured. The pulmonary lacerations and one segmental artery of the left upper lobe were sutured. The patient was extubated after 7 hours and remained in the ICU for three days.

This case of complex TMI emphasizes the importance of shortening impalement objects exceeding CT length limits, and the critical role of multidisciplinary trauma management.

Perforated duodenal ulcer (PDU) is a rare complication of Roux-en-Y gastric bypass (RYGB), with few cases reported in the literature. Diagnosis of perforation is difficult because of the lack of free air in radiologic images. Helicobacter pylori (HP) screening and consideration for additional risk factors such as smoking and non-steroidal anti-inflammatory drugs are recommended.

We present a case of a 54-year-old patient who had a recurrence of a PDU, three months after first surgical repair and 12 years after RYGB.

Following the first surgery for laparoscopic repair of a PDU, the patient missed all the out-patient appointments and failed to take prescribed proton-pump inhibitors (PPI). Three months later, she presented in the emergency department with an acute abdomen. Abdominal CT scan showed abundant extradigestive fluid without the presence of free air. An emergency laparoscopy was planned.

Laparoscopic exploration revealed biliary fluid and fibrin in all four abdominal quadrants. Adhesions among the transverse colon, gallbladder and duodenal bulb were dissected, revealing a perforated ulcer at the level of the duodenal bulb. The ulcer was 5 mm in diameter, at the same location of the first operation. The margins of the ulcer were harvested and sent for histological analysis. The defect was sutured and reinforced with an omental patch. The postoperative course was complicated by dermo-hypodermitis and a retroperitoneal abscess, both of witch were successfully managed by radiological drainage. The ulcer biopsy results were negative for HP or malignant tumor.

DPU is a rare complication after RYGB. Diagnosis may be difficult because of the absence of free air on CT scan. Fundamental is to exclude the presence of risk factors and to continue PPI treatment in the postoperative period, in order to avoid early recurrence.

Gastroesophageal reflux disease is one of the most common gastrointestinal disorders, especially in industrialized nations, with an increasing burden of disease. The first line of treatment consists of lifestyle changes, weight loss and medical therapy. About 10-40% of all patients will not respond to this treatment and eventually need surgical intervention. Although fundoplication remains the gold standard, an increasing variety of different and less invasive techniques are nowadays available.

To present a unique case of late complete esophageal obstruction after LINX device implantation, also referred to as magnetic sphincter augmentation. (Figure 1)

A 72-year-old female patient was admitted to our emergency department for aphagia. Vomiting upon food or liquid intake was reported without other symptoms. Her medical history was bland except for LINX Reflux Management System implantation seven years prior for refractory gastroesophageal reflux disease (rGERD). CT-scan of the abdomen showed a properly positioned LINX with a big mass located in the esophagus just above the device. (Figure 2)

Emergency endoscopy revealed the presence of a big occlusive phytobezoar just above the device which was safely removed. Immediately after the intervention the patient reported complete resolution of all symptoms and oral food intake was well tolerated. The patient was discharged home the next day with an intact LINX device in place.

Fundoplication remains the first choice for patients with rGERD. Even though performed in few institutions, LINX device seems to be a safe alternative to surgical procedures in selected patients. Early dysphagia is a common problem but usually resolves spontaneously. Late complications are rare and treatable, the need for urgent intervention for severe dysphagia or aphagia is highly uncommon. To our knowledge, this is the only reported case with bezoar formation after LINX device implantation.

Background

Lemmel syndrome is a rare condition with upper abdominal pain and jaundice due to a periampullary duodenal diverticulum compromising the common bile duct and/or the pancreatic duct. Magnetic resonance cholangiopancreatography (MRCP) and esophagogastroduodenoscopy (EGD) are considered diagnostic gold standards. Endoscopic retrograde cholangiopancreatography (ERCP), diverticulectomy or observational management are possible treatment options.

Aims

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Methods

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Results

A 74-year-old woman was admitted to our hospital with fever, scleral icterus, and upper abdominal pain. Bloodwork showed elevated hepatic, cholestatic and pancreatic enzymes. We saw marginally wide bile and pancreatic ducts in the MRCP. The EGD with biopsy confirmed a highly inflamed duodenal diverticulum. We started the patient on intravenous antibiotics and opted for watchful waiting. She showed clinical improvement and laboratory regression, and we discharged her after nine days without further intervention. The endoscopic ultrasound after 3 months showed no signs of inflammation or complications due to the duodenal diverticulum, therefore we abstained from any surgical interventions.

Conclusion

We should be aware of rare pathologies like Lemmel syndrome in patients presenting with jaundice and upper abdominal pain, especially in the absence of bile stones. At first occurrence, conservative management is a viable option. In case of clinical recurrence ERCP and diverticulectomy may be considered.

Gastric cancer, particularly adenocarcinoma, poses a substantial health burden with its high mortality rate.

We report a rare case of a large tubular papillary gastric adenocarcinoma with multi-organ abdominal invasion, emergent due to mass size and suspected active hemorrhage, in the absence of preceding symptoms.

A detailed retrospective analysis of a single patient case was performed, including clinical data, imaging, surgical procedure, and histopathology. A targeted literature review was conducted using Pubmed and Scopus databases with specific keywords focusing on huge asymptomatic gastric cancer and the emergency surgery for gastric adenocarcinoma.

A patient with no known history of gastric tumors presented with abdominal pain and anemia. Medical imaging (Image 1) revealed a substantial mass adjacent to the stomach, transverse colon, and small intestine, with indications of active bleeding. Under typical circumstances, such tumors are evaluated with gastroscopy and addressed laparoscopically; however, the tumor's dimensions and the suspected active bleeding necessitated immediate open surgery. The patient underwent successful en-bloc resection (Image 2 and 3) and intestinal reconstruction. Postoperative recovery was uneventful. Histopathological examination confirmed a well-differentiated tubulo-papillary gastric adenocarcinoma with lymph node metastasis, expressing CK7, HER2, and microsatellite instability markers. Despite recommendations for adjuvant chemotherapy, the patient opted for surveillance only.

This case highlights diagnostic and therapeutic challenges in managing asymptomatic gastric cancer and underscores the need for early detection strategies. The deviation from standard management due to tumor size and active bleeding emphasizes the necessity for a flexible approach in surgical emergencies. The patient’s refusal of adjuvant therapy raises questions regarding postoperative care and patient autonomy, warranting further exploration in clinical and ethical research domains.

Transthoracic esophagectomy results in a radical change in foregut anatomy with multiple consequences for digestive physiology.

The aim of this study was to identify factors associated with poor functional outcomes by assessing multiple dimensions of digestive performance and health-related quality of life (HRQL).

Patients with cancer-free survival after Ivor Lewis esophagectomy were included. Four functional syndromes (dysphagia, gastroesophageal reflux disease (GERD), delayed gastric conduit emptying (DGCE), and dumping syndrome (DS)) and HRQL were assessed using specifically designed questionnaires. Patient outcomes were compared with healthy controls. Independent factors associated with poor digestive performance were identified by multivariable analysis.

Sixty-five postoperative patients and 50 healthy volunteers participated in this study. Compared with controls, patients had worse outcomes for dysphagia, GERD, DS, and HRQL, but not for DGCE. Multivariate analysis showed a significant correlation of reduced digestive performance with ASA score, squamous cell carcinoma, open or hybrid surgical approach, and (neo)adjuvant therapy. In contrast, no individual patient factor was found to be associated with dumping syndrome.

Digestive function and HRQL are substantially impaired after Ivor Lewis esophagectomy for cancer. Comorbid patients undergoing multimodal treatment and open access surgery for squamous cell carcinoma have the highest risk of poor functional outcome.

Graft infections after endovascular aneurysm repair (EVAR) are a major challenge in vascular surgery. Definitive treatment requires complete surgical removal of the infected endograft, local debridement and preferably, in-situ reconstruction with a biological graft that is resistant to reinfection.

To present an educational video showing a step-by-step approach to EVAR explantation and aortic in-situ reconstruction using a self-made xenopericardial graft.

Seven months after undergoing elective EVAR (Endurant II, Medtronic, Dublin, Ireland), a 69-year-old, highly comorbid patient was admitted with sepsis due to staphylococcus aureus. Imaging, including 18F-fludeoxyglucose positron emission tomography, confirmed abdominal endograft infection. The patient was scheduled for EVAR explantation and in-situ reconstruction with a xenopericardial graft. The graft was sutured during induction of anaesthesia on a sterile table using an 8 x 14 mm pericardial patch (Supple Peri-Guard, Baxter, Deerfield, IL, USA) and non-absorbable 4-0 polypropylene sutures. After laparotomy and suprarenal clamping, the aneurysm sack was opened and the endograft was explanted. Extensive local debridement and antiseptic rinsing was performed. The previously prepared bifurcated xenopericardial graft was anastomosed to the aorta just below the renal arteries and the flow to the renal arteries was restored. The distal anastomoses were performed to the distal common iliac artery on both sides. Retrocolic pedicled omentoplasty was performed to ensure separation of the new graft from the bowel.

After a complicated postoperative course, primarily due to severe comorbidities, the patient was discharged to a rehabilitation clinic. At three month, computed tomography angiography and laboratory results showed no signs of persistent or recurrent infection and antibiotic therapy was stopped.

Endograft explantation and aortic in-situ reconstruction in EVAR infection requires a high level of experience and a systematic approach. Using the technique presented in this video, a good result was obtained despite severe infection and a highly comorbid patient.

The Nutcracker syndrome is characterized by the extrinsic compression of the left renal vein by the superior mesenteric artery, leading to renal and/or pelvic congestion. Various treatment modalities have been described over the years, and currently, the classical approach involves open surgery with renal vein transposition or bypass to the inferior caval vein. Saphenous vein grafts or PTFE tubes are commonly employed but with some risks of external compression.

We report the case of a bypass using a handmade pericardial tube sutured on a self-expanding stent as interposition graft to treat a Nutcracker syndrome. 

A 35-year-old female patient presenting pelvic and left lower abdominal pain, along with dyspareunia, underwent duplex ultrasound and phlebography to confirm a pelvic congestion syndrome due to Nutcracker syndrome. She benefitted from coiling of the left ovarian vein and pelvic varicosities. Intraoperative intravascular ultrasound confirmed a Nutcracker syndrome with a 70% stenosis of the left renal vein. Due to increasing postoperative flank pain, open surgical treatment with transposition of the renal vein was planned.

Intraoperatively, a fibrotic middle segment of the left renal vein was resected, leading to shortage of length for direct venous transposition. An interposition graft was created by circumferentially sewing a pericardial bovine patch on a self-expanding Nitinol stent (10x60mm) with a 6.0 Prolene running suture (Figure 1). Postoperative anticoagulation was empirically started for 6 months.

Abdominal ultrasound on the second postoperative day confirmed a patent graft, and the patient reported complete symptoms relief. Follow-up angiographic CT at one month confirmed graft patency.

The use of a handmade pericardial-covered stent as an interposition graft offers a novel alternative in Nutcracker syndrome cases. This technique can be used in the absence of saphenous vein, minimizes surgical incision, facilitates anastomosis, and potentially prevents relapsing compression syndrome due to stent rigidity. Furthermore, stent migration is unlikely due to suture fixation. Further research is essential to evaluate the long-term outcomes and generalizability of this innovative approach.

While rare, iatrogenic subclavian artery perforation is related with considerable risks of morbidity and mortality. It is often attributed to an improper placement of a central venous line. Conventional open surgical repairs in this region pose substantial challenges due to the complex interplay of neural and vascular structures. Endovascular repair using a stent graft represents a much less invasive alternative, provided that the anatomy allows to do it.

To demonstrate the feasibility and efficacy of emergency endovascular repair of an iatrogenic subclavian artery perforation occurring after accidental puncture during jugular dialysis catheter placement.

A 50-year-old male with a history of acute myeloid leukemia (in remission), heart failure, and end-stage renal failure required iterative dialysis. A temporary right jugular dialysis catheter was accidentally placed into the right subclavian artery, where its entry point was close to the vertebral artery. Diagnosis was confirmed by CT scan imaging, which also revealed active bleeding with mediastinal hematoma and an arterio-venous fistula.

An immediate endovascular repair was performed via the right femoral artery, involving the placement of an Advanta 10x38 mm stentgraft into the left subclavian artery. Despite partial occlusion of the left internal mammary and vertebral arteries, this approach successfully stopped the bleeding. The patient was discharged home six days later with no neurological or vascular complication. 1 month outpatient’s follow-up showed a permeable stent and a diminishing mediastinal hematoma.

This case demonstrates the feasibility and safety of an endovascular repair in such an emergency situation as an iatrogenic subclavian artery injury. Also, in the current literature we found increasing evidence, that an endovascular approach might be the preferred technique in such situations. However, further concerning prospective multicenter studies are mandatory.

Background

Ulcus Hypertonicus Martorell (UHM), known as hypertensive leg ulcer, poses significant challenges in surgical management due to chronic nature and relevant associated morbidity and mortality as typically a frail patient cohort is concerned. Little is known about the recurrence rate and possible treatment approaches to reduce it.

Aims

This study aims to analyze UHM’s mortality and recurrence rate in a secondary healthcare center to optimize patient outcomes.

Methods

A retrospective monocentric analysis included patients with histologically confirmed diagnosis of UHM. Primary endpoints were mortality and recurrence, while secondary endpoints were defined as the rate of non-complete healing, local infection (at the diagnosis and acquired during the follow up) and complications (myocardial, respiratory, renal and stroke).

Results

Eleven patients (median age 77 years old, 72% female) were included. After primary UHM excision, 72.7% of the cases had a local split skin graft recostruction. The medium follow up was 24 months (1-84 months). The overall mortality rate was 27.3%, primarily due to respiratory infection and cardiac failure. The overall recurrence rate was 27.3%. Reintervention rates were 18.2%, 54.5%, 9.1% and 18.2% at 30 days, 6, 12 and 36 months, respectively. Non-complete healing rate was 45.5%. Local infection rate was 36.4% at the first UHM excision, 27.3% at 30 days and 18.2% at 6 months. Overall complications rates were 45.4%, 45.4%, 9.1%, 9.1% and 9.1% at 30 days, at 6,12,24 and 36 months correspondently.  

Conclusion

Our study underlines the substantial mortality and recurrence rate associated with UHM, emphasising the need for multidisciplinary management and careful follow up. Further research is warranted to refine treatment approaches and recurrence prevention beyond blood pressure control and wound care. 

Background

In rare cases vascular aneurysms can be infected with a consuming chronic granulomatous disease, such as tuberculosis or chronic q-fever caused by coxiella burnetti (CB). These patients show a vascular aneurysm with concomitant spondylodiscitis and psoas abscess.

Aims

Despite of the consensus in literature, that CB-infected aneurysm should be treated with open surgery, may an endovascular approach lead to successful treatment of this infection.

Methods

A 68-year-old patient with an abdominal aortic aneurysm monitored since 2007 underwent endovascular aortic repair (EVAR) in our clinic. The postoperative computed tomography (CT) showed an excluded aneurysm with a suspicious L-3 collection infiltrating the psoas major and being in touch to the dorsal aneurysm wall. The lesion was retrospectively noted in the preoperative CT. The patient reported a 20 kilograms weight loss without any signs of infection in the past years. The short-term postoperative course was uneventful and the patient discharged. A subsequent CT-guided biopsy tested negative for microorganisms and tumor.

Results

Four months later, the patient presented with sciatic and lower back pain with CRP elevation. A CT and magnetic resonance imaging were suspicious for spondylodiscitis, a CT-guided drain was placed. Blood serum analysis was positive for CB, antibiotic therapy was started. Percutaneous stabilization of L2-L5, decompression and debridement was performed. The material tested positive for CB. The patient was discharged with an 18-months antibiotic regimen with Doxycycline and Hydroxychloroquine. The 6 and 12 month CT-follow-up showed a shrinking aneurysm sac without infection signs of the prosthesis. Meanwhile the patient is feeling well and has no signs of infection.

Conclusion

Patients with arterial aneurysms are at risk for infections by CB. This case suggests that an endovascular approach with EVAR as bridging or definite solution with orthopedic debridement and long term antibiotic therapy can lead to successful treatment of the infection. Of course, further follow-up is needed.

Pyoderma gangrenosum (PG) is a rare, slowly progressing and painful ulcerative skin disorder, often associated with underlying systemic problems. Its estimated incidence is 0.3 – 1 cases per 100’000 people annually. Since PG manifests and evolves in various forms, misdiagnosis is frequent.

To emphasize the diagnostic work and therapeutic strategies, especially to facilitate earlier diagnosis in clinical practice.

We present a challenging evolution of a histologically proven Necrotic Angiodermitis in an 80-year-old male with a history of long-term arterial hypertension and type 2 diabetes. After excision and skin grafting, the wound healed only partially. The anterior aspect evolved unfavorable to a painful large ulcer despite several surgical debridements, and the use of negative pressure wound therapy (Figure 1). A concomitant staphylococcus infection was treated with antibiotics.

The turning point in treatment occurred with the initiation of topic Tacrolimus application after biopsy results, which suggested PG as a differential diagnosis. Following that, the patient experienced a remarkable swift and substantial improvement in pain and wound healing. This extraordinary response to topical Tacrolimus strongly supported the diagnosis of PG, even in the absence of proving biopsy result. The therapy was intensified by adjunction of Adalimumab injections and finally conducted to a complete healing of the wound within 4 months (Figure 2).

This case highlights the complexity of the evolution, diagnosing and managing PG, especially when complicated by previous surgical interventions and concomitant infections. Long-term follow-up with tailored multidisciplinary therapeutic strategies remains essential to obtain favorable clinical outcomes in PG patients. The outstanding response to topic Tacrolimus application in our patient underlines its properties as a valuable diagnostic and therapeutic tool for PG. Early correct diagnosis is most important and this may be achieved with empiric topical Tacrolimus application.

Advanced endovascular aortic therapy now utilizes laser probes to seamlessly incorporate individual patients supra-aortic branches via in-situ fenestration into endoprostheses. This offers treatment alternatives for patients ineligible for classic open cardiothoracic surgery due to anticipated high morbidity and mortality rates.

 We present Switzerland's first complete thoracic endovascular aortic repair (TEVAR) with insitu fenestration in form of a case report.

Patient gave informed consent.

A 71-year-old female patient presented with infective native aortic aneurysms of the ascending (zone 0) and descending aorta (zone 5), most likely after treated intraspinal empyema and haematogenous dissemination of Streptococcus pneumonia. Following an interdisciplinary case discussion with cardiac surgery, the perioperative risk of a completely open biological (xenological) procedure was deemed too high. The decision was made in favour of a minimally invasive alternative in the form of a TEVAR with insitu fenestration for the supraaortic branches under cerebral ECMO protection, as well as long-term antibiotic suppression therapy. The operation was performed at the beginning of 2024, starting with a transposition of the left common carotid artery to the left subclavian artery (LSA). A TEVAR was then implanted percutaneously transfemorally in zone 0 to zone 3, which was subsequently provided with in-situ laser fenestrations for the brachiocephalic trunk and the LSA under cerebral ECMO perfusion (via right axillary artery Dacron-conduit). The fenestrations were lined with bridging stentgrafts. Finally, a distal extension was performed with two further thoracic endoprostheses landing just above the coeliac trunk. The postoperative course was uneventful, especially with no neurological deficit. CTA detected a small endoleak type 3, which was already regressing in the further course.

In limited cases, where alternatives are associated with significantly increased morbidity and mortality, the method described offers a relatively safe alternative. Long-term results are not yet available.

Dystrophic subcutaneous calcifications (DSC) are rare and may occur in injured or devitalized soft tissue of patients with a normal calcium and phosphate metabolism. DSC are often associated with chronic venous disease (CVD). DSC have also been known to inhibit wound healing and to increase the risk of refractory venous leg ulcers (VLU), since calcium deposits in the wound bed support an ongoing inflammatory response.

We describe here the surgical management and outcome of a patient with a refractory VLU due to extensive DSC.

An 82-years old female patient was referred to our hospital due to bilateral chronic, non-healing leg ulcers. Her medical history consisted in arterial hypertension, morbid obesity (BMI=51 kg/m²), lower extremities lipolymphedema and CVD with recurrent ulcerations over the past 15 years. Initial assessment revealed a 30.8 cm² wound of the lateral aspect of the left tibia and a 6.9 cm² wound of the right lateral malleolar region. All wounds presented a severe inflammatory reaction of the skin around it with multiple areas of calcifications in the wound bed. Both legs where incompressible with a circumferential wooden-like sensation on palpation. (Figure 1). Serum Ca²⁺ and PO₄ levels were normal. Plain radiographies of both legs revealed extensive subcutaneous calcifications (Figure 2). Surgical treatment consisted in repeated surgical cleaning/removal of all calcifications from the wound bed and application of negative pressure wound therapy (NPWT). Secondary wound closure was achieved by meshed split-thickness skin grafts (STSG). (Figure 3)

3 weeks after admission the patient could be dismissed home and was followed then in our outpatient wound clinic for another 3 weeks until complete healing. (Figure 4)

Aggressive surgical cleaning/removal of all calcifications from the wound bed together with NPWT and secondary STSG application is an effective treatment for VLU due to DSC.