Comprehensive clinicopathologic characteristics of intraabdominal neurogenic tumors:Single institution experience

BACKGROUND Neurogenic tumors are rare but represent an important consideration in the differential diagnosis of abdominal mesenchymal tumors.Reports on their incidence,pathological features and clinical characteristics are scarce.AIM To advance the overall knowledge on the histologic,immunohistochemical,clinical and radiologic characteristics of neurogenic tumors through this case series.METHODS An established database of a nationwide tertiary referral center,covering a 15-year period(2005 and 2020),was retrospectively re-evaluated.Diagnoses of neurogenic tumor cases were confirmed by two experts following review of the macroscopic,histological and immunohistochemical records along with findings from analysis of archived tissue sections for each included patient.Tissue microarrays were constructed for cases lacking necessary immunohistochemical studies.Clinical data and follow-up information were collected from the hospital records and the patients themselves,when available.RESULTS The study included 19 cases of intraabdominal neurogenic tumors,representing 12 women and 7 men, between 18 and 86 years of age (median: 51 years). Finalconfirmed diagnoses were 12 schwannomas, 2 diffuse submucosal neurofibromatoses,2 ganglioneuromas, 2 malignant peripheral sheath nerve tumors,and 1 mucosal Schwann cell hamartoma. Sizes of the tumors were variable, with amedian diameter of 4 cm;the two largest (> 10 cm) were schwannomas. Themajority of cases were asymptomatic at presentation, but the most frequentsymptom was abdominal pain. Gastrointestinal tract lesions were detected withendoscopy and extra-luminal lesions were detected with cross-sectional imaging.All cases were S100-positive and CD117-negative;most cases were negative fordesmin, epithelial membrane antigen, smooth muscle actin and CD34. In all but 5cases, the Ki67 proliferation index was ≤ 1%.CONCLUSION Re-evaluation of 19 cases of abdominal neurogenic tumors demonstrated considerablevariability in clinicopathologic characteristics depending on location,dimension and histological features.

Enhanced recovery after surgery in emergency colorectal surgery:Review of literature and current practices

Enhanced recovery after surgery(ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows:(1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay – without increased risks of readmission,reoperation and death after emergency colorectal surgery; and(2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.

Abdominal compartment syndrome among surgical patients

Abdominal compartment syndrome(ACS)develops when organ failure arises secondary to an increase in intraabdominal pressure.The abdominal pressure is determined by multiple factors such as blood pressure,abdominal compliance,and other factors that exert a constant pressure within the abdominal cavity.Several conditions in the critically ill may increase abdominal pressure compromising organ perfusion that may lead to renal and respiratory dysfunction.Among surgical and trauma patients,aggressive fluid resuscitation is the most commonly reported risk factor to develop ACS.Other conditions that have also been identified as risk factors are ascites,hemoperitoneum,bowel distention,and large tumors.All patients with abdominal trauma possess a higher risk of developing intra-abdominal hypertension(IAH).Certain surgical interventions are reported to have a higher risk to develop IAH such as damage control surgery,abdominal aortic aneurysm repair,and liver transplantation among others.Close monitoring of organ function and intra-abdominal pressure(IAP)allows clinicians to diagnose ACS rapidly and intervene with target-specific management to reduce IAP.Surgical decompression followed by temporary abdominal closure should be considered in all patients with signs of organ dysfunction.There is still a great need for more studies to determine the adequate timing for interventions to improve patient outcomes.

Polymyxin B hemoperfusion as a feasible therapy after source control in abdominal septic shock

BACKGROUND Polymyxin B hemoperfusion(PMX-HP)has been used as a treatment for intraabdominal septic shock by absorbing and removing endotoxins of gram-negative bacilli.AIM To investigate the clinical efficacy of PMX-HP in patients with gram-negative septic shock who underwent abdominal surgery.METHODS From January 2012 to December 2018,patients who had septic shock secondary to peritonitis were enrolled.They were classified into PMX-HP treated and control groups based on postopreative intervention using PMX-HP.The clinical outcomes were compared using 1:1 propensity score matching methods to balance the overall distribution between the two groups.RESULTS After propensity score matching,40 patients were analyzed(20 patients in the PMX group and 20 patients in the control group).The scores of total Sequential Organ Failure Assessment(SOFA)score,renal SOFA and coagulation SOFA were significantly improved in the PMX group but not in the control group.(from 11.2±5.8 to 4.7±3.5 in PMX group vs 10.0±4.0 to 8.7±7.3 in control group,P=0.047 from 2.6±1.0 to 0.7±1.0 in PMX group vs 2.6±1.5 to 2.8±1.6 in control group,P=0.000,from 1.6±1.5 to 1.3±1.3 in PMX group vs 1.2±1.2 to 2.8±1.8 in control group,P=0.014,respectively).Further,the length of intensive care unit(ICU)stay was significantly shorter in PMX group.However,no statistically significant difference was found in ICU mortality(50%in PMX group vs 50%in control group).CONCLUSION PMX-HP is a feasible adjunct treatment for peritonitis in ICU patients with peritonitis for improved organ impairment and to stabilize hemodynamics.It would be helpful to enhance clinical outcomes especially in patients with complete elimination of the source of gram-negative bacilli infection by surgical procedure accompanied with conventional treatment of sepsis.

Successful management of adhesion related small bowel ischemia without intestinal resection: A case report and review of literature

BACKGROUND Intraabdominal adhesions develop spontaneously or after an inflammatory process or surgical procedure in the abdomen.They are the most common cause of small bowel obstruction(SBO).SBO occasionally leads to intestinal ischemia(In Is)which can be a life-threatening condition that requires management as soon as possible.We herein report a case of SBO with In Is presented in our institution and treated without intestinal resection.CASE SUMMARY A 34-year-old man presented at the emergency department after a 12-h-onset diffuse abdominal pain,bloating and nausea.He had a history of traumatic right hepatectomy 11 years ago as well as adhesiolysis and resection of a long part of small bowel 2 years ago.An abdominal computed tomography(CT)showed dilated loops that led to the diagnosis of SBO.Due to deteriorating lactic acidosis,the patient was operated.Torsion of the small bowel around an adhesion led to2.30 m of ischemic ileum.After the application of N/S 40°C for 20 min,the intestine showed signs of improvement and it was decided to avoid resection and instead temporary close the abdomen with vacuum-pack technique.At the second-look laparotomy 48 h later,the intestine appeared normal.The patient was discharged on the 8 th post-op day in excellent condition.CONCLUSION In case of SBO caused by adhesions,extreme caution is needed if In Is is present,as the clinical signs are mild and you should rely for diagnosis in CT findings and lactate levels.Conservative surgical approach could reverse the effects of In Is,if performed quickly,so that intestinal resection is avoided and should be used even when minimum signs of viability are present.

Role of endoscopic ultrasound guided fine needle aspiration/biopsy in the evaluation of intra-abdominal lymphadenopathy due to tuberculosis

BACKGROUND Intra-abdominal lymphadenopathy due to tuberculosis(TB)poses a diagnostic challenge due to difficulty in tissue acquisition.Although endoscopic ultrasound guided fine needle aspiration/biopsy(EUS-FNA/B)has shown promise in the evaluation of mediastinal lymph nodes,its role in the evaluation of intra-abdominal lymphadenopathy is not clear.AIM To assess the role of EUS-FNA/B in the evaluation of intra-abdominal lymphadenopathy due to TB.METHODS This was a retrospective study where patients with intra-abdominal lymphadenopathy who underwent evaluation with EUS-FNA/B were included.TB was diagnosed if the patient had any one of the following:(1)Positive acid fast bacilli(AFB)stain/TB GeneXpert/TB-polymerase chain reaction/AFB culture of tissue sample;and(2)Positive Mantoux test and response to anti-tubercular therapy.EUS-FNA reports,clinical reports and imaging characteristics of patients were recorded for a detailed analysis of patients with TB.RESULTS A total of 149 patients underwent an EUS-FNA/B from lymph nodes(mean age 51±17 years,M:F=1.2).Benign inflammatory reactive changes were seen in 45 patients(30.2%),while 54 patients(36.2%)showed granulomatous inflammation with/without caseation.Among these,51 patients(94.4%)were confirmed to have TB as per pre-defined criteria.Patients with TB were more likely to have hypoechoic and matted nodes[40 patients(67.7%)].EUS-FNA/B was found to have a sensitivity and specificity of 86%and 93%respectively,with a diagnostic accuracy of 88%in the evaluation of intra-abdominal lymphadenopathy due to TB.CONCLUSION EUS-FNA/B has a high diagnostic yield with a good sensitivity and specificity in the evaluation of intra-abdominal lymphadenopathy due to TB.However,the validity of these findings in populations with low prevalence of TB needs further evaluation.

Safety in Surgery:Evaluation of Safety and Efficiency in Use of Aminoglycosides in Acute Appendicitis

Background: Aminoglycosides are used as empirical antibiotic treatment of intraabdominal infections which are caused by Gram negative bacteria and for which the treatment of choice is surgery. Aminoglycosides maintain good efficacy against these bacteria and reduce the need for prescribing fluoroquinolone, cephalosporin and carbapenem antibiotics which contribute to the development of resistant bacterial strains. In recent years, several clinical trials and international guidelines have advised against the use of aminoglycosides owing largely to doubts about their effectiveness and to the concern for their known nephrotoxicity and ototoxicity. Aim: In our study, we aimed to prove whether aminoglycosides are appropriate agents in the treatment of acute appendicitis. Methods: Retrospectively, patients with acute appendicitis we included in the trial. Demographic characteristics, comorbidities, clinical signs and symptoms, the type of antibiotic and surgical treatment were analyzed. The effect of independent variables on the occurrence of complications was calculated using Student’s T-test and Fisher’s precise test. The effect of aminoglycosides on the loss of kidney function was determined by means of a linear regression method. Results: 300 patients proved acute appendicitis were included in the study. Univariate statistical analysis showed that the risk factors for postoperative complications in treating acute appendicitis were: age over 76 years (p Conclusion: Aminoglycoside antibiotics are a safe and effective treatment of acute appendicitis;our not published data are positive of AGs use in acute cholecystitis and left colon diverticulitis which requires surgery. If used for a limited time period, they do not increase the risk for kidney injury and remain a stable low level of all over complications.