Risk factors for perioperative complications in laparoscopic surgeries of retrorectal cystic lesions

BACKGROUNDThe incidence of retrorectal lesions is low, and no consensus has been reachedregarding the most optimal surgical approach. Laparoscopic approach has theadvantage of minimally invasive. The risk factors influencing perioperativecomplications of laparoscopic surgery are rarely discussed.AIMTo investigate the risk factors for perioperative complications in laparoscopicsurgeries of retrorectal cystic lesions.METHODSWe retrospectively reviewed the medical records of patients who underwentlaparoscopic excision of retrorectal cystic lesions between August 2012 and May2020 at our hospital. All surgeries were performed in the general surgerydepartment. Patients were divided into groups based on the lesion location anddiameter. We analysed the risk factors like type 2 diabetes mellitus, hypertension,the history of abdominal surgery, previous treatment, clinical manifestation,operation duration, blood loss, perioperative complications, and readmission ratewithin 90 d retrospectively.RESULTSSevere perioperative complications occurred in seven patients. Prophylactictransverse colostomy was performed in four patients with suspected rectal injury.Two patients underwent puncture drainage due to postoperative pelvic infection.One patient underwent debridement in the operating room due to incisioninfection. The massive-lesion group had a significantly longer surgery duration,higher blood loss, higher incidence of perioperative complications, and higherreadmission rate within 90 d (P < 0.05). Univariate analysis, multivariate analysis,and logistic regression showed that lesion diameter was an independent riskfactor for the development of perioperative complications in patients whounderwent laparoscopic excision of retrorectal cystic lesions.CONCLUSIONThe diameter of the lesion is an independent risk factor for perioperative complicationsin patients who undergo laparoscopic excision of retrorectal cystic lesions.The location of the lesion was not a determining factor of the surgical approach.Laparoscopic surgery is minimally invasive, high-resolution, and flexible, and itsuse in retrorectal cystic lesions is safe and feasible, also for lesions below the S3level.

Recent advances in the diagnostic evaluation of pancreatic cystic lesions

Pancreatic cystic lesions(PCLs)are becoming more prevalent due to more frequent abdominal imaging and the increasing age of the general population.It has become crucial to identify these PCLs and subsequently risk stratify them to guide management.Given the high morbidity associated with pancreatic surgery,only those PCLs at high risk for malignancy should undergo such treatment.However,current diagnostic testing is suboptimal at accurately diagnosing and risk stratifying PCLs.Therefore,research has focused on developing new techniques for differentiating mucinous from non-mucinous PCLs and identifying high risk lesions for malignancy.Cross sectional imaging radiomics can potentially improve the predictive accuracy of primary risk stratification of PCLs at the time of detection to guide invasive testing.While cyst fluid glucose has reemerged as a potential biomarker,cyst fluid molecular markers have improved accuracy for identifying specific types of PCLs.Endoscopic ultrasound guided approaches such as confocal laser endomicroscopy and through the needle microforceps biopsy have shown a good correlation with histopathological findings and are evolving techniques for identifying and risk stratifying PCLs.While most of these recent diagnostics are only practiced at selective tertiary care centers,they hold a promise that management of PCLs will only get better in the future.

Needle-based confocal endomicroscopy in the discrimination of mucinous from non-mucinous pancreatic cystic lesions

BACKGROUND Pancreatic cystic lesions(PCLs)are considered a precursor of pancreatic cancer.Needle-based confocal endomicroscopy(nCLE)is an imaging technique that enables visualization of the mucosal layer to a micron resolution.Its application has demonstrated promising results in the distinction of PCLs.This study evaluated the utility of nCLE in patients with indeterminate PCLs undergoing endoscopic ultrasound fine-needle aspiration(EUS-FNA)to distinguish mucinous from non-mucinous lesions.AIM To evaluate the accuracy of nCLE in indeterminate PCLs undergoing EUS-FNA to distinguish mucinous from non-mucinous lesions.METHODS Patients who required EUS-FNA between 2015 and 2017 were enrolled prospectively.During EUS-FNA,confocal imaging,analyses of the tumor markers carcinoembryonic antigen and amylase,and cytologic examination were conducted.All patients were followed for at least 12 mo and underwent laboratory testing and computed tomography scanning or magnetic resonance imaging.nCLE videos were independently reviewed by 6 observers to reach a final diagnosis(mucinous vs non-mucinous)based on criteria derived from previous studies;if there was disagreement>20%,a final diagnosis was discussed after consensus re-evaluation.The sensitivity,specificity,and accuracy of nCLE were calculated.Adverse events were recorded.RESULTS Fifty-nine patients were included in this study.Final diagnoses were derived from surgery in 10 patients,cytology in 13,and imaging and multidisciplinary team review in 36.Three patients were excluded from final diagnosis due to problems with nCLE acquisition.Fifty-six patients were included in the final analysis.The sensitivity,specificity,and accuracy of nCLE were 80%[95%confidence interval(CI):65-90],100%(95%CI:72-100),and 84%(95%CI:72-93),respectively.Postprocedure acute pancreatitis occurred in 5%.CONCLUSION EUS-nCLE performs better than standard EUS-FNA for the diagnosis of indeterminate PCL.

Micro-computed tomography utility for estimation of intraparenchymal spinal cord cystic lesions in small animals

Precise assessment of spinal cord cystic lesions is crucial to formulate effective therapeutic strategies,yet histological assessment of the lesion remains the primary method despite numerous studies showing inconsistent results regarding estimation of lesion size via histology.On the other hand,despite numerous advances in micro-computed tomography(micro-CT)imaging and analysis that have allowed precise measurements of lesion size,there is not enough published data on its application to estimate intraspinal lesion size in laboratory animal models.This work attempts to show that micro-CT can be valuable for spinal cord injury research by demonstrating accurate estimation of syrinx size and compares between micro-CT and traditional histological analysis.We used a post-traumatic syringomyelia rat model to compare micro-CT analysis to conventional histological analysis.The study showed that micro-CT can detect lesions within the spinal cord very similar to histology.Importantly,micro-CT appears to provide more accurate estimates of the lesions with more measures(e.g.,surface area),can detect compounds within the cord,and can be done with the tissue of interest(spinal cord)intact.In summary,the experimental work presented here provides one of the first investigations of the use of micro-CT for estimating the size of intraparenchymal cysts and detecting materials within the spinal cord.All animal procedures were approved by the University of Akron Institutional Animal Care and Use Committee(IACUC)(protocol#LRE 16-05-09 approved on May 14,2016).

The Hong Kong consensus recommendations on the diagnosis and management of pancreatic cystic lesions

Background:The finding of pancreatic cystic lesions(PCL)on incidental imaging is becoming increasingly common.International studies report a prevalence of 2.2-44.7%depending on the population,imaging modality and indication for imaging,and the prevalence increases with age.Patients with PCL are at risk of developing pancreatic cancer,a disease with a poor prognosis.This publication summarizes recommendations for the diagnosis and management of PCL and post-operative pancreatic exocrine insufficiency(PEI)from a group of local specialists.Methods:Clinical evidence was consolidated from narrative reviews and consensus statements formulated during two online meetings in March 2022.The expert panel included gastroenterologists,hepatobiliary surgeons,oncologists,radiologists,and endocrinologists.Results:Patients with PCL require careful investigation and follow-up due to the risk of malignant transformation of these lesions.They should undergo clinical investigation and pancreas-specific imaging to classify lesions and understand the risk profile of the patient.Where indicated,patients should undergo pancreatectomy to excise PCL.Following pancreatectomy,patients are at risk of PEI,leading to gastrointestinal dysfunction and malnutrition.Therefore,such patients should be monitored for symptoms of PEI,and promptly treated with pancreatic enzyme replacement therapy(PERT).Patients with poor response to PERT may require increases in dose,addition of a proton pump inhibitor,and/or further investigation,including tests for pancreatic function.Patients are also at risk of new-onset diabetes mellitus after pancreatectomy;they should be screened and treated with insulin if indicated.Conclusions:These statements are an accurate summary of our approach to the diagnosis and management of patients with PCL and will be of assistance to clinicians treating these patients in a similar clinical landscape.

Cystic pancreatic lesions,the endless dilemma

Cystic pancreatic lesions involve a wide variety of pathological entities that include neoplastic and non-neoplastic lesions.The proper diagnosis,differentiation,and staging of these cystic lesions are considered a crucial issue in planning further management.There are great challenges for their diagnostic models.In our time,new emerging methods for this diagnosis have been discovered.Endoscopic ultrasonography-guided fine-needle aspiration cytology with chemical and molecular analysis of cyst fluid and EUS-guided fine needlebased confocal laser endomicroscopy,through the needle microforceps biopsy,and single-operator cho-langioscopy/pancreatoscopy are promising methods that have been used in the diagnosis of cystic pancreatic lesions.Hereby we discuss the diagnosis of cystic pancreatic lesions and the benefits of various diagnostic models.

Solitary intraosseous neurofibroma in the mandible mimicking a cystic lesion:A case report and review of literature

BACKGROUND Neurofibromas are benign tumors of a neurogenic origin.If these tumors occur without any other signs of neurofibromatosis,they are classified as isolated neurofibromas.Neurofibromas in the oral cavity mostly occur within soft tissues,indicating that solitary intraosseous neurofibromas in the mandible are rare.Due to the absence of specific clinical manifestations,early diagnosis and treatment of these tumors are difficult to achieve.CASE SUMMARY A 37-year-old female patient visited our hospital due to numbness and swelling of the gums in the right lower molar area that had persisted for half a month.The patient’s overall condition and intraoral examination revealed no significant abnormalities.She was initially diagnosed with a cystic lesion in the right mandible.However,after a more thorough examination,the final pathological diagnosis was confirmed to be neurofibroma.Complete tumor resection and partial removal of the right inferior alveolar nerve were performed.As of writing this report,there have been no signs of tumor recurrence for nine months following the surgery.CONCLUSION This case report discusses the key features that are useful for differentiating solitary intraosseous neurofibromas from other cystic lesions.

Pancreatic pseudocyst:The past,the present,and the future

A pancreatic pseudocyst is defined as an encapsulated fluid collection with a welldefined inflammatory wall with minimal or no necrosis.The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis.The clinical presentation is often nonspecific,with abdominal pain being the most common symptom.If a diagnosis is suspected,contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst.Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty.Pseudocyst of the pancreas can lead to complications such as hemorrhage,infection,and rupture.The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications,such as biliary or gastric outlet obstruction.Management options include endoscopic or surgical drainage.The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions,diagnosis,and management of this condition.

Intrahepatic biliary cystadenoma:A case report

BACKGROUND Biliary cystadenoma(BCA)is a rare benign tumor,accounting for only 5%of reported cystic lesions of the liver.Given its potential for malignancy and high rate of recurrence,surgical resection is the preferred treatment.Therefore,early and accurate preoperative diagnosis is critical to the choice of treatment.We here report the first male case of BCA in our hospital,diagnosed by our team and confirmed by pathological biopsy.This article aims to improve the understanding of this disease and help make a correct diagnosis to better manage it.CASE SUMMARY A 58-year-old man with irregular abdominal discomfort came to our clinic and was found to have a distended abdomen during physical examination.Computed tomography and magnetic resonance imaging both showed a huge cystic mass in the liver.The patient underwent left hepatic lobectomy,cholecystectomy,and liver cyst fenestration,and most of the masses had decreased in size as of the 6-mo follow-up.The pathological diagnosis was consistent with BCA,and no recurrence was detected after the surgery.BCA occurred mainly in middle-aged women.To the best of our knowledge,this patient is the 11th male case of BCA reported in the literature.CONCLUSION The combination of magnetic resonance imaging and magnetic resonance cholangiopancreatography is of great significance for the early accurate diagnosis of the disease and the choice of surgical methods.

A rare occurrence of a hereditary Birt-Hogg-Dubésyndrome:A case report

BACKGROUND Birt-Hogg-Dubé(BHD)syndrome is a rare autosomal dominant disease caused by germline mutations in the folliculin(FLCN)protein gene,which usually manifests as cutaneous fibrofolliculoma,pulmonary cysts,renal cell carcinoma,and spontaneous pneumothorax.CASE SUMMARY A 26-year-old woman with no history of smoking was admitted to the Respiratory Department of our hospital due to intermittent wheezing that lasted for 8 mo.She had experienced recurrent spontaneous pneumothorax more than four times during the past 8 mo.After admission,the patient again suffered from left pneumothorax without a clear reason.Lung computed tomography(CT)showed multiple low-density cystic changes in both lungs.Physical examination on admission revealed multiple white dome-shaped papules in the neck,the nape,and behind the ear.In addition,the patient had a family history of spontaneous pneumothorax.Her mother had suffered from pneumothorax four times(at age 36,37,42,and 50 years).Her second maternal aunt had suffered from a right pneumothorax at the age of 40.The multidisciplinary diagnosis of BHD,which included the Respiratory Department,Radiology Department,Pathology Department,and Dermatological Department,was BHD and was later confirmed by family genetic testing.The same variation(FLCN gene)was found in the patient’s mother and aunt.CONCLUSION This case highlights the importance of multidisciplinary diagnosis and a treatment platform for the diagnosis of BHD.

Retrorectal tumors:A challenge for the surgeons

Retrorectal or presacral tumors are rare lesions located in the presacral area and considered as being derived from multiple embryological remnants.These tumors are classified as congenital,neurogenic,osseous,inflammatory,or miscellaneous.The most common among these are congenital benign lesions that present with non-specific symptoms,such as lower back pain and change in bowel habit.Although congenital and developmental tumors occur in younger patients,the median age of presentation is reported to be 45 years.Magnetic resonance imaging plays a crucial role in treatment management through accurate diagnosis of the lesion,the evaluation of invasion to adjacent structures,and the decision of appropriate surgical approach.The usefulness of preoperative biopsy is still debated;currently,it is only indicated for solid or heterogeneous tumors if it will alter the treatment management.Surgical resection with clear margins is considered the optimal treatment;described approaches are transabdominal,perineal,combined abdominoperineal,and minimally invasive.Benign retrorectal tumors have favorable long-term outcomes with a low incidence of recurrence,whereas malignant tumors have a potential for distant organ metastasis in addition to local recurrence.

Machine learning in endoscopic ultrasonography and the pancreas:The new frontier?

Pancreatic diseases have a substantial burden on society which is predicted to increase further over the next decades.Endoscopic ultrasonography(EUS)remains the best available diagnostic method to assess the pancreas,however,there remains room for improvement.Artificial intelligence(AI)approaches have been adopted to assess pancreatic diseases for over a decade,but this methodology has recently reached a new era with the innovative machine learning algorithms which can process,recognize,and label endosonographic images.Our review provides a targeted summary of AI in EUS for pancreatic diseases.Included studies cover a wide spectrum of pancreatic diseases from pancreatic cystic lesions to pancreatic masses and diagnosis of pancreatic cancer,chronic pancreatitis,and autoimmune pancreatitis.For these,AI models seemed highly successful,although the results should be evaluated carefully as the tasks,datasets and models were greatly heterogenous.In addition to use in diagnostics,AI was also tested as a procedural real-time assistant for EUS-guided biopsy as well as recognition of standard pancreatic stations and labeling anatomical landmarks during routine examination.Studies thus far have suggested that the adoption of AI in pancreatic EUS is highly promising and further opportunities should be explored in the field.

Cystic changes associated with pulmonary tuberculosis:a case report

There are a wide range of computed tomography （CT） findings in patients with pulmonary tuberculosis, including diffuse or localized nodules, reticular opacities, ground glass attenuation, air trapping, consolidation, cavitation, fibrosis, lymph nodes enlargement, and septal thickening. However, CT findings of pulmonary tuberculosis that appeared as multiple cystic lesions were very rare. Herein, the CT findings appeared as multiple cystic lesions in a patient with pulmonary tuberculosis are reported.

Unusual presentation of gastric cancer during treatment of hairy cell leukemia:Exploring the etiological basis of this rare phenomenon

Hairy cell leukemia(HCL)is a rare B-cell lymphoproliferative disorder.Patients typically present with cytopenia and splenomegaly.We describe the case of a 78-year-old patient with refractory HCL who acutely developed a cystic lesion on the back while receiving moxetumomab pasudotox therapy.Biopsy of the lesion revealed the presence of adenocarcinoma,which prompted a detailed evaluation resulting in a diagnosis of stage IV gastric cancer.Nevertheless,to establish any association between moxetumomab pasudotox therapy and secondary cancer development,a satisfactory number of studies need to be conducted.