Background: The biomechanical impact of iliosacral screw fixation (ISF) on lumbosacral fixation (LSF) and lumbopelvic fixation (LPF) constructs remains unclear. This study evaluates the effects of ISF on screw strain distribution and construct stability in these fixation models. Methods: Sixteen ovine spine-pelvis specimens were divided into LSF and LPF groups. Biomechanical testing was performed under compressive loads of up to 400 N before and after ISF placement. Strain measurements were recorded at the distal fixation points – S1 screws in LSF and iliac screws in LPF. Baseline strain values under physiological loading conditions were compared with post-fixation strain values following ISF placement. Results: In the LPF model, ISF resulted in a more consistent redistribution of strain, including reductions in vertical strain magnitude and right-sided horizontal tensile strain. In the LSF model, ISF led to a significant increase in left-sided oblique strain ( P = 0.050) and a decrease in right-sided vertical strain ( P = 0.030). Pre-ISF comparisons showed distinct strain patterns between the constructs, with higher right-sided vertical strain in the LSF model and higher right-sided horizontal, bilateral oblique, and left-sided vertical strain in the LPF model. Conclusion: ISF enhances biomechanical performance, particularly in LPF constructs, by reducing screw strain and redistributing loads more effectively. These findings support its potential role in surgical decision-making for complex lumbosacral pathologies. Further human studies are required to validate these findings, given anatomical and biomechanical differences.
Although ileosto my formation during colorectal surgery is often life-saving, it carries risks of complications, notably electrolyte disturbances, dehydration, and acute or chronic kidney injury. When an ileostomy enters the high-output state (HOS), challenging complications may follow and disrupt a patient’s quality of life. By conducting this review, we aim to explore the underlying mechanisms, risk factors, and clinical presentation of renal injury among ileostomy patients. We further discuss the current management strategies, including preventive methods, pharmacological interventions, dietary modifications, and surgical approaches, emphasizing the need for individualized care plans tailored to patient-specific needs. Surgical options beyond ileostomy reversal, such as stoma relocation or small bowel lengthening, are also reviewed for their potential to mitigate HOSs. Despite advancements, significant gaps remain, including the lack of standardized protocols and challenges with patient adherence to preventive measures. By overcoming these challenges, this study can set the cornerstone for future studies to achieve the optimal management of ileostomy-associated renal dysfunction, ultimately leading to an improved quality of life for the affected patients.
Introduction and importance: Renal cell carcinoma (RCC) is the most common malignant renal neoplasm and may remain asymptomatic until advanced stages. Giant RCCs are rare and often present with extensive local invasion or venous involvement, posing significant diagnostic and therapeutic challenges. Case presentation: We report the case of a 65-year-old male with poorly controlled diabetes mellitus, hypertension, and a history of coronary artery disease who initially presented with abdominal pain. Physical examination revealed a large, non-tender right upper quadrant mass. Ultrasonography and contrast-enhanced computed tomography demonstrated a heterogeneous renal lesion with cystic and solid components, intralesional calcifications, and venous extension with inferior vena cava compression. Enlarged para-aortic lymph nodes were also identified. Laboratory findings showed impaired renal function and anemia. The patient underwent radical nephrectomy with complete excision of the tumor and thrombectomy of the renal vein. The adrenal gland was preserved. Perioperative management included glycemic control, and the postoperative course was uneventful, with improvement in renal function. Clinical discussion: RCC often grows silently, may present as giant renal masses with venous involvement, and requires radical nephrectomy with thrombectomy for optimal management and prognosis. Conclusion: This case illustrates the indolent nature of RCC, which may attain massive size before detection, and highlights the central role of imaging in diagnosis and surgical planning. Radical nephrectomy with thrombectomy remains the cornerstone of management in patients with locally advanced disease, offering the best chance for favorable outcomes when complete resection is achieved. Long-term follow-up is essential due to the risk of recurrence.
Introduction: Adenocarcinoma of the small intestine is uncommon, with the ileum being a particularly rare site of origin. Its nonspecific clinical features often result in delayed diagnosis. Presentation as bowel perforation with peritonitis is extremely rare. Case presentation: We report the case of a 35-year-old female who presented with acute abdominal pain and signs of generalized peritonitis. Emergency laparotomy revealed multiple perforations with gross thickening of the wall in the distal ileum accompanied by peritoneal contamination. Segmental resection and locoregional lymph node dissection with primary ileo-ileal anastomosis and proximal diversion loop ileostomy were performed. Histopathological examination confirmed poorly differentiated adenocarcinoma infiltrating up to the surrounding stroma along with vascular invasion. The postoperative course was uneventful, and the patient was subsequently referred for adjuvant chemotherapy (FOLFOX regimen). Genetic counseling and microsatellite instability testing were recommended given her young age. Discussion: Ileal adenocarcinoma accounts for a small fraction of gastrointestinal cancers and is difficult to diagnose preoperatively due to vague symptoms and the poor sensitivity of imaging for small bowel tumors. Perforation of ileal adenocarcinoma is a rare but life-threatening complication requiring urgent surgical management. A literature review demonstrates very few reported cases of ileal adenocarcinoma presenting with perforation. Conclusion: Primary ileal adenocarcinoma should be considered in the differential diagnosis of small bowel perforation. Prompt surgical intervention, accurate staging, and genetic evaluation are vital for optimal management. This case underscores the need to suspect small bowel malignancy in unexplained perforations, even in young adults.
Background: The demand for cost-effective surgical care has led to the wider adoption of day-case laparoscopic cholecystectomy (DCLC). The objective of this study was to assess the safety and outcomes of DCLC performed in a rural Australian hospital, quantify the unplanned admission rate and its causes, and compare these findings with published metropolitan data. Materials and methods: A retrospective observational cohort study of 68 consecutive patients with planned elective DCLC between January 2021 and August 2025 at a rural Australian hospital was conducted. Data were collected from paper-based medical records, recorded into the hospital database on an Excel spreadsheet, and included patient demographics, operative details, discharge outcomes, and readmissions within 7 days. Data were summarized using means, standard deviations, and percentages. Results: The mean patient age was 42.9 ± 14.7 years, and the mean BMI was 30.6 ± 5.3 kg/m 2 ; 75% were female, and 88% were American Society of Anesthesiologists grade I–II. A total of 68 patients were planned for elective DCLC, of which 63 (92.6%) successfully achieved same-day discharge. Seven-day readmission was 4.4%, and all were for minor postoperative reasons. A longer duration of operation and drain placement were the major contributors to failure of discharge. There was no surgical conversion to an open case and no severe postoperative complications. Conclusion: DCLC can be performed safely and effectively in a rural hospital and produces results comparable to those of metropolitan centers. Selective case identification, perioperative planning, and established discharge processes facilitate further expansion of same-day discharge in rural centers. Plain Language Summary: DCLC allows patients to return home on the same day after gallbladder removal. This study reviewed 68 patients treated at a rural Australian hospital between January 2021 and August 2025 to assess whether this approach is safe outside metropolitan centers. Most patients (92.6%) were able to go home on the same day, and only three returned to the hospital within a week for minor issues. No major complications occurred, and none required conversion to open surgery. These findings indicate that DCLC can be safely performed in a rural hospital setting.
Pleural effusion in young children is most commonly associated with infectious or inflammatory conditions. However, rare malignant causes should also be considered, particularly when symptoms persist despite standard interventions. A 2-year-old boy presented with cough, fever, and dyspnea unresponsive to initial pleural drainage. Imaging revealed a large, complex left pleural effusion with mediastinal shift. Surgical exploration uncovered a cystic lesion in the upper lobe of the left lung. Histopathological analysis confirmed pulmonary pleomorphic rhabdomyosarcoma – a rare and aggressive pediatric malignancy. The lesion was resected, and the patient’s condition improved postoperatively. A regional lymph node was tumor-free. The child was referred for further oncologic care. Although extremely rare, pulmonary pleomorphic rhabdomyosarcoma should be included in the differential diagnosis of persistent pleural effusion in children. Early surgical intervention and histological confirmation are essential for timely diagnosis and initiation of appropriate therapy.
Introduction and importance: Giant colonic lipomas are rare benign tumors that can closely mimic colorectal malignancies when they become large or symptomatic. Their nonspecific presentation and variable imaging appearances often complicate diagnosis, particularly in older adults. Advanced imaging modalities, such as computed tomography (CT) and magnetic resonance imaging (MRI), improve characterization, yet surgical confirmation is frequently required. This report describes a case of a giant rectosigmoid lipoma, emphasizing the diagnostic difficulties and clinical relevance of this rare entity. Case presentation: A 70-year-old male presented with a 2-month history of intermittent constipation and diffuse, cramp-like abdominal pain. Physical examination and laboratory investigations were unremarkable. CT revealed a well-circumscribed rectosigmoid mass, and MRI confirmed a giant lipoma with classic fat-signal characteristics and no signs of invasion. Clinical discussion: Giant lipomas exceeding 5 cm in size are more likely to become symptomatic and may imitate malignant lesions on endoscopy and imaging. The patient’s mild, nonspecific symptoms reflect patterns described in the literature, where luminal distensibility in certain colonic segments delays obstructive features. MRI provided diagnostic clarity in this case, contrasting with reports in which atypical features necessitated exploratory surgery. Laparoscopic segmental resection remains the recommended treatment for symptomatic, large, or diagnostically uncertain lipomas. Conclusion: Giant rectosigmoid lipomas, though uncommon, should be considered in the differential diagnosis of colorectal masses. MRI can facilitate a confident preoperative diagnosis, and timely surgical resection offers excellent outcomes when performed electively.
Introduction: Anastomotic leak is one of the most common and dreaded complications after intestinal anastomosis. The prevalence of anastomotic leak is reported to range from 0.5% to 30% in the literature. It usually occurs between the 3rd and 6th postoperative days. This study aimed to evaluate outcomes and identify the associated factors in adult patients following bowel resection and anastomosis at a tertiary hospital in northern Tanzania. Materials and methods: This was a cross-sectional study conducted at Kilimanjaro Christian Medical Centre. A total of 114 participants who had undergone bowel resection and anastomosis were recruited and followed up for 30 days postoperatively to assess the outcomes. The National Nosocomial Infection Surveillance Scheme was used to assess surgical site infections. C-reactive protein, leukocyte count, abdominal-pelvic contrasted CT-scan, and vital signs were used to assess anastomosis leaks. Data were analyzed using STATA version 14. Numerical variables were summarized as medians and interquartile ranges, while categorical variables were summarized as frequencies and percentages. The generalized linear model was used to assess factors associated with anastomosis. Results: A total of 114 participants were analyzed in this study. The prevalence of surgical site infection was 31.58%, mortality was 14.9%, intestinal obstruction/ileus was 14.04%, and an anastomotic leak was 9.65%. The factors that increased the odds of surgical site infection were emergency surgery and diabetes mellitus. Anastomotic leak was associated with a rise in leukocyte count, creatinine levels of 44–88 µmol/L, and elective surgery. Mortality was associated with leukocyte count, serum creatinine level, American Society of Anesthesiologists classification, HIV status, and the presence of malignancy. Conclusions: The most common outcome was surgical site infection with a prevalence of 31.6%, and anastomotic leak was the least at 9.7%. Emergency surgery was independently associated with surgical site infection and anastomotic leak. This study highlights the importance of other socio-clinical factors that increase morbidity and mortality, hence aids in the prediction value for unfavorable outcomes, which can then be used as an area for improvement to reduce associated complications.
Background: Pulmonary hydatid disease remains endemic in many Mediterranean and Middle Eastern regions. Complicated cysts with pleural extension or rupture may present with acute respiratory compromise and require urgent surgical management. Methods: A retrospective case series was conducted at Al-Mouwasat University Hospital over a 5-month period. Three consecutive patients diagnosed with complicated pulmonary hydatid cysts were identified from institutional medical records. Clinical, laboratory, radiological, operative, and outcome data were analyzed. This study is reported in accordance with the PROCESS 2020 guidelines for surgical case series. Results: The mean age was 23 years (range 16–28); two patients were female. All cases involved the right lung (100%). One patient (33%) presented with tension pneumothorax and mediastinal shift. All patients required emergency chest tube placement, and definitive management consisted of right thoracotomy with cyst excision and pleural decortication. Bronchopleural or pleural fistulas were identified intraoperatively in all cases. There was no mortality. All patients achieved full lung re-expansion and were discharged in stable condition. Conclusion: Complicated pulmonary hydatid cysts may present with acute pleuropulmonary manifestations, including tension pneumothorax. Early recognition and timely surgical intervention are essential for definitive management and favorable outcomes.
Background: Malignant chylothorax is a rare pleural effusion caused by thoracic duct disruption, often due to mediastinal tumors. High-output effusions can cause malnutrition, immunosuppression, and delay cancer treatment. Case presentation: A 55-year-old male heavy smoker presented with dyspnea, dry cough, and pleuritic chest pain. Imaging revealed a mediastinal mass compressing the superior vena cava and a massive right-sided chylous pleural effusion. Thoracentesis and chest tube drainage yielded milky chyle. Due to the high-risk tumor location, video-assisted thoracoscopic surgery (VATS) was performed for biopsy and thoracic duct ligation. Postoperatively, the effusion resolved, and the patient was referred for systemic chemotherapy. Histopathology confirmed metastatic intermediate-grade adenocarcinoma (CK7-positive, TTF-1-negative). Discussion: High-output malignant chylothorax is challenging due to chyle loss and the involvement of major mediastinal vessels. Conservative therapy often fails, making early procedural intervention essential. VATS allows for safe biopsy and simultaneous thoracic duct ligation, minimizing morbidity. Conclusion: Prompt recognition and a multidisciplinary approach are crucial. VATS ligation effectively controls chyle leakage, reduces systemic complications, and enables timely oncologic therapy.
Introduction: Extraskeletal Ewing’s sarcoma (EES) of diaphragmatic origin is exceptionally rare, with few cases documented. Preoperative diagnosis is challenging due to overlapping clinical and radiologic features with more common hepatic and retroperitoneal pathologies. Case presentation: A 17-year-old male presented with dyspnea, abdominal distension, and subacute intestinal obstruction. Imaging suggested a large cystic hepatic lesion. Exploratory laparotomy revealed a vascular diaphragmatic tumor with metastatic seedlings. Definitive resection via right posterolateral thoracotomy included partial diaphragm and rib excision with polypropylene mesh reconstruction. Histopathology and immunohistochemistry confirmed EES. Molecular confirmation using fluorescence in situ hybridization (FISH) demonstrated EWSR1 gene rearrangement. Adjuvant multi-agent chemotherapy and radiotherapy were administered, following the vincristine-doxorubicin-cyclophosphamide alternating with ifosfamide-etoposide (VDC/IE) regimen and conformal intensity-modulated radiotherapy (IMRT) to 45 Gray. At 10-month follow-up, the patient remained in complete remission. Discussion: Diaphragmatic EES presents unique diagnostic and surgical challenges due to its location and proximity to vital structures. Complete surgical excision with functional reconstruction, combined with multimodal adjuvant therapy, offers the best potential for local control and long-term survival. Vigilant surveillance is necessary given the early recurrence risk. Conclusion: EES should be considered in the differential diagnosis of large diaphragmatic masses. Coordinated multidisciplinary management enables effective treatment, and detailed reporting of such presentations enhances the collective understanding of rare tumor sites.
Background: Rapid control and correction of bleeding are critical for reducing mortality and improving outcomes in trauma patients. Given the burden of trauma-induced hemorrhagic shock, a comprehensive evaluation of current bleeding management strategies is essential. This review aimed to assess contemporary approaches to perioperative bleeding management in adult trauma patients. Methods: A systematic literature search was conducted across PubMed, HINARI, Google Scholar, and the Cochrane Library using predefined keywords. Studies addressing bleeding management in adult trauma patients were included. Duplicate records were removed using EndNote software, and study selection was performed using a standardized appraisal checklist. The review was conducted and reported in accordance with the PRISMA 2020 guidelines. Results: The initial search identified 49 151 records. After removal of duplicates and initial screening, 17 409 articles underwent title and abstract review, of which 16 409 were excluded. In total, 1000 full-text articles were assessed for eligibility, with 880 excluded due to ineligibility or overlapping objectives. Of the remaining 120 articles, 74 were excluded because full-text access was unavailable. Ultimately, 46 studies met the inclusion criteria and were included in the final analysis. Conclusions: Early and effective control of bleeding remains a cornerstone of trauma care and is strongly associated with improved survival and clinical outcomes in adult trauma patients.
Background: Hepatolithiasis is a life-threatening condition, and the incidence of secondary hepatolithiasis has increased in patients with a history of choledochoenterostomy who underwent pancreaticoduodenectomy (PD). In this study, we aimed to evaluate the risk factors and confirm the appropriate treatment for hepatolithiasis after PD. Materials and methods: Between January 2010 and December 2022, 314 patients who underwent PD were evaluated using a cross-sectional study. Eight patients who underwent PD with hepatectomy were excluded, leaving 306 patients for analysis. Patient demographics, surgical factors, and clinical and biochemical parameters were assessed to determine the predictive factors of hepatolithiasis after PD. Results: Among the 306 patients, 21 (6.9%) developed hepatolithiasis after PD. Of these, 17 patients (81.0%) experienced cholangitis, while 4 (19.0%) were asymptomatic. Cholangitis occurred on average 33.4 ± 10.3 months postsurgery. Fifteen patients received treatment (13 with cholangitis, two without). Fourteen underwent balloon enteroscopy-assisted endoscopic retrograde cholangioscopy (BE-ERC), with 100% scope insertion and 87.5% stone removal success rates. Univariate analysis revealed several risk factors for hepatolithiasis after PD, including heavy body weight ( P = 0.0096), high body mass index ( P = 0.0508), benign disease ( P = 0.0109), preoperative drainage ( P = 0.0680), and hepaticojejunostomy suture pitch greater than 2 mm ( P = 0.0222). Multivariate analysis indicated that only a suture pitch greater than 2 mm ( P = 0.0367) was a risk factor for hepatolithiasis after PD. Conclusion: BE-ERC is an effective treatment for hepatolithiasis after PD. For hepaticojejunostomy, the suture pitch should not exceed 2 mm to prevent hepatolithiasis after PD.
Introduction: Multicystic dysplastic kidney (MCDK) is a congenital, nonhereditary renal malformation characterized by multiple noncommunicating cysts separated by dysplastic stroma containing primitive ducts, cartilage, and glomeruli, with the absence of normal renal parenchyma. It results from abnormal interaction between the ureteric bud and metanephric blastema during fetal development. Most cases are unilateral and detected incidentally on prenatal or postnatal imaging, although large cystic kidneys may present with abdominal distension or respiratory distress due to mass effect. Associated anomalies, including contralateral renal or extrarenal defects, are not uncommon. Presentation of case: A 40-day-old male infant presented with progressive abdominal distension and respiratory distress. Ultrasound revealed a right kidney replaced by multiple noncommunicating cysts (88 × 72 mm) containing clear fluid, with no renal parenchyma – consistent with MCDK. The left kidney appeared normal. Additional findings included a right inguinal hernia containing bowel loops, a right-sided heart, and a club foot deformity. Voiding cystourethrography and renogram showed a nonfunctional right kidney (3%) and a left kidney with ureteropelvic junction obstruction (97%). The patient underwent right nephrectomy with simultaneous hernia repair and later correction of the left obstruction, recovering uneventfully. Clinical discussion: MCDK occurs in approximately 1 in 4000–5000 live births. It may coexist with contralateral or extrarenal anomalies, as in this case. Histopathology confirmed cystic renal dysplasia. Conclusion: This rare case of right-sided MCDK associated with inguinal hernia and club foot underscores the importance of early diagnosis, comprehensive evaluation of the contralateral kidney, and timely surgical management to ensure favorable outcomes.
Background: Computed tomography angiography (CTA) with 3D reconstructions and digital subtraction angiography (DSA) is the diagnostic cornerstone for aortic pathology. This case series highlights a critical diagnostic pitfall: thrombosed abdominal aortic aneurysms (AAAs) that mimic simple aortic occlusions on 3D reconstruction images and DSA a finding with significant implications for surgical management. Methods: We retrospectively reviewed all cases of radiologically diagnosed infrarenal aortic occlusion at the National University Hospital (previously known as Al-Assad University Hospital), Damascus, between January 2023 and January 2025 (n = 30). Within this cohort, we identified three cases where a discrepancy existed between the findings on 3D reconstructed/DSA images and those on axial CTA source images. Case Series: Three male patients, all active smokers presenting with chronic lower limb ischemia, were initially diagnosed with infrarenal aortic occlusion based on 3D reconstruction images and DSA. However, in all three cases, careful review of the axial CTA source images revealed a thrombosed infrarenal abdominal aortic aneurysm (AAA). The intraoperative diagnosis of a thrombosed aneurysm was established during successful open surgical repair in all cases, which involved the placement of a 16 × 8 mm Dacron graft via an end-to-end aortic anastomosis . Conclusion: In our institutional experience, this specific diagnostic finding was present in 3 of 30 cases (10%) initially diagnosed as aortic occlusion at the National University Hospital over the last 3 years. Consequently, meticulous review of axial source images is indispensable to ensure accurate diagnosis and appropriate surgical planning for thrombosed AAAs masquerading as simple occlusions.
