BACKGROUND Aortic stenosis (AS) often coexists with carotid artery stenosis. However, clear guidelines for the optimal treatment strategy and sequencing of interventions in patients with both conditions are lacking. CASE SUMMARY A 79-year-old man with a history of hypertension presented with right-sided paralysis and pain. Magnetic resonance imaging revealed multiple infarctions in the left cerebral hemisphere and severe stenosis of the left carotid artery. Transthoracic echocardiography also identified coexisting severe AS. Carotid artery stenosis increases the risk of stroke during aortic valve manipulation; therefore, carotid intervention may be recommended prior to aortic valve treatment. However, perioperative hypotension and bradycardia associated with carotid intervention can precipitate circulatory collapse in patients with severe AS. After a multidisciplinary conference, the decision was made to first perform transcatheter aortic valve implantation under general anesthesia, followed by carotid endarterectomy 4 months later. Both procedures were completed successfully without complications. CONCLUSION Treatment strategy should be individualized, balancing perioperative risks and benefits in patients with severe AS and carotid artery stenosis.
Psychiatric disorders significantly impact surgical outcomes, presenting unique challenges in perioperative care. The intricate relationship between preoperative psychiatric conditions and surgical complications involves complex mechanisms, including altered coagulation, cardiovascular function, and pain perception. Common psychiatric disorders in surgical patients, such as anxiety, depression, and substance use disorders, vary in prevalence and manifestation. Demographic factors, comorbidities, and psychotropic medications further modulate these effects on surgical outcomes. Effective screening and assessment strategies are crucial, yet they present both opportunities and limitations in the preoperative setting. Preoperative psychological interventions, including cognitive-behavioral therapy, supportive care, and mind-body techniques, show promise in mitigating psychological distress and improving surgical outcomes. Multidisciplinary approaches, involving collaborative efforts between psychiatric and surgical teams, are essential to provide comprehensive patient care. Emerging interventions, technological innovations, and personalized medicine approaches offer exciting possibilities to advance preoperative psychiatric care. By understanding the complex interplay between psychiatric disorders and surgical outcomes, healthcare professionals can implement integrated, patient-centered approaches to optimize perioperative care and improve overall patient outcomes.
Hemorrhoidal disease is a prevalent anorectal condition causing significant morbidity, affecting approximately 4% of the general population with incidence increasing with age and sedentary lifestyle. While conventional excisional hemorrhoidectomy techniques such as Milligan-Morgan and Ferguson remain standard for long-term efficacy, they are often associated with substantial postoperative pain and prolonged recovery. This narrative review evaluates the comparative clinical outcomes of laser hemorrhoidoplasty (LHP) versus conventional surgical interventions in the treatment of grade II and III symptomatic hemorrhoids. A comprehensive analysis of comparative studies, randomized controlled trials, and meta-analyses published between 2020 and 2025 was conducted, with primary outcomes including postoperative pain, recovery time, operative duration, complication rates, and recurrence. Key findings from studies by Maloku et al and Hassan et al. were analyzed to contextualize real-world LHP use. Across multiple high-quality studies, LHP was consistently associated with significantly lower postoperative pain scores, reduced analgesic requirements, and faster return to daily activities. Maloku et al demonstrated a shorter mean operative time (15.9 minutes) and reduced pain compared to open techniques (26.8 minutes; P < 0.01). Hassan et al confirmed these benefits in a cohort of 40 patients treated under local anesthesia. Operative time was generally comparable or shorter, and vessel ligation was suggested as an adjunct to improve outcomes in select cases. Complication rates were low and similar between groups, with LHP demonstrating minimal risk for major complications such as anal stenosis or incontinence. However, recurrence rates were higher with LHP in some studies, particularly in grade III disease. LHP offers a minimally invasive, low-morbidity alternative to excisional hemorrhoidectomy for appropriately selected patients. Despite superior short-term recovery profiles, potential for higher recurrence underscores the importance of patient selection and long-term follow-up. The role of local anesthesia and adjunctive vessel ligation merits further prospective evaluation.
BACKGROUND The majority of published reports on foreign bodies (FBs) involve the rectum and applied a transanal retrieval. Usually, patients with FB above the rectum are subjected to laparotomy for removal. Here, we illustrate the case of a man with an FB that had migrated into the descending colon, and its successful removal via a laparoscopic approach. CASE SUMMARY A 43-year-old man, who had the habit of FB insertion into his anus to aid defecation, presented upon experience of such an FB slipping through and migrating upward to the distal colon. Plain abdominal radiograph revealed a bottle-shaped FB, positioned in the left iliac fossa region. The FB was successfully removed via a laparoscopic-assisted procedure in which we combined diagnostic laparoscopic and endoscopic techniques during surgery. The patient was monitored for 2 d postoperatively and subsequently discharged home. CONCLUSION A minimally invasive approach should be adopted to aid extraction of colorectal FB as it is effective and safe.
BACKGROUND The management of tongue carcinoma is excision and radical neck dissection followed with reconstruction. This is a case report of a patient with tongue squamous cell carcinoma (SCC) who underwent the procedure with sternocleidomastoid (SCM) flap reconstruction. CASE SUMMARY A 52-year-old woman without smoking history complained tongue ulcer since 3 years ago. Based on the histopathological examination, the patient was diagnosed with T2N2M0 right tongue SCC and underwent wide excision of tumor; right mandibular; neck dissection and were reconstructed with SCM flap. CONCLUSION SCC of the tongue requires wide excision and dissection of the neck and mandible if infiltration into the surrounding lymph nodes has been found. The SCM flap reconstruction could be used post-surgery.
BACKGROUND Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently emer-ged as an alternative treatment for gastric outlet obstruction (GOO) in selected patients. AIM To report the initial experience of EUS-GE in patients with GOO. METHODS This study was a retrospective, observational, multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected. We analyzed technical success, clinical success, adverse events, and survival. Technical success was defined as adequate position-ing and deployment of the stent. Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure. Post-procedural adverse events were recorded. RESULTS Eleven procedures in 10 patients with GOO were included. The mean age of the patients was 67.5 years (range: 56-77 years). Malignant GOO was present in 9 patients. Technical success was achieved in 9/11 procedures (82%). Among them, clinical success was achieved in 9 patients (100%). Adverse events occurred in 1 patient (9%). The median survival was 3 months (n = 7; range: 1-8 months). CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.
BACKGROUND Endoscopic submucosal dissection is considered curative for patients with early rectal cancer when level of submucosal invasion is < 1000 microns with favourable histopathological features. Recent data suggests even deeper submucosal invasion can potentially be curative if R0 resection can be achieved and when no high-risk histopathological features are seen in the resected specimen. To achieve R0 resection, deeper dissection is required. CASE SUMMARY A 66 year old New Zealand European male presented with 3 mo history of per rectal bleeding. He was referred for a colonoscopy test to investigate this further. This revealed a malignant appearing lesion in the rectum. Biopsies however showed high grade dysplasia only. Given endoscopic appearances suspicious for deep submucosal invasion, patient was consented for endoscopic intermuscular dissection (EID). The case was successfully performed, and the presence of muscularis propria was confirmed in the resected specimen. There were no complications and total procedure time was 124 min. Lesion was clear of radial margins however deep margins were positive confirming it was at least a pT2 cancer. Patient was recommended to have further treatment but could not have radical surgery due to comorbidities and instead was referred for long course chemoradiotherapy. CONCLUSION EID is a safe and feasible option for management of rectal cancer in highly selected patients.
BACKGROUND Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections, adhesions, seromas, fistula formation and significant postoperative pain. The modified rectus muscle repair (RMR) is as an option to repair midline ventral hernias without mesh. AIM To evaluate the short term outcomes when the modified RMR was used to repair ventral hernias. METHODS This was a 5-year prospective study that examined the outcome of all consecutive patients with ventral abdominal wall hernias > 5 cm in maximal diameter who underwent repair using the modified RMR technique in a single surgeon unit. Patients were reviewed in an outpatient clinic at 3, 6 and 12 mo and evaluated for hernia recurrence on clinical examination. Each patient’s abdominal wall was also assessed with using ultrasonography at 24 mo to detect recurrences. All data were examined with SPSS ver 18.0. RESULTS Over the 5-year study period, there were 52 patients treated for ventral hernias at this institution. Four patients were excluded and there were 48 in the final study sample, at a mean age of 56 years (range 28-80). The mean maximal diameter of the hernia defect was 7 cm (range 5-12 cm). There were 5 (10.4%) seromas and 1 recurrence (2.1%) at a mean of 36 mo follow-up. CONCLUSION The authors recommend the modified RMR as an acceptable alternative to mesh repair of ventral hernias. The seroma rate can be further reduced with routine use of drains. The modified RMR also has the benefit of eliminating all mesh-specific complications.
BACKGROUND Ossifying fibroma is a type of benign fibro-osseous lesion. Most lesions affect the mandible region, particularly the molar and pre-molar areas. It predominantly affects females between the second to fourth decades of life. Larger ossifying fibroma tumors require more extensive resection.CASE SUMMARY A 39-year-old female complained of occasional pain and tumor enlargement on her left jaw for the 3 years prior to presentation. Intraoral examination revealed a firm swelling on her left lower gum. Extraoral examination revealed swelling on the left mandible body with no erythema and superficial ulcer. Computed tomography scan revealed a circular-shaped lesion on the patient’s left mandible body with a well-defined radiolucent border, sized 3.2 cm × 2.8 cm × 0.9 cm. The tumor was removed by marginal mandibulectomy. Biopsy from the resected tumor suggested cemento-ossifying fibroma（COF）.CONCLUSION COF is often unnoticed, but this slow-growing tumor can cause significant symptoms regarding its distortion into adjacent structures.
BACKGROUND Thyroid storm is an uncommon condition manifesting in severe thyrotoxicosis with a high mortality rate. The concurrence of peptic ulcer disease and hyperthyroidism is rare due to concurrent activation of both the sympathetic and parasympathetic pathways. We present a case of perforated giant gastric ulcer with concurrent thyroid storm who underwent damage control surgery with emergency patch repair with falciform ligament and recovered well.CASE SUMMARY A 53-year-old male chronic smoker, with no previous medical history, presented with severe generalized abdominal pain and vomiting for one day duration. Further history revealed weight loss, diarrhea, and anxiety over the past three months. On clinical examination, patient was febrile with temperature of 38.6 Degrees Celsius and tachycardic at 130-140 beats per minute, his blood pressure was low at 90/50 mmHg. His abdomen was tender with generalized peritonism. In view of his clinical history, a thyroid screen was ordered which showed raised thyroxine（T4） levels of 90.3 pmol/L and low thyroxine stimulating hormone（TSH） levels of 0.005 μU/mL. Chest X-ray showed no sub-diaphragmatic free air, but contrasted CT scan revealed pneumoperitoneum with large amount of intraabdominal free fluid. The working diagnosis was perforated peptic ulcer complicated by thyroid storm. An urgent endocrinologist consult was made, and patient was started on beta blocker and intravenous steroids pre-operatively. The patient underwent emergency laparotomy with washout and patch repair of the perforated gastric ulcer. Patient was monitored post-operatively in intensive care unit and required IV hydrocortisone and Lugol’s iodine. Histology of the ulcer edges showed no malignancy. On post-operative day seven, T4 decreased to 20.4 pmol/L, TSH was 0.005 mLU/L. His thyroid function test subsequently normalized 3 mo post-operatively with T4 18.1 pmol/L, TSH 1.91 mLU/L. Patient’s recovery was otherwise uneventful. Thyroid receptor antibody subsequently was positive, and patient was managed for Grave’s disease by the endocrinologist.CONCLUSION This case highlights the rare but life-threatening clinical emergency of peptic ulcer perforation complicated by thyroid storm. Multidisciplinary perioperative management is crucial to optimize patient for surgery and damage control principles should be taken for an acute surgical patient with concurrent endocrine crisis.
BACKGROUND Superior mesenteric artery syndrome（SMAS） is a rare condition, characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery（SMA）. Most cases of SMAS are associated with weight loss, and the most frequent clinical manifestations are nausea, vomiting, postprandial fullness, and abdominal pain. Treatment of SMAS is usually conservative, consisting mainly of adequate nutritional support, but in refractory cases surgery may be necessary, with gastrojejunostomy and duodenojejunostomy being the most commonly performed procedures.CASE SUMMARY We describe the case of a man in his forties with a pre-existing diagnosis of esophageal stricture due to sodium hydroxide ingestion, who suffered significant weight loss after replacement of his jejunostomy tube. He was admitted to the hospital due to pain and abdominal distension. A computerized tomography scan showed significant distension of the stomach and duodenum with narrowing of the duodenum at the point at which it is crossed by the superior mesenteric artery, thus establishing the diagnosis of SMAS. Due to the presence of the esophageal stricture, the patient was incapable of emesis; however, passage of a nasogastric tube for decompression was not possible. Considering the risk of gastric perforation due to distention, we opted for surgical treatment in the form of a surgical gastrojejunostomy after which he showed complete resolution of all symptoms and was discharged from the hospital 5 d after the procedure.CONCLUSION Diagnosis of SMAS can be challenging in patients with esophageal stenosis, and risk of gastric perforation may preclude conservative treatment.
BACKGROUND Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean, having been first performed in the region in the year 2011. We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.AIM To report our initial experience using the FreeHand? robotic camera holder（Freehand 2010 Ltd., Guildford, Surrey, United Kingdom） for laparoscopic colorectal surgery in Trinidad ＆ Tobago.METHODS We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand?（Freehand 2010 Ltd., Guildford, Surrey, United Kingdom） robotic camera holder between September 30, 2021 and April 30, 2022. The following data were recorded: patient demographics, robotic arm setup time, operating time, conversions to open surgery, conversions to a human camera operator, number and duration of intra-operative lens cleaning. At the termination of the operation, before operating notes were completed, the surgeons were administered a questionnaire recording information on ergonomics, user-difficulty, requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.RESULTS Nine patients at a mean age of 58.9 ± 7.1 years underwent colorectal operations using the FreeHand robot: Right hemicolectomies（5）, left hemicolectomy（1）, sigmoid colectomies（2） and anterior resection（1）. The mean robot docking time was 6.33 minutes（Median 6; Range 4-10; SD ± 1.8）. The mean duration of operation was 122.33 ± 78.5 min and estimated blood loss was 113.33 ± 151.08 mL. There were no conversions to a human camera holder. The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6 ± 0.88 times per case, with cumulative mean interruption time of 4.2 ± 2.15 minutes per case. The mean duration of hospitalization was 3.2 ± 1.30 days and there were no complications recorded. When the surgeons were interviewed after operation, the surgeons reported that there were good ergonomics（100%）, with no limitation on instrument movement（100%）, stable image（100%） and better control of surgical field（100%）.CONCLUSION Robot-assisted laparoscopic colorectal surgery is feasible and safe in the resource-poor Caribbean setting, once there is appropriate training.
BACKGROUND Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid（CSF） blockade due to arachnoidal adhesions and bands.Although many of the techniques currently in use, namely, the theco-peritoneal,syringo-pleural, syringo-peritoneal, and syringo-subarachnoid shunts, are effective, the results are often variable.CASE SUMMARY A 36-year-old man with a past history of pulmonary tuberculosis, presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation, difficulty in micturition, and decreased libido. He was bedridden a month before presentation. Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels. He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx. There was no direct surgical handling of the spinal cord involved. At the 15-mo follow up, the patient had significant improvement in his symptoms and function.CONCLUSION We present a novel technique aimed at correcting the primary cause of a postarachnoiditis syrinx, the subarachnoid cerebrospinal flow obstruction or block, which we believe is simple and effective, involves minimal handling of the normal neural structures, and attempts to restore the physiology of CSF flow across the obstruction, with favorable clinical results.
The role of regional lymphadenectomy has always been a matter of discussion in the surgical management of solid tumors – Pelvic and para-aortic lymphadenectomy in ovarian cancer is one such issue. A recently published randomized trial suggested that regional lymphadenectomy in patients with advanced ovarian cancer is unlikely to offer a survival advantage. However,para-aortic and pelvic lymphadenectomy is warranted in the presence of macroscopically suspicious nodes to achieve complete cytoreduction. A longterm follow-up of the trial will demonstrate whether a prophylactic regional lymphadenectomy is associated with survival benefit in a subgroup of patients with advanced ovarian cancer who have grossly normal regional lymphnodes as evident in a widely open retroperitoneum.
Cholangioscopy-assisted guidewire placement in a malignant biliary stricture: A case report
Can hyperthermic intraperitoneal chemotherapy effectively control gastric cancer-associated peritoneal carcinomatosis?
