Search Results (2,166)

Gallstone ileus is a rare but serious complication of gallstone disease, often requiring surgical intervention. While enterolithotomy remains the standard treatment, the role of additional biliary surgery, particularly subtotal cholecystectomy, remains controversial. This study examines the management of gallstone ileus in a rural setting, where limited surgical resources and access to specialized biliary interventions pose unique challenges. We present a case series of four patients diagnosed with gallstone ileus in a rural healthcare facility. All patients underwent initial enterolithotomy for bowel obstruction relief. Surgical outcomes, complications, and the necessity for a second intervention, including subtotal cholecystectomy, were evaluated. Ever patient had a successful recovery. Of the four cases, two patients underwent a subtotal cholecystectomy. No perioperative mortality was observed, but limited access to advanced imaging and specialized biliary surgery influenced clinical decision-making. The rural setting in which these series occurred comes with its unique challenges regarding resource management and technological demands. Full article

Background/Objectives: Finger amputation is frequently followed by complications, with reported revision rates of up to 20%. One of the most disabling sequelae is the formation of painful neuromas, occurring in approximately 3–9% of cases. Several biological and mechanical risk factors have been proposed, but the potential influence of psychological traits remains poorly understood. This study aimed to investigate whether a correlation exists between patients’ personality traits and the development of neuropathic pain or related symptoms. Methods: A retrospective study was conducted at a Level II Hand Trauma Center, including patients who underwent digital amputation between 2021 and 2023. Neuropathic pain and cold intolerance were assessed using the S-DN4 and CISS questionnaires, respectively. Personality traits were evaluated using the BFI-10 scale. Demographic data and other clinical risk factors, including work-related injuries, psychiatric history, infection, treatment delay, and surgical technique, were also analyzed. Results: A total of 54 patients were included. Neuropathic pain, defined by an S-DN4 score ≥ 4, was identified in 10 patients (18.5%). A significant correlation was found between the occurrence of neuropathic pain, cold intolerance, and the “neuroticism” personality trait. Patients with work-related injuries or psychiatric disorders also showed a higher risk of neuropathic pain and cold intolerance. Conversely, infection and delayed treatment were associated with an increased risk of revision procedures, whereas the type of surgical technique used for nerve stump management was not significantly correlated with pain outcomes. Conclusions: The study demonstrated a meaningful association between the neurotic personality trait and both neuropathic pain and cold intolerance after finger amputation. Additionally, work-related injuries and psychiatric comorbidities were identified as potential risk factors. Patients exhibiting these characteristics may benefit from early psychological assessment and multidisciplinary management to prevent further complications and improve postoperative outcomes. Full article

Background/Objectives: The growing population of women aged ≥ 80 years poses a new challenge for urogynecology. Advanced age, comorbidities, and polypharmacy raise concerns regarding the safety of procedures in the management of pelvic floor disorders (PFDs) such as pelvic organ prolapse (POP), stress urinary incontinence (SUI), and overactive bladder (OAB). Individualized, frailty-based assessment is essential in this group. The aim of the study was to evaluate the safety profile of urogynecological surgical procedures among women aged ≥ 80 years at a single tertiary center. Methods: In a retrospective observational single-center study, we analyzed the medical documentation of 774 hospitalizations of women aged ≥ 80 years admitted between 2014 and 2023. The analysis included indications, comorbidities, treatment types, anesthesia, and complications. Comorbidity and surgical risk were evaluated using the Charlson Comorbidity Index (CCI) and Clavien–Dindo classification. Results: A total of 720 admissions with complete medical records were analyzed, of which 65% were for urogynecological conditions. In this group, the mean age was 83.0 years and mean BMI was 27.2 kg/m². Most patients (92.9%) had comorbidities, mainly hypertension (84.2%) and diabetes (21.1%). POP was the leading indication (52%), followed by SUI (35%) and OAB (27%). Surgical management was performed in 95% of POP cases, predominantly via vaginal native tissue repair (80%), especially LeFort colpocleisis (20%). The transobturator sling (TOT) was the most frequent SUI surgery. Intraoperative complications occurred in 1.5% of cases and postoperative ones were mainly minor (Clavien–Dindo I–II). No procedure-related deaths were recorded. Conclusions: In this cohort, surgical treatment of urogynecological problems in women ≥80 years was associated with a low rate of major complications, suggesting that it can be safely offered to elderly patients. Careful preoperative assessment based on frailty and comorbidity rather than chronological age remains essential. Full article

Background and Clinical Significance: Superior mesenteric artery syndrome (SMAS) is a rare and often underdiagnosed cause of proximal intestinal obstruction, resulting from compression of the third portion of the duodenum between the SMA and the aorta. It typically occurs in individuals with significant weight loss due to mesenteric fat depletion. CasePresentation: We report the case of a 14.5-year-old female presented with a 6-day history of intractable vomiting and epigastric pain, on a background of intermittent vomiting over the preceding six months associated with a 7 kg unintentional weight loss, culminating in inability to tolerate oral intake. Her clinical course was complicated by a transient episode of blurred vision, numbness, and incoherent speech, initially suspected to be a neurological event. Extensive gastrointestinal and neurological investigations were inconclusive. Elevated fecal calprotectin levels raised suspicion for inflammatory bowel disease, given her family history, though endoscopy and histopathology were unremarkable. Advanced imaging ultimately demonstrated a markedly reduced aortomesenteric angle (6°) and distance (4 mm), confirming the diagnosis of SMAS. The patient was initially managed conservatively with total parenteral nutrition (TPN), achieving partial weight gain of 5 kg after 8 weeks of TPN. Due to persistent duodenal compression, surgical intervention was required. At 7-month follow-up, the patient remained symptom-free with restored nutritional status and a good weight gain. Conclusions: This case highlights the importance of considering SMAS in adolescents with chronic upper gastrointestinal symptoms and significant weight loss. Early recognition and appropriate imaging are essential to diagnosis, and timely surgical management can lead to excellent outcomes when conservative treatment is insufficient. Full article

Background: Pin tract infections (PTIs) are a frequent complication of external fixation, yet pediatric trauma-specific data—particularly for open long bone fractures—remain limited and heterogeneous. This study evaluated the frequency, severity, timing, management, and outcomes of PTIs in children and adolescents treated with external fixation for open long bone fractures. Methods: This retrospective single-center study included patients younger than 18 years with open long bone fractures treated with external fixation between 2002 and 2023. PTIs were graded using the Checketts–Otterburn classification (grades I–VI). Management included antibiotic regimen and surgical interventions. Outcome was reported by time to bony consolidation. Results: In 40 patients, 16 patients exhibited PTIs (mild: eight; moderate: five; severe: three. A higher grade of Gustilo–Anderson (p = 0.47) and evident macroscopic contamination (p = 0.73) did not appear to influence the occurrence of PTIs by similar duration of initial antibiotic regimen (p = 0.3). The median time to PTI onset was 49 days (IQR 22–80), with the majority occurring after completion of initial systemic antibiotic therapy. The management of PTIs was predominantly conservative: all eight mild cases resolved with intensified local pin tract care, while all eight moderate and severe cases were treated with systemic antibiotics and five required pin exchange or premature fixator removal. Overall bony consolidation was achieved in all patients, and reoperations were related to trauma severity rather than PTIs except in one patient. No cases of osteomyelitis were observed. Conclusion: Pin tract infections are frequently identified in pediatric open long bone fractures treated with external fixation. Using strict diagnostic criteria, any documented inflammatory change or local secretion at the pin–skin interface is considered indicative of PTI. However, the majority of these infections were classified as superficial and manageable with conservative measures, and all affected fractures healed radiologically. Full article

Background: Descemet membrane endothelial keratoplasty (DMEK) is the most frequently performed keratoplasty procedure in many countries. One of the most common early complications is an elevation of intraocular pressure (IOP). The aim of this study was to characterize early postoperative IOP behavior following DMEK performed with 10% sulfur hexafluoride (SF₆) tamponade and to determine the frequency and timing of required IOP-lowering interventions within the first 48 h. Methods: We retrospectively reviewed postoperative outcomes of 116 consecutive DMEK procedures between May and December 2024 at the University Medical Center in Mainz, Germany. No specific exclusion criteria were applied. All surgeries included a surgical iridectomy at the 6 o’clock position, 10% (SF₆) tamponade, and maintaining a mid-normal IOP at the end of surgery. Postoperative assessments included IOP measured using Goldmann applanation tonometry, the percentage of gas fill in the anterior chamber evaluated at the slit lamp, and the need for IOP-lowering interventions as determined by the on-call resident at 3, 24, and 48 h after surgery. IOP-lowering interventions consisted of venting in cases of elevated IOP, gas fill > 90%, and/or suspected angle closure or pupillary block, as well as intravenous or oral acetazolamide in cases of moderate IOP elevation with a lower gas fill and a patent iridectomy. If a single intervention was insufficient, a combined approach was used. Results: A total of 116 eyes from 98 patients (62 female, mean age 73.0 ± 9.8 years) were analyzed. DMEK was combined with cataract surgery in 41 eyes, and 4 eyes underwent phakic DMEK. Postoperatively, all iridectomies remained patent, and no cases of pupillary block occurred. Mean IOP and gas fill were within normal limits and declined steadily during the first 48 h. IOP-lowering procedures were performed in 11 eyes (9.5%), including venting (n = 3), acetazolamide administration (n = 7), and a combination of both (n = 1). There was no difference between DMEK and triple-DMEK regarding postoperative gas fill, IOP, or the need for IOP-lowering interventions. Mean postoperative IOP was significantly higher, and IOP-lowering interventions were more frequent in glaucoma vs. non-glaucoma patients. Re-bubbling was performed in 12 eyes (10.3%). Two cases of primary graft failure (1.7%) were recorded. Conclusions: In our patient cohort, a standardized surgical approach incorporating a surgical iridectomy at the 6 o’clock position, 10% SF₆ tamponade, and maintaining a mid-normal IOP at the end of surgery effectively prevented pupillary block. We recommend early postoperative assessment of IOP and percent gas fill to promptly identify and manage impending IOP elevation, which is particularly important in patients with glaucoma. Full article

Uveitis constitutes a heterogeneous group of intraocular inflammatory pathologies, including both infectious and non-infectious aetiologies, often leading to substantial morbidity and permanent loss of vision in up to 20% of the affected cases. Visual impairment is most prominent in intermediate, posterior, or panuveitis and is commonly associated with cystoid macular oedema, epiretinal membranes, macular holes, and retinal detachment. In the context of uveitis, these complications arise as a result of recurrent flare-ups or chronic inflammation, contributing to cumulative ocular damage. Pars plana vitrectomy (PPV) has an evolving role in the diagnostic and therapeutic approach to uveitis. Diagnostic PPV allows for the analysis of vitreous fluid and tissue using techniques such as PCR, flow cytometry, cytology, and cultures, providing further insights into intraocular immune responses. Therapeutic PPV can be employed for the management of structural complications associated with uveitis, in a wide spectrum of inflammatory clinical entities such as Adamantiades–Behçet disease, juvenile idiopathic arthritis, acute retinal necrosis, or ocular toxoplasmosis. Modern small-gauge and minimally invasive techniques improve visual outcomes, reduce intraocular inflammation, and may decrease reliance on systemic immunosuppression. Emerging technologies, including robot-assisted systems, are expected to enhance surgical precision and safety in the future. Despite these advances, PPV outcomes remain variable due to heterogeneity in indications, surgical techniques, and postoperative management. Prospective studies with standardized protocols, detailed subgroup analyses, and the integration of immunological profiling are needed to define which patients benefit most, optimize therapeutic strategies, and establish predictive biomarkers in uveitis management. Full article

Background: Coronary artery bypass grafting (CABG) is a well-established revascularization strategy for patients with multivessel coronary artery disease. The effectiveness of CABG is significantly influenced by antiplatelet therapy aimed at maintaining graft patency and reducing thrombotic complications. However, substantial inter-individual variability exists in platelet function responses to standard therapies such as aspirin and clopidogrel, leading to antiplatelet resistance. This variability has been linked to increased risks of myocardial infarction, stroke, and early graft failure. Platelet function testing (PFT) offers a potential strategy to identify resistance and guide more personalized antiplatelet therapy. This study aims to evaluate the association between perioperative platelet function test results and clinical outcomes following CABG. By assessing platelet responsiveness at multiple timepoints and correlating findings with postoperative events, the study seeks to determine whether PFT can stratify risk and improve patient management. Methods: This is a prospective, single-centre, observational cohort study conducted at a tertiary NHS cardiac surgery centre. Patients having elective or urgent isolated CABG will be enrolled and undergo perioperative PFT using the TEG6s system. Clinical outcomes will be monitored for 12 months postoperatively, with primary endpoints assessing the correlation between platelet function results and major adverse cardiovascular and cerebrovascular events (MACCE). Secondary endpoints will include the prevalence of antiplatelet resistance, demographic predictors, and the feasibility of integrating PFT into clinical workflows. Results: This study will report the prevalence of aspirin and clopidogrel resistance in CABG patients based on TEG6s PFT, as well as the correlation between platelet function results and MACCE, postoperative bleeding, and the need for surgical re-exploration. Additionally, it will examine the associations between demographic and clinical factors—such as diabetes status, renal function, BMI, and surgical technique—and variability in platelet responsiveness. The feasibility of incorporating PFT into perioperative workflows will also be evaluated, assessing whether results could support personalized antiplatelet management in future clinical trials. Conclusions: Findings from this study will provide real-world evidence regarding platelet function variability in CABG patients and suggest that PFT may identify those at increased risk of thrombotic complications. This exploratory analysis supports the need for larger interventional trials aimed at optimizing individualized postoperative antiplatelet therapy to improve surgical outcomes. Full article

Robotic retroperitoneal lymph node dissection (R-RPLND) represents an evolution in the surgical management of testicular germ cell tumors, offering reduced morbidity compared with open approaches. However, this procedure remains technically challenging, particularly after chemotherapy, due to dense fibrosis and distortion of the retroperitoneal anatomy. We report a case of an unrecognized intraoperative thermal injury causing a partial transection of the proximal ureter presenting postoperatively as a urinary fistula following R-RPLND for residual mass resection, along with a focused review of the contemporary literature on procedure-related complications. A review of large series highlights severe complications (Clavien–Dindo ≥ III) occurring in 6–12% of cases, with ureteral injuries occurring in up to 6%, often identified after surgery. This case underscores the importance of meticulous dissection, awareness of altered anatomy, and prompt intervention when unexpected events arise during R-RPLND. Full article

Background: Submacular hemorrhage (SMH) is a vision-threatening condition most associated with neovascular age-related macular degeneration (nAMD), although it may also arise from polypoidal choroidal vasculopathy, pathological myopia, retinal vascular diseases, trauma, and systemic factors. Rapid management is essential because subretinal blood induces photoreceptor toxicity, clot organization, and fibroglial scarring, leading to irreversible visual loss. The choice and urgency of treatment depend on hemorrhage size, duration, and underlying pathology, and the patient’s surgical risk category, which can influence the invasiveness of the selected procedure. This review aims to provide an updated synthesis of recent advances in the surgical and pharmacological management of SMH, focusing on evidence from the past five years and comparing outcomes across major interventional approaches. Methods: A narrative review of 27 recent clinical and multicentre studies was conducted. The included literature evaluated pneumatic displacement (PD), pars plana vitrectomy (PPV), subretinal or intravitreal recombinant tissue plasminogen activator (rtPA), anti-VEGF therapy, and hybrid techniques. Studies were analyzed about indications, surgical methods, timing of intervention, anatomical and functional outcomes, and complication and patient risk stratification. Results: Outcomes varied depending on the size and duration of hemorrhage, as well as the activity of underlying macular neovascularization. PD with intravitreal rtPA was reported as effective for small and recent SMH. PPV combined with subretinal rtPA, filtered air, and anti-VEGF therapy demonstrated favorable displacement and visual outcomes in medium to large hemorrhages or those associated with active nAMD. Hybrid techniques further improved clot mobilization in selected cases. Across studies, delayed intervention beyond 14 days correlated with reduced visual recovery due to blood organization and photoreceptor loss. Potential risks, including recurrent bleeding and rtPA-associated toxicity, were reported but varied across studies. Conclusions: Management should be individualized, considering hemorrhage characteristics and surgical risk. Laser therapy, including PDT, may serve as an adjunct in the perioperative or postoperative period, particularly in PCV patients. Early, tailored intervention typically yields the best functional outcomes. Full article

Tracheal stent fracture is a major complication of endoluminal tracheal stent (ELS) for canine tracheal collapse, and optimal management strategies remain unclear. A 4-year-old Yorkshire Terrier presented with respiratory distress caused by complete ELS fracture. Imaging and bronchoscopy revealed intraluminal protrusion of fractured stent segments, ventral tracheal cartilage invagination, and marked luminal deformation. A polypropylene linear prosthesis (PLLP) was selected as an external tracheal support. Its continuous band-like structure allowed broad and uniform reinforcement of the tracheal wall and redistribution of mechanical stress. PLLP placement successfully restored a near-normal tracheal contour and stabilized the fractured stent without introducing additional intraluminal material. Postoperative bronchoscopy confirmed improved tracheal patency, and no further deformation or stent damage was observed despite several months of altered airway dynamics associated with laryngeal paralysis. This case suggests that PLLP may represent a valid surgical option for managing tracheal stent fracture in dogs. Full article

Background: Atypical cartilaginous tumors (ACT), formerly classified as Grade 1 chondrosarcomas (CS1) of the extremities, are hyaline cartilage-producing neoplasms. The WHO classification (4th edition, 2013) redefined ACT as locally aggressive rather than malignant tumors, prompting a shift toward less aggressive surgical management. This study reports data of a single, tertiary musculoskeletal tumor center and compares the long-term oncological outcomes of wide resections and intralesional curettage for primary ACT. Methods: This retrospective study included 61 patients with ACT treated at a tertiary tumor center between 2003 and 2023. Patients were divided into two cohorts: Cohort 1 was treated before 2013 with wide or radical resection, while cohort 2 was treated with an intralesional approach. Data on recurrence, revision rates, survival, and predictors of outcomes were analyzed using Kaplan–Meier survival analysis and log-rank testing. Results: Wide resections were performed in 24 patients, requiring prosthetic reconstruction in 76% of cases. Intralesional curettage was performed in 37 patients. Local recurrence occurred in 8% in wide resections versus 16% of curettage cases (p = 0.198), with no significant difference in time to recurrence between cohorts. Unplanned revision rates were higher in the wide resection group (42%) compared to curettage (35%), driven primarily by prosthesis-related complications. Overall survival was high in both groups (88% in wide resections vs. 94% in curettage; p = 0.705). Resection margins, and metastases were identified as significant predictors of both recurrence and tumor-related death. Conclusions: Intralesional curettage provides comparable oncological outcomes to wide resections with reduced morbidity, supporting its use as the preferred treatment for ACT in appropriately selected patients. Full article

Background/Objectives: Surgical management of atypical femoral fractures (AFFs) stabilized with intramedullary (IM) nailing is frequently challenged by delayed union or nonunion due to the severely suppressed bone turnover characteristic of bisphosphonate-related bone pathology, often leading to a hypertrophic nonunion-like state at the fracture site. This consecutive case series aimed to evaluate the effectiveness of intraoperative percutaneous decortication at the hypertrophic cortex in promoting rapid bone healing in complete AFFs. Methods: This was a single-center consecutive case series of patients with complete atypical femoral fractures (AFFs) treated with intramedullary nailing and adjunctive percutaneous decortication since February 2021. The standardized surgical protocol—including percutaneous decortication performed through a small anterolateral incision using an osteotome to create bone chips and stimulate the sclerotic cortex—was applied prospectively to all consecutive patients from February 2021. Of the 20 patients who underwent surgery during this period, 14 with sufficient radiographic follow-up were included in the final retrospective analysis. Data collected included patient demographics, duration of bisphosphonate use, fracture location (diaphyseal vs. subtrochanteric), operative details (including iatrogenic fracture), and radiographic bone union time. Bone union was assessed on serial radiographs by two independent observers. Results: All 14 patients were female, with a median age of 75 years (IQR 67–79 years). Thirteen patients (92.9%) had prior bisphosphonate exposure for a median of 4.5 years (IQR 3–10 years). Six fractures were subtrochanteric fractures, and six were complicated by iatrogenic fracture during nail insertion. Postoperative teriparatide was administered to six patients. Radiographic bone union was achieved in all 14 patients at a median of 19 weeks (IQR 16–22 weeks; range 16–24 weeks). No major complications (infection, implant failure, nonunion, or neurovascular injury) occurred during follow-up. Conclusions: Percutaneous decortication is a simple, safe, and biologically plausible adjunct to intramedullary nailing. In this series of 14 elderly women with long-term bisphosphonate exposure (median 4.5 years), the technique was associated with 100% radiographic union at a median of 19 weeks without major complications, suggesting a promising strategy that warrants validation in larger, controlled trials. Full article

Charcot neuro-osteoarthropathy (CNO) is a devastating complication of peripheral neuropathy, characterized by progressive bone and joint destruction that leads to severe foot deformity, ulceration, and a high risk of amputation. The management of CNO is predicated on an accurate understanding of its biomechanical instability, yet conventional imaging modalities like non-weight-bearing computed tomography (CT) and magnetic resonance imaging (MRI) fail to capture the true, load-dependent nature of the deformity. This review elucidates the paradigm shift facilitated by weight-bearing computed tomography (WBCT) in the diagnosis and management of CNO. A comprehensive narrative review of the literature was conducted to synthesize the pathophysiology of CNO, the limitations of conventional imaging, and the technological principles, clinical applications, and future directions of WBCT in CNO management. The review integrates findings on CNO pathophysiology, radiological assessment, and the debate surrounding weight-bearing protocols in conservative management. WBCT provides a three-dimensional, functional assessment of the Charcot foot under true physiological load, overcoming the critical limitations of non-weight-bearing imaging. It reveals the full extent of osseous collapse, unmasking hidden instabilities and enabling the use of novel quantitative 3D metrics for deformity characterization and risk stratification. Clinically, WBCT enhances the entire management pathway, from improving early diagnostic accuracy and informing surgical strategy with patient-specific instrumentation to enabling objective postoperative evaluation of reconstructive outcomes. WBCT is a promising technology that redefines the assessment of CNO from a static, morphological description to a dynamic, quantitative biomechanical analysis. Its integration into clinical practice offers the potential to improve diagnostic precision, optimize surgical planning, and ultimately enhance patient outcomes. The future synergy of WBCT with artificial intelligence holds promise for further advancing patient care, moving towards a predictive and prescriptive model for managing this complex condition. Full article

Complex or difficult cesareans are associated with significant short- and long-term complications. The complication rate increases with the increasing number of cesareans, and the incidence of cesarean section is increasing. To accurately identify women at high risk of surgical difficulty during a cesarean, ultrasound, in addition to clinical assessment, can be used to evaluate many risk factors, including placenta previa, placenta accreta spectrum (PAS) disorders, fibroids, severe pelvic adhesions, and membranous fetal vessels. The role of preoperative ultrasound is to identify ultrasonographic signs of anatomic changes that may affect the risk of intraoperative complications in subsequent cesarean sections. It is important to look for maternal problems as well as fetal problems. Ultrasound is a well-established practice in obstetrical care as it is easily available, accessible, easy to perform, and well accepted by women. However, there are few studies on the role of preoperative ultrasound in the management of complex or difficult cesareans beyond the risk assessment of PAS. Currently, preoperative ultrasound is mostly performed in selected cases only, with the exception in some settings. The aim of this review article is to discuss the benefits and the use of ultrasound assessment before different types of complex or difficult cesareans. Whether ultrasound assessment should be performed before all cesarean sections will also be discussed. Full article