We report a rare and potentially life-threatening case of a young male with Behçet's disease complicated by Hughes-Stovin syndrome who presented with massive haemoptysis secondary to multiple pulmonary artery aneurysms with associated thrombosis. The patient presented to the emergency department with a 20-day history of cough and fever, followed by acute worsening haemoptysis over 2 days, accompanied by haemodynamic instability. Initial CT pulmonary angiography demonstrated multiple bilateral saccular pulmonary artery aneurysms involving the descending and segmental branches, with partial and complete thrombosis. Transthoracic echocardiography revealed an associated right ventricular thrombus.The patient required emergency airway protection, blood transfusion and vasopressor support. A multidisciplinary team involving pulmonology, rheumatology, cardiothoracic surgery and interventional radiology was engaged. High-dose systemic corticosteroids and immunosuppressive therapy were initiated for underlying vasculitis. Given the inaccessibility of the aneurysms for surgical repair, endovascular embolisation was recommended as definitive management. Despite transient relapses of haemoptysis during subsequent admissions, the patient was stabilised with aggressive immunosuppression and successfully underwent vascular intervention.This case highlights the importance of early recognition of vascular Behçet's disease and Hughes-Stovin syndrome as rare but critical causes of massive haemoptysis in young patients. Hughes-Stovin syndrome is a rare vasculitic disorder characterised by pulmonary artery aneurysms and thrombosis and is considered a cardiovascular variant of Behçet's disease. Rupture of pulmonary artery aneurysms frequently presents with massive haemoptysis and is associated with high mortality. Prompt multidisciplinary management combining immunosuppressive therapy and endovascular intervention is essential to prevent fatal complications.
Management of large to massive rotator cuff tears (RCTs) remains challenging, particularly when complete anatomic repair is not feasible. The current study aims to evaluate short-term clinical outcomes and complications following arthroscopic partial repair of large to massive RCT with incomplete footprint coverage and to compare outcomes according to concomitant subscapularis repair and post-operative rotator cuff integrity. Patients who underwent arthroscopic partial repair of the supraspinatus tendon, with or without associated infraspinatus tears, and incomplete footprint coverage between July 2022 and April 2023 were retrospectively identified. Inclusion criteria included intraoperative confirmation of incomplete anatomic footprint coverage, an anteroposterior tear size ≥ 3 cm, and the presence of either an intact subscapularis tendon or a reparable concomitant subscapularis tear (Lafosse type ≤3). Patients were excluded if they were lost to follow-up, had a history of prior shoulder instability surgery, or had insufficient clinical or radiologic data. Clinical outcomes were evaluated pre-operatively and at final follow-up using the visual analog scale for pain, Constant score, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, active range of motion (ROM), and shoulder strength. Radiologic assessment included evaluation of repair integrity, acromiohumeral distance, and progression of glenohumeral arthritis. After excluding 15 patients, 142 patients were included in the final analysis. At a mean follow-up of 26.2 months, significant improvements were observed in all pain, patient-reported outcome measures, ROM, and strength (all P < .001). Post-operative retear was identified in 43 patients (30.3%). Clinical outcomes did not differ significantly between patients with intact subscapularis tendons and those who underwent concomitant subscapularis repair. However, patients with intact post-operative repair integrity demonstrated significantly superior pain relief, functional scores, ROM, and strength compared with those who experienced retears (all P < .001). Arthroscopic partial repair with incomplete footprint coverage was associated with significant short-term improvements in pain, function, ROM, and strength in patients with large to massive RCT. Outcomes were similar between patients with intact subscapularis tendons and those undergoing concomitant repair of reparable subscapularis tears. However, post-operative structural failure occurred in 30.3% of patients and was associated with inferior outcomes and frequent revision surgery. These findings should be interpreted cautiously given the retrospective design, absence of a comparator group, and short-term follow-up.
The video demonstrates an arthroscopic technique for identification, dissection, and protection of the suprascapular nerve (SSN) during massive rotator cuff repair. The SSN, closely related to the transverse scapular ligament (TSL), may present anatomical variations that heighten the risk of iatrogenic injury. In this technique, careful dissection is performed to expose the nerve, especially in cases where it courses over the TSL rather than through the suprascapular notch. Key anatomical landmarks and stepwise visualization methods are illustrated to ensure safe exposure and preservation of the SSN during procedures such as subacromial decompression, medial-row anchor placement, massive rotator cuff tears, or SSN release. Emphasis is placed on meticulous preoperative planning and intraoperative vigilance to enhance procedural safety.
Benign prostatic hyperplasia (BPH) is a highly prevalent condition among elderly men and a major cause of lower urinary tract symptoms (LUTS), urinary retention, recurrent urinary tract infections (UTIs), hematuria, and bladder outlet obstruction (BOO). Management of severe BPH in elderly patients with multiple comorbidities remains challenging, particularly in those who are poor surgical candidates. Prostate artery embolization (PAE) has emerged as a minimally invasive alternative for symptomatic relief in patients with moderate-to-severe LUTS secondary to BPH. We present the case of an 87-year-old male with massive BPH (estimated prostate volume 263 g) complicated by recurrent urinary retention, recurrent catheter-associated UTIs (CAUTIs), gross hematuria, and chronic Foley catheter dependence despite maximal medical therapy with tamsulosin and finasteride. His medical history was significant for coronary artery disease with prior cardiac stent placement, prior stroke, chronic anticoagulation therapy, hypertension, nephrolithiasis, and cognitive impairment, making him a high-risk candidate for conventional surgical intervention. Imaging and cystoscopic evaluation confirmed severe prostatomegaly with intravesical prostatic protrusion and BOO. The patient underwent successful bilateral PAE via left radial artery access using 300-500 μm embospheres without procedural complications. At follow-up, he demonstrated marked symptomatic improvement with restoration of spontaneous voiding, absence of recurrent urinary retention, and reduction of post-void residual volume to 35 mL. No further catheter obstruction or catheter-associated infections were reported. This case highlights the effectiveness and safety of PAE as a minimally invasive therapeutic option for elderly high-risk patients with giant BPH and chronic catheter dependence. The favorable clinical outcome observed further supports the growing role of PAE in complex geriatric urologic populations who are not ideal candidates for traditional surgical management.
Pulmonary embolism (PE) is a thromboembolic disorder characterized by obstruction of the pulmonary arterial circulation, most commonly due to embolization of thrombi originating from the deep venous system of the lower extremities. Massive PE is a critical condition marked by hemodynamic instability not caused by a new arrhythmia, cardiogenic shock, or circulatory collapse. The patient is a 28-year-old male with no significant medical history who arrived at the Emergency Department with a self-inflicted neck wound. He received initial treatment, including securement of the airway, antibiotics, analgesia, and suturing. After neck exploration and tracheal repair, he was diagnosed with MRSA and ESBL + Klebsiella pneumoniae and treated with IV antibiotics. After 17 days of admission, the patient was discharged home but returned the same day with hypotension, shortness of breath, chest pain, and shock, with hypoxia. Point-of-care ultrasound (POCUS) revealed right ventricular dilatation suggestive of PE, which was finally confirmed with further testing. Echocardiogram confirmed substantial right ventricular and right atrial dilation with an estimated pulmonary artery pressure of 53 mm Hg and a positive McConnell's sign. In conclusion, cardiac POCUS is a non-invasive, quick, and cost-effective imaging technique used in emergency settings to diagnose PE by identifying PE markers. This case report underscores the importance of POCUS in promptly diagnosing PE, emphasizing its role in preventing fatal outcomes due to delayed diagnosis.
This technical note describes an arthroscopic technique that utilizes the autologous palmaris longus (PL) tendon to augment large to massive rotator cuff tears when complete repair is not feasible. The PL tendon is harvested through a minimal wrist incision and delivered intramuscularly into the supraspinatus and/or infraspinatus using a shuttle relay technique. Subsequently, standard double-row fixation is performed, incorporating the PL in a crossed suture bridge configuration. This method offers a biologically favorable and mechanically supportive alternative to dermal allografts, with minimal donor-site morbidity. This technique may enhance graft integrity and healing potential and could be adapted using alternative tendons when PL is absent. Further studies are warranted to assess the long-term clinical outcomes.
Idiopathic multicentric Castleman disease (iMCD) is a benign lymphoproliferative disease characterized by generalized lymphadenopathy and systemic inflammatory symptoms, occurring in individuals without infection with human immunodeficiency virus (HIV) or Kaposi sarcoma-associated herpesvirus (KSHV). iMCD is typically subclassified into iMCD-TAFRO, which is characterized by thrombocytopenia, ascites, fever, reticulin fibrosis, and organomegaly; iMCD with idiopathic plasmacytic lymphadenopathy (iMCD-IPL), which follows a chronic disease course with persistent lymphadenopathy, marked polyclonal hypergammaglobulinemia, and prominent plasma cell infiltration in lymph nodes; and iMCD-not otherwise specified (iMCD-NOS), which lacks features of both TAFRO syndrome and the IPL phenotype. Pleural thickening and effusion are extremely rare manifestations of iMCD-NOS. Herein, we present a rare case of iMCD-NOS presenting with unilateral pleural thickening and pleural effusion. A 76-year-old Japanese man was referred for further evaluation of a massive left-sided pleural effusion with tracheal compression. Fluorodeoxyglucose positron emission tomography/computed tomography showed increased uptake in the thickened pleura and multiple lymph nodes. Histopathological examination of a mediastinal lymph node demonstrated medullary and lymphoid follicular hyperplasia without structural destruction, while biopsy of the thickened pleura showed infiltration of lymphocytes and plasma cells without dysplasia. The patient was treated with corticosteroids and tocilizumab, resulting in marked improvement in symptoms and pleural effusion. This case highlights the importance of considering pleural and lymph node biopsies for accurate diagnosis and of not excluding iMCD in patients with unilateral pleural thickening accompanied by multiple lymphadenopathies.
Lower trapezius tendon (LTT) transfer can restore shoulder function, particularly active external rotation (ER) following massive rotator cuff tear (MRCT). However, the optimal graft type and its transfer location on the greater tuberosity remain unclear. To investigate the optimal graft type and location in LTT transfer for posterosuperior MRCT from a biomechanical perspective. Controlled laboratory study. Eight fresh-frozen cadaveric shoulders were tested on a shoulder simulator. LTT transfer was performed with an Achilles tendon fixed over the superior-middle facets (LTT-Achilles), a semitendinosus (ST) tendon to the superior facet (LTT-ST-S), or to the middle facet (LTT-ST-M). A 24-N load was applied to each transferred graft. Under each condition (intact rotator cuff, MRCT, LTT-Achilles, ST-S, and ST-M), humeral head translation and functional abduction force (FAF) were evaluated at 0°, 30°, and 60° of glenohumeral elevation. ER torque was assessed across 5 angles (60° internal rotation [60IR], 30° internal rotation [30IR], neutral, 30° ER [30ER], and 60° ER [60ER]) at 0°, 30°, and 60° of glenohumeral elevation. None of the LTT conditions significantly depressed humeral head posterosuperior migration as compared with MRCT. Compared with MRCT, FAF improved significantly with LTT-Achilles at 0° elevation (P = .014) and LTT-ST-S at 0° (P < .001) and 30° elevation (P = .003). LTT-ST-M improved ER torque compared with MRCT at 0° elevation (60IR, P = .04; 30IR, P = .02; neutral, P = .007; 30ER, P = .03; 60ER, P = .006) and at 30° elevation (60IR, P = .01; 30IR, P = .02; neutral, P = .006). LTT-ST-M showed higher ER torque than both LTT-Achilles and LTT-ST-S at 0° elevation (30IR [LTT-Achilles, P = .03; LTT-ST-S, P = .04]; neutral [LTT-Achilles, P = .02; LTT-ST-S, P = .007]). In LTT transfer for MRCT, LTT-ST-M most effectively restored ER torque, whereas LTT-Achilles and LTT-ST-S improved FAF. None of the conditions of LTT transfer suppressed humeral translation. Graft selection and transfer location in LTT transfer can be tailored to patient goals and graft availability, leading to a more patient-specific surgical strategy.
Since 2021, Rohingya refugee camps in Cox's Bazar, Bangladesh, have experienced a significant and concerning increase in the prevalence of scabies. In response to the massive outbreak, an extensive Mass Drug Administration (MDA) campaign was conducted by WHO Bangladesh, in collaboration with the Government of Bangladesh and Health Sector partners, from November 29, 2023, to February 01, 2024. The objectives of the study were: a) to determine the epidemiological characteristics (i.e., magnitude, age-sex distribution, and attack rate) of the scabies outbreak in the Rohingya refugee camps; and b) to evaluate the impact and durability of MDA in reducing the burden of scabies in the refugee camps. This was a retrospective observational study that utilized deidentified and anonymized data from 35 health facilities of the International Organization for Migration (IOM) spanning the period from January 1, 2021, to December 31, 2024. A total of 384,852 cases of scabies were reported, with an overall attack rate of 5,562.59 scabies cases per 10,000 population over 4 years. Females had a slightly higher case proportion (53.51%) and attack rate (ARR: 1.104, p < 0.001). Children under 5 years (36.31%) had the highest burden and attack rate, about twice the overall attack rate. Using this age group as reference, the attack rate declined significantly with increasing age, 5,561.85 among adolescents (ARR: 0.496, p < 0.001) to 4,377.88 among individuals over 60 years (ARR: 0.390, p < 0.001). 77% of the cases were reported among the Rohingya refugees; however, the attack rate was higher among host communities (7,721.34 per 10,000 vs. 5,138.24 per 10,000 among refugees). Overall, 5.80% of scabies cases were associated with secondary bacterial infections. Interrupted time series (ITS) analysis showed a sharp and immediate decline in scabies cases following MDA initiation, representing a reduction of 1,885 cases per week (p < 0.001) - equivalent to a weekly decline of approximately 100% from the pre-MDA peak. The decline persisted for 6 months (decreasing trend of 69.98 cases/week, p < 0.001), after which a statistically significant upward rebound was observed (72.04 additional cases per week, p = 0.002). The study revealed a high burden of scabies among the Rohingya refugees and the adjacent host community. MDA was an effective approach for a rapid and substantial reduction of the disease burden. However, the impact cannot be sustained unless the underlying factors of the scabies outbreak are addressed.
Large joint arthroplasty is among the most frequently performed procedures in orthopaedic surgery. One of the most common and challenging causes of prosthetic failure is periprosthetic joint infection (PJI). Periprosthetic soft tissue damage is often a critical yet underestimated factor influencing surgical outcomes. The aim of our meta-analysis is to evaluate the clinical efficacy, complications, failure rates, and the overall reliability of free flaps as a reconstructive solution. PubMed, Embase, and Google Scholar were searched, according to PRISMA guidelines. Studies were included if they reported healing rate, complications, type of free flaps, and pathogen characteristics. A quality evaluation was performed. The overall effect size was reported as survival rate of the free flaps, and the secondary effect sizes were determined as the rate of reinfection or persistent infection after coverage with free flaps and the amputation rate because of non-controlled infection. The statistical analysis was carried out using the software 'R', version 4.5.0 (2025-04-11). Fourteen papers were included, with a total of 185 observations and 161 events (free flap survived). All papers were retrospective studies. The pooled survival rate was 93% (I 2 = 66.7%). The pooled rate of reinfection or persistent infection after the index surgery was 16% (I 2 = 77.6%). The amputation rate was 8%. Free flaps are a reliable solution to manage tissue loss in patients with periprosthetic infection, but the results could be affected by technical errors and non-skilled intra- and post-operative management. Orthoplastic and microsurgical skills are mandatory to be successful.
Massive perivillous fibrinoid deposition (MPFD) is an extremely rare placental pathology associated with recurrent pregnancy loss and adverse perinatal outcomes. We present the case of a 41-year-old woman with systemic autoimmune disorders and a history of ten pregnancy losses, with histologically confirmed perivillous fibrinoid deposition in two available previous placental specimens and no evidence of chronic histiocytic intervillositis in the reviewed material. A personalized immunomodulatory protocol combining intravenous immunoglobulin (IVIg), corticosteroids, hydroxychloroquine, and antithrombotic therapy was associated with a successful full-term pregnancy, culminating in the live birth of a healthy infant by C-section. This case highlights the potential utility of tailored immunotherapy in complex recurrent pregnancy loss (RPL) cases associated with MPFD, although causal attribution to any single agent cannot be established given the single-case design, incomplete histological documentation of prior losses, and the simultaneous use of multiple interventions.
Colorectal barotrauma due to accidental high-pressure compressed air insufflation is rare. Prompt recognition and intervention are critical. In this report, we present a case of accidental anorectal insufflation of compressed air leading to hollow viscus perforation. Radiographs and computed tomography imaging demonstrated massive pneumoperitoneum, pneumomediastinum, dilated small bowel loops, and diffuse sigmoid wall edema. Emergency laparotomy revealed a 3 cm × 4 cm perforation at the rectosigmoid junction. A Hartmann's procedure was performed with thorough peritoneal lavage and pelvic drainage. The patient recovered well postoperatively and was extubated on postoperative day 1 with full clinical stabilization achieved by day 4. In conclusion, high-pressure colorectal barotrauma can result in large perforations and massive extraperitoneal and intraperitoneal air leakage. Rapid imaging and emergent surgical intervention are essential to prevent morbidity and mortality. Hartmann's procedure remains an effective management strategy with improved prognosis in patients with significant contamination and large colorectal perforations. RésuméLe barotraumatisme colorectal dû à une insufflation accidentelle d’air comprimé à haute pression est un événement rare. Une reconnaissance et une intervention rapides sont cruciales. Dans ce rapport, nous présentons un cas d’insufflation anorectale accidentelle d’air comprimé ayant entraîné la perforation d’un viscère creux. Les radiographies et l’imagerie par tomodensitométrie ont mis en évidence un pneumopéritoine massif, un pneumomédiastin, une dilatation des anses de l’intestin grêle et un œdème diffus de la paroi sigmoïdienne. Une laparotomie en urgence a révélé une perforation de 3 cm × 4 cm au niveau de la jonction rectosigmoïdienne. Une intervention de Hartmann a été réalisée, associée à un lavage péritonéal minutieux et à un drainage pelvien. Le patient a bien évolué en postopératoire et a été extubé au 1er jour postopératoire, une stabilisation clinique complète étant obtenue dès le 4e jour. En conclusion, le barotraumatisme colorectal à haute pression peut entraîner des perforations de grande taille ainsi qu’une fuite massive d’air, tant extra- que intrapéritonéale. Une imagerie rapide et une intervention chirurgicale en urgence sont essentielles pour prévenir la morbidité et la mortalité. L’intervention de Hartmann demeure une stratégie thérapeutique efficace, offrant un pronostic amélioré chez les patients présentant une contamination significative et des perforations colorectales de grande taille.
Patch augmentation with acellular dermal matrix (ADM) allograft is increasingly recognized as an effective method to enhance healing rates following rotator cuff repair in cases of massive rotator cuff tears. However, there is still variability in how patch augmentation is performed. In this study, the authors present a patch augmentation using an ADM allograft into the triple row-suture bridge technique for treatment of large to massive rotator cuff tear. This method, characterized by knotting the medial row sutures over the ADM allograft, is designed to enhance healing by increasing the contact area among the graft, the rotator cuff tendon, and the footprint, while reducing direct pressure on the tendon.
Interfacial solvation structures are crucial in wide-ranging applications, including lubrication and electrochemical energy storage. As the sole technique capable of in situ mapping of three-dimensional (3D) solvation structures, 3D atomic force microscopy (3D-AFM) resolves liquid-solid interfaces with angstrom precision. However, conventional analysis via global averaging or manual selection wastes the massive datasets generated by 3D-AFM, rendering the objective resolution of spatial heterogeneities and 3D features of the interfacial solvation structure unattainable. Here, leveraging the high-throughput capacity of unsupervised machine learning to handle massive datasets, we present a general method integrating 3D-AFM for the unbiased interpretation of interfacial force datasets. Applying this method to the graphite-water interface uncovers a previously obscured spatial heterogeneity, achieving a precise spatial partitioning of the interface into two distinct regimes with divergent mechanical responses. Molecular dynamics simulations attribute this heterogeneity to the non-uniform distribution of trace airborne hydrocarbon contaminants. This work not only elucidates the contaminant-mediated modulation of interfacial water structures but also provides a general paradigm for identifying chemical non-uniformities at diverse solid-liquid interfaces.
Parkinson's disease (PD), one of the most prevalent age-related neurodegenerative disorders, is neuropathologically defined by the progressive degeneration and massive loss of dopaminergic neurons within the substantia nigra pars compacta of the midbrain. Multiple pathological cascades, which include excessive oxidative stress, persistent neuroinflammation, aberrant cuproptosis, and mitochondrial dysfunction, converge to drive PD pathogenesis and aggravate its progression. Nuclear factor erythroid 2-related factor 2 (Nrf2), a pivotal transcription factor governing antioxidant defense and cellular stress responses, is markedly downregulated and functionally compromised within the pathological microenvironment of PD-affected brain tissue. A growing body of evidence has demonstrated that Nrf2 activators represent promising and innovative therapeutic candidates for the treatment of PD. These compounds effectively trigger the activation of the downstream Nrf2 signaling cascade, thereby promoting the initiation and execution of mitophagy to eliminate dysfunctional and damaged mitochondria and restore intracellular metabolism homeostasis. Meanwhile, activation of the Nrf2 signaling pathway suppresses aberrant intracellular copper accumulation and prevents excessive lipid peroxidation, thereby exerting a robust inhibitory effect on neuronal cuproptosis. This review systematically delineates the regulatory mechanisms by which Nrf2 activators modulate pivotal molecular-level biological processes. It further synthesizes and critically appraises the most recent preclinical findings as well as emerging early-stage clinical data regarding Nrf2-targeted therapeutic strategies for PD, while also delineating prevailing challenges and outlining prospective avenues for future investigation in this domain. Collectively, targeting the Nrf2 signaling pathway constitutes a promising integrative therapeutic strategy for the management of PD.
Replication stress poses a major threat to genome integrity, yet how higher-order chromatin organization contributes to replication fork protection remains unclear1,2. Here we show that replication stress induces the formation of transient chromatin loops that enclose de novo heterochromatin-enriched stalled replication forks3. Stressed forks preferentially stall at convergent CTCF motifs, triggering stress-dependent CTCF enrichment that constrains loop extrusion and stabilizes these structures. Loop stabilization requires both CTCF anchoring and G9a-dependent heterochromatin (trimethylation of Lys9 of histone H3 (H3K9me3)) deposition on nascent DNA within the loop body. These loops function as protective scaffolds that shield stalled and reversed forks from degradation by multiple nucleases. By contrast, combined loss of stress-induced heterochromatin and CTCF enrichment destabilizes the loop scaffold, exposing multiple entry points for nucleolytic attack and resulting in extensive nascent-strand degradation through mechanisms distinct from classical fork-reversal-dependent pathways. This protective architecture is similarly critical in BRCA2-deficient cells, in which replication-stress-associated loops predominantly safeguard replication initiation zones, while nascent DNA outside these loops undergoes massive degradation and remains highly susceptible to mutations. Our study elucidates the fundamental role of replication-stress-induced three-dimensional genome reorganization in preserving replication fork stability, thereby mitigating mutagenesis and genomic instability.
To investigate the association between previous caesarean section (CS) and major complications during first- and second-trimester surgical abortion. We conducted a national retrospective case-control study using prospectively collected data from all MSI Australia surgical abortion facilities between 2016 and 2024. Individuals undergoing surgical abortion between 5+0 and 23+6 weeks' gestation were eligible. Cases were procedures complicated by haemorrhage ≥500 mL, transfusion, uterine perforation, hospital transfer, laparotomy, laparoscopy, or hysterectomy. Each case was matched to four gestation-matched controls (±3 weeks) through a blinded process. A composite severe outcome included hysterectomy, laparotomy, intensive care admission, disseminated intravascular coagulation, or massive haemorrhage (≥2000 mL). Logistic regression estimated adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Among 159 major-complication cases and 636 gestation-matched controls, a history of previous CS was more common among cases than controls. After adjustment for age, gestational age, parity and body mass index, previous CS remained associated with increased likelihood of being a case (aOR 2.6, 95% CI 1.7-4.0). Odds of being a case increased with increasing numbers of previous CS (aOR 2.0 per caesarean, 95% CI 1.5-2.6). Previous CS was more common among composite severe adverse outcome cases than controls (OR 9.56, 95% CI 4.34-21.04). A history of previous CS was more common among cases than controls, with the odds of being a case increasing according to the number of prior CS. These findings may assist counselling, pre-procedure assessment and perioperative planning for patients with a history of caesarean birth. Previous caesarean section was more common among cases than controls, including cases with severe adverse outcomes. Increasing numbers of prior caesarean sections were associated with higher odds of being a case. These findings may inform counselling and perioperative planning.
Secondary aortoenteric fistula is a rare and life-threatening complication following aortic reconstructive surgery, most commonly involving the duodenum. Erosion of an aortofemoral bypass graft into the sigmoid colon is exceptionally uncommon; all reported cases were managed via open surgery with significant morbidity. Laparoscopic management with graft preservation has not been documented. A 59-year-old man presented with massive hematochezia 9 months after bilateral aortobifemoral bypass for an abdominal aortic and common iliac aneurysm. Colonoscopy revealed a vascular graft 25 cm from the anal verge. Computed tomography confirmed penetration of the graft into the sigmoid lumen without abscess or contrast extravasation. The patient underwent laparoscopic sigmoid colectomy with graft preservation and peritoneal coverage, followed by colorectal anastomosis and defunctioning ileostomy. He was discharged on postoperative Day 7. He was maintained on a 6-week course of targeted oral antimicrobial therapy. At 6-month follow-up, the patient remains well with a patent graft, no recurrent bleeding, and no graft-related complications. This case highlights the feasibility of minimally invasive management and selective graft preservation in carefully selected patients, challenging the paradigm of mandatory graft excision.
External defibrillation during ablation complicated a massive rotator cuff tear.
Phosphaturic mesenchymal tumor (PMT) is an ultrarare neoplasm responsible for tumor-induced osteomalacia (TIO). Spinal involvement is exceptionally uncommon, and the diagnostic and therapeutic strategies for spinal PMT remain inadequately defined. This report aims to present a case of thoracic vertebral PMT and review the clinical features, diagnostic challenges, and surgical management of spinal PMTs. We reported a 60-year-old male patient presenting with recurrent low back pain and persistent hypophosphatemia. Comprehensive imaging, including CT, MRI, and 18F-AlF-NOTA-octreotide PET/CT, was performed. Given the hypervascularity of the lesion, preoperative segmental artery embolization was conducted to reduce the risk of massive intraoperative hemorrhage. En-bloc tumor resection combined with posterior spinal stabilization was subsequently performed. The literature of previously reported spinal PMT cases was also reviewed. Imaging revealed an osteolytic lesion involving the T11 vertebral body and right pedicle with significant contrast enhancement on CT and MRI. 18F-AlF-NOTA-octreotide PET/CT demonstrated intense uptake in the tumor lesion, and histopathology confirmed the diagnosis of classical type PMT. Preoperative embolization effectively reduced intraoperative blood loss, enabling complete tumor resection. Postoperatively, serum phosphorus level normalized within one week, and his symptoms resolved completely. No recurrence was observed during six months of follow-up. Spinal PMT, though rare, should be considered in patients with unexplained hypophosphatemia and osteopenia. 18F-AlF-NOTA-octreotide PET/CT is a valuable tool for tumor localization. Preoperative embolization is an effective adjunctive strategy to reduce intraoperative hemorrhage for hypervascular spinal PMTs. Complete surgical resection remains the definitive treatment, offering excellent biochemical and clinical outcomes.