Postoperative spinal infections, including spondylodiscitis and surgical site infections (SSI) following instrumentation, remain significant complications associated with considerable morbidity and complex management. Standard treatment often involves extensive surgical debridement, implant removal or revision, and prolonged systemic antibiotic therapy; however, achieving adequate local antibiotic concentrations can be challenging. In this retrospective case series, we evaluate the use of bioabsorbable calcium sulfate as a local antibiotic delivery system in eight adult patients (≥18 years; four women; mean age: 58.6 years) managed for post-instrumentation spinal infections between 2021 and 2025. Patient inclusion required a confirmed deep surgical site infection or spondylodiscitis with implant involvement, while patients with severe renal impairment or superficial infections were excluded. Surgical management included thorough debridement combined with implant removal or revision and, where indicated, reconstructive procedures such as corpectomy and interbody fusion. Antibiotic-loaded calcium sulfate (Stimulan, Biocomposites Ltd., Staffordshire, United Kingdom) beads were used for local antibiotic delivery based on intraoperative assessment and microbiological considerations. All patients tolerated the procedure well, with no immediate complications attributable to the calcium sulfate implantation. Favorable clinical outcomes were observed in all cases, with the resolution of symptoms, normalization of inflammatory markers, and radiological evidence of infection control during follow-up. The mean duration of hospital stay was 6.0 days. These findings suggest that antibiotic-eluting calcium sulfate is a safe and effective adjunct in the management of postoperative spinal infections, facilitating targeted local antibiotic delivery and contributing to successful infection control.
Spontaneously dislodging pancreatic duct stents are generally expected to pass within several days. We report a rare case of markedly prolonged retention of such a stent in a patient with surgically altered anatomy. A 78-year-old man with a history of distal gastrectomy with Roux-en-Y reconstruction underwent single-balloon enteroscopy-assisted ERCP for choledocholithiasis. After successful biliary cannulation using pancreatic guidewire assistance, stone extraction was performed following a small sphincterotomy and papillary balloon dilation. A 5-Fr × 5-cm spontaneously dislodging pancreatic duct stent without an internal flange was prophylactically placed. The postoperative course was uneventful; however, spontaneous stent dislodgement was not observed on follow-up imaging. Because of the technical burden of repeat endoscopy in surgically altered anatomy, careful observation was initially selected. The stent remained in place for 104 days and was ultimately removed endoscopically using a single-balloon enteroscope without adverse events. This case illustrates that markedly prolonged retention of a spontaneously dislodging pancreatic duct stent may occur in patients with surgically altered anatomy. Careful follow-up, including imaging to confirm spontaneous stent passage, is important, and endoscopic removal should be considered when the stent remains in place, even if repeat endoscopy is technically challenging.
Introduction The frontal sinus and its outflow tract are integral to sinonasal physiology and play a key role in the development of chronic rhinosinusitis. Their complex anatomy often poses challenges in endoscopic sinus surgery. This study aimed to provide a morphometric characterization of the frontal sinus and its drainage patterns to support safer and more effective surgical planning. Methodology A descriptive cross-sectional cadaveric study was conducted on 30 hemisections derived from 15 formalin-fixed cadaveric head and neck specimens at the All India Institute of Medical Sciences (AIIMS) Bibinagar. Frontal sinus height and depth were measured using digital vernier calipers. Drainage routes were traced with a probe in relation to the uncinate process, and anatomical variations were recorded. Data were analyzed using descriptive statistics in Jamovi. Results The frontal sinus demonstrated a mean height of 21.3±5.9 mm and a mean depth of 14.9±4.0 mm. Drainage was predominantly anteromedial in 17 specimens (58.6%), followed by anterolateral in eight specimens (27.6%) and posterolateral in four specimens (13.8%). Frontal sinus aplasia was observed in one specimen (3.3%), hypoplasia in two specimens (6.7%), and septation in two specimens (6.7%). One aplastic frontal sinus was excluded from morphometric measurements. Conclusion This study shows significant variations in the dimensions and drainage pathways of the frontal sinus. An understanding of frontal sinus anatomy enhances surgical safety and reduces complications.
Giant schwannomas originating in the pterygopalatine fossa (PPF) with multicompartmental extension pose a considerable surgical challenge. This report details the management of a 34-year-old female who presented with progressive facial numbness, dysphagia, and unilateral facial asymmetry secondary to a voluminous PPF schwannoma. Preoperative imaging characterized a solid-cystic expansile mass with involvement of the maxillary sinus, infratemporal fossa, parapharyngeal space, and the anterolateral craniovertebral junction, including encasement of the internal carotid artery. Given the tumor's significant lateral and posterior-inferior extension that precluded a purely endoscopic resection, a tailored transcervical submandibular approach was utilized. This open corridor provided direct lateral access, enabling safe proximal vascular control and permitting meticulous neurovascular dissection. Gross-total resection was ultimately achieved without the need for mandibular osteotomy or transfacial incisions. The patient's postoperative course was uncomplicated, with preservation of neurological function, and follow-up imaging confirmed complete resection. This case highlights the novel single-stage transcervical submandibular approach as a viable and effective surgical strategy for select, extensive PPF schwannomas with dominant lateral and neurovascular involvement, serves as a critical alternative when endoscopic access is insufficient. To our knowledge, this is the first report of a single-stage transcervical submandibular resection for a multicompartmental PPF schwannoma with such extensive lateral and vascular involvement, unlike previous studies have described multi-staged procedures for similar complex lesions.
Physeal fractures account for a significant percentage of pediatric fractures and carry a unique risk of resultant limb deformity due to their potential to disrupt normal bone growth. While most of these fractures heal without consequence, up to 10% result in growth disturbances that can cause limb length discrepancy or angular deformity. Surgical strategies for managing these deformities include physeal bar excision, epiphysiodesis, and corrective osteotomies. These interventions aim to restore limb alignment and preserve function. In this review, we provide an overview of the growth plate physiology, classification systems for physeal fractures, and the spectrum of complications that may arise following growth plate injury. We also present an overview of surgical strategies and demonstrate their applications through several case examples.
Low rectal cancer is surgically managed with one of two primary procedures: low anterior resection (LAR) or abdominoperineal resection (APR). Each procedure has a unique profile of potential complications, oncologic outcomes, and quality-of-life impacts. The acceptability of these outcomes is highly driven by patient values. Consequently, shared decision-making is essential to selecting the optimal procedure for each patient. Evidence has shown that patient decision aids (PtDAs) improve patient knowledge, reduce decisional conflict, and support value-congruent decisions. This review describes the development of a rectal cancer PtDA for the choice between LAR and APR. This PtDA was designed according to the International Patient Decision Aid Standards and Ottawa Decision Support Framework. Evaluation of this rectal cancer PtDA demonstrated increased patient knowledge, reduced decisional conflict, and enhanced patient preparedness for decision-making. Despite strong evidence for their utility, PtDAs remain underutilized. This review highlights key barriers in implementing PtDAs and proposes strategies to facilitate the effective integration of PtDAs into surgical practice.
How can rare spermatozoa be identified efficiently during microsurgical testicular sperm extraction (micro-TESE)? An artificial intelligence (AI)-assisted system was developed to flag candidate rare spermatozoa in real time during micro-TESE, and it may support embryologists as a decision-support tool. Patients with non-obstructive azoospermia (NOA) can obtain sperm for procreation through micro-TESE. During this procedure, sperm retrieval primarily relies on embryologists or laboratory technicians visually searching for sperm under a microscope, which is not only laborious and inherently subjective but also susceptible to errors. Although AI technology has been applied to identify trace amounts of sperm, existing models lack sufficient efficiency and true real-time performance. This study included model development followed by a single-centre clinical evaluation. An improved YOLO (You Only Look Once)-based rare sperm detection model, termed YOLOv11-RSD, was developed using microscopy data from 1165 surgical patients, comprising 1932 image samples containing a total of 5032 annotated sperm objects with confirmed identification. Clinical evaluation was performed between May 2024 and July 2025. Performance was assessed across confidence thresholds in obstructive azoospermia (OA) patients with normal spermatogenesis, and the system was then applied during micro-TESE in NOA patients and compared with routine embryologist assessment. The model was developed using testicular sperm microscopy images collected at a single hospital. Real-time clinical feasibility was evaluated in 10 OA cases and 30 NOA cases. Embryologist assessment was used as the reference standard, and performance was assessed using PPV, sensitivity, F1-score, and 95% confidence intervals. Discordant AI-assisted detections were reviewed by embryologists in real time. YOLOv11-RSD achieved real-time detection of candidate spermatozoa in microscopy images with high sensitivity and acceptable PPV under the selected operating threshold. Compared with baseline YOLOv11, YOLOv11-RSD showed improved overall detection performance across representative evaluation settings. In OA cases, the system achieved high sensitivity for sperm detection, reaching up to 96.7% across evaluated thresholds. During micro-TESE in NOA patients, at a confidence threshold of 0.50, positive predictive value (PPV), sensitivity, and F1-score were 80.58%, 96.11%, and 87.66%, respectively. The system highlighted candidate spermatozoa that were not identified during the initial manual assessment in six NOA cases, including two cases initially classified as sperm-negative; these findings were confirmed upon immediate re-review. Follow-up reproductive outcomes were available for six cases in which AI-assisted detection contributed to the search-and-confirmation workflow: embryo cleavage was achieved in all six cases, and three cases ultimately resulted in live births. Notably, among the two cases initially classified as sperm-negative, one case resulted in a singleton live birth. N/A. This was a single-centre clinical evaluation with a limited clinical cohort. Although model inference was rapid, procedure-level efficiency was constrained by image acquisition and scanning logistics, and no definitive reduction in total procedure time was demonstrated. External multi-centre validation is required. AI-assisted sperm detection may support embryologists during micro-TESE by flagging candidate rare spermatozoa for rapid review. Further prospective multi-centre validation is required to determine whether this approach improves procedure-level efficiency or clinical outcomes. This work was supported by grants from National Natural Science Foundation of China (82301794), Shanghai Science and Technology Innovation Action Plan (24Y12800702), Natural Science Foundation of Shanghai (25ZR1401300), National Key Research and Development Program of China (2022YFC270300), China Jiliang University Research Grant (No. H251120), and Shanghai General Hospital Basic and Clinical Collaborative Research Program (JC202612). The authors declare no competing interests.
Accurate risk stratification before structural heart disease interventions is essential for clinical decision-making. Traditional risk models, such as the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM), were designed for surgical patients and show inconsistent performance in transcatheter cohorts. Biological age, reflecting cumulative physiological decline, may offer prognostic value beyond chronological age and established risk scores. In this retrospective study of 1269 patients [non-transcatheter aortic valve implantation (TAVI) n = 751, TAVI n = 518] treated at the German Heart Center Munich, biological age was estimated from pre-operative chest radiographs using CXR-Age, a validated deep learning model. Analyses were conducted separately for surgical (non-TAVI) and transcatheter (TAVI) groups. For 30-day mortality, biological age outperformed EuroSCORE II in both subgroups [area under the receiver operating characteristic curve (AUC): non-TAVI 0.874 vs. 0.785, P < 0.001; TAVI 0.952 vs. 0.745, P = 0.004] and remained independently predictive after adjustment [TAVI OR 1.58 per year, 95% confidence interval (CI) 1.27-2.12]. While STS-PROM was the strongest single predictor for non-TAVI patients (AUC 0.949), it was similar to EuroSCORE II for TAVI patients (AUC 0.729). Notably, patients whose biological age exceeded their chronological age by more than 10 years faced higher major complication rates (17.3% vs. 9.2%; P = 0.016). Biological age distinguished risk across both populations, suggesting that deep learning-based biological age estimation from routine chest radiographs could serve as an automated, accessible complement to existing risk models.
Up to 30% of patients with ulcerative colitis will ultimately require surgery. Generally, surgery for ulcerative colitis consists of total proctocolectomy with either end ileostomy or ileal pouch anal anastomosis, which may be performed in 1 to 3 stages. There are risks and benefits specific to undergoing permanent ileostomy creation or ileal pouch anal anastomosis, with each procedure resulting in different and dramatic changes in a patient's day-to-day life. Because most patients are eligible for either procedure, patient preferences are an important consideration when creating a treatment plan. Shared decision-making is a collaborative process where surgeons and patients work together to make a treatment decision that is evidence-based and incorporates patient values. Here, we review the differences between end ileostomy and ileal pouch anal anastomosis, focusing on the risks and lifestyle considerations that may inform treatment decisions, as well as the available tools to support shared decision-making during surgical consultations.
Cardiac complications from prior oncologic therapies and radiation are being increasingly recognized and patients with symptomatic severe aortic valve disease and a history of prior chest radiation represent a high-risk group in which the best management approach has not yet been established. A systematic search of PubMed, Scopus, and Cochrane identified studies comparing outcomes of transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR) in patients with a history of prior chest radiation. Nine studies comprising 11,572 patients were included in this meta-analysis. There were no significant differences between TAVR and SAVR in postoperative mortality (OR: 0.70; 95% CI 0.44-1.13, p = 0.147) or 1-year mortality (OR: 1.04; 95% CI 0.71-1.53, p = 0.84). TAVR was associated with significantly lower rate of postoperative major bleeding (OR: 0.38; 95%CI: 0.25-0.57, p < 0.01), acute kidney injury (AKI) (OR: 0.51; 95%CI: 0.27-0.97, p: 0.04), postoperative atrial fibrillation (OR: 0.20 95%CI: 0.16-0.24, p: <0.01) and respiratory complications (OR: 0.39; 95%CI: 0.24-0.63, p < 0.01) compared to SAVR. The incidence of postoperative permanent pacemaker insertion (OR: 2.27; 95%CI: 1.79-2.87, p < 0.01) and at least moderate aortic regurgitation (OR: 4.44 (95%CI: 2.93-6.73), p < 0.01) were higher among the patients undergoing TAVR. TAVR in patients with a history of prior radiation was associated with a lower risk for postoperative complications albeit at an increased risk for pacemaker insertion in the postoperative period compared to SAVR. In patients who have previously received radiation treatment to the chest and have severe narrowing of their aortic valve, replacing the aortic valve using a minimally invasive procedure, which is called transcatheter aortic valve replacement, had similar survival rates in the short term and at 1 year compared to replacing the valve with open-heart surgery. However, there were differences in the risks with each procedure. Patients that had the transcatheter procedure experienced fewer complications such as bleeding, an abnormal heart rhythm called atrial fibrillation, lung complications, and kidney problems compared with those undergoing open-heart surgery. On the other hand, the transcatheter aortic valve procedure was associated with a higher likelihood of needing a permanent pacemaker and a higher risk of valve leakage through or around the newly placed valve.
A randomized controlled trial was conducted to compare the clinical efficacy of lateral transperitoneal adrenalectomy (LTA) versus posterior retroperitoneoscopic adrenalectomy (PRA) and to explore suitable surgical approaches for different patients. This prospective study enrolled 184 adrenal tumor patients treated at our hospital from May 2023 to October 2025. Patients were randomly assigned to the LTA group or PRA group using minimization. Subgroup analyses were performed based on tumor diameter, location, and pathological type to investigate suitable surgical approaches for tumors with different characteristics. The impact of surgeon qualifications on outcomes was examined to indirectly assess the differences in learning curves. Primary outcomes included operative time, laparoscopic operation time, and blood loss. Secondary outcomes included trocar establishment time, number of trocars, transfusion rates, intraoperative complication rates, conversion rates, analgesic requirement grade on postoperative day 1, postoperative antibiotic use, postoperative recovery time of gastrointestinal function, postoperative drainage time, short-term postoperative complication rates, postoperative length of stay, and total hospitalization cost. The LTA and the PRA groups each comprised 92 patients. No significant differences were observed between LTA and PRA for primary outcomes. PRA demonstrated superiority over LTA in the number of trocars (p = 0.006), intraoperative complication rates (p = 0.047), analgesic requirement grade on postoperative day 1 (p = 0.042), postoperative recovery time of gastrointestinal function (p < 0.001), and postoperative drainage time (p < 0.001). When tumor diameter >3 cm, LTA demonstrated superiority in blood loss (p = 0.007) and intraoperative complication rates (p = 0.032). Subgroup analysis showed that LTA had a significantly higher complication rate than PRA (p = 0.027) when treating right adrenal tumors. Surgeon qualifications significantly influenced operative time (p < 0.001), laparoscopic operation time (p = 0.006), and blood loss (p = 0.002) of PRA, but had no apparent effect on perioperative indicators of LTA. Both LTA and PRA are safe surgical methods for treating adrenal tumors, but PRA has advantages, especially for right adrenal tumors, where it can significantly reduce the incidence of complications, but it requires a greater technical challenge for the surgeon. For adrenal tumors with a diameter greater than 3 cm, LTA can be considered. Clinicians should comprehensively consider their technical proficiency, patient characteristics, and tumor features when choosing the appropriate surgical method.
Colorectal cancer is the third most common cancer worldwide. There is a rising incidence of colorectal cancer in low- and middle-income countries, including Nigeria and Ghana. Surgical treatment for colorectal cancer has demonstrated efficacy, albeit with a higher incidence of postoperative complications in low- and middle-income countries. This review aimed to explore the complications following surgery for colorectal cancer, in Nigeria and Ghana. This review was guided by the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. We searched Science Direct, MEDLINE, Embase, CINAHL, Scopus, and APA PsycINFO databases. All searches were conducted in August 2024. All study designs reporting surgical treatment of colorectal cancer within the past 10 years in Nigeria and Ghana were included. Four authors extracted the data, and a fifth author reviewed the data for accuracy and completeness. The Joanna Briggs Institute critical appraisal tools for cross-sectional, case series, and case-control studies were used for data quality assessment. A total of eleven studies with 6971 patients were included in this review. Males accounted for 57.1% of the patients and 42.9% were females. Study designs were mostly cross-sectional with sample sizes ranging from 2 to 4898. About half (50.7%) of the surgeries performed for colorectal cancer were hemicolectomies. A total of 530 postoperative complications were reported with the most reported as surgical site infection 27.5%. Other postoperative complications were death (21.7%), fascial/wound dehiscence (12.6%), bowel obstruction (11.1%), fistulae (10.6%), anastomotic leak (6.4%), bleeding (1.5%) and others (8.3%). There is a significant burden of postoperative complications following colorectal cancer surgery. The findings from this review suggest that there are key challenges with surgical treatment for colorectal cancer in the West African region that need to be addressed to improve the postoperative outcomes of patients.
Caesarean section (CS) is one of the most commonly performed surgical procedures worldwide, yet considerable variation exists in operative techniques, particularly in low and middle-income countries. The aim of this study is to determine the common surgical techniques employed by senior obstetricians in Nigeria and evaluate the associations with demographic and institutional factors. A descriptive cross-sectional multicentre online survey was conducted between May 2023 and May 2024 among practising Senior Registrars and Consultants in Obstetrics and Gynaecology across Nigeria. Using a structured, pretested questionnaire, data were collected on sociodemographic characteristics, preoperative, intraoperative, and postoperative CS practices. Data were analysed using R statistical software, with descriptive statistics and multivariate analyses performed. Statistical significance was set at p < 0.05. A total of 293 complete responses were analysed. The mean age of respondents was 42.1±7.6 years, with a mean work experience of 11.9±6.4 years; 66.6% were male, and 78.8% practiced in federal tertiary hospitals. The most commonly reported techniques included skin preparation with Savlon plus alcohol (73.4%), Pfannenstiel abdominal incision (71.0%), bladder flap creation (73%), controlled cord traction for placental delivery (68.9%), double-layer uterine closure (99%), visceral peritoneal closure (60%), and subcuticular skin closure (96.6%). Routine postoperative thromboprophylaxis was used by only 18.4% of respondents. Most surgical choices were not significantly associated with age, work experience, or place of practice, except for visceral peritoneal closure, which varied by institution (p = 0.043). CS practices among obstetricians in Nigeria showed some consistency in key operative steps such as Pfannenstiel incision, double-layer uterine closure, and subcuticular skin closure, alongside notable variation in other aspects, particularly thromboprophylaxis use. These findings highlight the influence of institutional practice patterns and underscore the need for context-specific, evidence-based guidelines to harmonise CS techniques and optimise maternal outcomes nationwide.
Anterior chest wall deformities are rare in paediatric patients and may occasionally present with atypical clinical and radiological findings. We report the case of an adolescent presenting with intermittent chest pain, in whom imaging revealed an unusual anterior costal malformation associated with focal compression of the hepatic dome, initially raising suspicion of a hepatic lesion. Comprehensive cardiological and radiological evaluation excluded primary cardiac or hepatic disease. Cross-sectional imaging demonstrated a deformity of the anterior costal arch causing a well-defined indentation of the liver surface, consistent with extrinsic compression rather than true parenchymal pathology. Because of persistent symptoms and the anatomical abnormality, the patient underwent surgical correction. Intraoperative findings confirmed a costal deformity with direct mechanical compression of the liver. Surgical remodelling of the chest wall was successfully performed, with an uneventful postoperative course. This case emphasises the importance of considering chest wall anomalies in the differential diagnosis of apparent hepatic lesions and unexplained chest pain in children. Careful imaging interpretation is essential to avoid misdiagnosis, while a tailored surgical approach can provide effective symptom relief in selected patients.
Lateral snapping elbow is a rare condition, and cases attributed to intra-articular lesions of the annular ligament are particularly rare. This study was performed to analyze cases of lateral snapping elbow due to annular ligament entrapment to clarify its pathogenesis and clinical characteristics. We reviewed 4 patients who underwent surgical treatment for painful lateral snapping elbow caused by annular ligament entrapment at 3 institutions from 2010 through 2018. The patients included 2 men and 2 women with a mean age of 59 years (range, 45-69 years). Preoperative evaluations included physical examination, x-rays, magnetic resonance imaging (MRI), and the Mayo Elbow Performance Score (MEPS). All patients were followed up for an average of 10.5 months (range, 6-12 months). Significant tenderness at the lateral epicondyle of the humerus and snapping were noted preoperatively. MRI consistently demonstrated high signal intensity at the origin of the extensor carpi radialis brevis (ECRB). All 4 patients were diagnosed with snapping elbow associated with lateral epicondylitis, for which surgical intervention was performed because of resistance to conservative treatment. Intraoperatively, the degenerative, entrapped annular ligament within the radiocapitellar joint was observed to reposition during elbow flexion in forearm pronation. Partial resection of the degenerative, entrapped annular ligament was performed, along with ECRB debridement in all patients. The mean MEPS improved from 73.8 preoperatively to 100 postoperatively. Degeneration of the annular ligament can lead to its entrapment in the radiocapitellar joint, resulting in snapping elbow. Surgical partial resection of the annular ligament and debridement of the ECRB effectively resolve symptoms and restore function. Snapping elbow caused by annular ligament entrapment may be distinguished by snapping that occurs during pronation and flexion, indicating ligament relocation.
Unicuspid aortic valve (UAV) is an exceptionally rare congenital aortic valve anomaly. UAV is more commonly associated with significant aortic stenosis at a younger age than bicuspid aortic valve. Two forms of UAV have been described. Acommissural type of UAV typically presents in early infancy, and unicommissural type of UAV usually presents in late childhood or early adolescence. Echocardiography is the main imaging tool used to assess aortic valve morphology, aortic dimensions, and the presence and severity of stenosis or regurgitation. Early surgical intervention is typically required for UAV and is most commonly performed for aortic valve replacement. Postoperative echocardiograms are obtained on a regular basis to assess for proper function of the replaced valve and for signs of left ventricular dysfunction.  We present the case of a 16-year-old girl with genetically confirmed Marfan syndrome who presented with progressive exertional dyspnea, fatigue, and reduced exercise tolerance over several months and was found to have severe aortic stenosis due to unicommissural UAV. Computed tomography angiography demonstrated mid-ascending aortic dilation measuring 43 mm, corresponding to an indexed diameter of 25.0 mm/m² based on a body surface area of 1.72 m², while the aortic root measured 34 mm with a z-score of +1.8. She underwent successful surgical aortic valve replacement with a 19-mm mechanical prosthesis. Isolated aortic valve replacement was selected because the symptomatic severe valve obstruction required surgery, whereas the aortic root remained below the recommended surgical thresholds and the 43-mm mid-ascending aortic dilation was not considered an independent indication for replacement. No prior imaging was available to determine the aortic growth rate, and there was no confirmed family history of aortic dissection. The postoperative echocardiogram showed a well-functioning aortic prosthetic valve with preserved left ventricular systolic function. She was discharged on warfarin with structured international normalized ratio monitoring. Given her age, sex, significant aortopathy, mechanical prosthesis, and potential for future pregnancy, she received counseling regarding contraception, anticoagulation, pregnancy risk, and long-term aortic surveillance. Genetic counseling and cascade testing for the pathogenic fibrillin-1 gene variant were recommended for first-degree relatives. At the three-month follow-up, exertional dyspnea had improved, and she had resumed her usual daily activities.
Lynch syndrome, the most common hereditary colorectal cancer syndrome, is caused by inherited pathogenic germline mutations in one of the mismatch repair genes. Beyond colorectal cancer risk, Lynch syndrome is a pan-cancer syndrome necessitating lifelong high-risk surveillance measures and/or risk-reducing surgical interventions. Patients with a diagnosis of colon cancer in the setting of Lynch syndrome have long faced the decision of pursuing extended surgical interventions for risk reduction versus limited segmental resections, with mismatch repair gene-specific cancer risks now helping to inform such decisions. Importantly, recent advances in the field, such as the remarkable efficacy of immunotherapy, the value and limitations of colonoscopy surveillance, and the increased utilization of cancer prevention methods, including the promise of vaccines, have made decisions regarding the optimal management of such patients even more complex. Although there is no one-size-fits-all answer, given the importance of such decisions on patients' quality of life, we advocate for shared and individualized decision-making that encompasses the patient's perspective as well as the expertise of surgeons and physicians across varied disciplines. Such decisions get more complicated when patients have to consider risk-reducing surgery for endometrial cancer in the absence of cancer as a prophylactic measure as well. Thus, informed discussion about the available surveillance and prevention armamentarium is the mainstay of achieving well-informed shared decisions in these cases.
Congenital neck anomalies in neonates often present diagnostic dilemmas, particularly when they communicate with the aerodigestive tract. This report describes a rare case of a large, compressive neck cyst in a 28-day-old neonate. Initially presenting as a progressively enlarging cervical mass, the lesion's potential for airway communication was identified by the presence of intralesional air-fluid levels on computed tomography and magnetic resonance imaging. Advanced diagnostic techniques, including virtual bronchoscopy and intraoperative laryngoscopy, were utilized to successfully localize a direct communication between the cyst and the left false vocal cord. This finding confirmed the diagnosis of a rare branchial apparatus anomaly rather than a simple cervical abscess or cystic hygroma. The patient underwent definitive management through complete surgical excision and ligation of the communicating tract, resulting in a full recovery without recurrence. This case highlights the importance of recognizing specific radiological markers, such as air-fluid levels, as indicators of airway communication. It further emphasizes that while these lesions may mimic infectious processes, successful outcomes rely on a high index of clinical suspicion, precise anatomical localization through multimodal imaging, and definitive surgical intervention over simple drainage procedures.
Vascular compression syndromes result from compression of blood vessels by anatomical structures, impairing arterial or venous flow. Superior mesenteric artery (SMA) syndrome causes duodenal obstruction due to a narrowed aortomesenteric angle and a shortened distance. Nutcracker syndrome (NCS) involves compression of the left renal vein (LRV) between the SMA and aorta. Both conditions are rare, with concurrent cases infrequently reported. SMA syndrome has a notably low incidence, while the true prevalence of NCS is not well defined. Overlapping, nonspecific symptoms often delay diagnosis and increase morbidity. We report a 42-year-old woman presenting with two months of worsening abdominal pain, early satiety, nausea, diarrhea, and unintentional weight loss. Physical exam showed left-sided tenderness; laboratory results were unremarkable. Initial imaging, including upper GI series and gastric emptying study, was inconclusive. Symptoms improved with dietary changes but recurred on resuming normal intake, suggesting a structural cause. Computed tomography findings revealed a reduced aortomesenteric angle of 28° and a distance of 3.5 mm with duodenal narrowing, greater than 50% compression of the LRV, dilation of the gonadal veins, and pelvic varices, consistent with concurrent SMA syndrome and NCS. The patient was counseled on conservative management, including nutritional rehabilitation, with surgical options including duodenojejunostomy and renal vein procedures for refractory cases. Close follow-up was planned to monitor response and assess surgical need. This case underscores the importance of clinical suspicion for vascular compression syndromes and the value of advanced imaging when routine tests are inconclusive.
Background Combined aesthetic surgery ("mommy makeover") is increasingly performed to address postpartum body contour deformities; however, prolonged operative time remains associated with increased perioperative morbidity. The Eleganza Protocol was developed as a standardized workflow-oriented approach designed to optimize operative sequencing and operative efficiency during combined aesthetic surgery. Methods A retrospective observational study was conducted including 13 consecutive patients treated at two independent surgical centers using the Eleganza Protocol. The protocol consists of a predefined seven-step operative sequence integrating coordinated team-based execution, neuraxial anesthesia, and an anterior-to-posterior surgical workflow. Combined procedures included mastopexy, breast augmentation, abdominoplasty, and extensive liposuction. Primary outcomes were operative time and 30-day postoperative complications classified according to the Clavien-Dindo system. Secondary outcomes included estimated blood loss and intraoperative transfusion requirements. Results Most procedures were completed within four hours, with nine of 13 patients (69.2%) finishing within this threshold (median operative time: 3.5 hours; q25-q75: 3.0-4.5). The median estimated blood loss was 250 mL (q25-q75: 100-300 mL), and no intraoperative transfusions were required. No major postoperative complications (Clavien-Dindo grade ≥II) occurred during the 30-day follow-up period. Minor self-limited complications included transient edema and ecchymosis. No patient required prolonged hospitalization beyond the planned overnight stay. Conclusions This retrospective observational study describes operative performance and short-term safety in consecutive patients undergoing combined aesthetic surgery using the Eleganza Protocol. Operative times remained within a consistent range despite procedural variability, with low estimated blood loss and no major short-term postoperative complications. Further prospective multicenter studies are warranted to evaluate reproducibility, operative performance, safety, and long-term outcomes.