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Aim: To report a case of a perforated strangulated roux limb in diaphragmatic hernia as a rare complication following laparoscopic total gastrectomy for gastric cancer. Background: As minimally invasive surgery (MIS) becomes increasingly performed for esophagogastric cancers, diaphragmatic hernias (DHs) pose new challenges for surgeons. Case description: We report the case of a 59-year-old patient who presented with hematemesis, epigastric pain, and hemodynamic instability. The patient had a history of gastric adenocarcinoma and had undergone a laparoscopic total gastrectomy 3 years before. The computed tomographic scan demonstrated a diaphragmatic hernia with a strangulated and perforated roux limb. The patient underwent staged resection of the necrotic roux limb to manage sepsis, followed by restoration of alimentary continuity. Conclusion: A diaphragmatic hernia (DH) is a challenging complication of MIS for esophagogastric cancers and may be difficult to prevent. A staged approach was invaluable, allowing for careful assessment, expert opinion, and reconstruction. Clinical significance: As MIS becomes increasingly performed, cases of complicated DH may become more apparent. Preventing DH may be difficult. A sutured crural repair with or without pexy of the roux limb may be performed if DH is identified at the time of gastrectomy. The value of mesh is unclear, and erosion remains a main concern. [ABSTRACT FROM AUTHOR]

Background: Pregnancy and caesarean section are known to predispose to the development of acute colonic pseudo‐obstruction (ACPO), a rare form of functional ileus of the distal large bowel. Pathogenesis of ACPO is likely influenced by pregnancy and childbirth and subsequent changes to hormonal, autonomic and metabolic physiology. Identifying pregnancy risk factors will assist with early identification, as the insidious onset postpartum often leads to delayed diagnosis and bowel ischaemia, perforation and sepsis. Aims: To establish pregnancy risk factors associated with the development of ACPO after caesarean section. Materials and Methods: A retrospective case–control study included 19 121 women undergoing caesarean between 1 January 2008 and 31 December 2016 at a tertiary referral hospital. Twenty‐three cases of computerised tomography (CT)‐diagnosed ACPO post‐caesarean were identified from hospital medical records and imaging databases. Controls were matched for gestational and maternal age within one week of delivery with a ratio of 1:3. Results: The incidence of ACPO was one in 800 caesarean sections. ACPO was significantly more likely to occur in women who had been administered opioid analgesia in labour (odds ratio (OR) 4.67, P = 0.04), and a trend for increased estimated blood loss (OR 1.01, P = 0.01). There was no increased risk associated with emergency or elective caesarean classification, previous abdominal surgery, type of anaesthesia, duration of labour, oxytocin augmentation, intrapartum fever, hypertensive disorders, diabetes in pregnancy, antepartum haemorrhage, multiple gestation, fetal presentation or birthweight. Conclusions: Risk factors for developing ACPO post‐caesarean include opioid analgesia in labour and a trend for increased blood loss. [ABSTRACT FROM AUTHOR]

Background Recent data suggest that laparoscopic appendicectomy ( LA) in pregnancy is associated with higher rates of foetal loss when compared to open appendicectomy ( OA). However, the influence of gestational age and maternal age, both recognized risk factors for foetal loss, was not assessed. Method This was a multicentre retrospective review of all pregnant patients who underwent appendicectomy for suspected appendicitis from 2000 to 2012 across seven hospitals in Australia. Perioperative data and foetal outcome were evaluated. Results Data on 218 patients from the seven hospitals were included in the analysis. A total of 125 underwent LA and 93 OA. There were seven (5.6%) foetal losses in the LA group, six of which occurred in the first trimester, and none in the OA group. After matching using propensity scores, the estimated risk difference was 5.1% (95% confidence interval ( CI): 1.4%, 9.8%). First trimester patients were more likely to undergo LA (84%), while those in the third were more likely to undergo OA (85%). Preterm delivery rates (6.8% LA versus 8.6% OA; CI: −12.6%, 5.3%) and hospital length of stay (3.7 days LA versus 4.5 days OA; CI: −1.3, 0.2 days) were similar. Conclusion This is the largest published dataset investigating the outcome after LA versus OA while adjusting for gestational and maternal age. OA appears to be a safer approach for pregnant patients with suspected appendicitis. [ABSTRACT FROM AUTHOR]

18 F-FDG-avid thyroid incidentaloma (TI) is seen in approximately 2.5% of patients imaged for staging or response assessment of malignancy and represents thyroid cancer in approximately 35% of cases. Consequently, the 2015 American Thyroid Association guidelines strongly recommend investigation of all 18 F-FDG-avid nodules 1 cm or larger with ultrasound and fine-needle aspiration cytology (FNA). This study aimed to assess the overall and thyroid cancer-specific survival in a large cohort of patients with 18 F-FDG-avid TI with long-term follow-up to assess the validity of this approach. Methods: Retrospective review of 45,680 PET/CT scans performed at a comprehensive cancer center from January 2007 to January 2015 identified 2,588 18 F-FDG PET/CT reports referring to the thyroid. After exclusion of nonavid thyroid nodules, diffuse 18 F-FDG uptake, known thyroid cancer, abnormalities adjacent to the thyroid, and repeat studies, 500 patients (1.1%) with TI were identified, of whom 362 had confirmed death or more than 12 mo of clinical follow-up. Variables including age, sex, primary malignancy, overall survival, thyroid cancer-specific survival, FNA, and histopathology were collected until January 2016. Multivariate logistic regression and survival analysis were performed. Results: The 362 analyzed patients (65% female) had a median age of 65 y (range, 19-96 y) and follow-up of 24 mo (range, 1-103 mo). Lymphoid, lung, and colorectal malignancy were the most common staging indications. Median overall survival was 20 mo (interquartile range, 9.5-39 mo). Most of the 180 observed deaths were due to the primary malignancy under investigation (92.2%) or to causes not related to cancer (7.2%); one patient (0.6%) died from incidentally detected medullary thyroid cancer. 18 F-FDG avidity in the index malignancy, an advanced stage for that malignancy, and a clinician decision not to investigate 18 F-FDG-avid TI were all predictors of mortality, with hazard ratios of 8.5, 3.0, and 3.3, respectively, and 95% confidence intervals of 4.6-15.8, 2.3-3.9, and 2.0-5.0, respectively ( P < 0.001). Of 131 patients suitable for cytologic or histopathologic evaluation, 47 (36%) had incidental thyroid cancer (24 papillary, 11 malignant FNA, 5 oncocytic/Hürthle cell, 2 medullary, 1 follicular, and 4 metastases from underlying malignancy). Conclusion: Overall survival with 18 F-FDG-avid TI was poor because of the prognosis associated with underlying malignancy, which must be considered before investigation of 18 F-FDG-avid TI and certainly before aggressive treatment. Active surveillance should be considered in this group of patients., (© 2018 by the Society of Nuclear Medicine and Molecular Imaging.)