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Introduction: Schwannomas (Schs) are benign tumor masses that rarely occur intra-abdominally and rarely reach larger diameters. When present, they occur as rare solitary nerve sheath tumors of peri-neural Schwann cells. Schwannoma mostly affects the nerves of the extremities, trunk, or the head and neck region. They are more common in female patients, mostly among patients between the third and fifth decade. They occur spontaneously but could also be found in association with a group of genetic autosomal dominant disorders called type 2. When present intra-abdominally, schwannomas grow slowly without significant clinical signs and symptoms. Clinical importance is presented in cases of occupying intra-abdominal space and impingement of surrounding structures, which causes intermittent pain. Only 0.5–5% of all retroperitoneal tumors are schwannomas and their malignant transformation is very rare. Case report: The authors present a case of a large intra-abdominal schwannoma in a 70-year-old female patient. She underwent CT scanning due to refractory left-sided subcostal pain, which revealed a large tumor mass in the left-sided hemiabdomen. Preoperative cytologic biopsy confirmed Sch. The patient underwent an MRI scan upon admission to our department, which revealed the origin of the tumor at the left-sided L3 level and intra-abdominal tumor spreading with the largest diameter of 25 cm. The patient underwent multidisciplinary surgical excision, confirmed by MRI scan in a period of five months postoperatively. Conclusions: Its rare presentation leads to the necessity to adequately evaluate such patients, especially to avoid any hidden diagnosis which might lead to further complications. The goal of a multidisciplinary approach should be emphasized as maintaining a good postsurgical condition without neurological deficits. [ABSTRACT FROM AUTHOR]

One-third of cancer pain patients do not experience adequate pain relief using analgesic ladder by the World Health Organization. Interventional procedures, such as epidural morphine, have been considered. This study aimed to review the literature comparing the effects of epidural administration of morphine with the oral route. This systematic review included randomized controlled trials (RCTs) conducted with patients with gastrointestinal neoplasm. A search was conducted on PubMed, EMBASE, Web of Science, Scopus, Cochrane Library, and CINAHL databases to identify studies published up to May 2023. The retrieved study was evaluated using the Risk of Bias 2 (RoB 2) tool and qualitatively synthesized. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Prospero: CRD42021264728). Only one RCT, a crossover trial, was included in this systematic review. The study was conducted with ten participants (one withdrawal) and reported a statistically significant difference between both subcutaneous and epidural morphine solutions and oral morphine. The adverse events were not described. The included study presents some concerns of bias and low certainty of evidence on the effectiveness and security of epidural morphine administration. The available literature does not suffice to elucidate whether morphine administration via the epidural route is more effective than other routes. Further RCTs are necessary to improve the level of evidence on the effectiveness and risk-benefit of epidural morphine in the management of cancer pain in gastrointestinal neoplasm patients. [ABSTRACT FROM AUTHOR]

Background. Teratomas are neoplasms that arise from pluripotent germ cells, derived from two or more layers of germ cells. They are classified as mature tumors (cystic or solid), which contain well-differentiated tissues, or as immature tumors, which contain immature and embryonic structures. Its most frequent location is the female and male gonads; the mesenteric location is rare and approximately 40 cases have been described in the world literature. Within the diagnostic and therapeutic approach, computed tomography and magnetic resonance imaging are used to characterize the lesion, assess intra-abdominal extension and the relationship with other structures. The diagnosis must be confirmed by histopathological examination. Clinical case. A 56-year-old female patient with a history of infiltrating ductal carcinoma of the left breast in remission. In follow-up studies, incidental abdominal tomography finding of an abdominopelvic lesion dependent on the mesentery at the level of the mesogastrium, smooth contours with fat-liquid level. Extension studies with negative tumor markers. Results: Due to high clinical and imaging suspicion of teratoma, the patient was taken to resection of the lesion. Histopathological examination confirmed the diagnosis of mature cystic teratoma of the mesentery. Conclusion: Mesenteric teratoma is a rare clinical entity and is considered one of the differential diagnoses of an abdominal mass with a compressive effect. Diagnosis is mainly based on clinical examination and imaging findings. Early surgical excision is the mainstay of treatment; laparoscopic or open approach depends on the clinical characteristics and the experience of the surgeon. [ABSTRACT FROM AUTHOR]

BackgroundThis study aimed to determine the impact of pulmonary complications on death after surgery both before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.MethodsThis was a patient-level, comparative analysis of two, international prospective cohort studies: one before the pandemic (January-October 2019) and the second during the SARS-CoV-2 pandemic (local emergence of COVID-19 up to 19 April 2020). Both included patients undergoing elective resection of an intra-abdominal cancer with curative intent across five surgical oncology disciplines. Patient selection and rates of 30-day postoperative pulmonary complications were compared. The primary outcome was 30-day postoperative mortality. Mediation analysis using a natural-effects model was used to estimate the proportion of deaths during the pandemic attributable to SARS-CoV-2 infection.ResultsThis study included 7402 patients from 50 countries; 3031 (40.9 per cent) underwent surgery before and 4371 (59.1 per cent) during the pandemic. Overall, 4.3 per cent (187 of 4371) developed postoperative SARS-CoV-2 in the pandemic cohort. The pulmonary complication rate was similar (7.1 per cent (216 of 3031) versus 6.3 per cent (274 of 4371); P = 0.158) but the mortality rate was significantly higher (0.7 per cent (20 of 3031) versus 2.0 per cent (87 of 4371); P

Introduction: Schwannomas (Schs) are benign tumor masses that rarely occur intra-abdominally and rarely reach larger diameters. When present, they occur as rare solitary nerve sheath tumors of peri-neural Schwann cells. Schwannoma mostly affects the nerves of the extremities, trunk, or the head and neck region. They are more common in female patients, mostly among patients between the third and fifth decade. They occur spontaneously but could also be found in association with a group of genetic autosomal dominant disorders called type 2. When present intra-abdominally, schwannomas grow slowly without significant clinical signs and symptoms. Clinical importance is presented in cases of occupying intra-abdominal space and impingement of surrounding structures, which causes intermittent pain. Only 0.5–5% of all retroperitoneal tumors are schwannomas and their malignant transformation is very rare. Case report: The authors present a case of a large intra-abdominal schwannoma in a 70-year-old female patient. She underwent CT scanning due to refractory left-sided subcostal pain, which revealed a large tumor mass in the left-sided hemiabdomen. Preoperative cytologic biopsy confirmed Sch. The patient underwent an MRI scan upon admission to our department, which revealed the origin of the tumor at the left-sided L3 level and intra-abdominal tumor spreading with the largest diameter of 25 cm. The patient underwent multidisciplinary surgical excision, confirmed by MRI scan in a period of five months postoperatively. Conclusions: Its rare presentation leads to the necessity to adequately evaluate such patients, especially to avoid any hidden diagnosis which might lead to further complications. The goal of a multidisciplinary approach should be emphasized as maintaining a good postsurgical condition without neurological deficits.

Adult intussusception presents a diagnostic challenge given its non-specific symptoms. It is not as common as in infants and young children. Traditionally, diagnostic steps are invariably fit for normal adults, but not in pregnancy which faces certain limitations. A 40-year-old pregnant mother, gravida 9 para 8 at 34-week gestation, complained of intermittent epigastric pain for 2 days, requiring hospitalization. She soon developed minimal per rectal bleeding that was ruled out as hemorrhoid. Imaging was limited due to her pregnancy status. She later developed spontaneous delivery to a premature baby. Computed tomography (CT) revealed an ileocolic intussusception, which was confirmed via exploratory laparotomy. Histology was consistent with inflammatory fibroid polyp. Acute abdomen in pregnancy can be due to various causes, thus a high index of suspicion and early CT abdomen might help in early diagnosis and treatment. The benefit of doing CT on the mother and the risk of CT on the fetus is to be weighed as the timely diagnosis can prevent bowel ischemia and reduce maternal morbidity and mortality. Surgery remains the definite management in adult intussusception and an exact diagnosis can be made during the operation.

Desmoid-type fibromatosis (DF) is a locally aggressive myofibroblastic tumor accounting for approximately 0.03% of all neoplasms and less than 3% of all soft tissue tumors.1 The estimated incidence in the general population is 2 to 4 cases per million per year. In the past, this lesion was considered as an aberrant healing response against local trauma, irritation, or inflammation; however, later a clonal proliferation of the spindle cell was confirmed, and local recurrence as well as distant metastasis was identified.2 DF affects 10%-20% of patients with familial adenomatous polyposis. Sporadic DF predominantly affects young adults, especially women, and it is often related to pregnancy.3 Although it may occur in nearly every body part, it usually involves the extremities and trunk, including the abdominal wall and intra-abdomen. Intra-abdominal desmoid tumors are mainly located within the mesentery or pelvis.4 A bulky desmoid tumor located in the pelvis or lower abdominal wall near the uterus may be preoperatively suspected as a large subserosal uterine leiomyoma. Genetic alterations in theAPCandCTNNB1genes are thought to be vital events resulting in hereditary and sporadic DF. Sporadic DF is associated with a high incidence (85%) of mutations in theCTNNB1gene, which may lead to uninhibited activation of the Wnt pathway and the accumulation of excessive cytoplasmic β-catenin, ultimately resulting in tumor development.5 The early diagnosis of DF is challenging. The findings of computed tomography (CT) and magnetic resonance imaging (MRI) can guide the decisions regarding patient management, but the ultrasound features of DF are non-specific. The relationship between the tumor and the adjacent structures should be carefully evaluated to decide the feasibility of surgery.6 Complete surgical resection is usually the standard treatment in patients with resectable desmoid tumors. However, the local recurrence rate is still high after resection alone due to its infiltrative pattern and positive margins after surgical resection.7 Radiotherapy is another treatment modality for desmoid tumors, but its efficiency is controversial. Recently published meta-analysis and the review suggested the benefit of postoperative radiotherapy over surgery alone in long-term cure and prevention of recurrence.8 Low-dose chemotherapy or systemic therapy (such as hormonal therapy, non-steroidal anti-inflammatory therapy, or targeted therapy) in patients with advanced unresectable tumors or recurrent disease after surgery and/ or radiotherapy is also used.9 A 24-year-old lady presented with gradually progressive pain in the whole abdomen for six months. She had a prior history of lower uterine cesarean section done 3 years back and a history of missed abortion 4 years back. On per-abdominal examination, a 10x8 cm large mass was palpated mainly in the right lower abdomen, with side-to-side mobility. The speculum examination showed a smooth cervix. Per-vaginal examination revealed a large mass felt through the right fornix. Abdominal computed tomography showed bilateral normal ovaries and a large heterogeneous mass measuring 11x9 cm close to the uterus. A possibility of pedunculated subserosal leiomyoma was considered. Given progressive clinical symptoms, laparotomy was performed. On per-operative examination, a large mass was identified as closely adhered to the mesentery of the right colon. The uterus and bilateral adnexa were free of tumor. The tumor was excised in toto with the right colon. Gross examination revealed a rounded mass of size 11x9 cm with a smooth outer surface. The tumor was densely adhered to the cecum and appendix and had engulfed the appendix (Figure 1A). The cut surface shows a solid, whitish, firm lesion with prominent trabeculations (Figure 1B). Figure 1 A - Gross view of the giant globular tumor with a smooth surface and closely adhered to the right colon and appendix;the white arrowhead points towards the tip of the adhered appendix (scale bar= 5 cm); B - Cut surface of the tumor shows a solid, well-circumscribed whitish tumor with areas of trabeculations (scale bar= 5 cm); C - Photomicrograph shows a low-grade spindle cell mesenchymal tumor of low cellularity densely adhered to the serosal surface of the appendix with infiltration of muscularis of the appendix (H&E,40x); D - Photomicrograph shows spindle cell tumor with bland elongated nuclei and moderate cytoplasm disposed over a hyalinized and myxoid stroma interspersed with thin-walled vessels. (H&E, 100x); E - Photomicrograph shows tumor cells positive for smooth muscle actin (SMA) immunohistochemistry (100x); F - Photomicrograph shows tumor cells with nuclear localization of beta-catenin (100x).: Microscopic examination revealed a mesenchymal tumor with low cellularity, composed of bland spindled cells over a densely collagenized matrix interspersed with thin vascular channels (Figure 1D). Mitosis, necrosis, and significant atypia were absent. The tumor was adhered within the serosal surface of the appendix and colon and also showed infiltration of the retroperitoneal skeletal muscle fibers (Figure 1C). On IHC, the tumor cells were positive for Vimentin, Smooth muscle actin (SMA) and showed nuclear localization of beta-catenin with cyclinD1 (Figures 1E and 1F). IHC for h-caldesmon, S-100, CD117, DOG-1, myogenin, ALK, and STAT-6 were negative, ruling out other differential diagnoses, including leiomyoma, nerve sheath tumor, gastrointestinal stromal tumor, spindle cell rhabdomyosarcoma, inflammatory myofibroblastic tumor, and solitary fibrous tumor. Ki-67 labeling was ~2-3%. The DF diagnosis was rendered based on the histology and IHC features. Our patient was advised postoperative close follow-up with clinical and imaging modalities at regular intervals. In summary, awareness about this rare tumor in intra-abdominal locations in young female patients with a prior history of childbirth and surgery and its possible clinical and imaging overlap with leiomyoma prevents aggressive treatment in DF patients. A pre-operative biopsy can confirm the diagnosis. However, in symptomatic patients, surgery is the mainstay of therapy. A search for possible CTNNB1 and APC gene mutation is vital.

Objectives: The management of chronic pain among patients with abdominal cancer is complex; against that, the neurolysis of the celiac plexus (CPN) is the best technique at the moment to determine the efficacy and safety in the treatment of chronic pain secondary to oncological pathology of the upper abdomen. Material and Methods: This was a systematic review of controlled clinical trials between 2000 and 2021, in the sources MEDLINE/PubMed, Cochrane, Scopus, Web of Science, and Google Scholar. Three independent evaluators analysed the results of the bibliographical research. The quality of the studies was assessed with the Jadad scale and the mean difference (95% confidence interval) and heterogeneity of the studies (I2) were calculated with Review Manager 5.3. Results: Seven hundred and forty-four publications were identified, including 13 studies in the qualitative synthesis and three studies in the quantitative synthesis. No difference was found in the decrease in pain intensity between 1 and 12 weeks after the intervention, comparing the experimental group with the control (P > 0.05). The adverse effects related to neurolysis were not serious and transitory, mentioning the most frequent adverse effects and reporting a percentage between 21% and 67% (with 17% for echoendoscopic neurolysis and 49% for percutaneous neurolysis). Conclusion: Celiac plexus neurolysis for the treatment of severe chronic pain secondary to oncological pathology in the upper hemiabdomen produces similar pain relief as conventional pharmacological analgesic treatment. It is a safe analgesic technique since the complications are mild and transitory. [ABSTRACT FROM AUTHOR]