Maželytė, Rūta

Introduction Breast abscess in male patients is a rare entity, accounting for 1–3% of all documented breast diseases, while Salmonella-associated cases are exceptionally uncommon [1,2]. This case demonstrates an unusual clinical presentation and highlights diagnostic and therapeutic challenges. Case Presentation A 52-year-old man presented with a two-year history of recurrent left breast pain, swelling and intermittent purulent discharge, with fever episodes. The patient underwent multiple incision and drainage procedures combined with empirical antibiotic therapy. Relevant comorbidities included poorly controlled type 2 diabetes mellitus. Examination revealed fistulous openings in the left inframammary region with purulent secretion. MRI was nonspecific, showing superficial abscesses. Histopathological examination of a surgical biopsy from the left breast lesion excluded malignancy. Pus culture revealed Salmonella enteritidis, susceptible to ampicillin and trimethoprim-sulfamethoxazole. Blood culture was not performed, and the patient was HIV-negative. The man reported no occupational or household exposure to poultry. Despite targeted antibiotic therapy, persistent fistulae required surgical intervention. Surgical excision of two fistulous tracts in the left breast was done. Recovery was uncomplicated. Discussion Breast abscess in men is usually caused by Staphylococcus aureus, whereas Salmonella species are reported mainly in isolated cases[2,3]. Salmonella-associated breast abscesses occur more often in patients with metabolic or immunological risk factors, such as diabetes, likely due to hematogenous spread [2,3,4]. Reports highlight Salmonella-associated breast abscesses as diagnostically challenging and often imitating inflammatory or neoplastic disease [5]. As imaging and histopathology are nonspecific, microbiological culture is essential for diagnosis [2,4]. Management requires culture-directed antimicrobial therapy, combined with surgical intervention for source control, with successful outcomes [2,3,4]. Conclusions Salmonella-associated breast abscess, although rare, should be considered in recurrent or treatment-resistant infections. Early microbiological investigation and combined medical and surgical management are essential for accurate diagnosis and favorable outcomes [2,3,4].

Introduction: Treatment of Hepatocellular carcinoma (HCC) is based on various guidelines and most often used criteria are the Barcelona Clinic Liver Cancer (BCLC) criteria. Transcatheter arterial chemoembolization (TACE) is recommended for patients with disease of intermediate stage (B), when surgery and ablation are not possible due to multimodal disease. Acute pancreatitis is one of the rarest complications after TACE with an incidence of 0.4%. Method: A retrospective analysis of data from a prospectively maintained database at the tertiary university hospital of the Lithuanian University of Health Sciences, Kaunas Clinics, in Kaunas, Lithuania, was performed. Patients diagnosed with hepatocellular carcinoma, who underwent transarterial chemoembolization (TACE) were included in the study. Data on patients demographic information, CT scan, HCC localization, number of lesions, number of TACE procedures, post-TACE abdominal pain, serum amylase and other complications was analyzed Results: Fifty-one (51) patient was included and most of them (34 (66.6%) had a single lesion. Most of the patients underwent transarterial chemoembolization once (64.7%) and one third - multiple times (35.3%). Post-TACE pancreatitis was diagnosed in 5 (9.8%) patients. All 5 patients had elevated amylase levels (1077±987 U/L) and abdominal pain. Two patients died of septic complications after TACE. Conclusion: Acute pancreatitis is rare complication after TACE. Routine monitoring of pancreatic enzymes after TACE are recommended, especially in symptomatic patients as complications of TACE might be lethal.

Introduction. Laparoscopic gastric surgery offers numerous advantages over open procedures but is associated with transient liver enzyme elevations (TLEE), particularly in cases involving liver retraction. Nathanson liver retractor (NLR) is commonly used in gastric surgeries to improve surgical exposure but may contribute to TLEE. Aim: To evaluate the impact of liver retractor use during laparoscopic gastric surgeries on liver enzyme tests and other biochemical blood markers and assess its clinical significance. Methods. A prospective cohort study was conducted including 119 patients undergoing elective laparoscopic surgeries at the Lithuanian University of Health Sciences Hospital Kaunas Clinics between June and November 2024. Patients were divided into two groups: the retractor group (n=59; fundoplication or gastric resection) and the control group (n=60; cholecystectomy). Laboratory parameters were assessed preoperatively, immediately postoperatively, and on the first postoperative day. Statistical analysis included ANCOVA, logistic regression, and ROC curve analysis. Results. ALT and AST levels were significantly elevated postoperatively in the retractor group (p75 min and >95 min were predictive of ALT and AST elevations, respectively. CRP and LDH levels were significantly higher in the retractor group (p<0.001). Surgery duration >75 min and >95 min were predictive of ALT and AST elevations, respectively. CRP and LDH levels were significantly higher in the retractor group (p<0.001 and p=0.007), while bilirubin, coagulation and renal markers showed less pronounced differences. ROC analysis identified surgery duration as a moderate predictor of AST elevation (AUC=0.683). Conclusion. Liver retraction during laparoscopic gastric surgery is associated with transient elevations in liver enzymes and inflammatory markers, particularly in prolonged procedures. These findings emphasize the importance of perioperative monitoring and highlight the need for further research on long-term hepatic outcomes.

Introduction Dirofilaria repens is a mosquito-borne filarial parasite, mainly affecting carnivorous animals but can also cause zoonosis in humans as incidental hosts leading to ocular or subcutaneous dirofilariasis [1]. This case highlights the rarity of subcutaneous dirofilariasis with only seven cases reported in Lithuania for non-travelers [1,2]. Case Presentation A 64-year-old woman presented with a firm, mobile nodule on her right thigh, following an insect bite two months prior. After the bite, she experienced painful erythematous patches that spread bilaterally but without systemic symptoms. She had no history of traveling abroad. Her medical history includes atopic dermatitis. On examination, a firm, mobile 0,6 x 0,5 cm nodule on the right thigh was observed. Laboratory findings revealed no eosinophilia or elevated total IgE levels. Borrelia burgdorferi IgM/IgG antibodies test was negative. Stool examinatiom for helminth eggs and larvae was negative. Ultrasound revealed a well-defined 0,6 x 0,4 cm subcutaneous hypoechogenic lesion with multiple internal thin worm-like structures. The nodule and capsule were excised under local anesthesia and histopathological examination confirmed D. repens. Following the procedure, the patient experienced complete resolution of symptoms. Discussion Subcutaneous dirofilariasis typically presents as a painless, solitary, erythematous nodule with mild swelling [1]. Lithuania has recently been identified as an endemic region for D. repens, reflecting its growing prevalence [2]. The diagnosis relies on ultrasonography, histopathology and polymerase chain reaction, as serology lacks specificity. Pharmacotherapy is not recommended, and surgery remains the treatment of choice [1,3]. Conclusions This case highlights the increasing prevalence of Dirofilaria repens in Lithuania and raises awareness about the importance of considering dirofilariasis in patients presenting with subcutaneous nodules at any body site.

Introduction Liver enzyme elevation, pain in the epigastric region or under the left rib arch are common after laparoscopic fundoplication, gastric resection, or gastrectomy. According to studies it is often due to liver blood flow disturbances caused by left lobe elevation with a retractor.[1–6] Factors like body mass index (BMI) and surgery duration may also contribute.[7] However, studies identifying risk factors for these changes remain limited. Comprehensive evaluation of these factors is crucial to prevent undiagnosed pathologies and ensure optimal care.[8] Aim To elucidate the principal factors contributing to transient postoperative liver enzyme elevations following laparoscopic surgeries involving a liver retractor. Methods This prospective cohort study included 120 patients who underwent laparoscopic surgery at the Surgery Department of Kaunas Clinics between 2023 and 2024. Patients were divided into two groups: a control group (undergoing laparoscopic cholecystectomy without liver retraction) and a retractor group (undergoing laparoscopic fundoplication, gastric resection, or cardiomyotomy involving liver retraction). Blood tests, including complete blood count, biochemistry, kidney function, coagulation, and liver markers, were conducted preoperatively, intraoperatively, and postoperatively. Additional variables, such as BMI, surgery duration, and demographic data, were collected for analysis. Preoperative non-invasive ultrasonography of the upper abdomen was performed to assess left liver lobe dimensions. Statistical analyses were conducted using IBM SPSS 29.0 software to evaluate associations with liver enzyme elevations and identify potential risk factors. Results An elevation in CRP levels was observed in the retractor group on the first postoperative day (p<0.05). Notable elevations in ALT, AST, and LDH levels were also detected on the day of surgery and the first postoperative day in the group where liver retractors were involved (p<0.05). No association between electrolytes, kidney function tests, coagulation profiles and postoperative liver enzymes elevation was found (p>0,05).The increase in liver enzymes was not dependent on BMI but correlated with the duration of surgery. Binary logistic regression analysis revealed that surgeries lasting longer than 75 minutes were associated with a sixfold increased risk of elevated liver enzymes. After the first postoperative day, liver enzyme levels in the retractor group returned to preoperative ranges, while no increase in liver enzymes was observed in the control group. Conclusions Our study identified liver retractor use and surgery duration as key factors in liver enzyme elevation, which do not impact short-term outcomes. BMI did not affect postoperative liver enzyme elevation. Intermittent breaks in retractor use are recommended during longer surgeries to reduce this risk.

This study assessed the potential cost-effectiveness of high (80-100%) vs low (21-35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa.

This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardized assessment tools are needed.

Background: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58-5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23-0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised.

Introduction The incidence of primary linea alba hernia applies up to 5-10% and midline incisional - 10-20% [1,2]. Minimally invasive primary linea alba and midline incisional hernia treatment gains more and more popularity among treatment options. Aim To compare the early results of minimally invasive and open sublay mesh repair of small and medium size primary linea alba and midline incisional ventral hernias. Methods The prospective cohort study of patients who underwent for small and medium size of primary and incisional ventral hernia repair in the Hospital of Lithuanian University of Health Sciences Kaunas Clinics, Department of Surgery during 2019-2020 years. The patients were divided into two groups: minimally invasive (TARM, SCOLA) and open mesh repair (sublay) groups. There were documented: demographic and hernia features, operation time, postoperative pain, use of analgesics, length of hospital stay, complications. Postoperative pain was assessed by using Visual Analogue Scale. All patients were invited for follow-up in our institution after 1, 3 and 6 months. Abdominal wall ultrasound was performed to evaluate possible complications: seroma, mesh dislocation, hernia recurrence. Results Thirty four patients were included in the study: 21 patients in the minimally invasive group (TARM - 12, SCOLA - 9) and 13 patients were in the open mesh repair group. The groups were comparable in terms of patients characteristics and hernia data. Study included 14 male and 20 female with median of age 56 years. Incisional hernias were for 20 (58.8%) and primary ventral - 14 (41.2%) patients. The time of hernia occurrence was 31.33 (SD 50.1) months in minimally invasive group and 35.1 (SD 46.7) open mesh group. The hernia defect diameter was 4.4 (SD 1.6) cm in the open repair and 3.25 (SD 2.16) cm in the minimally invasive group. The operation time was longer for the minimally invasive surgery group (224.3 (SD 106.2[...].

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29).[...].