Open Access Indonesian Journal of Medical Reviews

Laparoscopic Management of Incarcerated Femoral Hernia with Bowel Necrosis: A Case Report

Handito Sarwwotatwadhiko — 2025-09-02

Femoral hernias, though representing less than 5% of all abdominal wall hernias, pose a significant clinical challenge due to their anatomical constraints and high complication rates. Exhibiting a pronounced female predominance, these hernias carry a substantial risk of incarceration and strangulation, estimated between 5-20%, stemming from the narrow and unyielding nature of the femoral canal. This anatomical predisposition frequently mandates urgent surgical intervention to prevent bowel ischemia and necrosis. Diagnostic difficulties often arise, particularly in occult presentations lacking a discernible groin mass. The advent of laparoscopy has revolutionized the approach, offering distinct advantages in both the diagnosis of clinically obscure hernias and the execution of minimally invasive repair, potentially improving patient outcomes. We present the case of a 63-year-old female who arrived at the emergency department complaining of a three-day duration of severe, intermittent abdominal pain associated with obstipation, progressive abdominal distension, nausea, and vomiting. Clinical examination revealed marked abdominal distension but failed to identify any palpable mass in the inguinal or femoral regions. Plain abdominal radiography indicated findings consistent with small bowel obstruction. Consequently, an exploratory laparoscopy was undertaken. Intraoperatively, an incarcerated right femoral hernia was discovered, containing a 4 cm segment of ileum that exhibited frank necrosis. A completely laparoscopic procedure involving small bowel resection, creation of a side-to-side ileoileal anastomosis, and subsequent repair of the femoral hernia defect using primary purse-string sutures was performed successfully. In conclusion, the laparoscopic approach was indispensable for the accurate diagnosis and effective management of this complex case involving an occult, incarcerated femoral hernia with resultant bowel necrosis. Employing a minimally invasive strategy facilitated simultaneous bowel resection and hernia repair, offering potential benefits including diminished postoperative discomfort, expedited recovery, and possibly lower long-term recurrence rates relative to traditional open surgical techniques. This case reinforces the critical importance of considering femoral hernia in the differential diagnosis of female patients presenting with acute small bowel obstruction, even in the absence of classical external signs. Furthermore, it underscores the feasibility and efficacy of a purely laparoscopic approach for managing such complex surgical emergencies.

Mature Teratoma of the Mediastinum in an Adolescent: Clinical Camouflage as Meningioma with Hemoptysis and Pleural Effusion

Adi Astron Prasetio — 2025-09-02

Mediastinal mature teratomas are relatively common germ cell tumors in adolescents, typically located in the anterior mediastinum. While often benign and slow-growing, they can cause symptoms like hemoptysis through compression or local invasion. The differential diagnosis can rarely include ectopic meningioma, posing significant diagnostic challenges. The aim of this report is to describe this unusual presentation of a mediastinal mature teratoma and to emphasize the importance of a comprehensive, multidisciplinary diagnostic workup for achieving an accurate diagnosis and guiding appropriate management in such complex cases of mediastinal pathology. A 17-year-old female presented with a two-month history of blood-streaked hemoptysis and intermittent central chest pain. She had no systemic symptoms such as fever or weight loss. Physical examination was largely unremarkable, though laboratory tests revealed mild anemia (Hb 9.2 g/dL). Imaging studies, including chest X-ray and contrast-enhanced thoracic multi-slice computed tomography (MSCT), identified a large, heterogeneous anterior to middle mediastinal mass. The mass was noted to compress the right main bronchus, causing right lower lobe atelectasis, and was associated with minimal right-sided pleural effusion and mediastinal lymphadenopathy. The MSCT findings were suggestive of a teratoma. A core biopsy of the mediastinal mass indicated a mature teratoma but also raised meningioma as a differential diagnosis. Bronchoscopy revealed mucosal hyperemia and hypervascularity in the tracheobronchial tree. A brain MRI was negative for intracranial metastasis. The patient was managed conservatively pending further comprehensive evaluation and multidisciplinary team discussion. In conclusion, this case underscores an atypical presentation of a mediastinal mature teratoma in an adolescent, characterized by hemoptysis, pleural effusion, and a rare histopathological differential of meningioma. It highlights the critical role of meticulous and comprehensive diagnostic evaluation, including advanced imaging and histopathology, along with a multidisciplinary approach, in accurately diagnosing and planning the management of such complex mediastinal masses, especially when faced with unusual clinical or pathological features.

A Rare Manifestation of Metastatic Breast Cancer: Cervical Esophageal Stenosis with Oropharyngeal Dysphagia Decades After Primary Treatment

Made Gede Krisna Rendra Kawisana — 2025-09-02

Esophageal metastasis from breast cancer is an infrequent occurrence, with cervical esophageal involvement being exceptionally rare. Presentation with oropharyngeal dysphagia, particularly decades after primary breast cancer treatment, poses a significant diagnostic challenge. This report details such a case, emphasizing the clinical course and diagnostic complexities. A 60-year-old female, with a history of primary breast cancer treated approximately two decades prior and subsequent treatment for a locoregional recurrence with surgery, chemotherapy, and radiotherapy in 2019, presented with progressive oropharyngeal dysphagia and aspiration over three months. Initial Fiberoptic Endoscopic Evaluation of Swallowing (FEES) suggested upper esophageal pathology with stenosis and extraluminal mass compression at the introitus esophagus. Esophagoscopy confirmed a high cervical esophageal stenosis impassable with the scope. Computed Tomography (CT) of the neck revealed a large heterogeneous solid mass at the C6-Th2 level, encasing the trachea and causing severe cervical esophageal stenosis with suspected wall infiltration, along with widespread metastatic disease including pulmonary and osseous metastases. In conclusion, this case highlights the critical importance of maintaining a high index of suspicion for metastatic breast cancer in patients presenting with new-onset oropharyngeal or esophageal dysphagia, even many years after their initial cancer diagnosis and treatment. Cervical esophageal metastasis, though rare, should be considered in the differential diagnosis. A multidisciplinary approach and comprehensive diagnostic evaluation, including advanced imaging, are paramount for accurate diagnosis and guiding appropriate palliative management.

Beyond Microcephaly: Semilobar Holoprosencephaly with Marked Macrocephaly due to Severe Congenital Hydrocephalus, Brachycephaly, and Hyponatremia – A Case Report

Cynthia Cynthia — 2025-09-02

Holoprosencephaly (HPE) is a rare, complex brain malformation arising from incomplete prosencephalon cleavage, typically associated with microcephaly and facial dysmorphism. Coexisting severe hydrocephalus leading to macrocephaly in HPE, particularly the semilobar type, presents a distinct clinical picture. Hyponatremia often complicates neurological conditions involving increased intracranial pressure, potentially worsening prognosis. The aim of this case report is to meticulously describe the clinical presentation, diagnostic evaluation, management approach, and early outcomes of this rare and complex neonatal neurological disorder. A male neonate, born at 35+3 weeks gestation to a mother with severe preeclampsia, presented with marked macrocephaly (head circumference 50 cm), a prominent fontanel, and bilateral sunset eyes. Initial CT scan confirmed hydrocephalus. Subsequent evaluation and a repeat CT scan at one month revealed brachycephaly (cephalic index 98) and semilobar holoprosencephaly. Head circumference progressed to 64 cm by the time of ventriculoperitoneal (VP) shunt surgery at approximately 5 weeks of age. Laboratory investigations showed hyponatremia (120 mEq/L), hyperkalemia, and hypochloremia. At three months, the patient exhibited significant growth and developmental delays and malnutrition. In conclusion, this case highlights an unusual presentation of semilobar HPE characterized by severe congenital hydrocephalus causing marked macrocephaly, rather than microcephaly, complicated by brachycephaly and significant hyponatremia. Early, comprehensive diagnostic evaluation and multidisciplinary management are crucial in such complex neurodevelopmental disorders to address multifaceted challenges and attempt to optimize outcomes.

Awake Fiberoptic Intubation for a Giant Multinodular Struma Presenting with Acute Respiratory Failure: A Case Report

Abdulrahman Rizky Sulajman — 2025-09-02

A giant multinodular struma can cause severe upper airway obstruction, presenting a formidable challenge to anesthesiologists and emergency physicians. Securing the airway is a priority, yet conventional intubation methods carry a high risk of failure and complete airway collapse. Awake Tracheal Intubation (ATI) is a critical technique for managing these anticipated difficult airways, allowing for the maintenance of spontaneous respiration while securing a definitive airway. This report details the emergency management of a patient with near-fatal airway compromise due to a massive goiter. A 51-year-old female presented to the emergency department with severe dyspnea that had worsened over three days. She had a 20-year history of a progressively enlarging neck mass, which was now of a massive size. The patient exhibited signs of acute respiratory failure, including stridor, subcostal retractions, a respiratory rate of 30 breaths/minute, and a decreased level of consciousness. Imaging confirmed a large soft tissue mass causing significant tracheal narrowing from the C4 to C6 vertebral levels. Given the impending airway collapse, an emergency awake fiberoptic intubation was performed. With minimal sedation and continuous oxygenation, a size 6.0 endotracheal tube was successfully placed into the trachea under direct bronchoscopic guidance. The patient’s oxygenation and ventilation improved immediately post-procedure. In conclusion, this case underscores the lifesaving potential of awake fiberoptic intubation in patients with a critically compromised airway from a giant multinodular struma. The ability to maintain spontaneous breathing and provide continuous oxygenation during the procedure is paramount in preventing catastrophic outcomes. This technique should be a core competency for clinicians managing difficult airways in the emergency setting.

Ileal Atresia Mimicking Hirschsprung Disease on Contrast Study: A Case Report and Diagnostic Re-evaluation

Anisa Ika Pratiwi — 2025-09-02

The differentiation between congenital causes of neonatal bowel obstruction, such as ileal atresia and Hirschsprung disease, is paramount for appropriate surgical planning. While clinically similar, their radiological findings can overlap, creating significant diagnostic challenges. Ileal atresia is a congenital anomaly characterized by the incomplete development of the ileum, resulting in intestinal obstruction. The aim of this study is to highlight the limitations of contrast studies in neonatal bowel obstruction and to reinforce the principle that in the face of discordant clinical and radiological evidence. We present the case of a full-term female neonate, born at 39 weeks of gestation, who developed symptoms of green vomiting and delayed bowel movements on her second day of life. An initial colon in loop contrast study at eight days of age was suggestive of short-segment Hirschsprung disease, showing a narrowed rectal lumen and a transition zone in the rectosigmoid region. However, due to persistent signs of distal bowel obstruction, surgical exploration was performed on the ninth day of life. Intraoperatively, the diagnosis was revised to Type 3A ileal atresia located 20 cm from the ileocecal junction, with significant adhesions. The management involved adhesiolysis, resection of the atretic ileal segment, and a primary ileo-ascending anastomosis. The postoperative course was complicated by hypovolemic shock and suspected sepsis neonatorum, which were managed successfully with intensive care support, including intravenous antibiotics and parenteral nutrition. The patient showed significant improvement by the fifth postoperative day and was discharged with normal gastrointestinal function. In conclusion, this case underscores a critical diagnostic pitfall where the 'microcolon of disuse' in distal ileal atresia radiologically mimicked the transition zone of Hirschsprung disease. It highlights that while contrast studies are invaluable, a high index of clinical suspicion and readiness for surgical exploration are essential for accurate diagnosis and timely intervention in complex cases of neonatal bowel obstruction.

Navigating the Triad of Trauma: A Case Report on Managing Concurrent Pulmonary Contusion, Traumatic Brain Injury, and Cervical Fracture in a Geriatric Patient

Yasyfie Asykari — 2025-09-02

The management of geriatric patients with multiple severe injuries presents a formidable clinical challenge due to reduced physiological reserve and the complex interplay of competing therapeutic goals. This report details the case of a geriatric patient suffering from the triad of pulmonary contusion (PC), moderate traumatic brain injury (TBI), and an unstable cervical spine fracture, highlighting the intricate balance required in neuroprotective and lung-protective ventilatory strategies. A 68-year-old male was admitted following a 10-meter fall, sustaining a moderate TBI with a temporoparietal subdural hemorrhage, a complete C3 vertebral fracture, and significant bilateral pulmonary contusions. His hospital course was marked by acute respiratory distress and neurological deterioration, with a Glasgow Coma Scale (GCS) score of E3V4M5 and hypoxemia requiring intubation and mechanical ventilation in the intensive care unit (ICU). Management focused on the cautious application of positive end-expiratory pressure (PEEP) to improve oxygenation without exacerbating intracranial pressure (ICP), alongside strict cervical spine immobilization and neuro-monitoring. After eight days of complex critical care, the patient’s prolonged need for mechanical ventilation and significant sputum retention necessitated a percutaneous dilational tracheostomy (PDT) to facilitate respiratory weaning and improve pulmonary toilet. In conclusion, this case underscores the profound difficulty of managing concurrent lung and brain injuries in the context of cervical instability. The successful navigation of this trauma triad hinged on a highly individualized, multidisciplinary approach, with judicious ventilator management and timely procedural intervention like PDT being pivotal. It affirms the need for integrated care protocols that can dynamically balance competing organ-system priorities in complex geriatric trauma.

Comparative Diagnostic Accuracy of CT and Ultrasonography for Bowel Obstruction: A Systematic Review and Meta-Analysis

Moch Nurul Jadid — 2025-09-02

The prompt and accurate diagnosis of bowel obstruction is a critical challenge. This systematic review and meta-analysis aimed to determine and compare the pooled diagnostic accuracy of computed tomography (CT) and ultrasonography (USG) for detecting bowel obstruction in adult patients. Following PRISMA-DTA guidelines, we systematically searched PubMed, ScienceDirect, and SagePub for primary diagnostic accuracy studies published between 2014 and 2024 that evaluated CT and/or USG against a reference standard (surgical findings or clinical follow-up). Two reviewers independently screened studies, extracted data, and assessed bias using the QUADAS-2 tool. Bivariate random-effects models were used to calculate pooled sensitivity and specificity. Our search yielded 15 studies comprising 2,876 patients. For the diagnosis of bowel obstruction, CT had a pooled sensitivity of 95.2% (95% CI: 92.8%–96.9%) and a pooled specificity of 96.1% (95% CI: 93.5%–97.7%). For USG, the pooled sensitivity was 91.5% (95% CI: 88.4%–93.8%), and the pooled specificity was 94.3% (95% CI: 91.2%–96.4%). The area under the summary receiver operating characteristic curve confirmed superior overall diagnostic performance for CT (0.98) compared to USG (0.95). In conclusion, CT demonstrates a slightly higher diagnostic accuracy than USG for bowel obstruction in adults. It should be considered the preferred modality for definitive evaluation, particularly for identifying etiology and complications. However, USG remains an excellent and highly accurate alternative, especially as a first-line, point-of-care tool in emergency settings, in pregnant patients, or where CT is contraindicated. The choice of modality should be guided by the specific clinical context.

The Protective Paradox of Operative Delivery: A Case-Control Analysis of Maternal and Neonatal Risk Factors for Asphyxia in a Balinese Hospital

Ida Ayu Sintya Pratiwi — 2025-09-02

Neonatal asphyxia constitutes a primary driver of neonatal morbidity and mortality worldwide, with a disproportionate burden in developing nations like Indonesia. The identification of localized, modifiable risk factors is a critical prerequisite for the development of targeted and effective preventive healthcare strategies. This study was designed to meticulously identify the significant maternal, intrapartum, and neonatal risk factors associated with neonatal asphyxia within a tertiary care hospital setting in Bali, Indonesia. We executed a retrospective matched case-control study at a specialized Maternal and Child Hospital in Denpasar, Bali. The study included all neonates diagnosed with asphyxia (cases, n=103) born between January 1^st and December 31^st, 2023, and 103 randomly selected neonates without asphyxia (controls), also born within the same period. To control for potential confounding, cases and controls were matched by gender and month of birth. An exhaustive review of maternal and neonatal medical records was conducted. The data were analyzed using Chi-square tests for bivariate analysis and a multivariate logistic regression model to isolate the independent predictors of asphyxia. The multivariate analysis identified prematurity as the most profound risk factor for neonatal asphyxia, conferring a more than tenfold increase in risk (Adjusted Odds Ratio [aOR] = 10.33, 95% CI: 4.50-23.71, p<0.001). Significant maternal risk factors included anaemia during pregnancy (aOR = 6.56, 95% CI: 2.36-18.20, p<0.001), maternal age outside the optimal range of 20-35 years (aOR = 3.93, 95% CI: 1.50-10.32, p=0.005), and maternal obesity (aOR = 2.92, 95% CI: 1.20-7.11, p=0.018). Premature rupture of membranes (PROM) was identified as a significant intrapartum risk factor (aOR = 3.16, 95% CI: 1.30-7.72, p=0.011). Notably, delivery by caesarean section or instrumental assistance appeared to be a significant protective factor (aOR = 0.22, 95% CI: 0.08-0.59, p=0.003). In conclusion, prematurity, maternal anaemia, age extremes, maternal obesity, and PROM are confirmed as critical, independent risk factors for neonatal asphyxia in this Balinese population. The striking protective association of operative delivery likely represents a "protective paradox," a statistical artifact arising from confounding by indication, wherein timely and decisive obstetric intervention for high-risk pregnancies successfully mitigates adverse outcomes. Preventive strategies must therefore be multifaceted, prioritizing the public health imperatives of preterm birth prevention and the rigorous clinical management of maternal anaemia and obesity throughout the continuum of antenatal care.

Efficacy and Safety of IL-5 Pathway-Targeting Biologics (Mepolizumab, Reslizumab, Benralizumab) in the Management of Hypereosinophilic Syndromes: A Systematic Review and Meta-Analysis

Yuniza — 2025-09-02

Hypereosinophilic syndromes (HES) are rare disorders defined by persistent eosinophilia and eosinophil-driven organ damage. Interleukin-5 (IL-5) is the central cytokine governing eosinophil maturation and survival, establishing its pathway as a critical therapeutic target. While individual trials of biologics targeting the IL-5 pathway—mepolizumab, reslizumab, and benralizumab—have shown promise, a quantitative synthesis of their class-wide efficacy and safety in HES is needed. This study aimed to meta-analyze the evidence for these agents in managing HES. Following PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane Library through December 2024 for randomized controlled trials (RCTs) and prospective observational studies of IL-5 pathway biologics in patients with HES. Primary outcomes were the proportion of patients achieving hematologic response and the annualized rate of clinical exacerbations. Key secondary outcomes included oral corticosteroid (OCS) dose reduction and adverse events (AEs). Data were pooled using a random-effects model, with extensive, pre-planned subgroup and sensitivity analyses to explore heterogeneity. Seven studies (3 RCTs, 4 observational) involving 388 patients were included. Patients receiving IL-5 pathway biologics had significantly higher odds of achieving hematologic response (Odds Ratio [OR] 9.85; 95% Confidence Interval [CI] 5.12-18.96; p<0.0001), a finding robust to sensitivity analyses of different response definitions. The annualized exacerbation rate was reduced by 64% (Rate Ratio 0.36; 95% CI 0.25-0.52; p<0.0001). The intervention led to a mean daily OCS reduction of 12.5 mg (95% CI -15.8 to -9.2 mg; p<0.0001). Subgroup analysis revealed this effect was more pronounced in observational studies than in RCTs. The overall risk of AEs was not significantly increased. This meta-analysis provides robust evidence that biologics targeting the IL-5 pathway are highly effective and generally safe for managing PDGFRA-negative HES. They induce high rates of hematologic remission, substantially reduce clinical exacerbations, and facilitate a significant corticosteroid-sparing effect. These findings strongly support their role as a foundational component of modern HES therapy, though long-term safety and efficacy within distinct HES subtypes warrant further investigation.

Salvage Total Laryngectomy with Bilateral Deltopectoral Flap Reconstruction for Metastatic (Stage IVC) Laryngeal Carcinoma: A Case Report

Steven Yohanis Latupeirissa — 2025-09-02

The management of advanced laryngeal squamous cell carcinoma (SCC) that persists or recurs after definitive chemoradiotherapy presents a significant clinical challenge. This challenge is profoundly amplified in the setting of distant metastatic disease (Stage IVC), where the goals of treatment shift from curative intent to palliation and quality of life preservation. Surgical salvage in this context is controversial and reserved for highly selected cases with severe, unmanageable local symptoms. We present the case of a 58-year-old male, a long-term smoker, with Stage IVC (T3N2cM1) laryngeal SCC, complicated by bone metastases. He initially underwent definitive chemoradiotherapy. Ten months later, he presented with progressive local disease, including a fungating cervical mass and impending airway compromise. A palliative salvage total laryngectomy with bilateral Modified Radical Neck Dissection (MRND) was performed to control severe local symptoms. The extensive pharyngocutaneous defect was reconstructed using bilateral pedicled deltopectoral fasciocutaneous flaps. The final histopathology confirmed viable, moderately differentiated SCC with extensive cartilage invasion and, critically, a positive deep resection margin. The postoperative course was managed successfully, with the patient showing significant improvement in local symptoms and quality of life at short-term follow-up. This case highlights the complex decision-making required for palliative surgery in metastatic head and neck cancer. The discussion focuses on the justification for aggressive local intervention to palliate debilitating symptoms, the rationale for selecting the robust bilateral deltopectoral flap for reconstruction in a hostile, irradiated field, and the profound prognostic implications of a positive surgical margin in the salvage setting. In conclusion, palliative salvage total laryngectomy can be a viable strategy to improve quality of life in selected patients with Stage IVC laryngeal cancer and overwhelming local disease. However, achieving complete oncologic clearance is a formidable challenge, and management must be tailored within a multidisciplinary framework.

Defining the Threshold: A Dose-Response Meta-Analysis of Daily Screen Time and Adverse Behavioral Outcomes in Children and Adolescents

Andreas Eric — 2025-09-02

The pervasive integration of digital media into the lives of children and adolescents has generated significant concern regarding its impact on developmental health. While associations between high levels of screen time and negative outcomes are frequently reported, the precise dose-response relationship remains poorly quantified, leaving clinicians and parents without evidence-based thresholds for guidance. This study aimed to quantitatively synthesize the evidence linking daily screen time duration to the risk of adverse behavioral outcomes in youth. Following PRISMA guidelines, a systematic search of PubMed, Embase, PsycINFO, and Scopus was conducted through February 2025. Observational studies that reported quantifiable measures of daily screen time and validated assessments of behavioral outcomes in individuals aged 3-18 years were included. Two reviewers independently performed study selection, data extraction, and risk of bias assessment using the Newcastle-Ottawa Scale (NOS). A two-stage, random-effects dose-response meta-analysis using restricted cubic splines was employed to model the non-linear association between screen time (in hours/day) and the odds of adverse behavioral outcomes. From an initial 4,891 records, 7 key studies comprising 46,882 participants were included in the quantitative synthesis. The dose-response analysis revealed a significant, non-linear relationship. Compared to 30 minutes of daily screen time, the pooled odds ratio (OR) for adverse behavioral outcomes was minimal at 1 hour/day (OR 1.05; 95% CI, 0.97-1.14) but began to increase significantly thereafter. The risk became more pronounced at 2 hours/day (OR 1.31; 95% CI, 1.17-1.47), rose substantially at 4 hours/day (OR 1.82; 95% CI, 1.60-2.07), and continued to climb at 6 hours/day (OR 2.55; 95% CI, 2.15-3.03). The association was stronger in preschool-aged children compared to adolescents. In conclusion, this focused meta-analysis provides quantitative evidence for a dose-dependent association between daily screen time and behavioral problems in youth, with a notable increase in risk observed beyond two hours per day. These findings provide an evidence-based foundation for clinical guidance and public health recommendations aimed at mitigating the behavioral risks of excessive digital media exposure during critical developmental periods.

Anesthetic and Analgesic Management for Mastectomy of a Giant Phyllodes Tumor: A Case Report on the Central Role of the Serratus Anterior Plane Block

Heri Dwi Purnomo — 2025-09-02

Mastectomy for giant breast tumors presents a formidable clinical challenge due to the anticipated extensive surgical trauma, significant inflammatory response, and high risk of severe postoperative pain. This intense nociceptive barrage can lead to central sensitization and the development of debilitating Post-Mastectomy Pain Syndrome (PMPS). A robust, opioid-sparing multimodal analgesic strategy is therefore not just beneficial, but essential. The Serratus Anterior Plane Block (SAPB) is a regional anesthetic technique integral to such a strategy. We present the case of a 39-year-old, 60 kg female with a giant (24 x 22 x 18 cm) right-sided phyllodes tumor scheduled for mastectomy. The anesthetic plan consisted of general anesthesia and a preemptive, ultrasound-guided deep SAPB using 20 mL of 0.25% levobupivacaine. The procedure was performed with meticulous attention to sonoanatomy and technique. Intraoperatively, the patient maintained profound hemodynamic stability with minimal requirement for volatile anesthetic. Postoperatively, the patient reported complete analgesia, with Visual Analog Scale (VAS) scores of 0 at rest and 0-1 with movement (dynamic pain) for the first 24 hours. Sensory testing confirmed a dense block from T2 to T7. The patient required no rescue analgesia, mobilized early, and reported high satisfaction with her recovery. The final pathology confirmed a borderline phyllodes tumor. In conclusion, this case report demonstrates that a meticulously performed, ultrasound-guided deep SAPB can serve as the cornerstone of an effective, opioid-sparing analgesic regimen for high-pain-risk breast surgery. It can provide complete and functional postoperative analgesia, enhance hemodynamic stability, and facilitate recovery, embodying the core principles of Enhanced Recovery After Surgery (ERAS) pathways.

Acinar Gland Hyperplasia Masquerading as Pancreatic Head Carcinoma: A Case Report on a Diagnostic and Surgical Dilemma

Prima Maulana Cahyo Nugroho — 2025-09-02

The preoperative differentiation of benign from malignant pancreatic head masses presents a significant clinical challenge. While pancreatic ductal adenocarcinoma (PDAC) is the primary concern, rare benign pathologies can be radiologically and clinically indistinguishable from cancer, leading to diagnostic uncertainty and complex surgical decisions. A 61-year-old male presented with a classic triad of obstructive jaundice, significant weight loss, and right upper abdominal pain. A contrast-enhanced computed tomography (CT) scan of the abdomen revealed a solid mass in the head of the pancreas, causing concomitant dilation of the common bile and pancreatic ducts—the "double duct sign." These findings were highly suggestive of pancreatic head carcinoma, prompting a decision for surgical intervention. The patient underwent a standard pancreaticoduodenectomy (Whipple procedure). Surprisingly, the final histopathological examination of the resected specimen revealed no evidence of malignancy. The diagnosis was benign acinar gland hyperplasia. The postoperative course was complicated by a delayed post-pancreatectomy hemorrhage from a gastroduodenal artery pseudoaneurysm, which was successfully managed with minimally invasive transarterial embolization (TAE). In conclusion, acinar gland hyperplasia is an exceedingly rare benign condition that can precisely mimic the clinical and radiological features of pancreatic cancer. This case underscores the current limitations of preoperative diagnostics and affirms that aggressive surgical management is justified in patients with a high suspicion of malignancy, as the risk of withholding surgery for a potentially curable cancer outweighs the risk of resecting a benign lesion. Furthermore, it highlights that the Whipple procedure carries a significant risk of life-threatening complications, such as delayed hemorrhage, irrespective of the underlying pathology, necessitating vigilant postoperative care.

Preoperative Fasting Duration as a Potential Predictor of Glycemic Instability in Non-Diabetic Emergency Surgery Patients: A Prospective Observational Pilot Study

Mustaqiem Isda — 2025-09-02

Preoperative fasting is a cornerstone of anesthetic safety, yet in emergency surgery, fasting periods are frequently prolonged and unregulated. The metabolic consequences of such extended fasting in non-diabetic patients, who are often assumed to be metabolically resilient, are poorly understood. This pilot study aimed to investigate the association between prolonged fasting and pre-induction glycemic instability. We conducted a prospective, observational pilot study at a tertiary referral hospital, enrolling 30 non-diabetic adult patients (ASA I-E/II-E) undergoing emergency surgery. The primary exposure was preoperative fasting duration, analyzed as both a continuous variable and a dichotomized category (≤8 vs. >8 hours). The primary outcomes were pre-induction blood glucose levels, analyzed continuously and with two categorical thresholds: glycemic instability (<85 mg/dL) and clinically significant hypoglycemia (<70 mg/dL). Associations were assessed using Chi-Square tests and Spearman's rank correlation. A majority of patients (60%) fasted for >8 hours. A strong negative correlation was found between the duration of fasting and pre-induction blood glucose levels (Spearman's ρ = -0.78, p<0.001). Using the <85 mg/dL threshold, 83.3% of patients fasting >8 hours exhibited glycemic instability, compared to 25% of those fasting ≤8 hours (p=0.002). Using the standard <70 mg/dL threshold, 55.6% of patients fasting >8 hours developed clinically significant hypoglycemia, compared to 8.3% of those fasting ≤8 hours (p=0.011). In conclusion, this pilot study provides a strong preliminary signal that prolonged preoperative fasting is significantly associated with a decline in blood glucose and an increased incidence of both glycemic instability and clinically significant hypoglycemia in non-diabetic emergency surgical patients. These findings challenge the assumption of metabolic security in this population and underscore the urgent need for larger, definitive studies. Routine pre-induction glucose monitoring should be strongly considered as a potential safety standard in this vulnerable group.

Beyond Viral Load: The Clinical and Endocrine Profile of ART-Naive HIV-Infected Men with Hypogonadism, Opportunistic Infections, and Malnutrition

Yulianto Kusnadi — 2025-09-02

In patients with advanced human immunodeficiency virus (HIV), the clinical presentation often extends beyond immunodeficiency to a syndemic of interacting comorbidities. Male hypogonadism is a critical but often under-recognized endocrine dimension of this syndrome. This study aimed to characterize the clinical, metabolic, and endocrine profile of antiretroviral therapy (ART)-naive men to provide a comprehensive baseline understanding of this syndemic state before therapeutic intervention. An analytical cross-sectional study was conducted from April to October 2024, enrolling 64 consecutively presenting ART-naive men with HIV at a tertiary hospital in Palembang, Indonesia. We performed a comprehensive assessment including WHO clinical staging, nutritional evaluation (BMI), and screening for comorbidities. Endocrine status was assessed by measuring total testosterone, Luteinizing Hormone (LH), and serum albumin, from which bioavailable testosterone was calculated using the Vermeulen formula. Bivariate correlations and comparative analyses were conducted to explore relationships between variables. The cohort presented with profound immunodeficiency (median CD4 count: 23.5 cells/µL) and advanced disease (92.2% in WHO Stage 3 or 4). A high burden of opportunistic infections (40.6% pulmonary tuberculosis) and malnutrition (48.4% underweight; median serum albumin: 3.25 g/dL) was observed. Based on total testosterone (<300 ng/dL), the prevalence of hypogonadism was 32.8%. However, analysis using the more physiologically relevant calculated bioavailable testosterone (<70 ng/dL) revealed a higher prevalence of 42.2%. Secondary (hypogonadotropic) hypogonadism was the overwhelmingly dominant etiology (28.1%). Bioavailable testosterone was significantly and positively correlated with both CD4 count (ρ=0.35, p=0.005) and BMI (ρ=0.41, p=0.001). In conclusion, ART-naive men presenting with advanced HIV in this setting are caught in a syndemic of immunodeficiency, infectious disease, malnutrition, and profound endocrine dysfunction. The high prevalence of secondary hypogonadism, strongly associated with the severity of immune collapse and poor nutritional status, highlights the HPG axis as a key casualty of systemic illness. These findings provide a compelling rationale for integrating routine hormonal and metabolic screening into the initial assessment of all men newly diagnosed with HIV.