Introduction

Kienbock’s disease, a relatively rare condition affecting the lunate bone in the wrist, presents significant challenges for both patients and surgeons. This progressive disorder is characterized by avascular necrosis (death of bone tissue due to insufficient blood supply) of the lunate, one of the eight small carpal bones that make up the wrist. Left untreated, the condition leads to wrist pain, diminished grip strength, limited motion, and eventually, debilitating arthritis.

This case study explores an advanced surgical approach – the vascularized bone graft – for managing a case of advanced Kienbock’s disease in a young patient. The procedure, performed at Burjeel Hospital in Abu Dhabi, demonstrates how microsurgical techniques can offer hope for patients with conditions previously considered difficult to treat effectively.

Understanding Kienbock’s Disease

Pathophysiology

Kienbock’s disease involves the progressive collapse of the lunate bone in the wrist due to compromised blood supply. This vascular disruption leads to bone necrosis, fragmentation, and eventual collapse, resulting in altered wrist mechanics, pain, and functional limitations.

The condition typically progresses through several stages:

• Stage I: Ischemia (reduced blood supply) without radiographic changes
• Stage II: Sclerosis (hardening) of the lunate visible on X-rays
• Stage III: Collapse and fragmentation of the lunate
  • Stage IIIA: Lunate collapse without scaphoid rotation
  • Stage IIIB: Lunate collapse with fixed scaphoid rotation
• Stage IV: Advanced collapse with degenerative changes throughout the wrist

Risk Factors

Several factors may contribute to the development of Kienbock’s disease:

• Anatomical variations: A shorter ulna relative to the radius (negative ulnar variance) may increase mechanical stress on the lunate
• Vascular anatomy: Variations in blood supply to the lunate can predispose to ischemia
• Trauma: History of wrist injury
• Systemic factors: Conditions affecting blood flow or coagulation
• Occupational factors: Activities involving repetitive wrist loading or vibration

Clinical Presentation

Patients with Kienbock’s disease typically present with:

• Wrist pain, particularly during activities
• Swelling and tenderness over the lunate area
• Limited range of motion
• Decreased grip strength
• In advanced stages, wrist instability and crepitus

Case Presentation

Patient Profile

A 31-year-old female presented with persistent pain in her left wrist of approximately one year’s duration. Her medical history included a traumatic injury to the left wrist one year prior, which was conservatively managed at another facility. Despite this management, she continued to experience persistent wrist pain, leading to her referral to Burjeel Hospital with a diagnosis of Kienbock’s disease.

Clinical Findings

On examination, the patient exhibited:

• Diffuse swelling around the left wrist
• Tenderness throughout the wrist, particularly over the lunate area
• Painful and restricted range of motion

Diagnostic Imaging

The radiographic assessment revealed:

• X-rays showing sclerosis of the lunate
• Loss of height of the lunate bone
• Fragmentation of the lunate structure

Magnetic Resonance Imaging (MRI) confirmed these findings and supported the diagnosis of advanced Kienbock’s disease, classified as Stage 3A according to Lichtman’s classification system. At this stage, the lunate had undergone collapse but without scaphoid rotation or carpal instability.

Treatment Approach

Surgical Options Assessment

For Stage 3A Kienbock’s disease, several surgical options exist:

1. Proximal Row Carpectomy: Removal of the scaphoid, lunate, and triquetrum bones
2. Limited Wrist Fusion: Joining certain carpal bones to redistribute forces
3. Revascularization Procedures: Techniques to restore blood supply to the lunate
4. Total Wrist Arthrodesis: Complete fusion of the wrist in severe cases
5. Denervation Procedures: To reduce pain while maintaining some motion

After thorough discussion with the patient regarding the risks, benefits, and long-term outcomes of each approach, a revascularization procedure was selected. This decision was based on the patient’s young age, the stage of disease, and the desire to preserve wrist function.

Surgical Technique

The patient underwent a specialized procedure combining several techniques:

1. 4+5 Extensor Compartmental Artery-Based Vascularized Bone Graft: This microsurgical procedure involves harvesting bone with its blood supply from the dorsal distal radius and transferring it to the lunate to provide both structural support and blood supply.
2. Posterior Interosseous Nerve (PIN) Neurectomy: Division of a nerve branch to reduce pain signals from the affected area.
3. Scapho-capitate Pinning: Temporary stabilization of these carpal bones with Kirschner wires (K-wires) to maintain proper alignment during healing.

Technical Challenges

The surgical team faced several challenges during this procedure:

1. Microsurgical Complexity: The harvesting of bone with its minute blood vessel supply requires advanced microsurgical expertise and specialized equipment.
2. Anatomical Variations: The 4+5 extensor compartmental artery is small and can have variable anatomy between patients.
3. Vascular Pedicle Preservation: Maintaining the viability of the blood vessels during transfer is critical and technically demanding.
4. Recipient Site Preparation: Creating an appropriate cavity in the necrotic lunate while preserving its outer shell.

Surgical Implementation

The procedure was performed under general anesthesia with a tourniquet applied to the upper arm. A detailed step-by-step approach was followed:

1. A dorsal approach to the wrist was utilized to expose both the 4th and 5th extensor compartments and the lunate.
2. The Posterior Interosseous Nerve was identified and neurectomy performed to provide pain relief.
3. The lunate was accessed and a cavity created after curettage of the necrotic bone while preserving its outer shell.
4. A vascularized bone graft based on the 4+5 extensor compartmental artery was harvested from the distal radius, with careful preservation of its vascular pedicle.
5. The vascularized bone graft was transferred and inserted into the prepared cavity in the lunate.
6. Temporary scapho-capitate pinning was performed with K-wires to provide stability during the healing process.
7. Meticulous closure was performed in layers.

Intraoperative photographs documented key steps of the procedure, including:

• PIN nerve identification before neurectomy
• Preparation of the cavity in the lunate after curettage
• Harvesting of the bone graft with its vascular pedicle
• Insertion of the vascularized bone graft into the lunate cavity

Post-Operative Course

The perioperative period was uneventful, with the patient discharged on the same day following appropriate pain management and wound care instructions. A below-elbow splint was applied to protect the wrist during the initial healing phase.

Post-operative radiographs demonstrated:

• Restoration of lunate height
• Proper positioning of the scapho-capitate K-wires
• Maintained carpal alignment

Clinical Outcome

At the six-month follow-up assessment, the patient reported significant improvement:

• Pain-free wrist
• Ability to perform daily activities without discomfort
• Progressive improvement in range of motion
• Return to normal hand function for most activities

Radiographic evaluation at six months showed signs of lunate revascularization with maintenance of carpal height and alignment.

Discussion

Significance of Vascularized Bone Grafting

Vascularized bone grafting represents an important advancement in the management of Kienbock’s disease, particularly for younger patients in whom preservation of wrist mechanics is crucial. The technique offers several advantages over conventional approaches:

1. Biological Reconstruction: Provides both structural support and blood supply to the necrotic lunate.
2. Potential Disease Modification: May halt the progression of avascular necrosis and prevent further collapse.
3. Preservation of Natural Anatomy: Maintains normal carpal relationships and biomechanics.
4. Avoidance of Salvage Procedures: May prevent the need for more drastic surgeries like proximal row carpectomy or wrist fusion.

Contraindications and Limitations

Despite its benefits, vascularized bone grafting is not suitable for all patients with Kienbock’s disease:

• Advanced Stages (Stage IV): When significant degenerative changes are present throughout the wrist
• Technical Demands: Requires microsurgical expertise and equipment
• Recovery Period: Longer rehabilitation compared to some alternative procedures
• Limited Evidence Base: Long-term outcomes still being established through research

Comparison with Alternative Treatments

For Stage 3A Kienbock’s disease, the main treatment alternatives include:

1. Proximal Row Carpectomy (PRC):
   • Advantages: Reliable pain relief, maintained motion
   • Disadvantages: Loss of carpal height, potential grip weakness, non-reversible
2. Limited Wrist Fusion:
   • Advantages: Stable construct, pain relief
   • Disadvantages: Reduced wrist motion, potential non-union
3. Vascularized Bone Graft:
   • Advantages: Preserves native anatomy, biological solution, reversible
   • Disadvantages: Technical complexity, variable outcomes

The selection of vascularized bone grafting in this case reflects a treatment philosophy prioritizing anatomical preservation and function, particularly appropriate for a young patient.

Clinical Implications

This case demonstrates several important points for practitioners:

1. Early Diagnosis: Recognition of Kienbock’s disease before advanced collapse is crucial for preserving treatment options.
2. Stage-Appropriate Treatment: Surgical approach should be tailored to the disease stage, patient age, and functional demands.
3. Microsurgical Advances: Techniques previously considered experimental are increasingly becoming viable options with experienced surgical teams.
4. Team Approach: Collaboration between hand surgeons, radiologists, and rehabilitation specialists optimizes outcomes.

Conclusion

Vascularized bone grafting represents an advanced approach for managing Kienbock’s disease that aims to restore both structure and blood supply to the affected lunate. This case illustrates the successful application of a 4+5 extensor compartmental artery-based vascularized bone graft in a young patient with Stage 3A disease, resulting in pain relief and return to function without resorting to more radical salvage procedures.

The complexity of the procedure necessitates specialized training and expertise, but in appropriate cases and experienced hands, it offers the potential to halt disease progression while preserving wrist anatomy and function. As microsurgical techniques continue to evolve, such reconstructive approaches may become increasingly important in the treatment algorithm for Kienbock’s disease and other conditions characterized by avascular necrosis.

This case adds to the growing body of evidence supporting the role of vascularized bone grafting in the management of selected cases of advanced Kienbock’s disease, offering hope for improved outcomes in this challenging condition.

Experts

Introduction

Complex Regional Pain Syndrome (CRPS) represents one of the most challenging pain conditions to manage effectively. Characterized by intense pain disproportionate to the inciting event, along with autonomic, sensory, and motor abnormalities, CRPS can be severely debilitating for patients. This case study explores the successful implementation of lumbar sympathetic block as an interventional pain management technique for CRPS following knee surgery, highlighting its efficacy in providing relief when conservative treatments fail.

Understanding Lumbar Sympathetic Block

A lumbar sympathetic block is a minimally invasive pain management procedure designed to disrupt the nerve supply from the sympathetic chain to the lower extremities. This intervention targets the sympathetic nervous system, which plays a critical role in pain perception and transmission, particularly in conditions with sympathetically maintained pain components.

Anatomical Considerations

The lumbar sympathetic ganglia form a chain of nerve cell bodies that run parallel to the vertebral column in the retroperitoneal space. The densest portion of these ganglia is typically found at the L2 and L3 vertebral levels, making these the optimal targets for intervention. The procedure is most commonly performed at the L3 level, providing effective disruption of sympathetic innervation to the lower limbs.

Procedural Approach

The lumbar sympathetic block procedure typically follows a two-step approach:

1. Diagnostic Block: Initially, a diagnostic block using only local anesthetic is administered to assess the patient’s response. This serves as a predictor of success for more definitive interventions.
2. Therapeutic Intervention: If optimal relief is achieved with the diagnostic block, radiofrequency ablation is subsequently performed at the L2, L3, and L4 levels to provide longer-lasting relief.

Primary Indications

Lumbar sympathetic blocks are primarily indicated for several painful conditions affecting the lower extremities:

• Complex Regional Pain Syndrome (CRPS)
• Phantom limb pain
• Hyperhidrosis (excessive sweating)
• Vascular insufficiencies
• Herpes zoster affecting the lower limbs

Understanding Complex Regional Pain Syndrome

CRPS is a disabling pain condition that typically affects limbs following an injury or surgery. The condition manifests with pain that is disproportionate to the inciting event and is associated with abnormal sensory, motor, sudomotor, vasomotor, and trophic findings.

Classification

CRPS is classified into two types:

1. CRPS Type 1 (Reflex Sympathetic Dystrophy): Occurs when there is no obvious nerve injury. This type primarily involves nociceptive pain mechanisms.
2. CRPS Type 2 (Causalgia): Occurs when there is an obvious nerve injury. This type involves significant neurogenic components of pain.

In clinical practice, these conditions often present with overlapping symptoms, making clear distinction challenging in some cases.

Clinical Presentation

Patients with CRPS typically present with a constellation of symptoms:

• Severe, burning pain
• Paresthesia (abnormal sensations)
• Edema (swelling)
• Limited range of motion
• Temperature changes in the affected limb
• Skin changes, including color and texture alterations
• Hyperalgesia (increased sensitivity to pain)
• Allodynia (pain from stimuli that are not normally painful)

Pathophysiology

While the definitive pathophysiology of CRPS remains incompletely understood, current evidence suggests it is a disorder of the immune system that affects the nervous system. The condition involves complex interactions between:

• Peripheral and central sensitization
• Neurogenic inflammation
• Autonomic dysregulation
• Immune system activation
• Psychological factors

Diagnosis

Diagnosis of CRPS is primarily clinical, based on established criteria such as the Budapest Criteria, which include:

1. Continuing pain disproportionate to any inciting event
2. At least one symptom in each of the four categories: sensory, vasomotor, sudomotor/edema, and motor/trophic
3. At least one sign at time of evaluation in two or more categories
4. No other diagnosis better explaining the signs and symptoms

Case Study: CRPS Following Knee Surgery

Patient Profile

A young male patient was referred to the pain management service from the orthopedic department at Burjeel Day Surgery Center, Al Reem Island. The patient had undergone right knee surgery three months prior and subsequently developed symptoms consistent with CRPS.

Clinical Presentation

Upon evaluation, the patient presented with:

• High skin temperature in the affected limb
• Severe pain (VAS 7/10)
• Mild swelling
• Hypoesthesia (decreased sensation) along the lateral limb
• Allodynia (pain from non-painful stimuli) along the anterior aspect of the limb
• Limited range of motion

Previous Management

The patient had previously received conservative management, including:

• Analgesic medications
• Physical therapy
• Activity modification

Unfortunately, these conventional approaches proved ineffective in providing adequate pain relief or functional improvement.

Intervention Plan

After comprehensive evaluation and proper counseling regarding expectations and potential outcomes, a management plan was formulated:

1. Perform a diagnostic lumbar sympathetic block at the right L3 level to assess response
2. If favorable response achieved, proceed with radiofrequency ablation for longer-term relief
3. Continue multimodal pain management alongside interventional approaches

Procedure Details

Under appropriate monitoring and sterile conditions, a lumbar sympathetic diagnostic block was performed at the right L3 level. Local anesthetic was precisely delivered to the sympathetic chain using fluoroscopic guidance to ensure accurate needle placement.

Outcomes

The results of the intervention were impressive:

• The patient reported being pain-free immediately following the procedure
• Significant improvement in range of motion was observed
• Reduced allodynia in the affected limb
• Normalization of skin temperature

Based on this positive response to the diagnostic block, the patient was scheduled for radiofrequency ablation to provide more sustained relief. The treatment plan continues at Burjeel Day Surgery Center, Al Reem Island.

Discussion

Efficacy of Lumbar Sympathetic Block in CRPS

This case illustrates the potential efficacy of lumbar sympathetic blockade in managing CRPS of the lower extremity. While CRPS is notoriously difficult to treat and often has no definitive cure, timely interventional procedures can:

1. Slow disease progression
2. Provide crucial pain relief
3. Improve function and quality of life
4. Help patients cope with daily activities
5. Potentially prevent long-term disability

Timing of Intervention

Early intervention is critical in CRPS management. Research suggests that outcomes are generally better when appropriate treatments are initiated within 3-6 months of symptom onset. In this case, the patient was referred approximately three months after surgery, allowing for timely intervention before the condition became more refractory to treatment.

Limitations of Treatment

It’s important to acknowledge certain limitations in CRPS management:

• CRPS typically has no definitive cure
• Treatment responses can be variable
• Multiple interventions may be necessary
• A multimodal approach is often required

Advantages of Lumbar Sympathetic Block

As demonstrated in this case, lumbar sympathetic blockade offers several advantages:

1. Minimally Invasive: The procedure requires only needle insertion rather than open surgery
2. Diagnostic and Therapeutic: Can serve both to confirm sympathetically maintained pain and provide relief
3. Targeted Approach: Directly addresses the sympathetic component of pain
4. Low Complication Rate: When performed by experienced practitioners
5. Option for Progression: Can progress from diagnostic blocks to more permanent interventions like radiofrequency ablation

Clinical Implications

This case highlights several important clinical implications for pain practitioners:

1. Early Recognition: Identifying CRPS early improves outcomes. Healthcare providers should maintain a high index of suspicion for CRPS in patients with disproportionate pain following surgery or injury.
2. Prompt Referral: Timely referral to pain specialists when conservative measures fail can prevent progression to chronic, refractory pain states.
3. Stepped Approach: A graduated approach from diagnostic blocks to more definitive interventions allows for personalized treatment planning.
4. Multimodal Strategy: Even with successful interventional procedures, a comprehensive approach including physical therapy, psychological support, and appropriate medications optimizes outcomes.

Conclusion

Lumbar sympathetic block represents a safe and effective procedure for alleviating pain in patients with CRPS who are refractory to medical management. This case demonstrates the potential for significant improvement in pain and function following appropriate interventional management.

While CRPS remains a challenging condition to treat, a timely, multimodal approach that includes targeted interventions like lumbar sympathetic blockade can significantly improve patient outcomes and quality of life. This case emphasizes the importance of early diagnosis, prompt referral to pain specialists, and individualized treatment planning in the management of complex pain conditions.

For patients suffering from CRPS of the lower extremities who have not responded to conservative management, lumbar sympathetic block should be considered as part of a comprehensive pain management strategy.

Experts

Introduction

Infective endocarditis is a serious infection of the endocardial surface of the heart, often affecting one or more heart valves. When complicated by septic shock, it presents a significant clinical challenge with high mortality rates, requiring prompt medical intervention and potentially emergent surgical management. This case study details the successful management of a complex case of septic shock and endocarditis in a 42-year-old male patient, marking a significant milestone as the first cardiac surgery performed at Burjeel Specialty Hospital, Sharjah.

Patient Presentation

A 42-year-old Filipino male presented to a non-Burjeel healthcare facility on April 4, 2024, with complaints of sudden-onset breathing difficulty that began at approximately 10:30 PM that same evening. Upon arrival at the emergency department, the patient was in a gasping state, unresponsive, and exhibiting concerning symptoms of desaturation and hypotension.

Initial Emergency Management

The severity of the patient’s condition necessitated immediate intervention. The emergency team promptly:

• Initiated endotracheal intubation to secure the airway
• Established inotropic support to stabilize blood pressure
• Began diagnostic workup to identify the underlying cause

Diagnostic Findings

The initial diagnostic evaluation resulted in a diagnosis of:

• Septic shock
• Cardiogenic shock
• Multi-organ failure

Further history revealed that the patient had been experiencing:

• Intermittent fever for three months
• Significant weight loss
• Known thyroid disease with no surgical history

Due to bed unavailability at the initial facility, the patient was transferred to Medeor Hospital the following day. There, additional diagnostic tests were performed.

Key Laboratory Findings

Laboratory tests demonstrated:

• Elevated white blood cell count
• Markedly elevated C-reactive protein (CRP)
• High procalcitonin levels, strongly suggestive of bacterial infection

Imaging and Microbiological Results

• 2D Echocardiography: Revealed large vegetation on the mitral anterior leaflet with severe mitral regurgitation
• Blood Cultures: Identified Streptococcus species from samples taken at the non-Burjeel facility

Comprehensive Diagnosis

Based on the clinical presentation and diagnostic findings, the patient was diagnosed with:

1. Rheumatic Heart Disease
2. Severe Mitral Regurgitation
3. Infective Endocarditis
4. Severe Pulmonary Arterial Hypertension (PAH)
5. Acute Kidney Injury (AKI)

Treatment Course

Initial Medical Management

The patient showed a positive response to antimicrobial therapy with:

• Vancomycin
• Linezolid

Within two weeks of initiating antibiotic therapy, the patient’s CRP levels normalized, indicating effective control of the infection. He was subsequently discharged home on oral Linezolid tablets.

Surgical Planning

Following stabilization and initial treatment of the acute infection, the patient was scheduled for mitral valve replacement at Burjeel Specialty Hospital, Sharjah. This procedure would represent a significant milestone as the first cardiac surgery to be performed at this facility.

Surgical Intervention

Procedure Details

The surgical team performed:

1. Mitral valve replacement using a 31 mm Carbomedics mechanical valve
2. Excision of vegetation from the aortic valve
3. Repair of the aortic valve, where small vegetation was identified on the non-coronary cusps

Surgical Team

The landmark procedure was performed by an expert team comprising:

• Dr. Dinesh Sadasival, Consultant Cardiothoracic Surgeon
• Dr. Tarig Ali, HOD, Cardiothoracic Surgeon
• Dr. Y. A. Nazer, Consultant Cardiac Surgery
• Dr. Arun Vijaykumar, Cardiac Anesthesia
• Dr. Sival Pillai, HOD, Cardiac Anesthesia

Discussion

This case highlights several important clinical considerations in the management of infective endocarditis complicated by septic shock:

Diagnostic Challenges

Infective endocarditis can present with varied and nonspecific symptoms, making early diagnosis challenging. In this case, the patient had experienced prolonged fever for three months before presenting in extremis with respiratory distress. This underscores the importance of considering endocarditis in patients with:

• Unexplained, persistent fever
• Significant weight loss
• New cardiac murmurs
• Predisposing factors such as rheumatic heart disease

Timing of Surgical Intervention

The timing of surgical intervention in infective endocarditis requires careful consideration. Key factors include:

1. Hemodynamic stability: In this case, initial stabilization with medical therapy was necessary before proceeding to surgery.
2. Control of infection: The two-week course of antibiotics resulting in normalization of inflammatory markers indicated adequate control of the acute infection.
3. Prevention of complications: Surgery was planned to prevent further complications such as embolization of vegetation, progressive valve destruction, and persistent heart failure.

Choice of Prosthetic Valve

The decision to use a mechanical valve (31 mm Carbomedics) in this 42-year-old patient aligns with current guidelines that often favor mechanical valves in younger patients who can tolerate long-term anticoagulation. Factors influencing this decision typically include:

• Patient age
• Anticoagulation compliance
• Risk of reinfection
• Hemodynamic performance of the valve

Management of Multi-Valve Involvement

This case also demonstrates the surgical approach to multi-valve involvement in endocarditis. While the mitral valve required replacement due to severe damage, the aortic valve had only small vegetation on the non-coronary cusps, allowing for successful repair rather than replacement. This valve-sparing approach offers several advantages:

• Avoids the need for a second prosthetic valve
• Reduces the risk of prosthetic valve endocarditis
• Preserves native valve hemodynamics
• Potentially reduces the intensity of required anticoagulation

Clinical Significance

This case holds particular significance as the first cardiac surgery performed at Burjeel Specialty Hospital, Sharjah. It demonstrates:

1. Successful multidisciplinary collaboration between emergency medicine, infectious disease, cardiology, and cardiac surgery.
2. Effective management of a life-threatening condition through appropriate medical stabilization followed by definitive surgical intervention.
3. Expansion of advanced cardiac surgical capabilities to Burjeel Specialty Hospital, Sharjah, enhancing access to specialized cardiac care in the region.

Conclusion

This landmark case of successful management of septic shock and infective endocarditis demonstrates the importance of prompt diagnosis, appropriate antimicrobial therapy, and timely surgical intervention. The successful outcome underscores the value of a multidisciplinary approach to complex cardiac conditions and highlights the expanding capabilities of cardiac surgical centers in the region.

The case serves as an important reminder of the need for high clinical suspicion for infective endocarditis in patients with prolonged fever and weight loss, particularly in those with underlying structural heart disease. Early diagnosis and appropriate management remain critical in reducing morbidity and mortality in this challenging clinical entity.

Experts

Introduction

Pancreatic surgery has historically been associated with significant morbidity and mortality. However, advancements in robotic surgical technology have revolutionized the approach to complex pancreatic procedures. This case study highlights the successful implementation of a totally robotic spleen-sparing distal pancreatectomy for a patient with multiple pancreatic neuroendocrine tumors, demonstrating the precision and advantages of robotic-assisted surgery in preserving critical organs while effectively treating pathology.

Patient Presentation and History

A 58-year-old male with multiple comorbidities including type 2 diabetes, hypertension, and hyperlipidemia initially presented with back pain in 2019. Despite not exhibiting classic symptoms typically associated with pancreatic tumors (such as jaundice, weight loss, or digestive difficulties), diagnostic imaging revealed concerning findings that warranted further investigation.

The patient’s initial workup included:

• MRI and MRCP (Magnetic Resonance Cholangiopancreatography) scans that detected a non-functioning pancreatic tumor
• Identification of a large cystic lesion in the liver
• Institution of regular imaging surveillance due to the asymptomatic nature of the findings

Comprehensive Diagnostic Evaluation

In March 2024, following a period of watchful waiting with regular imaging follow-ups, the patient underwent a comprehensive diagnostic evaluation to better characterize the lesions and determine appropriate management.

Advanced Imaging and Tissue Sampling

1. Endoscopic Ultrasound (EUS)
   • Revealed a 3.4 cm cystic lesion in the pancreatic body and tail region
   • Identified a concurrent liver lesion in the right lobe
   • Facilitated fine needle aspiration (FNA) biopsies of both lesions
2. Histopathological Analysis
   • Pancreatic lesion: Confirmed a well-differentiated Grade 1 neuroendocrine tumor
   • Liver lesion: Showed evidence of steatohepatitis without malignancy
3. CT Scan of Abdomen and Pelvis
   • Documented progression with multiple pancreatic lesions:
     • 3.3 × 3.3 cm lesion in the mid-body
     • 10 mm lesion in the tail
     • 9 mm lesion in the proximal body
   • Revealed a 4 × 3 cm lobulated cystic lesion in segment 6 of the liver
4. DOTA PET Scan
   • Demonstrated somatostatin receptor-expressing lesions in the pancreas
   • Identified additional satellite lesions
   • Provided functional characterization of the tumors

Multidisciplinary Approach to Treatment Planning

Despite negative tumor markers and normal serum Chromogranin-A levels (a biomarker typically elevated in neuroendocrine tumors), a multidisciplinary team (MDT) recommended surgical intervention based on the imaging findings and histological confirmation. The patient was specifically referred to the Department of Gastrointestinal Surgery for consideration of robotic surgery—an approach that would allow for precise tumor removal while potentially preserving the spleen.

Surgical Approach and Technical Considerations

Following thorough preoperative counseling and evaluation, the surgical team proceeded with a totally robotic spleen-sparing distal pancreatectomy. This approach offered several key advantages:

1. Enhanced Visualization: The robotic system provided magnified, high-definition 3D visualization of the surgical field, essential for identifying and preserving the splenic vessels.
2. Intraoperative Ultrasonography: Used to precisely locate the tumors and guide the extent of resection, ensuring complete removal of all lesions while preserving maximum healthy pancreatic tissue.
3. Precision Dissection: The robotic instruments allowed for meticulous dissection around critical vascular structures, particularly important in separating the pancreas from the splenic vessels.
4. Minimal Blood Loss: The procedure was completed with less than 100 mL of blood loss, significantly lower than traditional open approaches.
5. Efficient Operative Time: Despite the complexity of the procedure, the operation was completed in 5 hours.

Surgical Technique: Preserving the Spleen While Removing Diseased Pancreas

The spleen-sparing technique employed in this case deserves special attention. In traditional distal pancreatectomy, the spleen is often removed along with the distal pancreas because of their shared blood supply. However, preserving the spleen offers significant immunological benefits, particularly important for long-term health and prevention of post-splenectomy infections.

The robotic approach facilitated:

1. Warshaw Technique Modification: Preservation of the splenic vessels while completely mobilizing the pancreas from surrounding structures.
2. Selective Vascular Control: Precise ligation of small pancreatic vessels without compromising the main splenic vasculature.
3. Real-time Assessment: Continuous evaluation of splenic perfusion throughout the procedure.

Postoperative Course and Outcomes

The patient experienced an exceptionally smooth recovery:

• Minimal postoperative pain, effectively managed with standard analgesics
• Resumed oral intake on the first postoperative day
• Normalized bowel function by the second postoperative day
• Discharged home on the third postoperative day
• No evidence of pancreatic fistula or other complications
• Maintained excellent follow-up status with preserved glycemic control

Technical Challenges and Considerations

The case presented several technical challenges that highlight why robotic approaches offer advantages in complex pancreatic surgery:

1. Patient Factors: The patient’s obesity represented a technical challenge that was mitigated by the enhanced dexterity and visualization of the robotic system.
2. Multiple Pancreatic Neoplasms: The presence of several tumors throughout the distal pancreas required precise localization and comprehensive resection.
3. Splenic Preservation: Maintaining adequate blood supply to the spleen while completely removing the distal pancreas was technically demanding, particularly due to the intricate vascular anatomy behind the pancreas.

Discussion: Advantages of Robotic Approach in Pancreatic Surgery

This case exemplifies the unique advantages of robotic-assisted surgery for complex pancreatic procedures:

Enhanced Technical Capabilities

The da Vinci Robotic Surgical System offers:

• Superior Visualization: High-definition 3D imaging allows for better appreciation of fine tissue planes.
• Increased Dexterity: The robotic “wrists” enable 540-degree rotation and movement in tight spaces, critical when working around major vessels.
• Tremor Filtration: Elimination of natural hand tremor enhances precision during delicate dissection.
• Improved Ergonomics: The surgeon’s improved positioning reduces fatigue during lengthy procedures.

Clinical Benefits

Patients undergoing robotic pancreatic surgery often experience:

• Reduced blood loss compared to open procedures
• Lower conversion rates to open surgery compared to conventional laparoscopy
• Shorter hospital stays
• Faster return to normal activities
• Improved cosmetic outcomes due to smaller incisions

Organ Preservation Benefits

The spleen plays critical roles in:

• Immune function, particularly against encapsulated bacteria
• Blood filtration and recycling of red blood cells
• Serving as a blood reservoir

Preserving this organ provides long-term benefits to the patient, including reduced risk of overwhelming post-splenectomy infection (OPSI) and maintained hematological function.

Conclusion

This case demonstrates the successful application of robotic technology in performing a complex spleen-sparing distal pancreatectomy. The robotic approach facilitated precise tumor removal while preserving the immunologically important spleen, despite the technical challenges posed by the patient’s body habitus and the presence of multiple neoplasms.

The excellent postoperative outcome, characterized by minimal blood loss, short hospital stay, and rapid recovery, underscores the potential benefits of robotic surgery in selected patients with pancreatic pathology. As this technology continues to evolve and surgical teams gain more experience, robotic approaches may become increasingly important in the management of complex pancreatic diseases.

This case, managed by Dr. Ali Iyoob Valiyaveettil, Consultant & Head of Gastrointestinal Surgery, serves as an excellent example of how cutting-edge robotic technology can be leveraged to achieve optimal surgical outcomes while prioritizing organ preservation and minimizing surgical trauma.

Experts

Introduction

Intussusception, a condition where one segment of the intestine telescopes into an adjacent segment, is predominantly seen in children but rarely occurs in adults. When it does appear in adults, it presents unique diagnostic and treatment challenges that require careful consideration. This case study examines an unusual presentation of ileocolic intussusception in a middle-aged patient and highlights the importance of prompt surgical intervention.

Patient Presentation

A previously healthy 56-year-old woman presented to the emergency department with a two-day history of concerning gastrointestinal symptoms. Her chief complaints included:

• Lower abdominal pain that had progressively worsened
• Multiple episodes of vomiting
• Constipation with no bowel movements for two days

These symptoms had developed suddenly with no apparent trigger, leading to her seeking medical attention after conservative measures at home failed to provide relief.

Diagnostic Journey

Initial Assessment

Upon presentation, the patient appeared uncomfortable but had stable vital signs. Physical examination revealed tenderness in the lower right quadrant of the abdomen with mild distension. The initial clinical impression suggested a possible bowel obstruction, necessitating further investigation.

Laboratory Findings

Blood work demonstrated a mild elevation of inflammatory markers:

• Slightly elevated white blood cell count
• Moderately increased C-reactive protein levels
• Other laboratory parameters remained within normal ranges

Imaging Studies

A computed tomography (CT) scan of the abdomen and pelvis proved crucial for diagnosis, revealing:

• Classic “target sign” indicating ileocecal intussusception
• Proximally dilated small bowel loops suggestive of partial obstruction
• No evidence of perforation or ischemia

Based on these findings, a diagnosis of ileocolic intussusception was established, and the patient was prepared for urgent surgical intervention.

Surgical Management

Given the patient’s age and the rarity of intussusception in adults, the surgical team approached the case with careful consideration that the condition likely had a pathological lead point.

Operative Approach

The patient underwent laparotomy, which confirmed the preoperative diagnosis of ileocolic intussusception. The surgical procedure involved:

• Careful manual reduction of the intussusception
• Identification of a large, smooth-surfaced, rubbery ileal polyp as the lead point
• Ileocecal resection with primary ileocolic anastomosis

The decision for bowel resection rather than simple reduction was based on the understanding that adult intussusception typically has a pathological lead point that requires removal.

Histopathological Findings

Examination of the resected specimen confirmed:

• A benign ileal polyp measuring approximately 3.5 cm in diameter
• No evidence of dysplasia or malignancy
• Normal surrounding mucosa

These findings validated the surgical approach and provided reassurance regarding the patient’s prognosis.

Post-Operative Course

The patient’s recovery proceeded smoothly with:

• Gradual return of bowel function on the second postoperative day
• Successful transition from intravenous to oral nutrition
• Adequate pain control with standard analgesics
• No postoperative complications

She was discharged home on the fourth postoperative day with appropriate follow-up arrangements and dietary guidance.

Discussion

Uniqueness of Adult Intussusception

This case highlights several important aspects of adult intussusception:

1. Epidemiological rarity: While common in children, intussusception accounts for only 1-5% of all cases of intestinal obstruction in adults.
2. Etiology differences: Unlike pediatric cases that are usually idiopathic, adult intussusception nearly always has a pathological lead point, which in this case was a benign ileal polyp.
3. Surgical management: The standard approach in adults is resection rather than reduction alone due to the high likelihood of pathological lead points and potential for malignancy.

Diagnostic Challenges

Diagnosing adult intussusception can be challenging due to:

• Non-specific symptoms that can mimic other abdominal conditions
• Chronic, intermittent presentations in some cases
• Varying clinical presentations depending on location and duration

In this case, the acute presentation and comprehensive imaging studies facilitated timely diagnosis and intervention.

Surgical Considerations

The surgical management of this case illustrates important decision-making factors:

• Assessment of the lead point’s nature during surgery
• Determining appropriate extent of resection
• Balancing oncological principles with preservation of bowel length

The confirmation of a benign pathology justified the limited resection performed.

Conclusion

This case demonstrates the successful management of adult ileocolic intussusception caused by a benign ileal polyp. Despite being uncommon in adults, intussusception should remain in the differential diagnosis for patients presenting with bowel obstruction symptoms. The case underscores the importance of prompt surgical intervention and careful pathological assessment in adult intussusception cases.

The patient’s smooth recovery and uncomplicated postoperative course highlight the effectiveness of timely surgical management. This case, managed by Dr. Talat Shaban Abdullah Al-Shaban, Consultant General Surgeon, represents a textbook example of the proper approach to adult intussusception.

Key Learning Points

• Adult intussusception is rare but should be considered in the differential diagnosis for bowel obstruction.
• CT scanning is the imaging modality of choice for diagnosis.
• Unlike in children, adult intussusception typically requires surgical resection rather than simple reduction.
• Identifying the nature of the lead point is crucial for determining the extent of surgical resection.
• Most adult intussusceptions have an identifiable lead point, which can range from benign polyps to malignant lesions.

Experts

A novel technique combining laparoscopic surgery with on-table flexible ureteroscopy has been successfully implemented at Lifecare Hospital, a Burjeel Holdings facility, offering new hope for patients with complex ureteric strictures.

Complex Case Presentation

A 41-year-old male presented with persistent left flank pain and recurrent urinary tract infections over a one-year period. His medical history revealed a previous ureteroscopic intervention for a left mid-ureteric stricture that had developed secondary to an impacted ureteric stone. The initial management included balloon dilation and stenting, but despite these standard interventions, the patient experienced symptom recurrence indicative of stricture reformation.

Diagnostic ultrasound demonstrated left-sided hydronephrosis, while previous intraoperative retrograde ureterogram had confirmed a mid-ureteric stricture approximately 2 cm in length with proximal ureteral dilation. Laboratory tests showed normal renal function with no active infection at the time of presentation.

Innovative Surgical Approach

The urology team at Lifecare Hospital, led by Dr. Althaf Hussain and Dr. Anand Srivastava, implemented a novel combined approach that integrated both laparoscopic and endourological techniques in the same procedure.

Traditional management of recurrent ureteric strictures typically involves either:

1. Endoscopic management (balloon dilation, endoureterotomy)
2. Open surgical reconstruction (ureteroureterostomy, ureteral reimplantation)
3. Standard laparoscopic repair

The innovative aspect of this case was the simultaneous use of flexible ureteroscopy during the laparoscopic procedure, providing enhanced visualization and precision that neither technique alone could achieve.

Technical Advantages

This combined approach offers several significant benefits over conventional methods:

Enhanced Visualization: The flexible ureteroscope provides real-time endoluminal imaging during laparoscopic dissection, allowing for precise identification of the stricture’s proximal and distal extent. This dual visualization prevents inadvertent injury to healthy segments of the ureter.

Minimally Invasive: The laparoscopic approach minimizes surgical trauma compared to open surgery, while the addition of flexible ureteroscopy reduces the need for extensive ureteral mobilization and dissection.

Improved Technical Precision: The combined technique enables more accurate placement of sutures during reconstruction and immediate confirmation of ureteral patency following repair.

Reduced Morbidity: By minimizing dissection and handling of the ureter, this approach potentially reduces the risk of devascularization, which can lead to recurrent stricture formation.

Advancing Urological Care

“Recurrent ureteric strictures, particularly in the mid-ureter, present significant therapeutic challenges,” notes Dr. Hussain. “This novel approach represents a promising advancement in the management of complex strictures that have failed conventional treatment.”

The technique demonstrated at Lifecare Hospital merits further investigation and could potentially become a standard approach for managing similar cases, offering patients the benefits of minimally invasive surgery with enhanced precision and potentially improved long-term outcomes.

This case exemplifies the commitment to surgical innovation within the Burjeel Holdings network, where specialists continuously explore new approaches to address challenging clinical scenarios and improve patient outcomes.

Patients suffering from complex regional pain syndrome (CRPS) often experience debilitating symptoms that significantly impact their quality of life. At Burjeel Day Surgery Center, specialists are employing advanced interventional pain management techniques to provide relief for these challenging cases.

Understanding Complex Regional Pain Syndrome

CRPS is a disabling condition that typically affects limbs following an injury or surgery. The condition manifests through severe pain, swelling, limited range of motion, temperature changes, and skin discoloration. While the definitive pathology remains incompletely understood, current evidence suggests CRPS involves immune system disruption affecting the nervous system.

Dr. Shailendra Chauhan, Consultant Anesthesia and Pain Management at Burjeel Day Surgery Center, explains: “CRPS is categorized into two types: Type 1 (Reflex Sympathetic Dystrophy) when there is no obvious nerve injury, and Type 2 (Causalgia) when there is a clear nerve injury. Both types present with overlapping symptoms but differ in their underlying mechanisms.”

Diagnosis relies on clinical criteria such as the Budapest Criteria, which evaluates sensory, vasomotor, sudomotor/edema, and motor/trophic changes to establish the presence of CRPS.

Targeted Intervention

A lumbar sympathetic block is a minimally invasive pain procedure designed to disrupt nerve signals from the sympathetic chain to the lower extremities. This intervention is particularly valuable for various painful conditions, including CRPS, phantom limb pain, hyperhidrosis, vascular insufficiencies, and herpes zoster.

“The densest portion of the lumbar sympathetic ganglia is located at the L2 and L3 vertebral levels,” notes Dr. Chauhan. “For optimal results, we typically perform the initial diagnostic block at the L3 level using only local anesthetic. If significant relief is achieved, we proceed with radiofrequency ablation at L2, L3, and L4 levels for longer-lasting benefit.”

Case Study: Post-Surgical CRPS

A young male patient was referred from the orthopedic department after developing CRPS following right knee surgery three months prior. His presentation included:

• Elevated skin temperature around the knee
• Moderate to severe pain (VAS 7/10)
• Mild swelling
• Hypoesthesia (decreased sensation) along the lateral aspect of the limb
• Allodynia (pain from normally non-painful stimuli) along the anterior aspect

Conservative management had failed to provide adequate relief, prompting consideration of interventional techniques.

After thorough counseling and informed consent, the patient underwent a lumbar sympathetic diagnostic block at the right L3 level. The procedure was performed under fluoroscopic guidance to ensure precise needle placement.

Remarkable Results

Following the diagnostic block, the patient experienced immediate pain relief and demonstrated improved range of motion in the affected knee. This dramatic response confirmed the sympathetic nervous system’s involvement in his pain condition and established him as an excellent candidate for radiofrequency ablation.

The patient was subsequently scheduled for radiofrequency ablation, which involves creating controlled lesions to interrupt pain signals for a longer duration than temporary nerve blocks allow. This comprehensive treatment plan will continue at Burjeel Day Surgery Center, Al Reem.

“While CRPS typically doesn’t have a definitive cure, timely interventions like lumbar sympathetic blocks can significantly slow disease progression and provide crucial pain relief, helping patients maintain daily function and quality of life,” Dr. Chauhan emphasizes.

This case highlights the importance of a multidisciplinary approach to chronic pain conditions and the value of specialized interventional techniques in managing complex pain syndromes refractory to conventional medical management.

Experts

In a remarkable surgical achievement, specialists at Burjeel Hospital have successfully treated a rare vascular condition that affects only a tiny fraction of the population worldwide. The patient presented with debilitating symptoms that were successfully resolved through an innovative surgical approach.

Extremely Rare Diagnosis

A young male patient arrived at Burjeel Hospital with short-distance claudication – severe pain that occurred after walking only brief distances. This symptom significantly limited his mobility and quality of life, prompting a thorough diagnostic investigation.

CT angiogram and MRI examinations of the right knee revealed an unusual finding: cystic adventitial disease affecting the popliteal artery. This exceedingly rare vascular disorder involves cystic degeneration in the wall of an artery, most commonly occurring in the popliteal artery behind the knee.

“Since its first description in 1947, only about 300 cases have been reported worldwide,” explains Dr. Moatasiem Bukhari, Consultant Vascular Surgeon at Burjeel Hospital. “This makes it one of the rarest vascular conditions we encounter in clinical practice.”

Tissue biopsy confirmed the diagnosis, and the case was thoroughly reviewed in Burjeel’s Vascular Multidisciplinary Team meeting, where specialists concurred on the optimal approach to treatment.

Surgical Management Challenges

The consensus was to perform an open surgical procedure using a posterior approach to access the affected area. This challenging operation was further complicated by several factors:

1. The rarity of the condition, with minimal precedent cases for reference
2. Severe inflammatory changes affecting both the artery itself and surrounding tissues
3. The compact anatomical space of the popliteal fossa where the affected artery was located
4. This was the first such case to be treated within the Burjeel Holdings hospital network

The surgical team successfully performed an interposition graft procedure, using the patient’s own long saphenous vein from the same leg to create a bypass around the affected arterial segment. This approach preserves blood flow while eliminating the diseased portion of the vessel.

Excellent Patient Outcome

Following surgery, the patient remained in the hospital for five days for observation and recovery before being discharged in good health. The procedure restored normal blood flow to the lower extremity, alleviating the painful claudication symptoms and allowing the patient to resume normal daily activities.

This case exemplifies the specialized expertise available at Burjeel Hospital for treating even the most uncommon vascular conditions. The successful outcome resulted from meticulous diagnosis, careful surgical planning, and the precise execution of a complex vascular procedure.

The case underscores the importance of considering rare vascular disorders in the differential diagnosis of patients with atypical claudication symptoms, particularly in younger individuals without traditional risk factors for peripheral arterial disease.

Experts

A remarkable case of a forgotten double J stent retained for six years presented unique challenges for urologists at LLH Hospital, who successfully removed the heavily encrusted stent through a combination of innovative techniques.

Case Background

A 35-year-old female patient presented to LLH Hospital with right flank pain and burning during urination. Her medical history revealed that she had undergone ureteroscopy with double J stent placement six years prior while working outside the UAE. Due to various circumstances, the stent—which is typically removed after 4-6 weeks—had never been extracted.

“Double J stents are essential tools in urological practice, providing effective drainage from kidney to bladder in various conditions,” explains Dr. Jai Pal Paryani, Specialist Urologist at LLH Hospital. “However, when forgotten or neglected, these temporary devices can create serious complications including stone formation, infection, and renal impairment.”

Diagnostic Findings

Initial ultrasound and X-ray KUB (kidney, ureter, bladder) examinations revealed a heavily encrusted double J stent with a large bladder stone measuring approximately 6 cm. CT scan confirmed the findings, showing calculus deposits along the entire length of the stent, with particular concentration around the upper coil in the kidney.

Laboratory tests revealed slightly elevated creatinine levels and a urinary tract infection with Staphylococcus aureus. This case represented one of the longest-retained stents with the highest stone burden documented in the UAE.

Treatment Approach

The management strategy developed by Dr. Paryani and Dr. Jana Kalyan Vijaya Kumar involved a multi-step approach:

1. Initial Antibiotic Treatment: The patient received appropriate antibiotics to address the urinary infection before surgical intervention.
2. Extracorporeal Shock Wave Lithotripsy: An initial attempt to break up the stones around the upper coil of the stent using ESWL proved unsuccessful in releasing it from the renal pelvis mucosa.
3. Combined Endourological Procedure:
   • Introduction of a 20 Fr nephroscope sheath to remove the large bladder stone using pneumatic lithotripsy
   • Deployment of a 6 Fr ureteroscope alongside the encrusted stent within the ureter
   • Careful internal lithotripsy to fragment stone formations throughout the ureter
   • Delicate freeing of the upper coil from renal pelvis mucosa where it had become embedded
   • Successful removal of the entire stent with all fragmented stones

Technical Excellence

The case presented extraordinary technical challenges. The stent had become an integrated part of the urinary tract after six years, with significant encrustations throughout its length. The bladder stone alone was substantial, while the embedded nature of the upper coil required exceptional care to avoid renal injury.

“Managing forgotten stents requires a careful, individualized approach,” notes Dr. Vijaya Kumar. “In this case, we utilized multiple techniques across several specialties, including endourology, lithotripsy, and minimally invasive approaches to achieve complete removal with minimal trauma.”

Preventive Strategies

This case underscores the importance of proper stent management systems in urological practice. Key preventive measures include:

• Comprehensive patient education about temporary nature of stents
• Clear follow-up protocols with reminder systems
• Maintenance of stent registries in hospitals
• Patient tracking mechanisms for those relocating between healthcare systems

The successful management of this complex case highlights the sophisticated urological capabilities available at LLH Hospital and serves as an important reminder about the potential complications of medical device oversight.