BACKGROUND: Pneumatosis intestinalis is a radiological finding characterized by the presence of gas in the bowel wall that is associated with multiple entities. Our aim is to know its incidence in lung transplant patients, its physiopathology and its clinical relevance.
METHODS: A search of patients with pneumatosis intestinalis was performed in the database of the Lung Transplant Unit of our hospital. The presence of pneumatosis after transplantation was confirmed in all of them and relevant demographic, clinical and imaging variables were collected to evaluate its association and clinical expression, as well as the therapeutic approach after the findings.
RESULTS: The incidence of pneumatosis intestinalis after lung transplantation in our center was 3.1% (17/546), developing between 9 and 1270 days after transplantation (mean, 198 days; median 68 days). Most of the patients were asymptomatic or with mild symptoms, without any major analytical alterations, and with a cystic and expansive radiological appearance. Pneumoperitoneum was associated in 70% of the patients (12/17). Conservative treatment was chosen in all cases. The mean time to resolution was 389 days.
CONCLUSIONS: Pneumatosis intestinalis in lung transplant patients is a rare complication of uncertain origin, which can appear for a very long period of time after transplantation. It has little clinical relevance and can be managed without other diagnostic or therapeutic interventions.

UNASSIGNED: We aimed to assess the efficacy and safety of low-pressure pneumoperitoneum (LPP) in minimally invasive colorectal surgery.
UNASSIGNED: A PRISMA-compliant systematic review/meta-analysis was conducted, searching PubMed, Scopus, Google Scholar, and clinicaltrials.gov for randomized-controlled trials assessing outcomes of LPP vs standard-pressure pneumoperitoneum (SPP) in colorectal surgery. Efficacy outcomes [pain score in post-anesthesia care unit (PACU), pain score postoperative day 1 (POD1), operative time, and hospital stay] and safety outcomes (blood loss and postoperative complications) were analyzed. Risk of bias2 tool assessed bias risk. The certainty of evidence was graded using GRADE.
UNASSIGNED: Four studies included 537 patients (male 59.8%). LPP was undertaken in 280 (52.1%) patients and associated with lower pain scores in PACU [weighted mean difference: -1.06, 95% confidence interval (CI): -1.65 to -0.47, P = 0.004, I 2  = 0%] and POD1 (weighted mean difference: -0.49, 95% CI: -0.91 to -0.07, P = 0.024, I 2  = 0%). Meta-regression showed that age [standard error (SE): 0.036, P < 0.001], male sex (SE: 0.006, P < 0.001), and operative time (SE: 0.002, P = 0.027) were significantly associated with increased complications with LPP. In addition, 5.9%-14.5% of surgeons using LLP requested pressure increases to equal the SPP group. The grade of evidence was high for pain score in PACU and on POD1 postoperative complications and major complications, and blood loss, moderate for operative time, low for intraoperative complications, and very low for length of stay.
UNASSIGNED: LPP was associated with lower pain scores in PACU and on POD1 with similar operative times, length of stay, and safety profile compared with SPP in colorectal surgery. Although LPP was not associated with increased complications, older patients, males, patients undergoing laparoscopic surgery, and those with longer operative times may be at risk of increased complications.

Chilaiditi syndrome is defined as the interposition of the colon between the liver and the diaphragm or abdominal wall and is known as Chilaiditi\'s sign on X-rays. Although rare, this procedure can lead to serious complications. Due to its infrequency and propensity for severe complications, diagnosing and differentiating this syndrome from other acute abdominal emergencies are very important for preventing unnecessary treatment or surgical procedures. We present a 72-year-old male with a history of chronic obstructive pulmonary disease (COPD) who presented to the emergency department with persistent shortness of breath, abdominal discomfort, and vomiting. Physical examination revealed chest crepitation, tenderness in the left iliac fossa, and high blood pressure. Laboratory tests revealed a positive COVID-19 status, elevated C-reactive protein level, and respiratory alkalosis. Imaging, including a chest X-ray and CT scan, confirmed the presence of bowel loops under the diaphragm, confirming the diagnosis of Chilaiditi syndrome. Collaborative management by surgical and medical teams was essential in navigating this complex condition. This case highlights the complexity of chilaiditi syndrome, which can be episodic and intermittent, in addition to the importance of recognizing Chilaiditi\'s sign on imaging, particularly on CT scans, to differentiate it from pneumoperitoneum. Vigilance is crucial in identifying potential complications and guiding appropriate treatment to prevent adverse outcomes.

BACKGROUND: Necrotizing enterocolitis (NEC) is a life-threatening disease that affects premature infants. However, the role of inflammatory biomarkers in identifying surgical/death NEC without pneumoperitoneum remains elusive.
OBJECTIVE: We aimed to verify the value of platelet-to-lymphocyte ratio (PLR) and the combination of white blood cell (WBC), absolute neutrophil count (ANC), absolute lymphocyte count (ALC), neutrophil lymphocyte ratio (NLR), PLR, C reactive protein (CRP) and procalcitonin (PCT) in predicting the severity of NEC, and to construct a model to differ surgically NEC from non-surgically NEC.
METHODS: A retrospective analysis was performed on 191 premature infants with NEC. Based on the inclusion and exclusion criteria, 90 infants with Stage II and IIIA NEC were enrolled in this study, including surgical/death NEC (n = 38) and medical NEC (n = 52). The values of inflammatory biomarkers were collected within 24 h of onset.
RESULTS: The univariate analysis revealed that the values of WBC (p = 0.040), ANC (p = 0.048), PLR (p = 0.009), CRP (p = 0.016) and PCT (p < 0.01) in surgical/death NEC cohort were significantly higher than medical NEC cohort. Binary multivariate logistic regression analysis indicates that ANC, PLR, CRP, and PCT are capable of distinguishing infants with surgical/death NEC, and the AUC of the regression equation was 0.79 (95% CI 0.64-0.89; sensitivity 0.63; specificity 0.88), suggesting the equation has a good discrimination.
CONCLUSIONS: Elevated PLR is associated with severe inflammation in surgical/death NEC patients. The prediction modelling of combination of ANC, PLR, CRP and PCT can differentiate surgical/death NEC from infants with medical NEC, which may improve risk awareness and facilitate effective communication between nurses and clinicians. However, multicentre research is needed to verify these findings for better clinical management of NEC.

BACKGROUND: During laparoscopic surgery, pneumoperitoneum and Trendelenburg positioning applied to provide better surgical vision can cause many physiological changes as well as an increase in intracranial pressure. However, it has been reported that cerebral autoregulation prevents cerebral edema by regulating this pressure increase. This study aimed to investigate whether the duration of the Trendelenburg position had an effect on the increase in intracranial pressure using ultrasonographic optic nerve sheath diameter (ONSD) measurements.
METHODS: The near infrared spectrometry monitoring of patients undergoing laparoscopic hysterectomy was performed while awake (T0); at the fifth minute after intubation (T1); at the 30th minute (T2), 60th minute (T3), 75th minute (T4), and 90th minute (T5) after placement in the Trendelenburg position; and at the fifth minute after placement in the neutral position (T6).
RESULTS: The study included 25 patients. The measured ONSD values were as follows: T0 right/left, 4.18±0.32/4.18±0.33; T1, 4.75±0.26/4.75±0.25; T2, 5.08±0.19/5.08±0.19; T3, 5.26±0.15/5.26±0.15; T4, 5.36±0.11/5.37±0.12; T5, 5.45±0.09/5.48±0.11; and T6, 4.9±0.24/4.89±0.22 ( p < 0.05 compared with T0). ). No statistical difference was detected in all measurements in terms of MAP, HR and ETCO2 values compared to the T0 value (p > 0.05).
CONCLUSIONS: It was determined that as the Trendelenburg position duration increased, the ONSD values ​​increased. This suggests that as the duration of Trendelenburg positioning and pneumoperitoneum increases, the sustainability of the mechanisms that balance the increase in intracranial pressure becomes insufficient.
BACKGROUND: This study was registered at Clinical Trials.gov on 21/09/2023 (registration number NCT06048900).

We present here an interesting case report of two patients with spontaneous pneumomediastinum and iatrogenic pneumoperitoneum. The patients were assessed and queried following a chest X-ray abnormality and query based on the history of recent urological procedures on a background of awaiting gastro-oesophageal surgery at a tertiary centre respectively. Although these patients were successfully managed with the best supportive approach and periodic imaging review, it remains important to be aware that fatalities have been reported in the literature. We hope this case report will help those involved in the care of the patient to be aware of these conditions as differentials when history points towards episodes of coughing or recent surgical input.

UNASSIGNED: Patients with chronic kidney disease (CKD) who undergo hemodialysis are predisposed to interstitial cerebral edema. Robotic-assisted laparoscopic surgery can increase optic nerve sheath diameter (ONSD) and intracranial pressure. The impact of robotic-assisted kidney transplant (RAKT) on ONSD is complicated by the presence of CKD, the administration of furosemide and mannitol, and the manipulation of hemodynamics. We examined ONSD variations in patients undergoing RAKT over a 1-year period at our institution. Furthermore, we attempted to identify any perioperative hemodynamic factors influencing these changes.
UNASSIGNED: This prospective study included 20 patients undergoing RAKT. ONSD, heart rate, central venous pressure, systolic blood pressure, diastolic blood pressure (DBP), and mean arterial pressure (MAP) were measured following intubation (T1), after assuming the steep Trendelenburg position (T2), 1 hour after docking (T3), upon reperfusion (T4), after transition to the supine position (T5), and 3 hours postextubation (T6). Repeated measures analysis of variance with post hoc Bonferroni correction was employed to compare variables at each time point. Pearson correlation analysis was utilized to assess relationships between variables. P-values ≤0.05 were considered to indicate statistical significance.
UNASSIGNED: ONSD (in mm) increased from T1 (3.60±0.44) to T3 (4.06±0.45, P=0.002) and T4 (3.99±0.62, P=0.046), before falling to its lowest value at T6 (3.42±0.64, P=0.002). Pearson correlation analysis revealed significant correlations (P<0.05) between changes in ONSD at T3 and both DBP (r=0.637) and MAP (r=0.522).
UNASSIGNED: During RAKT with open ureteric anastomosis, ONSD initially increased, then decreased following reperfusion. DBP and MAP displayed positive correlations with ONSD changes at T3.

UNASSIGNED: Improvement in the perioperative care has led to increased use of minimally invasive surgeries. Multiple physiological changes during minimally invasive surgeries are attributed to the creation of pneumoperitoneum.
UNASSIGNED: One hundred and nine patients who underwent laparoscopic cholecystectomy at a tertiary care hospital in north India meeting the inclusion and exclusion criteria were enrolled.
UNASSIGNED: Out of the total 109 patients, 13 were males and 96 females (M:F = 1:7.3), the mean basal metabolic rate was 28.95 kg/m2. The mean systolic and diastolic blood pressure of the upper limb were 134.33 + 17.545 and 80.69 + 11.59 respectively. The mean systolic and diastolic blood pressure in lower limb (LL) were 142.32 + 21.552 and 79.44 + 11.94, respectively. Significant rise in the SBP was noticed in LL at the time of creation of Pneumoperitoneum and after changing the position for surgery (P < 0.05). The diastolic pressure in the LL rises significantly in the LL after creation of pneumoperitoneum, at induction, after reverse Trendelenburg position and extubation (P < 0.05). The mean arterial pressure increased significantly in the LL after the creation of pneumoperitoneum and persisted till the extubation (P < 0.05). A significant rise of ankle-brachial index (ABI) was observed in the patients after the creation of pneumoperitoneum and it remained significant till 15 min into surgery (P < 0.05). There was no correlation of ABI with weight and age of the patients on Pearson correlation.
UNASSIGNED: There is rise in ABI of the patients undergoing laparoscopic cholecystectomy at the time of creation of pneumoperitoneum, after Trendelenburg position and 15 min into surgery.

Pneumatosis intestinalis and pneumoperitoneum are not pathological entities in themselves, they are radiological signs that result from some underlying condition. In general, these are associated with serious intra-abdominal processes that result in emergency surgeries with bowel resections. Below, we present the case of an 80-year-old woman, diagnosed with stage IV breast cancer under treatment with fulvestrant and ribociclib, who was admitted to our center due to abdominal pain and vomiting. She was diagnosed with intestinal pneumatosis and pneumoperitoneum, so she underwent exploratory laparotomy for suspected intestinal ischemia. There was no evidence of intestinal necrosis or perforation, so resection was not performed. She progressed satisfactorily during hospitalization and in the tomographic control one month after discharge there was complete resolution of the condition. Although this condition has been described in relation to episodes of increased intra-abdominal pressure, such as emesis, it has also been described in patients with neoplasms, mainly of the digestive tract, either due to local damage or toxicity associated with chemotherapy. We found no reports in the literature of pneumatosis intestinalis linked to this antineoplastic medication in humans. Probably in our case the etiology was multifactorial. It is possible that ribociclib played a role, either through an indirect mechanism associated with vomiting and immunosuppression or directly on the enterocyte due to its non-specific cellular mechanism of action.
La neumatosis intestinal y el neumoperitoneo no son entidades patológicas en sí mismas, son signos radiológicos que resultan de alguna condición subyacente. En general, estos se asocian con procesos graves intraabdominales que resultan en cirugías de urgencias con resecciones de intestino. A continuación, presentamos el caso de una mujer de 80 años, con diagnóstico de cáncer de mama estadio IV en tratamiento con fulvestrant y ribociclib, que ingresó a nuestro centro por dolor abdominal y vómitos. Se diagnosticó neumatosis intestinal y neumoperitoneo por lo que se procedió a laparotomía exploradora por sospecha de isquemia intestinal. No hubo evidencia de necrosis o perforación intestinal por lo que no se realizó resección. Evolucionó durante la internación de forma satisfactoria y en el control tomográfico al mes del egreso hubo resolución completa del cuadro. Si bien está descrito esta afectación en relación a los episodios de aumento de presión intraabdominal, como en la emesis, también se describió en pacientes con neoplasias, principalmente del tubo digestivo, ya sea por daño local o por toxicidad asociada a la quimioterapia. No encontramos reportes en la literatura de neumatosis intestinal vinculada a esta medicación antineoplásica en humanos. Probablemente en nuestro caso la etiología haya sido multifactorial. Es posible que el ribociclib haya jugado un rol, ya sea por un mecanismo indirecto asociado a los vómitos y la inmunosupresión o directo sobre el enterocito debido a su mecanismo de acción celular no específico.

OBJECTIVE: This study aimed to investigate the hypothesis that an alveolar recruitment maneuver can restore lung compliance to initial values after laparoscopic gynecological surgery.
METHODS: A total of 31 patients who underwent laparoscopic gynecological surgery were enrolled. Protective mechanical ventilation was applied, and the radial artery was catheterized in all patients. An alveolar recruitment maneuver (incremental and decremental positive end-expiratory pressure) was applied ten minutes after the release of pneumoperitoneum. The respiratory mechanics and blood gas results were recorded at eight different time points: after induction of anesthesia (T1), in the lithotomy position (T2), in the Trendelenburg position (T3), 10 and 90 min after insufflation of carbon dioxide (T4 and T5), in the supine position (T6), after desufflation (T7), and 10 min after an alveolar recruitment maneuver at the end of surgery (T8).
RESULTS: Pneumoperitoneum and the Trendelenburg position caused a decline of 15 units in compliance (T7 vs. T1; p < 0.05) compared to baseline. After the alveolar recruitment maneuver, compliance increased by 17.5% compared with the mean value of compliance at time T1 (T8 vs. T1; p < 0.05). The recruitment maneuver had favorable results in patients with low initial compliance (41.5 mL/cmH2O, IQR: 9.75 mL/cmH2O), high Body Mass Index 30.32 kg/m2 (IQR: 1.05 kg/m2), and high initial plateau airway pressure (16.5 cmH2O, IQR: 0.75 cmH2O).
CONCLUSIONS: Lung compliance does not return to initial values after performing laparoscopic gynecological procedures. However, after the release of pneumoperitoneum, an alveolar recruitment maneuver is beneficial as it improves compliance and gas exchange.