International Journal of Medical Science and Clinical Research Studies

Anatomy of the Cystic Artery and Its Variations: Implications for Gallbladder Surgery

2026-09-22T22:14:47+00:00

Anatomical variations of the hepatobiliary arterial supply represent a significant challenge during gallbladder surgery, as they may increase the risk of hemorrhage and bile duct injury when not recognized promptly. Among these, hepatic arterial variations described by the Michels classification are particularly relevant because of their impact on the planning and performance of hepatobiliary procedures. We present the case of a 48-year-old male patient diagnosed with acute calculous cholecystitis who underwent laparoscopic cholecystectomy. During dissection of the hepatocystic triangle, a vascular variant corresponding to Michels type V was identified, characterized by the presence of an accessory left hepatic artery arising from the left gastric artery. Intraoperative recognition of this variant allowed modification of the surgical strategy, preservation of the accessory vessel, and successful completion of the procedure without vascular or biliary complications. The postoperative course was uneventful, and the patient was discharged the following day with outpatient follow-up demonstrating no evidence of complications. This case highlights the importance of thorough knowledge of hepatobiliary vascular anatomy, the Michels classification, and the systematic application of the Critical View of Safety to reduce the risk of iatrogenic injuries during laparoscopic cholecystectomy. Furthermore, it emphasizes the importance of recognizing anatomical variations as a fundamental element for optimizing surgical safety and improving clinical outcomes.

Large Vulvar Fibroepithelial Stromal Polyp Vs. Aggressive Angiomyxoma: The Importance of Histopathological and Immunohistochemical Diagnosis. A Case Report

2026-09-04T16:56:38+00:00

We present the case of a 34-year-old woman with a history of asthma, cesarean section, and bilateral tubal ligation, who reported progressive growth of a tumor on her right labium majus over nine years. Initially measuring 1 × 1 cm, it subsequently reached approximately 12 × 8 cm, causing discomfort during ambulation. Abdominopelvic computed tomography revealed a lobulated vulvar soft tissue lesion without evidence of deep infiltration. Complete surgical excision of the lesion was performed, revealing a tumor originating from the right labium majus and not adherent to deeper tissues. Histopathological examination revealed a stromal polyp. A 12.5 × 8 × 3 cm fibroepithelial lesion was found to be negative for malignancy. Immunohistochemistry showed positivity for desmin, CD34, and smooth muscle actin, confirming the diagnosis. The postoperative course was satisfactory, with no recurrence or complications. Stromal polyps fibroepithelial Vulvar tumors represent a rare entity whose main diagnostic challenge lies in differentiating them from other mesenchymal neoplasms Vulvar polyps , particularly aggressive angiomyxoma , are often compared to stromal polyps due to their clinical and histopathological similarities. Although they are usually lesions smaller than 5 cm, there are exceptional reports of massive growth. Definitive diagnosis requires surgical excision and histopathological analysis supplemented with immunohistochemistry . Positivity for desmin, CD34, and smooth muscle actin supports the benign mesenchymal origin of the lesion. Complete resection is the treatment of choice, as incomplete resections are associated with local recurrence. fibroepithelial Vulvar lesions are rare benign lesions that should be considered in the differential diagnosis of slow-growing vulvar masses. Histopathological and immunohistochemical evaluation is essential to distinguish them from aggressive neoplasms. Complete surgical excision allows for confirmation of the diagnosis, relief of symptoms, and a reduction in the risk of recurrence, thus improving patients' quality of life.

Bile Duct Injury Following Cholecystectomy: Diagnosis, Timing of Repair, And Surgical Reconstruction

2026-09-17T00:26:27+00:00

Iatrogenic bile duct injury (BDI) remains one of the most serious complications of cholecystectomy. Although uncommon, BDI may result in bile leakage, biliary peritonitis, sepsis, obstruction, recurrent cholangitis, anastomotic stricture, secondary biliary cirrhosis, and repeated interventions. Outcomes are influenced by the timing of recognition, effective source control, complete definition of biliary and vascular anatomy, preservation of ductal blood supply, and access to an experienced hepatopancreatobiliary (HPB) team. This narrative review synthesizes evidence published between 2022 and 2026 regarding epidemiology, mechanisms of injury, classification, diagnosis, endoscopic and percutaneous management, timing of definitive repair, and surgical reconstruction. Minor injuries with preserved ductal continuity are frequently amenable to endoscopic decompression and selective stent placement. Major injuries, particularly Strasberg type E lesions, most commonly require bilioenteric reconstruction, with Roux-en-Y hepaticojejunostomy representing the most established reconstructive option. Contemporary evidence supports favorable outcomes after both carefully selected early repair and delayed reconstruction; however, the 2025 SAGES-AHPBA guideline conditionally favors definitive repair after 6 weeks when the clinical setting permits. Across contemporary series, favorable long-term outcomes are consistently associated with early referral to specialist HPB centers, adequate control of sepsis and bile collections, and construction of a wide, well-vascularized, tension-free mucosa-to-mucosa anastomosis. Long-term surveillance is essential because biliary strictures may develop years after reconstruction.

Intron Retention: Organisation, Genome and Biological Roles and Associated Diseases

2026-10-07T11:50:14+00:00

Alternative splicing expands transcript and protein diversity by generating multiple isoforms from individual genes. Intron retention (IR), a major form of alternative splicing, occurs when intronic sequences remain in mature RNA transcripts and is now recognized as a regulated mechanism of post-transcriptional gene control. IR can influence mRNA stability, localization, translation, and degradation, leading to transcript clearance through nonsense-mediated decay, nuclear retention, or production of alternative protein isoforms. Its regulation involves splice-site features, cis-regulatory elements, chromatin state, DNA methylation, transcriptional kinetics, and splicing factors. IR displays cell- and tissue-specific patterns and contributes to development and cellular responses to stresses such as hypoxia, heat, and infection. Aberrant IR is associated with cancer, neurodegeneration, aging, and immune dysfunction and may contribute to altered protein function and the generation of immunogenic peptides. Advances in RNA sequencing, long-read technologies, and computational tools have facilitated genome-wide detection and functional analysis of IR. This review summarizes current knowledge of the mechanisms, regulation, detection, function and biological significance of IR, with emphasis on its roles in normal cellular processes, stress adaptation, and disease.

Paramedian Forehead Flap for Complex Nasal Reconstruction: Clinical Application and Surgical Outcomes

2026-09-22T04:21:38+00:00

Background:Reconstruction of major nasal defects is challenging because restoration of skin coverage alone is insufficient to reproduce nasal contour, structural support, and function. The paramedian forehead flap remains a versatile option for defects involving one or multiple nasal subunits and permits staged refinement before definitive pedicle division. This study describes the clinical application of the paramedian forehead flap in a Mexican patient population, with emphasis on reconstructive characteristics, staging, and surgical outcomes.

Methods:An observational study was conducted in 30 patients treated at the Plastic Surgery Department of Hospital General de México between January 2019 and December 2023 for nasal defects requiring forehead flap reconstruction. Demographic characteristics, defect etiology, affected nasal subunits, pedicle laterality, number of reconstructive stages, donor-site management, and postoperative complications were analyzed. Descriptive statistics were used to summarize the study population and reconstructive characteristics.

Results:Thirty patients were included: 18 men (60%) and 12 women (40%), with a mean age of 40.63 years. Oncologic resection was the most frequent etiology (40%), followed by animal or human bites (33.3%) and nasal trauma (20%). Multiple nasal subunits were involved in 70% of patients, with the nasal tip being the most frequently affected subunit (63.3%). An ipsilateral pedicle was used in 28 patients (93.3%). Three-stage reconstruction was performed in 20 patients (66.6%), whereas 10 (33.3%) underwent two-stage reconstruction. Primary donor-site closure was achieved in 28 patients (93.3%). Partial dehiscence occurred in two patients (6.6%), and one patient (3.3%) was considered to have a suboptimal aesthetic result. No total flap losses or major complications were observed.

Conclusions:The paramedian forehead flap provided reliable reconstruction of complex nasal defects involving single or multiple aesthetic subunits, with no total flap losses and a low incidence of minor complications in this series. The versatility of pedicle design, staged reconstruction, and the opportunity for contour refinement support its role as an important reconstructive option for major nasal defects.

Usefulness of the Singh Index in Predicting Hip Fracture Patterns in Older Adults: A Retrospective Study in A Second Level Hospital

2026-10-02T18:39:44+00:00

Introduction: The elderly population has increased in recent years, leading to a rise in age-related diseases. Hip fractures are particularly noteworthy, as over 90% of patients in the Traumatology and Orthopedics service are over 65 years old.

General Objective: To determine the usefulness of the Singh index in hip fractures in adults over 65 years of age at Regional General Hospital No. 1 Orizaba, and to identify related risk factors.

Methods: A retrospective, cross-sectional, descriptive, observational study was conducted. The study population consisted of 129 patients hospitalized in the Traumatology and Orthopedics Service between January 2023 and December 2024 at Regional General Hospital No. 1 in Orizaba, Veracruz.

Results: Of the 129 patients, 63.16% (84 patients) presented with transtrochanteric fractures, with a higher incidence in women (64 cases, 64.6%) and in patients over 75 years of age (94 patients, 72.86%). A statistically significant correlation was found between the Singh index and the anatomical location of the fracture (r = -0.39, p < 0.001), suggesting that greater trabecular bone loss is associated with intracapsular fractures.

Conclusions: The Singh index showed a statistically significant association with hip fracture type in older adults, and therefore can be considered a useful tool as an indirect estimator of bone quality in resource-limited clinical settings. However, its value should be interpreted with caution due to its methodological limitations. Level of evidence: III (retrospective analytical observational study).

Choledochal Cysts: Contemporary Diagnosis, Surgical Management, and Long-Term Surveillance

2026-10-03T19:20:43+00:00

Choledochal cysts, increasingly referred to as congenital biliary dilatation, are uncommon abnormalities of the biliary tree associated with biliary stasis, pancreatobiliary reflux, recurrent inflammation, pancreatitis, cholangitis, stone formation, progressive hepatobiliary injury, and an increased lifetime risk of biliary tract malignancy. Although many cases are diagnosed during childhood, adult presentation remains clinically relevant because delayed diagnosis is often associated with complicated disease, chronic inflammation, biliary stones, adhesions, and greater concern for cholangiocarcinoma or gallbladder carcinoma. Contemporary evaluation relies on ultrasonography, magnetic resonance cholangiopancreatography, computed tomography in selected cases, and therapeutic or problem-solving use of endoscopic retrograde cholangiopancreatography. Complete cyst excision with cholecystectomy and biliary reconstruction remains the cornerstone of treatment for most extrahepatic choledochal cysts. However, important controversies persist regarding the timing of surgery in prenatally diagnosed neonates, hepaticoduodenostomy versus Roux-en-Y hepaticojejunostomy, the role of laparoscopic and robotic surgery, and the optimal strategy for long-term surveillance. This narrative review provides a contemporary overview, updated through May 2026, of classification, pathogenesis, diagnostic evaluation, operative principles, reconstruction strategies, minimally invasive approaches, postoperative complications, malignancy risk, and follow-up.

Z-Plasty for First Web Space Contracture: A Reconstructive Approach

2026-10-03T15:50:34+00:00

Introduction. Z-plasty is a local flap transposition technique widely used in plastic and reconstructive surgery for scar revision and contracture release. In the hand, contracture of the first web space can significantly compromise thumb abduction and opposition, as well as pinch and grip strength, thereby affecting overall limb function. Z-plasty and its various modifications allow for tissue lengthening, scar reorientation, and redistribution of tension forces, constituting a useful reconstructive alternative in selected cases.

Methods. A narrative literature review was conducted focusing on the principles, historical evolution, surgical anatomy, diagnosis, classification, and treatment of first web space contractures. Particular attention was given to the geometric foundations, indications, limitations, and surgical technique of Z-plasty, including its simple, multiple, four-flap, and five-flap variants. Conservative treatment modalities, objective methods for assessing thumb mobility, and reconstructive alternatives available for more complex contractures were also reviewed.

Conclusions. Z-plasty remains a versatile and effective technique for the management of mild to moderate first web space contractures, particularly when the restriction is predominantly cutaneous and adequate adjacent tissue is available. Reconstructive success depends on accurate assessment of the depth and extent of the contracture, appropriate flap design, complete release of the scar band, preservation of vascularity, and postoperative rehabilitation. Severe or deep contractures involving fascia, muscle, or joint capsule, or presenting extensive tissue deficits, may require skin grafts or coverage with local, regional, or free flaps. Outcomes should be assessed not only by the widening of the first web space but also by the recovery of thumb abduction, opposition, pinch, and grip. Comparative studies are needed to standardize indications and determine the optimal Z-plasty configuration for each contracture pattern.

Surgical Techniques in Otoplasty for Correction of the Prominent Ear: A Contemporary Review

2026-10-03T22:24:49+00:00

Prominent ear is the most frequent congenital deformity of the external ear, affecting approximately 5% to 10% of the population, and remains a recognised source of psychosocial distress in children and adults. More than a century of surgical innovation has produced an extensive armamentarium of corrective procedures, yet no single technique has proved universally superior. This review synthesizes contemporary evidence on otoplasty surgical technique. It examines the anatomical basis and normative measurements that govern operative planning, the timing of intervention, and the technical detail of the two dominant families of procedures: cartilage-sparing suture techniques, exemplified by the Mustardé conchoscaphal and Furnas conchomastoid sutures, and cartilage-modifying techniques based on anterior scoring, incision or excision. Adjunctive refinements are appraised, including postauricular fascial and dermofascial flaps designed to prevent suture extrusion and relapse, conchal reduction, lobule repositioning and reduction otoplasty for the coexisting macrotic ear. Minimally invasive alternatives, comprising incisionless suture otoplasty, laser-assisted cartilage reshaping, electromechanical reshaping and implantable clip systems, are discussed alongside neonatal auricular molding. Pooled contemporary data indicate a mean reduction of the mastoid-to-helical rim distance of approximately 12 mm, a cumulative complication rate close to 14%, a pooled recurrence rate of 2.8% and a revision rate of 2.1%, with suture extrusion the single most common adverse event. Cartilage-sparing approaches, particularly modified Mustardé–Furnas methods reinforced by a vascularized postauricular flap, currently offer the most favorable balance of durability and morbidity, whereas anterior scoring remains safe and reliable in high-volume units with disciplined case selection. Technique selection should be anatomically driven and individualized, dictated by the deformity and by cartilage pliability rather than by surgeon habit

Management of the Difficult Airway in Anesthesia: Prediction, Oxygenation, and Rescue Strategies

2026-10-14T15:42:48+00:00

Difficult airway management remains one of the most critical areas in anesthetic practice because failure to oxygenate or intubate can rapidly lead to hypoxic brain injury, cardiac arrest, or death. A difficult airway includes situations in which a trained clinician encounters difficulty with facemask ventilation, supraglottic airway placement, laryngoscopy, tracheal intubation, or emergency surgical access. Preoperative assessment can identify high-risk patients but has limited ability to reliably exclude difficulty, making universal preparation essential. Risk factors include high Mallampati score, reduced mouth opening, short thyromental distance, limited neck extension, obesity, obstructive sleep apnea, craniofacial abnormalities, airway masses, trismus, and subglottic stenosis. Contemporary management emphasizes preoxygenation, continuous oxygen delivery, early use of videolaryngoscopy or flexible bronchoscopy when indicated, limitation of repeated attempts, rapid transition between airway devices, mandatory waveform capnography, and timely front-of-neck access when ventilation fails. Awake tracheal intubation remains the preferred strategy for anticipated difficult airway when aspiration risk, rapid desaturation, or impossible rescue ventilation is expected. Successful management depends less on a single device and more on structured decision-making, team communication, oxygenation preservation, and early rescue escalation.

Fulminant Acute Liver Failure Secondary to Leptospirosis: A Case Report

2026-08-18T23:00:08+00:00

Background: Leptospirosis is a worldwide zoonosis caused by pathogenic species of the genus Leptospira. Although most infections are mild or self-limited, severe forms may progress to multiorgan dysfunction, including acute kidney injury, pulmonary hemorrhage and, less frequently, fulminant acute liver failure. Early diagnosis is often challenging because of the nonspecific clinical presentation, which makes timely antimicrobial therapy crucial to improve outcomes.

Case Presentation: We report the case of a 31-year-old man who presented with fever, progressive jaundice, marked direct hyperbilirubinemia, severe transaminase elevation and rapidly progressive fulminant acute liver failure complicated by hepatic encephalopathy, coagulopathy, septic shock, acute kidney injury requiring renal replacement therapy and lower gastrointestinal bleeding. Initial investigations for viral hepatitis were negative and autoimmune hepatitis was initially considered. The microscopic agglutination test (MAT) subsequently identified Leptospira interrogans serovar Mankarso at a titer of 1:800, establishing the diagnosis of severe leptospirosis. Antimicrobial therapy was adjusted to ceftriaxone plus doxycycline, together with intensive supportive care, and the patient was ultimately referred to a tertiary center for liver transplantation evaluation.

Conclusion: This case highlights fulminant acute liver failure as an uncommon but life-threatening manifestation of leptospirosis. Clinicians should maintain a high index of suspicion in patients presenting with acute liver failure and compatible epidemiological risk factors, even when an infectious etiology is not initially apparent. Early recognition and prompt antimicrobial treatment remain essential to improve clinical outcomes.