Background. Situs inversus totalis (SIT) is a rare genetic anomaly involving the mirror-image transposition of organs. This transposition can potentially make surgical treatments difficult because of the reversed anatomy and intraoperative confusion. The aim of this systematic review is to compare the perioperative outcomes and safety of robotic and laparoscopic gastrectomy in patients with SIT. Methods. We included full-text case reports with brief reviews and standalone case studies on SIT patients age ≥21, undergoing laparoscopic or robotic gastrectomy. We excluded case studies focusing on procedures other than laparoscopic and robotic gastrectomy, namely, open gastrectomy, gastric banding, and gastric bypass. English was selected as the language and articles published in the last 10 years were selected with a date range from Jan, 2011, to Aug, 2021. We focused on intraoperative and postoperative outcomes including blood loss, vascular aberrancy, operation duration, mortality, operative complications, duration of hospitalization, and follow-up interval. Online databases included Clinical Key, Embase, ScienceDirect, Ovid, and Google Scholar. The last search was conducted on Aug 15, 2021. For all eligible articles, risk of bias assessment was carried out using JBI critical appraisal checklist (Table 1). Continuous data were analyzed using t-test with value of 0.05. Results. From our search, we retained 29 case reports which reported information from 30 cases. The results reported in each study were summarized (Table 2). The laparoscopic procedure was used in 21 cases and robot-assisted surgery was used in 9 cases. Operative time was mentioned in 24 out of the 30 cases and the average operative time was 205.67 min. Blood loss was reported in 16 out of the 30 cases, with an average blood loss of 51.9 mL. Hospital stay information was provided in 26 out of the 30 cases, with an average length of stay of 8.5 days. A statistically significant difference was not found for the operative time, length of hospitalization, or age of the patient. However, intraoperative blood loss in robot-assisted gastrectomy was lower compared to laparoscopic gastrectomy, with a value of 0.0293. Perioperative death was not reported in any of the cases. Only three cases of postoperative complications were reported in laparoscopic surgery. Only one of the three cases suggested that the complication was due to an anomaly, whereas the other two of them reported complications due to procedural errors. Conclusion. Laparoscopic and robotic gastrectomy can be safely used for SIT patients if performed cautiously. Some precautions include thoroughly assessing anatomical aberrations using preoperative imaging, adjusting the operative set up, and having experienced surgeons. The robotic approach may have a few advantages over laparoscopic procedures that may enhance the surgical safety for SIT patients and need to be further explored in future research. Advantages of the robotic approach may include improved surgical safety with better visualization of the surgical field, promoting the stability of surgical instruments and perhaps allowing ease of surgical orientation and positioning when operating on patients with SIT. Further research in this field is merited.

Rectus sheath hematoma (RSH) is an uncommon yet clinically significant cause of acute abdominal pain, often overlooked due to its variable presentation and resemblance to other intra-abdominal pathologies. Predisposing factors include anticoagulation therapy, trauma, pregnancy, and strenuous activity, with anticoagulation-associated RSH carrying particularly high morbidity and mortality. We report a case of bilateral RSH in a 68-year-old female with multiple comorbidities, including atrial fibrillation, who was admitted for community-acquired pneumonia. During hospitalization, she developed atrial flutter with rapid ventricular response, necessitating a transition from her home apixaban to therapeutic-dose low molecular weight heparin (LMWH) in anticipation of potential cardioversion or invasive procedures. Later, she experienced sudden-onset severe abdominal pain and distension, accompanied by a marked hemoglobin drop (from 10.2 g/dL to 7.4 g/dL). An emergent abdominal CT scan confirmed bilateral RSH without active extravasation. Given hemodynamic stability, she was managed conservatively with packed red blood cell transfusions, serial hemoglobin monitoring, analgesia, and warm compresses. Her condition improved gradually, with no further bleeding or recurrence of arrhythmia. To our knowledge, this is the second reported case of bilateral RSH linked to LMWH use.

Carotid artery stenosis remains a major cause of ischemic stroke worldwide, and its management continues to evolve in parallel with advances in surgical, endovascular, and medical therapies. Carotid endarterectomy (CEA) was established as the standard of care for symptomatic high-grade stenosis following landmark randomized trials, while carotid artery stenting (CAS) subsequently emerged as a less invasive alternative for appropriately selected patients. This review aims to summarize the historical evolution of carotid artery stenting, critically appraise evidence from major clinical trials comparing CAS and CEA, and examine contemporary practice patterns in the era of intensive medical therapy. A comprehensive review of randomized trials, registries, guideline statements, and recent literature was performed to synthesize current evidence regarding procedural outcomes, patient selection, and emerging technologies, including transcarotid artery revascularization (TCAR). Large, randomized trials have demonstrated comparable long-term composite outcomes between CAS and CEA in selected patients, although peri-procedural risk profiles differ, with higher stroke risk observed after CAS and higher myocardial infarction rates after CEA. Technological advancements in embolic protection devices, stent platforms, and alternative access strategies have further refined endovascular approaches. Concurrently, improvements in intensive medical therapy—including lipid-lowering, antiplatelet therapy, blood pressure control, smoking cessation, and lifestyle modification—have substantially reduced overall stroke risk, particularly in asymptomatic patients. In the contemporary era, optimal stroke prevention requires individualized, multidisciplinary decision-making that integrates symptom status, anatomical complexity, comorbid conditions, procedural expertise, and sustained long-term vascular risk factor management following revascularization.

Background: A myriad of risk factors and comorbidities have been determined to influence COVID-19 mortality rates; among these is pneumonia. This study considers pneumonia as a risk factor for increased mortality in patients admitted with COVID-19 in a rural healthcare system. We predicted that the presence of pneumonia of any kind would increase mortality rates in patients admitted with COVID-19. Methods: A retrospective observational study was conducted using data collected from hospitals in the Freeman Health System (FHS) located in Joplin and Neosho, Missouri. Data were collected between April 1, 2020, and December 31, 2021. Using International Classification of Diseases, Tenth Revision (ICD-10) codes, the investigators identified five distinct patient populations: patients with COVID-19 and pneumonia due to COVID-19 (P1); patients with COVID-19 but without pneumonia due to COVID-19 (P2); patients with COVID-19 and any type of pneumonia (P3); patients with COVID-19 but without any type of pneumonia (P4); and patients without COVID-19 and with any type of pneumonia (P5). In order to understand how pneumonia influences COVID-19 outcomes, the investigators used Wald’s method and a two-sample proportion summary hypothesis test to determine the confidence interval and to compare the mortality rates between these populations, respectively. Results: The population of patients with COVID-19 and any type of pneumonia (P3) and the population of patients with COVID-19 and pneumonia due to COVID-19 (P1) showed the highest mortality rates. The population of patients with COVID-19 but without any type of pneumonia (P4) had the lowest mortality rate. The data revealed that having pneumonia combined with COVID-19 in any patient population led to a higher mortality rate than COVID-19 alone. Conclusion: Mortality rates were higher among COVID-19 patients with pneumonia compared to COVID-19 patients without pneumonia. Additionally, pneumonia, by itself, was found to have a higher mortality rate compared to COVID-19 alone.