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Appendicular mucinous neoplasms, constituting less than 1% of gastrointestinal tract neoplasms, are heterogeneous entities. They may be asymptomatic, discovered incidentally, or present as large tumors due to mucin accumulation. The lack of standardized treatment complicates management. Imaging studies, particularly CT scans, are crucial for diagnosis and follow-up. This case report presents two clinical cases of women in their sixth and seventh decades of life with a history of lower gastrointestinal bleeding, mild anemia in laboratory studies, and incomplete colonoscopies. The diagnosis, confirmed through CT scans, led to the decision for surgical intervention in both cases, involving laparoscopic right hemicolectomy with ileotransverse anastomosis. Subsequently, histopathological reports confirmed the diagnosis of high-grade appendicular mucinous neoplasms, and a follow-up plan was established with imaging studies every six months with no recurrence at two years. Over 50% of appendicular tumors are mucinous neoplasms originating from low-grade mucinous neoplasms. Given the low lymph node invasion (2%), appendectomy may suffice if the entire tumor is excised. Extensive resections or right hemicolectomy are reserved for larger tumors or high-grade neoplasms to minimize local recurrence risk. Mucinous neoplasms with acellular mucin and peritoneal invasion may require cytoreduction or right hemicolectomy, while those with mucinous epithelium may need hyperthermic intraperitoneal chemotherapy (HIPEC) due to the risk of local recurrence, worsened by the presence of extra appendiceal epithelial cells. Disease-free and overall survival depend on treatment and initial lesion characterization. A five-year survival rate of 86% is reported for low-grade mucinous neoplasms. Follow-up approaches lack an ideal standard, generally involving physical examinations and imaging studies every six months to one year during the first six years.

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INTRODUCTION: There are still controversies regarding the time of surgical management for acute appendicitis (AA). The main objective of this study was to recognize the surgical deferral time in patients with acute appendicitis and its relationship with the severity of presentation. MATERIALS AND METHODS: We performed a retrospective review of prospectively collected data of all patients with acute appendicitis undergoing appendectomy from August 2018 to August 2020 in an academic, public hospital. Elapsed time from arrival to the emergency room to skin incision was determined. Patients were divided into three groups based on the elapsed time: less than 6 h, between 6 and 12 h, and more than 12 h. RESULTS: A total of 782 patients were included. Of them, 443 (56.6%) patients had a surgical deferral time of less than 6 h, 238 (30.4%) patients between 6 and 12 h, and 101 (13%) patients of more than 12 h. Patients with more than 12 h of surgical deferral time had a more complicated clinical presentation (P = 0.013), a higher frequency of abscess formation (P = 0.022), higher requirement for the use of surgical drainage (P = 0.018), and longer length of hospital stay (P = <0.001). CONCLUSION: Surgical deferral >12 h was associated with a higher incidence of complicated appendicitis, intra-abdominal abscesses, and overall hospital stay. However, in the multivariate analysis, only total evolution time, from the first symptom to surgery, was a significant independent predictor of complicated appendicitis.

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Endometriosis is the presence of normal endometrial tissue outside the uterus, which may appear in up to 15% of fertile female population. Bowel endometriosis is uncommon, and obstruction due to endometrial ileocolic intussusception is extremely rare. Herein, we report a case of a 27-year-old female who presented with bowel obstruction due to ileocolic intussusception secondary to endometriosis. A 27-year-old female, without pregnancies, and with a 1 year history of endometriosis presented to the emergency department referring severe abdominal pain in right lower quadrant, nausea and vomiting, she had medical history of prior episodes of mild abdominal pain due to endometriosis with OB/GYN follow-up. Physical examination revealed abdominal distension with decreased bowel movements to auscultation. A CT scan reported suspicion of intussusception. Colonoscopy was ordered, where an ileocolic intussusception was found. Diagnostic laparoscopy was performed, and the initial diagnosis was confirmed. A right hemicolectomy with extracorporeal anastomosis was achieved without any surgical complications. The patient was discharge on postoperative day 4 and continues doing well on a 12 month follow-up. Ileocolic intussusception due to endometriosis is a very rare condition, and it must be considered a differential diagnosis in female patients in reproductive age, when presenting with intestinal obstruction.

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BACKGROUND: Bariatric surgery has been a popular way for many women to reach a healthy body mass index, and as a consequence, a decreased body mass, which causes a greater chance of fertility, with improved pregnancy and better maternal outcomes. OBJECTIVE: Describe a single-center experience of pregnancies complicated by internal hernias after gastric bypass. SETTING: Academic Medical Center. METHODS: During 2011 and 2019 a series of patients were treated for internal hernia after gastric bypass at our teaching hospital. The hospital records were retrospectively reviewed. RESULTS: Seven women were treated. Median age was 33 years (range: 24-39 yr). Median gestational age was 25.6 weeks (range: 5-33 wk). Median time from Roux-en-Y gastric bypass to pregnancy was 4 years (range: 1-7 yr). Median body mass index was 24 kg/m2 (range: 24-31 kg/m2). Five (71.4%) patients underwent an exploratory laparotomy, and 2 (28.5%) patients a diagnostic laparoscopy. In all patients, an internal hernia of the small bowel in the Petersen space was encountered. Median length of pregnancy was 38 weeks (range: 33.6-39.6 wk). Six (85.7%) patients underwent C-section, and 1 (14.2%) patient gave birth by vaginal delivery. There was only 1 maternal postoperative complication and no fetal postoperative complications. Median follow-up was 9 months (range: 2-20 mo). CONCLUSION: The rapid growth in bariatric surgery on obese women of fertile age could result in more cases of internal herniation during pregnancy in the future. An internal hernia should be suspected when encountering a postgastric bypass pregnant patient with abdominal pain, nausea, and vomiting.

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