case study gastrointestinal surgery

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Center for Bloodless Medicine and Surgery

Case study: gastroenterology, severe gastrointestinal (gi) bleed secondary to xarelto with a hemoglobin-based oxygen carrier (sanguinate) available as precautionary measure.

A 78-year old man who is one of Jehovah’s Witnesses presented with fatigue and weakness along with a 4-week history of maroon colored stools.  He was recently admitted to another hospital for a pulmonary infection, where he was found to be in atrial fibrillation (AF) and diagnosed with a non-ischemic cardiomyopathy.  He was placed on Xarelto, one of the newer anticoagulants, as a preventative measure, due to his AF.  His past medical history included hypertension, type-2 diabetes mellitus, mild aortic stenosis, hematuria, and arterio-venous malformations in the gastrointestinal tract. 

His hemoglobin upon admission was 4.1 g/dL, which decreased to 3.1 on the 3rd day after admission.  Xarelto was discontinued upon admission and he was placed on aspirin 325 mg/day.  An upper GI endoscopy, was normal.  A colonoscopy revealed a transverse colon polyp but no active bleeding.  He also had a video capsule endoscopic exam where a small “pill camera” is swallowed and video pictures of the entire GI tract are recorded.  This exam was significant for an arterial-venous malformation (AVM) in the proximal small bowel, which was not actively bleeding at that time.  An echocardiogram showed a left-ventricular ejection fraction of 40%, which was much improved over a prior exam at an outside hospital showing a 10% ejection fraction. 

His treatment plan included the following regimen given daily:  folate 1 mg IV, vitamin B12 1,000mcg SQ, iron sucrose 200 mg IV, and erythropoietin 40,000 units IV.  Phlebotomy blood loss was minimized using neonatal tubes, which require about 10% of the blood volume compared to the full adult sized tubes. 

Given his very low hemoglobin, and his risk factors for coronary artery disease, our team decided to obtain a hemoglobin-based oxygen carrier (Sanguinate), in case he developed congestive heart failure or symptomatic myocardial ischemia.  This was procured within 24 hours after the necessary FDA phone calls and paperwork, along with the Johns Hopkins IRB emergency applications.  These measures were required given that Sanguinate (and all other hemoglobin based oxygen carriers) are not yet FDA approved, and are only available for “compassionate use”.  Since the half-life of these compounds is relatively short, the concept is to use them as a temporary measure while the erythropoietic regimen is given to promote red blood cell production.  Although the Sanguinate was obtained, its use was not necessary since the patient did not exhibit symptoms, despite severe anemia, and responded well to the erythropoietic therapy.

The hemoglobin level upon discharge on day #7 was 5.1 g/dL.  He was not symptomatic from this anemia (his heart rate was 50 bpm).  He was sent home on all his prior medications except for Xarelto.  Aspirin 325 mg/day, and iron sulfate 325 mg/day were recommended upon discharge.  He visited the infusion clinic three times in three weeks, where iron dextran 1 gram IV, and erythropoietin 40,000 units IV, were given during each visit.  His last hemoglobin was 11.1 g/dL after these three treatments.   He is being followed up by Cardiology, Gastroenterology and Hematology.  

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Bariatric Surgery Case Study – Gastric Bypass with ICG Leak Test

Johns Hopkins Center for Bariatric Surgery, National Capital Region

Patient presentation

• A 38-year-old female with a history of class 3 obesity (BMI 45.9), gastroesophageal reflux disease (GERD), hypertension and sleep apnea presented with multiple failed attempts at medical weight-loss. She was initially interested in a minimally invasive sleeve gastrectomy, but a gastric bypass was recommended due to her history of GERD. A sleeve gastrectomy can worsen heartburn postoperatively, but a gastric bypass is a surgical treatment for both morbid obesity as well as GERD. The patient was evaluated by the bariatric multidisciplinary team at Sibley Memorial Hospital and approved for surgery.

Treatments received

• The patient underwent a minimally invasive Roux-en-Y gastric bypass using the latest camera technology. After her procedure, a new technique was used to test the gastro-jejunal anastomosis for any signs of a leak. A novel fluid solution containing indocyanine green dye was instilled into the stomach, and a laparoscopic camera with near-infrared fluorescence visualization was used to transilluminate the anastomosis. It gave real-time feedback and confirmed no leak was present.

 Patient outcome after surgery

• The patient was kept overnight and discharged the following day after passing an oral fluid challenge. She was seen two weeks later and was feeling well, tolerating a soft diet and already beginning to see weight loss results.

Johns Hopkins Center for Bariatric Surgery at Sibley Memorial Hospital in Washington, D.C., is accredited from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) as a Comprehensive Center with Adult Qualifications. The team performs open and minimally invasive surgery using state-of-the art equipment. In addition to surgery, the multidisciplinary team provides nutrition counseling, exercise training and close follow-up after surgery. 

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Presentation

The condition, lessons for the clinician, poster presentations:, section editor’s note, suggested readings, case 5: a 13-year-old boy with abdominal pain and diarrhea.

AUTHOR DISCLOSURE

Drs Sudhanthar, Okeafor, and Garg have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

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Anjali Garg , Sathyan Sudhanthar , Chioma Okeafor; Case 5: A 13-year-old Boy with Abdominal Pain and Diarrhea. Pediatr Rev December 2017; 38 (12): 572. https://doi.org/10.1542/pir.2016-0223

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A 13-year-old boy presents to his primary care provider with a 5-day history of abdominal pain and a 2-day history of diarrhea and vomiting. He describes the quality of the abdominal pain as sharp, originating in the epigastric region and radiating to his back, and exacerbated by movement. Additionally, he has had several episodes of nonbloody, nonbilious vomiting and watery diarrhea. His mother discloses that several family members at the time also have episodes of vomiting and diarrhea.

He admits to decreased oral intake throughout the duration of his symptoms. He denies any episodes of fever, weight loss, fatigue, night sweats, or chills. He also denies any hematochezia or hematemesis. His medical history is significant for a ventricular septal defect that was repaired at a young age, but otherwise no other remarkable history.

During the physical examination, the adolescent is afebrile and assessed to be well hydrated. Examination of the abdomen reveals tenderness in the epigastric region and the right lower quadrant on light to deep palpation, with radiation to his back on palpation. There are no visible marks or lesions on his abdomen. Physical examination is negative for rebound tenderness, rovsing sign, or psoas sign. The remainder of the examination findings are negative.

Complete blood cell count, liver enzyme levels, pancreatic enzyme levels, and urinalysis results are all within normal limits.

Our patient was asked to observe his hydration status and pain at home and to report any changes. However, he arrived at the emergency department the next day due to increased severity of abdominal pain. The pain had localized into the right lower quadrant. Further imaging revealed the diagnosis.

The differential diagnosis for an adolescent who presents with abdominal pain is broad, including gastrointestinal causes such as gastroenteritis, appendicitis, or constipation and renal causes such as nephrolithiasis or urinary tract infections. With our patient, the more plausible answers were ruled out through laboratory studies and physical examination, and he was assumed to have gastroenteritis based on the history of similar symptoms in his family members. However, with the worsening of his abdominal pain, further diagnostic study became imperative and a computed tomographic (CT) scan of the abdomen was obtained to assess for appendicitis or nephrolithiasis.

The CT scan showed a cecum located midline; the large intestine was on the left side of the abdomen, and the small intestine was on the right ( Figs 1 and 2 ). The appendix was buried deep in the right pelvis, and there was no indication of appendicitis. These findings were consistent with intestinal malrotation. Intestinal malrotation is rare beyond the first year of life. Maintaining a higher index of suspicion in any patient with an acute presentation of severe abdominal pain is imperative because of the severity of potential complications such as bowel obstruction, volvulus, and eventual necrosis. Our patient’s pain is assumed to have been due to compressive effects of the peritoneal bands (Ladd bands), which were irritated by an initial gastroenteritis. He did not have the signs or symptoms of a more severe complication, such as bowel obstruction or volvulus.

Computed tomographic scan of the abdomen showing intestinal malrotation, specifically of the subtype nonrotation. The small bowel is present in the right hemi-abdomen and the large bowel in the left hemi-abdomen. The cecum is midline in the pelvis. Haustra are still present, excluding any sign of obstruction.

Swirling appearance of the mesentery is known as the whirl sign, which is also indicative of malrotation. This computed tomographic scan shows the superior mesenteric vein wrapped around the superior mesenteric artery.

Owing to the severity of the pain, our patient was taken for surgery, specifically, a Ladd procedure and a prophylactic appendectomy. Ladd bands were seen to extend from the cecum to above the duodenum. During the procedure, these bands were lysed, then the mesentery was spread out, and the bowels were rearranged. He tolerated the surgery well and was discharged 3 days after the operation.

His abdominal pain improved after surgery, and he has been doing well at his postoperative checks.

Intestinal malrotation is when the intestines fail to rotate properly in utero. From the fifth to 10th weeks of embryologic development, the small intestine lies in the right aspect of the abdomen, with the ileocecal junction midline, and the large intestine in the left hemi-abdomen. The segments are then pushed out of the abdomen into the umbilical cord. Both segments grow in the first stage of rotation. During the second stage of rotation, the small intestine rotates counterclockwise 270 degrees around the superior mesenteric artery. The remaining intestine is pulled into the abdomen, and the mesentery is fixed to the retroperitoneal space. The large intestine comes in last, with the final segment of the cecum lying anterior to the small intestine in the right lower quadrant.

Nonrotation is the most frequent cause of intestinal malrotation. Nonrotation occurs when the 270-degree rotation does not occur and, thus, the mesentery is not fixed to the retroperitoneal space. Derangements of the second stage of rotation are defined as having the small intestine in the right hemi-abdomen, with the cecum midline in the pelvis, and the large intestine in the left hemi-abdomen.

One percent of the population has intestinal rotation disorders. The incidence decreases with age. Approximately 90% of patients are diagnosed within the first year of their life, with 80% among them within the first month after birth. Due to a delay in diagnosis, the 10% of patients who present beyond that first year after birth can have severe complications.

Symptoms of malrotation are different in infants compared with adolescents. Neonates typically will have bilious emesis. In contrast, children and adults commonly exhibit acute abdominal pain. Some older patients have had chronic abdominal pain that goes unnoticed; others may be asymptomatic before diagnosis. The co-occurrence of intestinal malrotation with congenital cardiac anomalies is a common finding. Twenty-seven percent of intestinal malrotation patients were found to have a concurrent cardiovascular defect such as ventricular septal defect or another minor/major abnormality.

The diagnostic modality of choice is an upper gastrointestinal tract contrast study. This study modality shows any obstruction and depicts the malrotation through contrast media. Sometimes a contrast medium is not needed for diagnosis, as in the case of our patient, where CT scanning was enough to diagnose the malrotation.

Asymptomatic neonates and all symptomatic individuals, regardless of age, go through the Ladd procedure to correct the abnormality. However, the guidelines are not as clear for treatment of children older than 1 year who are asymptomatic. Currently, there is some consensus for performance of the procedure regardless of symptom status because of the severity of the complications or mortality that can occur due to malrotation. The narrow pedicle of the mesentery that forms in malrotation is prone to volvulus and ischemia, leading to complications at any point in an individual’s life. A diagnostic laparoscopy should be performed at the very least and can be therapeutic as well. Removal of the appendix has been suggested to prevent any diagnostic complications on future presentation. Additionally, the Ladd procedure can lyse Ladd bands, which are abnormal fibrous adhesions from the cecum that also arch over the duodenum. Removal of these bands is imperative because they can cause intestinal obstruction and ischemia as well.

Diagnosis of intestinal malrotation should be considered in a patient presenting acutely with severe abdominal pain, especially in a patient with known cardiac anomalies.

Often the symptoms of intestinal malrotation can be vague, and a patient can be asymptomatic for years before presentation.

The diagnostic modality of choice is an upper gastrointestinal tract series, but other imaging, such as computed tomographic scan, can help diagnose the presence of malrotation in emergency situations.

A Ladd procedure should be conducted on a patient even if he/she does not have current symptoms of obstruction due to increased risk of obstruction or complications such as volvulus and gut necrosis with this disease.

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 39th Annual Michigan Family Medicine Research Day Conference in Howell, MI, May 26, 2016.

Poster Session: Student and Resident Case Report Poster Presentation

Poster Number: 23

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 2016 AAP National Conference and Exhibition in San Francisco, CA, October 22-25, 2016.

Poster Session: Section on Pediatric Trainees Clinical Case Competition

Abdominal Pain in Children: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Abdominal-Pain-in-Children.aspx

Diarrhea: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Diarrhea.aspx

For a comprehensive library of AAP parent handouts, please go to the Pediatric Patient Education site at http://patiented.aap.org .

This case was selected for publication from the finalists in the 2016 Clinical Case Presentation program for the Section on Pediatric Trainees of the American Academy of Pediatrics (AAP). Ms Anjali Garg, BS, was a medical student from Michigan State University College of Human Medicine, East Lansing, MI, when she wrote this case report, and she now is a medical resident at Rainbow Babies and Children's Hospital in Cleveland, OH. Choosing which case to publish involved consideration of not only the teaching value and excellence of writing but also the content needs of the journal. Other cases have been chosen from the finalists presented at the 2017 AAP National Conference and Exhibition and will be published in 2018.

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Gastrointestinal Case Studies

Gastrointestinal (GI) disorders refer to conditions affecting the digestive system, including the esophagus, stomach, small and large intestines, liver, pancreas, and gallbladder.

Source: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gastrointestinal-tract

Common GI disorders

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease
• Inflammatory bowel disease (IBD)
• Irritable bowel syndrome (IBS)
• Celiac disease
• Colorectal cancer
• Gallbladder disease
• Pancreatitis
• Gastrointestinal infections (e.g., gastroenteritis)

Symptoms and signs

Symptoms and signs of GI disorders vary depending on the specific condition. Common symptoms may include abdominal pain, bloating, nausea, vomiting, diarrhea, constipation, difficulty swallowing, heartburn, and rectal bleeding.

Diagnostic Investigation

Diagnostic tests for GI disorders may include imaging studies such as endoscopy, colonoscopy, CT scan, MRI, and ultrasound, as well as blood tests, stool tests, and breath tests.

Options for GI disorders may include lifestyle modifications such as dietary changes and exercise, medications, and surgery. Examples of treatment modalities for specific conditions include:

• GERD: proton pump inhibitors (PPIs), H2 receptor blockers, antacids
• Peptic ulcer disease: antibiotics to eradicate H. pylori bacteria, PPIs, H2 receptor blockers, antacids
• IBD: immunomodulators, biologics, corticosteroids, aminosalicylates
• IBS: dietary changes, probiotics, antispasmodics, fiber supplements
• Celiac disease: gluten-free diet
• Colorectal cancer: surgery, radiation therapy, chemotherapy
• Gallbladder disease: surgery to remove the gallbladder (cholecystectomy)
• Pancreatitis: supportive care, pain management, enzyme supplements
• Hepatitis: antiviral medications, liver transplant
• Gastrointestinal infections: antibiotics, anti-diarrheal medications, fluid replacement therapy

Treatment plans are individualized based on the patient’s specific condition and medical history, and may involve a combination of different therapies.

HEALTH & MEDICAL CASE STUDIES (V1.01) Copyright © by Dr. Tranum Kaur is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License , except where otherwise noted.

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• Review Article
• Published: 13 July 2020

Gastrointestinal surgery and the gut microbiome: a systematic literature review

• Suzie Ferrie 1 , 2 ,
• Amy Webster 1 ,
• Betty Wu 3 ,
• Charis Tan 2 &
• Sharon Carey   ORCID: orcid.org/0000-0003-4155-5240 1 , 2  

European Journal of Clinical Nutrition volume  75 ,  pages 12–25 ( 2021 ) Cite this article

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Background/objectives

The impact of gastrointestinal surgery on the profile of the human gut microbiome is not fully understood. This review aimed to identify whether there is a change to the profile of the gut microbiome as a result of gastrointestinal surgery.

Subjects/methods

In August 2018, a systematic literature search was conducted in Medline, PreMedline, Embase, CINAHL and The Cochrane Register of Clinical Trials, identifying and critically appraising studies which investigated changes to gut microbiome pre- and post-gastrointestinal surgery.

Of 2512 results, 14 studies were included for analysis. All studies reported post-surgical change to the microbiome. In 9 of the 14 studies, prevalence of specific bacteria had significantly changed after surgery. Improved outcome was associated with higher levels of beneficial bacteria and greater microbiome diversity post-surgery.

There were methodological limitations in the included studies leading to uncertainty regarding the impact of gastrointestinal surgery alone on the microbiome profile. An ideal future model for research should encompass case-controlled or cohort design with longer term follow-up in a homogeneous patient group. Future research should seek to clarify the gold standard testing method and standardised timing for post-surgical microbiome sample collection. It is imperative that controls for confounders be put in place to attempt to identify the true association between gastrointestinal surgery and changes to gut microbiome.

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Suzie Ferrie, Amy Webster & Sharon Carey

Royal Prince Alfred Hospital, Sydney, NSW, Australia

Suzie Ferrie, Charis Tan & Sharon Carey

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SC was responsible for conceptualisation of the study. AW, SF and SC were responsible for designing study. SC, SF and AW conducted the search, quality assessments and analysis of results. BW, SF and CT were responsible for reviewing the analysis. SF led the interpretation of results with all authors having involvement. AW and SF drafted the paper and all authors contributed to reviewing the paper.

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Ferrie, S., Webster, A., Wu, B. et al. Gastrointestinal surgery and the gut microbiome: a systematic literature review. Eur J Clin Nutr 75 , 12–25 (2021). https://doi.org/10.1038/s41430-020-0681-9

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Received : 31 October 2019

Revised : 09 June 2020

Accepted : 01 July 2020

Published : 13 July 2020

Issue Date : January 2021

DOI : https://doi.org/10.1038/s41430-020-0681-9

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This article has been reviewed according to Science X's editorial process and policies . Editors have highlighted the following attributes while ensuring the content's credibility:

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Road of recovery in gastrointestinal surgery: From ERAS to FRAS

by KeAi Communications Co., Ltd.

In the 1990s, Dr. Henrik Kehlet introduced the concept of enhanced recovery after surgery (ERAS), pioneering multimodal surgical care. Initially applied to patients undergoing colonic surgery, ERAS has also been dedicated to developing multimodal perioperative care to improve patients' recovery after major surgery through research, education, audit and implementation of evidence-based practice, aiming to close the "knowing-doing" gap.

Representing a paradigm shift in perioperative care, ERAS challenges traditional practices, replacing them with evidence-based best practices in perioperative care.

Currently, the debate has shifted away from whether colorectal surgery following ERAS principles or traditional care is superior, towards enhancing the approach and streamlining its implementation. One such improvement involves transitioning patients from a surgical procedure requiring a 3–4 day hospital stay to a 1–2 day, or even same-day outpatient visit.

To this end, a team of researchers from China proposed a new concept called fastest recovery after surgery (FRAS) and implemented it in clinical practice to expedite recovery in patients undergoing elective major gastrointestinal surgery, building upon existing ERAS protocols.

"FRAS is a series of strengthened multimodal perioperative care pathways to optimize physiologic function, minimize surgical stress response, improve response to stress, and facilitate fastest postoperative recovery with improving comfort and satisfaction," explains Xiaohuang Tu, co-corresponding author of the study.

The researchers conducted pilot studies comparing short-term outcomes between FRAS and ERAS, and found that FRAS demonstrated "zero" complications, significantly reduced hospital stay duration, substantial cost savings and notably superior perioperative comfort and satisfaction.

The team reported their study in the journal Gastroenterology & Endoscopy .

"Considering the evidence underpinning the recommendations is continuously evolving, clinical guidelines need to be challenged and updated on a regular basis. More clinical evidence from high quality of randomized controlled trials or real-world medical data with large sample size are needed," notes Tu.

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CASE REPORT article

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Changing Backgrounds and Groundbreaking Changes: Gynecological surgery in the third decade of the 21st century Volume II

A rare case of Malacoplakia resembling a malignant tumor of the cervix: a case report and review of the literature Provisionally Accepted

• 1 Department of gynecology, Ningbo No. 2 Hospital, China

The final, formatted version of the article will be published soon.

Malacoplakia is a rare chronic granulomatous disease that mostly affects the gastrointestinal tract and urinary tract of immunocompromised patients; malacoplakia rarely effects the female reproductive tract. Here, we report a 56-year-old patient who underwent thymectomy for thymoma and myasthenia gravis prior to developing cervical and vaginal malacoplakia. The patient presented with recurrent vaginal bleeding.. We discovered that there were alterations in the cervical cauliflower pattern during colposcopy, which is suggestive of cervical cancer. Pathological examination of the lesion tissue showed that a large number of macrophages aggregated, and M-G bodies with concentric circles and refractive properties were observed between cells.Immunostaining for CD68 and CD163 was positive, and special staining for D-PAS and PAS was positive. The discovery of Escherichia coli in bacterial culture can aid in the diagnosis of malacoplakia. Following surgery, we performed vaginal lavage with antibiotics in addition to resection of local cervical and vaginal lesions. This study provides a fresh perspective on the management of genital malacoplakia.

Keywords: Malacoplakia, malignant tumor of the cervix, Pathology, Vaginal bleeding, case report

Received: 29 Mar 2024; Accepted: 13 May 2024.

Copyright: © 2024 Li, Mi, Wang and ZHUO. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: PhD. Zhihong ZHUO, Department of gynecology, Ningbo No. 2 Hospital, Ningbo, China

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Rapunzel syndrome in children: a retrospective review of ten cases combined with literature review in a tertiary referral center

• Original Article
• Published: 04 May 2024
• Volume 40 , article number  121 , ( 2024 )

Cite this article

• Yiyuan Liang 1 ,
• Liuming Huang 1 ,
• Dayong Wang 1 ,
• Tingting Liu 1 ,
• Xianling Li 1 ,
• Wei Wang 1 ,
• Qiulong Shen 1 ,
• Jinbao Han 1 ,
• Shuanling Li 1 ,
• Li Wang 1 &
• Long Chen 1  

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Rapunzel syndrome is an uncommon condition in children, and its clinical features remain unclear. This study presents the largest single-center series of pediatric cases to date, with the objective of documenting the clinical characteristics and treatment approaches for children with Rapunzel syndrome.

A retrospective study was conducted in children with Rapunzel syndrome from 2019 to 2023. We recorded age, gender, symptoms, locations of bezoar, complications, and treatment options.

Ten patients with Rapunzel syndrome were included. The median age was 9.1 years, with all of whom were female. The most common clinical symptoms were upper abdominal mass (90%), abdominal pain (80%), and nausea and vomiting (50%). Complications occurred in six cases (60%), including small bowel obstruction (20%), severe gastric dilatation (10%), intestinal perforation (10%), choledochodilation (10%), acute pancreatitis with cholecystitis (10%). Preoperative ultrasonography suggested low-echoic foreign bodies continuing to the jejunum or ileocecal region in five cases (50%). Preoperative gastroscopy attempted in four cases (40%) to remove the foreign bodies, all of which failed. All patients underwent surgical treatment, with nine cases undergoing gastric incision foreign body removal, and one case undergoing gastric incision foreign body removal combined with intestinal perforation repair. All patients recovered well. No recurrence was observed during follow-up.

The accuracy of ultrasound diagnosis in identifying Rapunzel syndrome is high; however, it may lead to misdiagnosis if not complemented with the patient’s medical history. Endoscopic presents a heightened treatment risk and a reduced success rate. The condition commonly presents with severe complications, thus making laparotomy a safe and effective option for intervention.

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Gastrointestinal trichobezoars in the pediatric population: a retrospective study

The role of endoscopic ultrasound in children with pancreatobiliary and gastrointestinal disorders: a single center series and review of the literature.

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Yiyuan Liang, Liuming Huang, Dayong Wang, Tingting Liu, Xianling Li, Wei Wang, Qiulong Shen, Jinbao Han, Shuanling Li, Li Wang & Long Chen

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Yiyuan Liang: Visualization; writing – original draft. Dayong Wang，Tingting Liu，Xianling Li: Data curation;resources; software. Wei Wang，Qiulong Shen，Jinbao Han: Data curation; formal analysis;resources. Shuanling Li ， Li Wang，Long Chen: Data curation; formal analysis; visualization; Liuming Huang: Conceptualization; project administration;supervision. All authors reviewed the manuscript

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Liang, Y., Huang, L., Wang, D. et al. Rapunzel syndrome in children: a retrospective review of ten cases combined with literature review in a tertiary referral center. Pediatr Surg Int 40 , 121 (2024). https://doi.org/10.1007/s00383-024-05705-0

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DOI : https://doi.org/10.1007/s00383-024-05705-0

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