The SCARE 2018 statement: Updating consensus Surgical CAse REport (SCARE) guidelines

The management of esophago-gastric necrosis due to caustics ingestion: Anastomotic reinforcement with Cyanoacrylate glue and damage control with Vacuum Assisted Closure Therapy-A case report

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Optimal timing to treat esophago-gastric necrosis due to caustic ingestion.

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Proposal of three steps approach to manage esophago-gastric necrosis.

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Use of Cyanoacrylate glue to reinforce anastomosis.

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Vacuum Assisted Closure for damage control after surgery.

Introduction

The surgical treatment of a complete gastric necrosis due to caustic ingestion is extremely challenging and life threatening. In this emergency scenario, a first-time reconstruction of the gastrointestinal tract is often dangerous for the patient because of the high risk of infections and anastomosis leakage. Literature lacks of clear indications for the management of this condition.

Presentation of case

Male patient with history of major depression disorder was admitted to our Emergency Unit after the ingestion of muriatic acid. CT scan showed massive pneumo-peritoneum with esophago-gastric thickening. Free fluids in the abdominal cavity were detected. Intraoperative finding was a complete necrosis of the stomach and corrosion of the lower esophagus.

Discussion

In this case report we proposed a first approach with the drainage and lavage of the abdomen cavity. Then, an esophago-jejunum anastomosis reinforced by Cyanoacrylate glue was performed and a damage control with VAC therapy (Vacuum Assisted Closure) was carried out.

Conclusion

Cyanoacrylate glue could be considered useful and efficient in the reinforcement of anastomosis even in emergency surgical procedures. Damage control using VAC allows to keep a good control of the surgery performed.

Mixed neuroendocrine and squamous cell carcinoma of the colon: A case report and literature review

INTRODUCTION

The occurrence of Neuroendocrine Carcinoma (NEC) of the colon is <2% of all colon cancers. Squamous Cell Carcinoma (SCC) is even more unusual and has an occurrence in the colon as low as 0.1% of colon cancers. Coupled together mixed NEC-SCC, is nearly unheard of. SCC of the gastrointestinal tract is usually found in the esophagus and rectum, rarely are there squamous cells even present in the colon.

PRESENTATION OF CASE

A 62-year-old female presented with abdominal pain and a palpable mass in the left lower quadrant. CT scan revealed a poly-lobulated mass in the left abdomen attached to the left colon. A left hemicolectomy was performed. There were no distant metastases at the time of diagnosis. Microscopic examination revealed NEC mixed with SCC demonstrated by keratin pearl formation.

DISCUSSION

NEC and SCC individually are unusual in the colon but together are extraordinarily rare. Histologically, the NEC in this case demonstrated squamous cell differentiation with keratin pearl formation. The median survival in studies of patients with colonic NEC is 5-10 months due to the aggressive behavior and lymph node metastases, which were present in this case. There is insufficient literature addressing ideal adjuvant therapy after resection of mixed NEC and SCC of the colon.

CONCLUSION

We present the first case of primary colon mixed NEC and SCC which presented as abdominal pain. There is a current absence of ideal therapy recommendations in the medical literature following resection of mixed NEC and SCC of the colon.

Bilateral spontaneous simultaneous femoral neck occult fracture in a middle-aged man due to osteoporosis and vitamin D deficiency osteomalacia: A case report and literature review

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Physicians should take spontaneous femoral neck occult fracture into consideration if they report groin pain or difficulty in walking, even when findings from plain X-ray are normal.

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In a patient with spontaneous femoral neck occult fracture, diagnosing and treating the underlying etiology of osteoporosis and osteomalacia are essential for improving prognosis.

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This is the first report of a case of bilateral spontaneous simultaneous occult fracture of the femoral neck caused by osteoporosis and osteomalacia in a middle aged man.

Introduction

Bilateral stress fracture of the femoral neck is very rarely seen in healthy young patients who are neither athletes nor military recruits.

Presentation of case

The present report describes a 51-year-old male patient, not an athlete and with no previous history of disease, who developed bilateral stress fracture of the femoral neck without displacement.

Discussion

Simultaneous bilateral femoral neck fracture is a rare injury. In the present case, two factors predisposed to bilateral occult fracture of the femoral neck. The first was osteoporosis due to the patient’s smoking and alcohol abuse. The second was vitamin D deficiency osteomalacia associated with inadequate sun exposure.

Conclusion

All patients who present with spontaneous hip pain should be evaluated for osteoporosis and osteomalacia and assessed for underlying occult fracture if they report groin pain or difficulty in walking, even when findings from plain X-ray are normal, to improve prognosis in this rare and serious condition.

Perforated mucocele of the appendix in the left upper quadrant: A challenging anatomy and an improvised surgical technique

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Pseudomyxoma peritonei (PMP) is a devastating consequence of perforated appendicular mucocele. It is considered a rare disease.

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The presence of asymptomatic gut malrotation in adults can complicate the clinical picture of acute abdomen. ** (starting a new highlight point): Not considering possible anatomical variations initially during assessment could delay the diagnosis and managment.

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The introduction of Cytoreductive Surgery/Heated Intraperitoneal Chemotherapy (CRS/HIPEC) improved the outcome of many patients with PMP.

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Preserving part of the colon during challenging colorectal resection to allow a colo-rectal anastomosis offers a superior quality of life.

Introduction

Pseudomyxoma peritonei (PMP) is a feared complication of appendicular mucocele perforation. Although a rare disease, its major sequel mandates recognition and early intervention. Intestinal malrotation is mostly asymptomatic in adults. Its significance arises when it complicates another coinciding condition by confusing the presentation, leading to delay in diagnosis and treatment. PMP and incidental finding of gut malrotation in adults are two rare events, and the chance of both occurring in the same patient is very slim. This can complicate the clinical picture and lead to devastating outcomes.

Presentation of the case

We present a case of PMP in a patient with gut malrotation, managed with cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC).

Discussion

Management with CRS/HIPEC has been found to improve outcomes for patients with PMP. However, the extensive disease and abnormal anatomy of the patient in our report proposed unique intraoperative challenges. Preserving part of the colon was possible with an improvised surgical technique that we used which proved to be safe and effective.

Conclusion

Early recognition and consideration of uncommon but serious surgical conditions are essential for improved patient outcomes. To our knowledge, this is the first report in the English literature that describes the use of CRS/HIPEC for PMP in a case of intestinal malrotation. This improvised surgical technique was found to be safe and can provide a surgical solution for preserving part of the colon in selected patients.

Buccal oncocytoma: Report of a case and literature review

Introduction

More common in major salivary glands, oncocytomas are very rare tumors. They commonly occur in the parotid gland and are painless slow growing predominantly benign tumors. The term “oncocytoma” was introduced by Jaffe to designate those tumors of the salivary glands that consist predominantly of oncocytic cells lining the salivary ducts (1) Similalry, Meza- Chavez had proposed the name “oxyphilic granular cell adenoma. (2) Oncocytomas are extremely rare, benign and slow growing in nature. Here we present a rare case of buccal oncocytoma which is to our knowledge the 19th case of intraoral minor salivary gland tumor and the 7th reported case of buccal oncocytoma.

Case presentation

Here we present an exceedingly rare case of buccal oncocytoma in a 14 years boy who presented to the department of ENT with right buccal swelling for 6 months. He was posed the diagnosis of buccal cyst after cytological examination supported by CT scan. He then underwent an excisional biopsy where the final diagnosis was made as Buccal Oncocytoma.

Conclusions

Though very rare in the picture, conditions like salivary gland oncocytomas still are reported on and off in the literature. The treatment of which is complete surgical excision.

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Buccal oncocytoma is one of the rare entities salivary gland oncocytoma.

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So far only 6 cases of buccal oncocytoma has been mentioned in literature.

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The definitive treatment is surgical excision.

Jejunal GIST: Hunting down an unusual cause of gastrointestinal bleed using double balloon enteroscopy. A case report

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Bleeding jejunal GIST is very rare with only a handful of published case reports.

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Double-balloon enteroscopy and capsule endoscopy can be used to diagnose bleeding small intestine GIST.

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Occult small bowel bleeding can go undetected for years.

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Age is one of the determining factors for the type of small bowel pathology detected.

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Surgical resection remains the mainstay treatment for GIST.

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Laparoscopic surgery offers similar oncologic outcomes as an open surgery.

Introduction

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms of the alimentary tract but accounts for only 0.1–3% of all gastrointestinal neoplasms. The most common presentation of GISTs is acute or chronic gastrointestinal bleeding, in which the patient presents with symptomatic anaemia.

Presentation of case

With that in mind, we describe a 66-year-old man who presented with recurrent episodes of obscure gastrointestinal bleeding for two years. Video capsule endoscopy (VCE) showed several small telangiectasias in the proximal small bowel. Oral route double-balloon enteroscopy (DBE) revealed abnormal mucosa 165 cm from incisor with central ulceration and vascular component. He subsequently underwent surgical excision. The histopathological report confirmed the diagnosis of GIST arising from the jejunum. During his clinic follow up, he remains symptom-free with no evidence of recurrence.

Discussion

The diagnosis of bleeding small intestine GISTs can be challenging as these are inaccessible by conventional endoscopy. Imaging modalities such as double-balloon enteroscopy, capsule endoscopy, CT angiography, intravenous contrast-enhanced multidetector row CT (MDCT) and magnetic resonance enterography (MRE) have been used to assist in the diagnosis of bleeding small intestine GISTs. The mainstay of management for small intestine GIST is complete surgical excision.

Conclusion

Bleeding jejunal GIST is very rare and only a handful of case reports have been published. The mainstay of management for small intestine GIST is complete surgical excision. It is essential to obtain a complete excision of localised disease and avoiding tumour spillage in order to reduce the risk of local recurrence and metastatic spread of GISTs.

Pericecal hernia in a pediatric patient: Case report and literature review

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Pericecal hernia is a rare type of internal hernias accounting for 0.1–6.6% of all internal hernias.

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Pericecal hernia is rare in pediatric patients, clinical presentation depends on the degree of bowel obstruction.

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Keeping in mind the radiation risks. CT scan is the key for internal hernia diagnosis and management.

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High index of clinical suspicion and early intervention saves the patient from extensive bowel resection.

Introduction

Pericecal hernia is a rare cause of small bowel obstruction. They tend to affect the adult population more commonly but also may occur in the pediatric age group.

Case presentation

We herein present a 16-year-old male who presented with 4 days of abdominal pain and distention. CT scan revealed evidence of dilated small bowel loops with evidence of ischemia. A laparotomy was performed and revealed a 20 cm segment of distal ileum protruding through the superior ileocecal recess. Ileocecectomy with primary side to side anastomosis was successfully performed and the patient recovered uneventfully after the procedure.

Discussion

Although internal hernias may have a congenital etiology, most of the reported cases have occurred during adulthood and its presentation in childhood is uncommon. CT scan is the key for internal hernia diagnosis and management as it provides information about the presence of bowel obstruction, strangulation, and ischemia.

Conclusion

High index of clinical suspicion and early intervention saves the patient from extensive bowel resection and other serious complications.

Challenges in the management of adenocarcinoma of ampulla of Vater in pregnancy: A case report and review of literature

INTRODUCTION

Ampullary adenocarcinoma is a rare entity during pregnancy. It accounts for 0.5% of all gastrointestinal malignancies. The best treatment modality for resectable tumors with the best reported outcome is surgical resection in the form of pancreaticoduodenectomy (Whipple procedure). In this case report, we discuss the challenges in the management of ampullary adenocarcinoma in a pregnant patient.

CASE PRESENTATION

We report a case of 22 years old pregnant women who presented with vague abdominal pain and jaundice at the 28th week of gestation. Endoscopic retrograde cholangiopancreatography (ERCP) showed a stricture around the ampulla and distal common bile duct (CBD). The CBD was stented and a biopsy was taken. Histopathology revealed: an invasive adenocarcinoma. The patient was managed by elective pancreaticoduodenectomy after induction of vaginal delivery at the 34th week of gestation.

CONCLUSION

Diagnosing and managing ampullary adenocarcinoma in pregnant patients in their 3rd trimester is challenging. Yet, a delayed viable delivery followed by a definitive surgery in the form of pancreaticoduodenectomy offers the best outcomes for both the mother & fetus in case of early stage disease.

Hydatid cyst of the calf presenting as painless mass: A case report

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Hydatid disease is endemic in certain parts of the globe.

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High index of suspicion is required for the diagnosis of this disease specially in rare anatomical sites like the calf.

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Involvement of other organs must be excluded as the disease may affects many organs simultaneously.

Background

Hydatid disease is a zoonotic disease that is transmitted to the human by ingesting the eggs of the parasite Echinococcus granulosus, it most commonly affects the liver but every organ could be affected, musculoskeletal system involvement occurs in 0.5–4% of patients. Most patients present as soft tissue mass in the affected muscle.

Preoperative diagnosis usually done radiologically by ultrasound or MRI examination.

Case presentation

We present a 60-year-old lady presented with painless mass in the right calf for 2 years.

The mass was soft, non-tender, mobile from side to side. Ultrasound of the mass showed cystic lesion that contained multiple small cysts inside, and the diagnosis of hydatid disease was made before surgery.

During surgery and after opening the mass the lesion appeared to be hydatid cyst containing innumerable daughter cysts. Complete evacuation of the all the daughter cysts done. The patient discharged next day with no postoperative complications.

The patient received postoperative albendazole therapy for 2 months and follow up done 6 months after surgery with no complications.

Conclusion

Hydatid disease should be thought when patients present with mass lesion in any part of the body especially in endemic areas. The most important step in the diagnosis is to exclude the presence of other cysts in other parts of the body.

Paraganglioma of the spermatic cord: A case report and literature review

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A paraganglioma, or an extra-adrenal catecholamine-producing tumor, is a clinically significant neuroendocrine tumor with an incidence of 3–8 cases per million population.

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The majority of paragangliomas, 85–90%, occur in the adrenal glands and 98% are found in the abdomen.

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Unlike pheochromocytomas, where only 10% are malignant, paragangliomas carry a 40–50% malignancy rare, and their development is part of a hereditary syndrome in 30% of cases.

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The most common hereditary syndromes associated with paragangliomas are von Hipple-Lindau (VHL), multiple endocrine neoplasia 2 (MEN 2) and neurofibromatosis type 1 (NF1).

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Herein we describe and review the 13th paraganglioma documented arising from the spermatic cord.

Introduction

Neuroendocrine tumors are a diverse and well-described entity with most arising from the gastrointestinal tract. A clinically significant example is the paraganglioma, or an extra-adrenal catecholamine-producing tumor.

Presentation of case

Herein we describe and review a paraganglioma arising from the spermatic cord in a 55 year old asymptomatic man.

Discussion

Paragangliomas are rare, with an incidence of 3–8 cases per million population. To date there are only 12 cases found in the literature.

Conclusion

In this article, we review our patient’s presentation, follow-up, and screening followed by a review of the literature of this fascinating tumor. Although rare, paraganglioma should be considered in the differential diagnosis of unusual groin masses. This work has been reported in line with the SCARE criteria (Agha et al., 2018).

Torsion of wandering spleen treated by laparoscopic splenopexy: A case report

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Wandering spleen.

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Laparoscopic splenopexy.

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Torsion of splenic pedicle.

Introduction

A wandering spleen is a mobile spleen as a result of deficient splenic peritoneal ligaments and elongation of its vascular pedicle. It is a rare entity affecting mainly young adults commonly females and children, presenting as an asymptomatic abdominal mass or abdominal discomfort due to torsion and de-torsion of the pedicle.

Presentation of case

We report a 35-year-old female presented with intermittent colicky abdominal pain that worsened in severity over three weeks. Diagnostic laparoscopy showed torsion of spleen without infarction. Detorsion and Splenopexy in an extra-peritoneal pouch was performed. Post operatively, the patient recovered well and was healthy at two months follow up.

Discussion

A wandering spleen is either congenital or acquired. The condition results in a long vascular pedicle, which predispose to the torsion resulting in a partial or complete infarct of the spleen. Laparoscopic approach is the preferred technique and de-torsion of the splenic pedicle and splenopexy is a reasonable surgical option, when there is no evidence of infarction of the spleen.

Conclusion

The diagnosis of wandering spleen is very rare and extremely difficult to establish and is clinically nonspecific. An early diagnosis and surgical care are required for preserving the spleen. Additional imaging examinations can help establish a diagnosis.

Metachronous isolated locally advanced pancreatic metastasis from chromophobe renal cell carcinoma

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Isolated pancreatic metastasis from renal cell carcinoma is relatively rare and it's usually seen in clear cell renal cell carcinoma (CCRCC), but its occurrence from chromophobe renal cell carcinoma is extremely rare.

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Pancreatic location is often diagnosed during routine surveillance imaging for the primary lesion.

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Patients in whom the pancreas is the only metastatic site and who are fit enough to undergo pancreatic surgery appear to be good candidates for the surgical treatment chemotherapy can improve the quality of life but not survival.

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It is necessary a long- term follow-up for patients treated for tumors with known low-grade metastatic potential and relatively good prognosis such as chromophobe renal cell carcinoma.

Introduction

Metastasis to the pancreas is relatively uncommon occurrence. Isolated pancreatic metastasis from renal cell carcinoma (RCC) is relatively rare and it’s usually seen in clear cell renal cell carcinoma (CCRCC), but its occurrence from chromophobe renal cell carcinoma (chRCC) is extremely rare, due to its relatively low-grade metastatic potential.

Presentation of case

The authors report an unusual case of metachronous isolated pancreatic metastasis, in a 65-year-old female patient two years after left nephrectomy for chRCC, diagnosed during routine surveillance imaging and confirmed after a CT-guided pancreatic biopsy.

Discussion

The pancreas is an elective site for metastases from RCC, and this particularity has been reported by several studies, but only described for CCRCC. In the English literature there is only one case of pancreatic metastasis from chRCC diagnosed in an autopsy study. Surgical resection of metastasis remains the most effective treatment, particularly for pancreatic metastases from chRCC, since radiotherapy, chemotherapy, hormonal therapy, and targeted therapy have generally proved ineffective for metastatic chRCC. In case of an unresectable disease, surgical or endoscopic palliation in association with palliative chemotherapy can improve the quality of life but not survival.

Conclusion

This case highlights the unique behavior of chRCC with an unusual site of metastasis, and the necessity of long-term follow-up after primary tumor removal, even if it is known for a low-grade metastatic potential and a relatively good prognosis.

Laparoscopic intrapancreatic accessory splenectomy: A case report of recurrent immune thrombocytopenia in a 33 years old male patient after 6 years of splenectomy

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Intrapancreatic Accessory Spleen (IPAS) is a rare embryological benign abnormality.

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(IPAS) should be considered in patients with recurrent immune thrombocytopenia (ITP).

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Although IPAS is a challenging diagnosis, it can be detected by the recent advancement of medical imaging.

Introduction

Intra-pancreatic Accessory Spleen (IPAS) is a rare benign abnormality of splenic embryology that should be considered in any patient with recurrence of immune thrombocytopenia (ITP). The case demonstrates that remission could be achieved if an IPAS is correctly identified and safely removed.

Case presentation

We report a 33-years-old male patient who presented with chronic ITP relapsed 3 years post initial splenectomy. The patient presented with severe thrombocytopenia requiring steroids and intravenous immunoglobulin (IVIG).

Discussion

IPAS can be identified using enhanced CT scan along with Tc-99 m sulfur colloid scintigraphy. Our patient underwent CT scan of abdomen and pelvis and was found to have an IPAS originating from the tail of the pancreas which was subsequently removed laparoscopically. The patient was then tapered off steroids and was followed up regularly and found to have acceptable platelet levels and no symptoms for 30 months post-surgery.

Conclusion

The diagnosis of IPAS can be non-invasively made by an experienced radiologist with the recent advancement of medical imaging. Recognizing IPAS as a possible cause of ITP recurrence, and using minimally invasive approach can be performed safely and lead satisfactory outcomes.

Intraoperative aortic endograft placement for an unexpected plaque rupture during lung surgery

BACKGROUND

Surgical resection of tumors invading the aorta is a challenging procedure. More recently, the use of thoracic aortic endografts has been reported to facilitate en bloc resection of tumors invading the aortic wall. The best treatment option is to keep the procedure separated before lung resection to reduce the risks of bleeding, therefore avoiding adverse consequences for the patient. However, an aortic stent placement before surgery is not mandatory with no clear signs of tumor or atherosclerotic plaque infiltrating the entire aortic wall.

CASE PRESENTATION

A 72-year-old man came to our Department for a persistent cough. Computed tomography (CT) scan with enhancement showed a mass located in the left upper lobe of the lung with no clear sign of infiltration or calcified plaques along the entire vascular wall. A positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-d-glucose integrated with computed tomography (PET/CT with 18F-FDG) was positive for hypermetabolic mass with negative lymph node stations bilaterally. Patient was undergone surgery for major lung resection by left thoracotomy. For an unexpected intraoperative bleeding due to the rupture of a calcified plaque, a stent was placed before proceeding with lung surgery. Patient was persistently stable, discharged after six days from surgery with no morbidities.

CONCLUSIONS

In our case, no signs of the atherosclerotic plaque infiltration as well as no tumor infiltration were shown. In these situations, the aortic stent placement is possible in emergency, even during another operation. Nevertheless, surgeon experience and the good coordination among specialists is mandatory to yield a satisfying solution.

Robot-assisted Toupet fundoplication and associated cholecystectomy in symptomatic giant hiatal hernia with situs viscerum inversus-A case report and literature review

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All symptomatic paraesophageal hiatal hernias should be repaired, particularly those with acute obstructive symptoms or which have undergone volvulus.

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Laparoscopic hiatal hernia repair is as effective as open transabdominal repair, with a reduced rate of perioperative morbidity and with shorter hospital stays. It is the preferred approach for the majority of hiatal hernias.

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Robotic Assisted Giant-Paraesophageal Hernia repair remain technically challenging predominantly in the dissecation of the hernia sac from the posterior mediastinum.

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The robotic platform have the same benefits of the laparoscopic approach in terms of complication rate, total surgical time, and hospital length of stay and in particular case is superior.

Introduction

Giant hiatus hernia is defined as migration of >30% of the stomach with or without other intra-abdominal organs into the chest. Situs Viscerum Inversus is a rare congenital condition in which the major visceral organs are reversed from their normal arrangement; they are translated (completely or partially) on the opposite side of the body. Diagnosis is often incidental. We report a Robot-assisted Toupet fundoplication for a giant hiatal hernia with gastro oesophageal reflux disease and cholelithiasis, in a 63-years-old woman with situs viscerum inversus.

Presentation of case

A 63-year-old woman with Situs Viscerum Inversus was diagnosed with giant sliding hiatus hernia. We performed a Robot-assisted procedure of reduction of hiatal hernia in abdomen and Toupet fundoplication with Bio A mesh placement and gastropexy procedure associated to cholecystectomy. The operation time was of 190 min. The patient was discharged on third postoperative day after X-ray check and he tolerated a solid food.

Discussion

Minimally invasive surgery represents, nowadays, the standard approach for hiatal hernia and cholelithiasis.

Conclusion

In challenging cases as the giant hernias ad rare anomaly as situs viscerum inversus, the surgical treatment can be facilitated by the use of robotic technology.

Malignant fibrous histiocytoma, now referred to as Undifferentiated Pleomorphic Sarcoma: A Case Report of an unexpected histology of a subcutaneous lesion

INTRODUCTION

An 85year old male presented to his General Practitioner with a vague history of a lump on his back that was mobile and non tender. He had a previous history of advanced prostate cancer and radiotherapy treatment.

PRESENTATION

We present an unexpected diagnosis of malignant fibrous histiocytoma of a subcutaneous lesion removed from the patient's back.

DISCUSSION

Excisions of subcutaneous lesions along with cutaneous lesions form the majority of cases on a usual minor operations list. All lesions are sent for histopathological analysis and most are confirmed benign sebaceous cysts or lipomas. However the entity of malignant fibrous histiocytoma, now referred to as undifferentiated pleomorphic sarcoma (UPS) should be kept in mind. Patients will usually present late with advanced local disease or metastasis, usually to lungs and lymph nodes. Treatment is surgical with wide local excision and neoadjuvant/adjuvant radiotherapy has been advocated as well.

CONCLUSION

Undifferentiated pleomorphic sarcoma should be a differential in subcutaneous lesions in older adults with a previous history of malignancy, radiation therapy and a mass in the subcutaneous tissue of the back.

Metastatic testicular retroperitoneal teratoma in an adult: Case report

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Differential diagnoses of retroperitoneal masses should remain wide in adults.

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Teratomas should be considered as a potential cause of abdominal pain and distention in young adults.

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Testicular examination and past history of any intervention should be sought inn any retroperitoneal masses.

Introduction

Teratomas are bizarre neoplasms derived from embryonic tissues typically found in the gonads and sacrococcygeal tissues of adults.

Case presentation

We report a case of histologically proven metastatic teratoma with an unusual presentation. The 32-year old male patient had a retroperitoneal tumour detected on computed tomography during the workup of abdominal pain.

Discussion

Retroperitoneal teratomas are uncommon and a challenge to manage. Differential diagnoses could be a dilemma without a thorough history and a high index of suspicion.

Conclusions

Recurrent metastatic teratoma is one of the rare differential diagnoses of any retroperitoneal mass and can present years after complete resection of the primary tumour.

Left side gallbladder with agenesis of right anterior sector and absence of right hepatic duct. A case report

INTRODUCTION

Left sided gallbladder is a rare congenital abnormality more often discovered as incidental finding during laparoscopic cholecystectomy requiring surgical challenge to prevent complication. We present a case of a true left sided gallbladder treated with laparoscopic cholecystectomy.

CASE

A 90 y/o woman with acute abdominal pain was hospitalised and underwent a laparoscopic cholecystectomy. A preoperative CT scan didn't show the variation. Intraoperative finding revealed a true left sided gallbladder that was carefully dissected at the Calot's triangle with identification of the cystic duct and artery. After a complete separation of the gallbladder from the liver, the cystic duct and the artery were safely clipped and transected. CT scan reconstruction reveal agenesis of the right superior sector with simultaneous absence of the right biliary duct.

DISCUSSION

True left sided gallbladder is defined as one attached in the left of the ligamentum teres and falciform ligament. This abnormality predispose to a numerous anatomical variation. Unfortunately its finding is more often incidentally during intervention and recognition of such variation could be difficult that can be of high risk for surgical injury.

CONCLUSION

Left sided gallbladder presents a significant challenge to the surgeon and makes it even more difficult to avoid postoperative complications. Therefore, a careful dissection of Calot's triangle and the complete mobilisation of the gallbladder should be done before clipping the cystic duct and artery. However, if a preoperative finding suggests a left sided gallbladder, then an in-depth preoperative anatomical study is advocated.

Giant myxoid liposarcoma of the stomach: Report of a case

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Myxoid liposarcoma of the stomach is extremely rare.

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The tumor in the present case was too large to confirm its origin.

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Imaging findings of liposarcoma vary, and few reports have described gastric liposarcoma with a huge cyst.

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Even for large tumors, curative resection can provide the patient a good prognosis.

Introduction

Liposarcoma is one of the most common soft tissue sarcomas in adults, but liposarcoma arising primarily from the stomach is very rare.

Presentation of case

A 56-year-old man was referred to our hospital with abdominal distension and discomfort. A computed tomography scan showed a huge mass located between the stomach and transverse colon. The preliminary differential diagnoses were sarcoma with a mucinous component, gastrointestinal stromal tumor, lymphangioma, and mesenteric cyst. Upper and lower endoscopy was not performed because the patient declined. The patient underwent surgical resection, and the tumor was completely removed. Macroscopic examination revealed a 39- × 26- × 20-cm tumor weighing 13,000 g. On histological examination, the tumor was diagnosed as a myxoid liposarcoma in the gastric submucosa. The patient was still doing well 2 years postoperatively.

Discussion

Preoperative diagnosis of liposarcoma of the stomach is difficult. In the present case, the tumor was very large but was able to be resected completely.

Conclusion

Even in patients with very large myxoid liposarcoma, curative resection can provide a good prognosis.

Tension hemothorax due to iatrogenic subclavian artery perforation: Hybrid management of a very rare complication

BACKGROUND

Tension hemothorax is a rare event, due to different causes: trauma, ruptured thoracic aorta aneurysms, or as a complication of central venous line placement due to inadvertent artery puncture or cannulation. Tension hemothorax leads to both hypovolemic and obstructive shock and can require emergency management.

PRESENTATION OF CASE

A 63 years old lady underwent a complicated surgical procedure for a postoperative small bowel obstruction after radical cystectomy. During the procedure, a central venous catheter was placed, under ultrasound guidance, in the right jugular vein but an unknown puncture of the right subclavian artery occurred. In the early phase of the postoperative course, a hypovolemic/obstructive shock developed because of a tension hemothorax. The patient underwent an emergency thoracotomy in the hybrid room, followed by an endovascular repair of the arterial laceration. A recurrent hemothorax developed a few hours later because of an endoleak that was treated successfully with a second endovascular approach and a balloon dilatation of the stent.

CONCLUSIONS

tension hemothorax due to inadvertent subclavian artery laceration can be life-threatening and should be managed in a hybrid room with endovascular and surgical capabilities.

Metastasis of endometrial cancer to right hemidiaphragm: A case report

INTRODUCTION

Tumors of the diaphragm are uncommon. The overwhelming number of cases is metastatic combined with metastases to the liver, lungs and other organs. Only a minority of cases are described as solitary lesions.

CASE PRESENTATION

Fifty-five years old female with a history of radical curative surgery for pT3N0M0 endometrial cancer eight years ago was admitted to the Department of Thoracic Surgery with a feeling of discomfort in the right hypochondrium. The contrast-enhanced MDCT revealed a large, well-circumscribed lesion of the right hemidiaphragm deforming upper contour of the liver. A clear boundary between the lesion and the liver suggested former's diaphragmatic origin. PET-CT did not show any distant metastasis. Intraoperative revision revealed a tumor growing from the dome of the diaphragm with well-defined contours and without any signs of lung involvement. The diaphragmotomy was performed. The morphological study with immunohistochemistry showed an endometrial carcinoma metastasis to the diaphragm.

CONCLUSION

The diaphragm lesions can have various etiology, but a probability of tumor metastasis after a previous radical surgery should not be excluded. Preoperative differential diagnostics can be difficult, leaving surgical treatment followed by a pathology study as the most informative diagnostic method of tumor morphology.

Intercostal hemangioma: Case report of a rare chest wall tumor in childhood

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Intercostal hemangioma is an extremely rare disease, accounting for approximately 0.01% of all benign hemangiomas.

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Hemangiomas are prone to bleed spontaneously or after minor traumatic injury.

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Complete excision of the tumor is mandatory even after embolization to prevent recruitment of a collatera1 blood supply.

Introduction

Intercostal hemangioma is an extremely rare disease. It is difficult to distinguish intercostal hemangioma from other chest wall tumors. The difficulty in preoperative diagnosis may result in incomplete surgical resection and hence a high rate of recurrence.

Case presentation

A 14-year-old boy who presented with asymptomatic right lateral chest wall mass with no history of trauma. Different radiological modalities were employed for diagnosis including computed tomography (CT) showed a soft tissue mass 6.5 × 4 × 5.6 cm in size abutting 5th and 6th ribs. Magnetic resonance imaging (MRI) revealed iso-intense signal in T1 and hyperintense signal in T2, that is higher than that of adjacent muscles in the inferolateral right chest wall which was compatible with intercostal hemangioma. The patient underwent surgery for excision of the mass. Through right posterolateral thoracotomy, there was a well-demarcated mass abutting 5th, and 6th ribs filling the right 5th interspaces. Histopathological examination confirmed the diagnosis of intercostal hemangioma.

Discussion

Chest wall hemangiomas are uncommon and mostly arise outside the rib cage. Hemangiomas rarely occur in the intercostal space, and most of these originate from intercostal muscles (Agarwal et al., 2006). Watson and McCarthy postulated two theories for the etiology of hemangiomas. The more widely supported theory claims that hemangiomas are of congenital origin. The other theory proposes a traumatic origin of hemangiomas.

Conclusion

Complete surgical resection should not be compromised by the resultant chest wall defect to prevent recurrence.

Pulmonary Langerhans cell histiocytosis with thyroid involvement manifesting as recurrent bilateral pneumothorax and tension bullae in a 3-year-old child

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The main complication of PLCH is the occurrence of pneumothorax (PTX) and tension bullae with subsequent recurrence and persistence despite conservative management.

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Although it is difficult to treat recurrent PTX and tension bullae in advanced PLCH, continuous treatment of the primary disease (LCH) and the complications of pulmonary lesions can improve prognosis.

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Positive-pressure ventilation should be performed with extreme caution in suspected PLCH.

Introduction

Pulmonary Langerhans cell histiocytosis (PLCH) is a well known entity in adults but is exceedingly rare in children. The main complication of PLCH is the occurrence of pneumothorax (PTX) and tension bullae with subsequent recurrence and persistence despite conservative management.

Case presentation

A 3-year-old child was diagnosed with PLCH with thyroid involvement. Chemotherapy was immediately initiated and continued with chest tube drainage for repeated bilateral PTX. Tension bullae developed in the right lung 1 month after initiating treatment. Emergency resection of the bullae and ligation of pulmonary cysts were performed. On the tenth postoperative day, she developed a tension bulla in the left lung. Emergency thoracotomy was performed. On the tenth postoperative day, chest X-ray and CT suggested return of the right bulla and mediastinal shift, and reoperation was performed. Repeated lung biopsy showed no sign of active LCH. Although her condition improved after the operation, subsequent repeated PTXs occurred and were difficult to treat. She was discharged home after four months. Currently, she is receiving maintenance therapy as an outpatient. During the 12-month follow-up, the pulmonary lesions also showed a tendency for improvement.

Discussion

Although it is difficult to treat recurrent PTX and tension bullae in advanced PLCH, continuous treatment of the primary disease (LCH) and the complications of pulmonary lesions can improve prognosis.

Conclusion

Treatment of PLCH accompanied by recurrent PTX and tension bullae is challenging. The condition can be resolved by treating the primary disease in parallel with combined modality treatment, including surgical operation for complications.

Simultaneous resection of a gastric submucosal lipoma in the setting of bariatric surgery: A case report and review of current literature

•

Important to rule out other tumors, such as GIST and malignancy.

•

Pre-operative imaging including EUS is critical in choosing the appropriate surgery.

•

Multiple modalities exist for excision of lipoma in setting of bariatric surgery.

Introduction

Gastric submucosal lipoma is an uncommon finding in the stomach. A benign fatty tumor that is asymptomatic majority of the time. However, symptomatic and bigger tumors can be difficult to manage surgically and require detailed surgical planning prior to proceeding with bariatric surgery.

Presentation of case

58 year old female who presented for weight loss consultation. Underwent an esophagogastroduodenoscopy (EGD) that demonstrated a 3 cm mass near the incisura. Endoscopic ultrasound (EUS) and biopsy demonstrated a submucosal lipoma. Due to the lipoma's location, resection was critical, as it would have led to obstructive symptoms following sleeve gastrectomy. The patient underwent a simultaneous laparoscopic vertical gastrectomy, gastric lipoma excision, EGD, and laparoscopic cholecystectomy

Discussion

Gastric lipomas are benign gastric submucosal tumors, representing less than 3% of all benign gastric neoplasms. Computer tomography and endoscopic ultrasound are important in establishing diagnosis. In current literature, excision with negative margins is standard of care, but small asymptomatic lesions can be followed without intervention.

Conclusion

Gastric lipoma are a rare type of gastric submucosal tumors. Size is highly variable. Observation is a reasonable approach when small and asymptomatic, but multiple surgical modalities can be utilized to remove the tumor. Careful utilization of pre-operative imaging including EUS is critical in choosing the appropriate surgery if simultaneous bariatric management is undertaken

Osteosynthesis of bilateral Vancouver B2 periprosthetic femoral fracture after a bilateral RM® total hip arthroplasty at 24 and 21-years follow-up: A case report

•

The management of periprosthetic femoral fractures following hip arthroplasty is challenging.

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Vancouver type-B2 periprosthetic femoral fractures require revision arthroplasty by replacement of the femoral component.

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In older patients with multiple comorbidities the osteosynthesis of Vancouver type-B2 periprosthetic femoral fracture is a valid treatment.

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Anatomically fracture reduction, the use of locking compression plates, and the preservation of the hip joint, are the key-points to a successful outcome.

Introduction

The management of periprosthetic femoral fractures following hip arthroplasty is challenging, and the choice between osteosynthesis of the fracture and the revision of the prosthesis is still matter of discussion.

Case report

In a 81-year-old male patient, a bilateral Vancouver type-B2 periprosthetic femoral fracture with stem loosening occurred after an accidental fall. The patient had severe medical comorbidities. The radiographic study showed a bilateral Robert Mathys cementless total hip arthroplasty at 24 and 21-years follow-up. The fractures were treated with open reduction and fixation with locking compression plates. Bicortical fixation of the loose stem was obtained by the screws of the locking plate, due to the polymeric composition of the isoelastic femoral stem. Both fractures sites were augmented with bone allografts. At follow-up period of 12 months, the X-rays showed bone union of both fractures and bilateral stable stem fixation. The patient expressed high degree of satisfaction with surgery result.

Discussion

The standard treatment for Vancouver type-B2 periprosthetic femoral fractures is the removal of the loose implant, fixation of the fracture, and implantation of a new revision femoral stem. However, the implantation of two long revision hip prostheses is a major operation for an older patient with precarious health condition, which can contribute to higher risk of medical and prosthetic complications.

Conclusion

In older patients with multiple comorbidities, the use of locking plates can be a valid treatment of bilateral Vancouver B2-periprosthetic femoral fractures following RM^® cementless isoelastic stem, as an alternative surgical option to femoral stem revision.

Duplicated gall bladder with gall bladder polyp presenting with cholecystitis: Case report with literature review

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Duplicated gall bladder is a very rare finding.

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Complete identification of the anatomy is required before cholecystectomy.

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Sometimes one of the gallbladders may be missed during the first surgery which may require another operation.

Introduction

Gall bladder anomalies may be in the form of abnormalities in the shape, position, or number. It could be true duplication being completely separated or Y-shaped being united with single cystic duct.

Presentation of case

A 38-year-old lady presented with frequent attacks of right hypochondrial pain for the last 4 months. Ultrasound of the abdomen showed distended gall bladder with 1.3 cm gall bladder polyp at the region of the fundus. Decision done for laparoscopic cholecystectomy. During surgery a duplicated gall bladder found with single cystic duct. Successful surgery done and the gall bladder sent for the histopathological examination which showed a benign gall bladder polyp. There were no post-operative complications and the patient discharged on the third days.

Discussion

Duplicated gall bladder may be diagnosed with ultrasound or magnetic resonance cholangiopancreatography (MRCP) which is the investigation of choice however most cases diagnosed intraoperatively. It may be associated with other biliary anomalies. In some occasions a single gall bladder may be removed during the first operation and the second may be missed which require another surgery. In asymptomatic individuals with duplicated gall bladder no specific treatment is required and role of surgery is controversial.

Conclusion

duplicated gall bladder is a rare finding which may be completely asymptomatic. In symptomatic patients specially if associated with gall stones, surgery is required and the surgeon must be aware of any associated biliary anomalies.

Primary extraskeletal osteosarcoma of the mesentery: A case report

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Extraskeletal osteosarcoma is a rare malignant soft tissue tumor without attachment to the bone.

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This is the first report of a single incisional laparoscopic resection.

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Its diagnosis should be taken into consideration also when a soft tissue mass of the mesentery is found.

Introduction

Extraskeletal osteosarcoma is a rare malignant soft tissue tumor without attachment to the bone. To the best of our knowledge, we present here the first report of a primary extraskeletal osteosarcoma of the mesentery in Japan.

Case presentation

A 46-year-old female underwent a health examination, with no complaint. Following an ultrasonography a solid mass was detected in the abdominal cavity. Computed tomography showed a 38 × 25 mm heterogeneously enhancing mass. The latter was characterized by the presence of mottled calcifications and a cystic portion. The tumor was resected with a single incisional laparoscopic curative resection. Histopathological examination revealed the presence of a primary extraskeletal osteosarcoma arising from the mesentery. Postoperative course was uneventful. The patient did not receive chemotherapy during follow-up. She was recurrence free 10 months post-surgery.

Discussion

Patients with extraskeletal osteosarcoma generally have a poor prognosis. A tumor size <5 cm represents an important prognostic factor. Unexpectedly, our case was detected by ultrasonography at an early stage. This is the first report of a single incisional laparoscopic resection.

Conclusion

A primary extraskeletal osteosarcoma of the mesentery is an extremely rare occurrence. Its diagnosis should be taken into consideration also when a soft tissue mass of the mesentery is found.

Intussuscepted Metachronous small bowel tumor after treatment for colorectal adenocarcinoma

INTRODUCTION

Small Bowel adenocarcinoma (SBA) is a rare malignant neoplasm without specific signs or symptoms. It's been associated with late stage disease presentations. Midterm outcomes have suggested that after successful removal of colorectal carcinoma, there is higher risk for developing a further primary (metachronous) colorectal tumor. However when it comes to small bowel, metachronous carcinomas are unusual.

CASE PRESENTATION

A 46-year-old female who underwent an emergency Hartmann's procedure two years previously and treatment of adjuvant chemotherapy for adenocarcinoma of the sigmoid colon at stage IIB with loco-regional recurrence. The patient presented with bowel obstruction secondary to a small bowel intussusception, confirmed by computed tomography. An emergent exploratory laparotomy was performed and confirmed of an ileal tumor as the cause of small bowel intussusception and clinical bowel obstruction. Histopathology confirmed a primary small bowel mucinous adenocarcinoma with node metastasis (T3N1M0, stage IIIB).

DISCUSSION AND CONCLUSION

Patients who develop a small or large bowel adenocarcinoma have high risk of presenting a second tumor at both sites. Since data available to guide therapeutic decisions for patients presenting with small bowel metachronic tumors are scarce, the role of adjuvant therapy in patients who undergo curative resection remains unclear. The aim of this manuscript is present a case report of a patient admitted for a rare obstructive small bowel intussusception therefore underwent surgery for metachronic small bowel carcinoma from colorectal primary witch previously treated by surgery and adjuvant chemiotherapy. Studies about strategies for detection at an earlier stage, optimal treatment and prognosis are mandatory for this disease.

Cervical canal stenosis due to cervical spondylotic myelopathy C4-C5: A case report

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Mini plate can be used as alternative material for laminoplasty procedures.

•

Modified spacer for laminoplasty is needed in case of the conventional one is not available.

•

Posterior cervical laminoplasty decompression is important issue to investigate.

Introduction

Cervical spondylotic myelopathy (CSM) is a complex disease that presents with various signs and symptoms of cervical spinal cord impairment that may lead to significant clinical morbidity.

Presentation of case

We present the case of a 50-year old man who was diagnosed with CSM. The patient underwent decompression and posterior stabilisation with open-door laminoplasty. At the 2-month follow-up, the pain subsided, function improved significantly, and weakness disappeared. The patient was also able to defecate and urinate normally.

Discussion

Cervical spondylotic myelopathy is a complex disease that may lead to significant clinical morbidity. The management requires an extensive knowledge of the anatomy, biomechanics, and surgical options. The variable clinical findings, radiological evidence and scoring system, such as JOA, are important for preoperative evaluation and individualising surgical planning. The choice of the most appropriate technique is affected by patient's clinical condition and radiologic findings as well as surgeon's experience. It is demonstrated that the Kurokawa-type laminoplasty that involves splitting the spinous processes in the midline offers the advantage of reduced bleeding as the lateral epidural venous plexus is not disturbed in comparison to that with the former Hirabayashi's expansive open-door laminoplasty. Moreover, the body symmetry is preserved; therefore, this procedure may be considered more anatomical and physiological. However, differences in the outcomes between the two approaches remain unknown.

Conclusions

These findings suggest that the decompression and posterior stabilisation method may help achieve good patient outcomes.

A giant jejunal gastrointestinal stromal tumor misconceived as pancreatic cystic neoplasm: A case report

INTRODUCTION

Gastrointestinal stromal tumors (GISTs), although not common in gastrointestinal (GI) tumors, constitute the most frequent mesenchymal tumors of the GI tract. This report describes a patient with a large sporadic GIST at proximal jejunum that mimicked the pancreatic cystic neoplasm.

CASE PRESENTATION

We report a 59-year-old female patient with unexplained weight loss and palpable left upper quadrant abdominal mass for 6 months. Computed tomography (CT) scan demonstrated a heterogeneously mass measuring 10 cm in a maximal diameter at pancreatic body and tail. Laparotomy was done, and the tumor was found at proximal jejunum closed to the ligament of Treitz, so en bloc resection of the tumor was done. The pathological and immunohistochemical study confirmed GISTs.

DISCUSSION

Although most GISTs are originated from the intestine, they frequently arise from the stomach, the duodenum and rarely from the jejunum. And jejunal GISTs are usually asymptomatic. The misdiagnosis as mucinous cystadenoma of this case might be due to the proximity of the tumor to the body and tail of pancreas, and compressing the adjacent organ due to its large size.

CONCLUSION

GISTs are most frequently small and arising from the stomach. GISTs are rarely present as a large tumor of the jejunum, and particularly mimicked a pancreatic tumor.

Intrapericardial diaphragmatic hernia in a 6-month-old girl: A case report and review of the literature

INTRODUCTION

Intrapericardial congenital diaphragmatic hernia (IPCDH) is extremely rare: only 18 cases in children have been reported in the literature since 1981. We report the 19th case of infantile IPCDH in a 6-month-old girl and compare with previous reports.

PRESENTATION OF CASE

Our patient initially presented with four days of dyspnea and was diagnosed with CDH by preoperative radiography. She was taken to the operating room, where an IPCDH was discovered, and successfully reduced.

DISCUSSION

CDH may present with cardiopulmonary compromise, but IPCDH directly compress the heart, leading to acute or subacute heart failure.

CONCLUSION

Pediatric surgeons should be aware of and prepared for the possibility of IPCDH when making surgical plans to correct CDH.

A case of mixed-pattern calcifications in multinodular goiter associated with a benign diagnosis

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Calcified nodules in a goiter are often found when performing an ultrasound of the neck.

•

Analysis of different calcification patterns could contribute to discriminating between nodules.

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Mixed pattern calcifications is not so frequent and not interpreted.

•

We believe that a better radiologic evaluation setting of thyroid nodules needs to be performed.

Background

Calcified nodules are often found in a goiter when performing an ultrasound of the neck. An analysis of different calcification patterns could contribute to discriminating between nodules with a lower malignancy risk and those with a higher malignancy risk. In certain cases, the results of a simple cytological analysis of a nodule are not specific enough to be completely trusted.

Case presentation

We present the case of a goiter with a mixed calcification pattern, including a type of calcification that is strongly associated with a malignant diagnosis, for which a completely benign diagnosis was determined.

Conclusion

We believe that further studies examining a combination of ultrasound (US) and computed tomography (CT) scan presentations of thyroid nodules need to be performed.

Resected thymic large cell neuroendocrine carcinoma: A case report and review of the literature

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Large cell neuroendocrine carcinoma (LCNEC) of the thymus is an extremely rare neoplasm and has a poor prognosis.

•

We report a surgical case of thymic LCNEC.

•

Further accumulation of knowledge and experience is needed to elucidate the optimal therapy for thymic LCNEC.

Introduction

Large cell neuroendocrine carcinoma (LCNEC) of the thymus is an extremely rare neoplasm.

Presentation of case

We report a rare case of LCNEC of the thymus in a 55-year-old woman. Her chest roentgenogram during a routine checkup revealed an abnormal shadow in the mediastinal left upper lung field. Chest computed tomography showed an anterior mediastinal mass measuring 4.8 × 4.0 cm. Positron emission tomography with 18F-fluorodeoxyglucose (FDG) showed high FDG accumulation at the lesion. To obtain a definitive diagnosis and achieve complete resection, a surgery was performed. The postoperative diagnosis was thymic LCNEC; it was classified as a Masaoka stage III tumor due to the invasion of tumor cells into the left lung. Postoperatively, the patient received adjuvant chemotherapy and survived without any signs of recurrence for 30 months after surgery.

Discussion/conclusion

The detailed clinical features of thymic LCNEC remain unknown because of its rarity. In total, 20 cases of resection for LCNEC, including the present case, have been reported in the English language literature; we have presented a review of these cases and discussed the optimal therapy for this rare and virulent tumor of the thymus.

Hand-assisted laparoscopic surgery for Bochdalek hernia in an adult patient with a history of laparotomy: A case report

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Bochdalek hernia (BH) is a congenital diaphragmatic hernia and rarely seen in adults.

•

Surgical approach is required for BH, but the optimal method is still controversial.

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Hand assisted laparoscopic surgery (HALS) allowed us to clear the adhesions easily.

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HALS should be considered as one of the options for adult BH in selected patients.

Introduction

Bochdalek hernia (BH) is a congenital diaphragmatic hernia that generally occurs in infants and is rarely seen in adults. Surgical repair of BH is recommended, but the approach for repairing BH should be selected carefully in individual cases. It is well known that hand-assisted laparoscopic surgery (HALS) has the advantage of preserving tactile sensation compared with standard laparoscopic surgery. We describe an adult patient with a history of abdominal incisional hernia who developed BH that was treated safely by HALS.

Presentation of case

An 87-year-old woman was admitted to our hospital with nausea. She had a history of right hemicolectomy and repair of an abdominal incisional hernia using mesh at 5 years after hemicolectomy. Chest and abdominal computed tomography revealed herniation of the gastric corpus through the left posterior diaphragm. BH was diagnosed and hernia repair by HALS was selected as the approach because dense adhesions were expected in the abdominal cavity. The operation was performed safely and her postoperative course was uneventful.

Conclusion

HALS was useful, especially when removing adhesions around the hernial orifice. HALS is a feasible approach for BH and should be considered as one of the options in patients with a history of previous abdominal surgery.

Stomal stenosis during gradual closure of a traumatic abdominal wall hernia

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Stomal stenosis can develop after repair of a traumatic abdominal wall hernia.

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Abdominal wall repair with negative-pressure wound therapy may be effective.

•

Stomal patency must be evaluated during the abdominal wall hernia repair.

Introduction

Traumatic abdominal wall hernias are often accompanied by intra-abdominal injuries, and a stoma may be required. Although rare, stomal stenosis can develop after the repair of a traumatic abdominal wall hernia.

Presentation of case

A 65-year-old woman was in a head-on collision with a truck and was brought by ambulance to our facility. The findings of a physical examination and computed tomography scan suggested bowel perforation for which exploratory surgery was performed. The lacerated small bowel and sigmoid colon were resected and an ileostomy and colostomy were created. Abdominal wall reconstruction was impossible because of the large defect size. Repair of the abdominal wall was achieved by gradual closure of the fascia after surgery in combination with negative pressure wound therapy. Stenosis of the ileostomy occurred during this process and was surgically repaired.

Discussion

We reconstructed the abdominal wall using negative pressure wound therapy in combination with sutures while minimizing the risk of abdominal compartment syndrome. This approach did not increase the intra-abdominal pressure, but it deformed the abdominal wall, resulting in unexpected stenosis of the ostomy.

Conclusion

Gradual postoperative closure of a traumatic abdominal wall hernia with an ostomy in place may result in stomal stenosis. Stomal patency must be carefully evaluated during this process.

Rare giant maxillay mucocele: A rare case report and literature review

Introduction

Mucocele is a slow growing, benign but locally aggressive cystic structure lined by true epithelium. It often results due to obstructed sinus outflow or obstruction of gland-like mucous retention cyst. It can cause bony destruction and might result in orbital symptoms like diplopia, orbital displacement, visual disturbances. Other clinical features are facial numbness, dental problems, etc. Radiological evaluation is the preferred diagnostic modality. Surgical removal is the treatment of choice both endoscopic and open (could well luc) approach or combined approach are preferred. Here we report a very typical case of maxillary mucocele who presented with subtle symptoms of nasal obstruction. The study was done in compliance with SCARE guidelines.[1]

Case presentation

We present a very unique case of 24 years man with complaints of nasal obstruction and swelling over the right cheek for 2 years. He had a history of facial trauma two years back. Diagnosis was made on the basis of radiological examination CT (Computed Tomography) scan. He underwent enucleation via Cold well Luc's approach with good postoperative results.

Conclusion

Maxillary mucoceles are slow growing benign lesions. However, they are locally aggressive and cause bony destruction resulting into orbital and dental symptoms. Thus early recognistion with regular folllowr up and planning for surgical intervention can help avoid complications.

•

Maxillary sinus mucoceles are rarer entities as compared frontoethmoidal mucoceles.

•

We report a case of a giant maxillay sinus mucocele with a history of nasal obstruction and right cheek swelling for 2 years.

•

Early diagnosis and surgical intervention is the mainstay of management in most of the cases.

Splenomesenteric bypass as revascularisation technique after iatrogenic injury of the superior mesenteric artery during radical nephrectomy: A case report

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Iatrogenic injury of the superior mesenteric artery is rare.

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This injury imparts a high risk of mortality due to visceral ischemia and death.

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An anastomosis to the splenic artery may be an easier solution than an aorto-mesenteric bypass.

Introduction

Iatrogenic vascular injuries during radical nephrectomy are rarely reported. In the case of an injury of the superior mesenteric artery, the consequences for the patient are potentially catastrophic. It occurs more frequently in patients with large renal tumors, due to the presence of bulky perihilar adenopathies, or in cases of pyelonephritis. In most cases, the inadvertent injury of the artery occurs due to the difficulty in distinguishing it from the left renal artery.

Case

69-year-old male, with a malignant neoplasm of the left kidney with the involvement of the tail of the pancreas, tumor thrombus in the left renal vein and multiple left para-aortic adenopathies, whose histological examination revealed to be a renal sarcomatoid carcinoma pT4N1M0G3. A radical nephrectomy was performed with caudal splenopancreatectomy and left paraaortic lymphadenectomy, with an iatrogenic injury of the superior mesenteric artery at its origin. A terminoterminal anastomosis was performed from the proximal stump of the splenic artery. The postoperative period went uneventfully. Control imaging in the follow-up showed permeability of the celiac trunk and the superior mesenteric artery.

Conclusions

Intra-operative superior mesenteric artery injury should be promptly identified and repaired to prevent gut ischemia and all its dire consequences. There are different repair options, and the technique should be chosen according to the degree of injury. The splenomesenteric bypass has numerous advantages.

Metastatic liver tumor from a primary gastric cancer with infiltration of the Glisson's pedicle: A case report

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A single metastatic liver tumour from a primary gastric cancer is rare.

•

Glisson’s pedicle invasion was identified on preoperative MR and PET-CT imaging.

•

Surgical resection, with R0 margin, was deemed possible based on imaging results.

•

The patient survived, without cancer recurrence for more than 1 year.

Introduction

Metastatic liver tumors from primary gastric cancer are rarely resected because of the high rate of metastasis and recurrence of gastric cancer, and there is little information regarding the pathological assessment of these tumors. We present a case of a single metastatic liver tumor from gastric cancer with invasion of the interlobular bile duct for which we achieved margin-free resection with good clinical outcomes.

Presentation of case

An 80-year-old patient presented with a tumor in segment V of the liver, with invasion of Glisson’s pedicle confirmed on preoperative magnetic resonance and positron emission tomography imaging. On the basis of the preoperative assessment, we proceeded with partial hepatectomy, with transection of one of the roots of Glisson’s pedicle performed under echography guidance. Pathological examination confirmed gastric cancer as the primary source of the metastatic tumor. R0 resection was achieved, with no evidence of cancer recurrence at one year after surgery.

Discussion

Our experience supports partial hepatectomy with R0 margin tumor resection as an oncologically feasible treatment for metastatic liver tumor arising from primary gastric cancer (in the absence of other metastatic lesions) and shows that a good prognosis can be achieved. Of note, intraoperative echography did not detect tumor invasion of Glisson’s pedicle, which was evident only on preoperative imaging.

Conclusion

This case suggests that magnetic resonance and positron emission tomography imaging findings are important for surgical planning of hepatectomy. Further follow-up data and more cases are needed to completely define the clinical significance of tumor invasion of Glisson’s pedicle.

Total hip arthroplasty for a woman with hemophilia A -case report

Hemophilia A is a congenital bleeding disorder caused by an X-linked hereditary pattern. Female hemophilia A carriers are usually asymptomatic, although some have far lower levels of clotting factor because more X chromosomes with the normal gene are switched off, a phenomenon referred to as "lyonization.” During a medical checkup at our hospital, a 56-year-old Japanese woman with coxalgia was also diagnosed as an obligate hemophilia A carrier based on World Federation of Hemophilia criteria. She underwent total hip arthroplasty using blood product coagulation factor VIII to address her hemophilia. Immediate female relatives (mother, sisters, daughters) of a person with hemophilia should have their clotting factor levels checked, especially prior to any invasive intervention or childbirth, or if any symptoms occur.

•

We report a case of total hip arthroplasty for a woman with hemophilia A.

•

Some female hemophilia A carriers have far lower levels of clotting factor.

•

Immediate female relatives of a person with hemophilia should have their clotting factor level checked.

Recurrent borderline phyllodes tumor of the breast submitted to mastectomy and immediate reconstruction: Case report

•

Phyllodes tumors of the breast are rare fibroepithelial neoplasms.

•

They are histologically classified into benign, borderline and malignant variants.

•

Anatomopathological examination is considered the definitive diagnostic method.

•

They have a high rate of local recurrence and the possibility of metastases.

•

Surgery is the definitive treatment and adjuvant therapy is controversial.

Introduction

Phyllodes tumors are biphasic fibroepithelial tumors that account for fewer than 1% of mammary tumors. They usually appear in middle-aged women, with an average size of 4–7 cm and rapid growth.

Presentation of case

A 25-year-old woman sought care after excision of recurrent nodules in the right breast, with a diagnosis of borderline phyllodes tumor. She had no new lesions on physical examination. Imaging studies revealed an anechoic collection and nodular areas in a previous surgical site, correlated with pathology. Immuno-histochemical examination was positive for vimentin, calponin, Ki-67 and estrogen receptor. Systemic staging did not show metastases. Skin-reducing mastectomy was performed on the right side, followed by reconstruction and left reduction mammaplasty for symmetry. At 8-month follow-up, there was no relapse of the lesions on clinical and ultrasonographic examinations.

Discussion

Phyllodes tumors are rare neoplasms characterized by rapid growth, occurring in women between 35–55 years of age. They are classified as benign, borderline and malignant, according to histological parameters. There are reports of genetic mutations in TP53 associated with malignant phyllodes tumor. On immunohistochemistry, there is a greater tendency to malignancy in tumors with Ki-67 and estrogen receptor expression. Imaging methods may aid in diagnosis, which is only definitive after excision and histopathological analysis of the tumor. These tumors have high local recurrence rates and possibility of metastases, closely related to histology.

Conclusion

Phyllodes tumors are a great challenge to the surgeon. Treatment is surgical, with wide excision; radiotherapy and chemotherapy are controversial.

A case of persistent sciatic artery aneurysm with recurrent embolism

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Recurrent embolism originated from the persistent persistent sciatic artery aneurysm.

•

Distal bypass was required due to the anomaly position of popliteal artery.

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Persistent sciatic artery aneurysm is rare, but remember in especially acute limb ischemia.

Introduction

Persistent sciatic artery (PSA) is a rare congenital vascular anomaly. It has several clinical features with the formation of aneurysms. Among the complications, leg ischemia is severe problem and the management involves revascularization and prevention of recurrence. We herein describe an anatomically annoying case of PSA aneurysm with recurrent embolism that necessitated thrombectomy and bypass surgery. And this work has been reported in line with the SCARE criteria.

Case presentation

A 76-year-old woman developed leg embolism twice from PSA aneurysm. PSA was complete type and the popliteal artery ran on the lateral side, which was difficult to approach from the standard medial side. Based on these anatomical conditions, thrombectomy of the posterior-tibial artery (PTA) and femoral-PTA bypass were performed. Additionally, the proximal side of PTA from the anastomosis site was ligated to avoid the recurrence of embolism. Residual PSA aneurysm has not yet been treated, but neither clinical complications nor dilatation have occurred.

Discussion

PSA is a rare disease, but should be remember in acute limb ischemia. Clear treatments have not yet been established; therefore, its plans need to be considered based on clinical symptoms and anatomical conditions.

Conclusion

Although there were anatomical issues in the present case, thrombectomy and bypass surgery were successful and no complications have occurred one year after surgery.

Incomplete bilateral duplication of the ureters identified during cytoreductive surgery for ovarian cancer: A case report

•

In adults, ureteral duplication is usually asymptomatic.

•

Ureteral anatomical varieties increase the possibility of iatrogenic injury.

•

Ureteral injuries may increase morbidity and even cause mortality.

•

If unilateral duplication is observed, bilateral duplication should be suspected.

Introduction

Incomplete bilateral ureteral duplication is a very rare condition. Ureteral duplication is often asymptomatic or may be associated with several urinary tract complications.

Case Report

We report a case of a 72- year- old Caucasian female who was referred to our clinic after she was diagnosed with FIGO IIIc ovarian cancer with peritoneal metastases. The patient underwent Cytoreductive Surgery plus Hyperthermic Intraperitoneal Chemotherapy. During the standard bilateral recognition of the ureters, intraoperatively, incomplete duplication of both of the ureters was identified. Bilaterally, the ureters were derived from a single renal parenchyma and duplication of the pyelocaliceal system in each kidney.

Discussion

The incomplete bilateral duplication of the ureters is a rare congenital renal abnormality. In a series of 51.880 autopsies ureteral duplication was observed in 0.66% of the cases, while in another autopsy series the ureteral duplication rate was 0.68%.

Conclusion

Anatomical varieties of the ureter are of utmost importance for the surgeons, because they increase the possibility of iatrogenic ureteral injury. Ureteral injuries are severe complications of pelvic operations and may increase morbidity and even cause mortality.

Subvesical bile duct and the importance of the critical view of safety: Report of a case

•

The critical view of safety is an important principle in performing laparoscopic cholecystectomy.

•

Aberrant anatomy is a major cause of biliary injury during laparoscopic cholecystectomy.

•

Using the critical view of safety principle may prevent such injuries.

Introduction

This is a case report in which a subvesical duct was identified intra-operatively during laparoscopic cholecystectomy.

Presentation of case

A 49-year-old man underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis. During the procedure, the cystic duct and cystic artery were dissected. After ligation and division of these structures, a subvesical bile duct draining directly into the gallbladder was noted. In the present case, the subvesical duct was ligated and divided. The patient had an uneventful recovery.

Discussion

Subvesical bile ducts, also known as ducts of Luschka, represent anatomic variations of the biliary tree in which one or more bile ducts traverse in close contact with the gallbladder fossa. Inadvertent and undetected injury of these ducts are a frequent cause of cholecystectomy-associated bile leaks.

Conclusion

Application of the critical view of safety principle may assist in intra-operative detection of aberrant biliary anatomy, thus preventing iatrogenic injury.

Inflammatory myofibroblastic tumor of the transverse colon with synchronous gastrointestinal stromal tumor in a patient with ulcerative colitis: a case report

INTRODUCTION

Inflammatory myofibroblastic tumor (IMT) is a rare proliferative disease of uncertain etiology, characterized by the proliferation of fusate or epithelioid myofibroblasts admixed with predominantly mononuclear inflammatory cells. IMT is generally considered a benign lesion, although in some cases this neoplasm has shown an aggressive behavior in terms of local recurrence and metastasis. We report the case of a patient with a ten-year history of ulcerative colitis affected by IMT of the transverse colon and by synchronous gastrointestinal stromal tumor (GIST) of stomach.

PRESENTATION OF CASE

A 59-year-old woman with a ten-year history of ulcerative colitis has been admitted to our hospital with signs and symptoms of acute recurrence of ulcerative colitis: abdominal pain, diarrhea, hematochezia and rectal tenesmus. Colonoscopy showed a left colon with diffuse hyperemia, mucosal erosions and a 2-cm, irregularly shaped, polypoid lesion at the level of the transverse colon. Histopathological examination of the specimen obtained via biopsy of the polypoid lesion has revealed a mesenchymal neoplasm with uncertain characters of malignancy. Due to the severity of the inflammatory bowel disease resistant to immunosuppressive and steroid drug treatment, surgical indication was given.

DISCUSSION

Although the relationship between IMT and Crohn's disease has been widely reported in literature, the relationship between IMT and ulcerative colitis has never been previously described.

CONCLUSION

To the best of our knowledge, this is the first case of IMT associated with ulcerative colitis reported in literature and the synchronous association with a gastric GIST represents another primacy.

Endoscopic endonasal resection via a transsphenoidal and transpterygoid approach for sphenoid ridge meningioma extending into the sphenoid sinus: A case report and literature review

INTRODUCTION

Large sphenoid ridge meningiomas are surgically challenging because of their extension to adjacent structures. Extracranial meningiomas are very rare; most are of the secondary type and have an intracranial origin. Improved surgical methods are required for treatment of this entity.

PRESENTATION OF CASE

Here, we describe a case of a huge sphenoid ridge meningioma extending into the sphenoid sinus that was resected by staged transcranial and endoscopic endonasal resection via a transsphenoidal and transpterygoid approach. It was possible to excise the tumor from the sphenoid sinus in a minimally invasive manner via this approach.

DISCUSSION AND CONCLUSION

The transsphenoidal and transpterygoid approach was useful for providing a surgical field that allowed adequate visualization for removal of a sphenoid tumor that had expanded well into the lateral fossa of the sphenoid bone.

Hepatic anisakiasis mimicking metastatic liver tumour

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Anisakiasis is a parasitic disease caused by anisakid nematode larvae in raw fish.

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Anisakiasis may increase with growing consumption of raw fish around the world.

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Hepatic anisakiasis presents as small, low density tumours in the liver margin.

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The lesions resemble recurrent carcinoma, and can lead to unnecessary surgery.

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Dietary investigation is warranted when liver tumour malignancy is not certain.

Introduction

Anisakiasis is a parasitic disease caused by anisakid nematode larvae, which are found in raw or undercooked fish. It occurs more frequently in the digestive tract, but has also been reported outside the gastrointestinal tract. This report details a case of rare hepatic anisakiasis that was initially diagnosed as metastatic rectal cancer.

Presentation of case

A 60-year-old male underwent radical resection for stage III rectal cancer followed by adjuvant chemotherapy for six months. Seven months after surgery, a new, 10 mm diameter area of low density was seen in segment 4/8 margin of the liver on enhanced computed tomography (CT) scan. Metastatic liver tumour from rectal cancer was suspected. Laparoscopic partial hepatectomy was performed. The diagnosis was revised to hepatic anisakiasis when pathological examination revealed anisakis simplex larvae in the necrotic tissue.

Discussion

Anisakiasis outside of the gastrointestinal tract is a rare finding, but may be seen more frequently with the recent increase in the consumption of raw fish around the world. Hepatic anisakiasis may mimic tumours in the liver. Clinicians should consider dietary inquiry and further evaluation in patients with liver margin tumours less than 20 mm in size that are not positively malignant, as hepatic anisakiasis may be a possible diagnosis.

Conclusion

We report a rare case of hepatic anisakiasis which initially presented as suspected metastatic cancer. Hepatic anisakiasis should be considered in the differential diagnosis of low density liver tumours less than 20 mm, where the patient’s diet includes raw fish.

Iatrogenic esophageal perforation that could be treated indirectly by cervical esophagostomy and laparoscopic surgery

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It is very rare case that each esophageal stump become connected and patent spontaneously.

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Two-stage surgery is useful for esophageal perforation if radical operation is difficult.

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Esophageal perforation can be resolved without direct closure if appropriate drainage is performed.

Introduction

Successful nonoperative management has been reported for esophageal perforation; however, some cases require surgery.

Case presentation

We presented the case of an 85-year-old woman with iatrogenic thoracic esophageal perforation in whom primary repair or resection of the perforated esophagus was difficult because she was elderly and had severe aortic valve stenosis. Therefore, we selected a two-stage surgery; laparoscopic gastrostomy, jejunostomy, posterior mediastinal drainage, and cervical esophagostomy were performed. We planned reconstruction after the perforation was closed, but endoscopic examination revealed spontaneous patency of each esophageal stump. Endoscopic balloon dilation was necessary because of esophageal stenosis; however, anastomotic surgery was unnecessary.

Conclusion

This case report suggests that esophageal perforation is resolved without direct closure if appropriate drainage is performed.

Sterile necrotizing and non-necrotizing granulomas in a heart transplant patient with history of PTLD: A unique finding

INTRODUCTION

Posttransplant lymphoproliferative disease (PTLD) is a known complication in patients with solid organ transplant. It can present as localized or disseminated tumor. The cornerstone of management consists of reduced immunosuppression (RI). In select cases, localized disease can potentially be curative with surgical excision.

PRESENTATION OF CASE

Here we present a case of a 19-year-old female with orthotopic heart transplant with two episodes of recurrent PTLD. After the second episode she was found to have asymptomatic splenic lesions which were refractory to RI and chemotherapy. She subsequently underwent splenectomy that showed sterile necrotizing and non-necrotizing granulomas with no evidence of PTLD.

DISCUSSION

Based on our literature search this is the first ever reported case of sterile granulomas in a patient with recurrent PTLD which could potentially be diagnosed with minimally invasive biopsy rather than diagnostic splenectomy.

CONCLUSION

This report is an attempt to create awareness regarding potential for presence of sterile granulomas in patients with recurrent PTLD and discuss the use of percutaneous biopsy before splenectomy.

Persistent cloaca and caudal duplication in a monovular twin, a rare case report

INTRODUCTION

A cloaca occurs when genitourinary tract and bowel converge into a common channel. We report a case of partial caudal duplication, persistent cloaca and vestigial appendage in a monovular female twin infant.

PRESENTATION OF CASE

This is a monochorinonic-diamniotic twin born at 36 weeks with apgars of 9/9. She had a duplicated labia with two clitorises, and a partially formed accessory foot with 2 toes protruding from the right gluteal region. There was anal atresia and a punctate urethral opening in the right genitalia through which she voided spontaneously. X-ray of the accessory foot had rudimentary metatarsals and phalanges. There was left hydroureteronephrosis and a hydrocolpos causing severe mass effect. On the first day of life, she had exploratory laparotomy with a diverting colostomy and mucus fistula and drainage of hydrocolpos. At 6 months of age, she had removal of the accessory foot with flap closure of the perineal defect and vesicostomy. At 15 months of age she had laparotomy for repair of cloaca, excision of presacral pelvic mass and the duplicated vulva.

DISCUSSION

Theories of etiology include failure of regression of Kovalevsky's canal (a communication that connects the amniotic and yolk sac), an incomplete form of twinning through iatrogenic damage to the zona pellucida or a failed triplet formation from a single embryo.

CONCLUSION

Caudal duplication with persistent cloaca and vestigial appendage is a rare and complex malformation. Having a unified surgical and medical team to preserve quality of life and to treat complications is of key importance.

If there is smoke, there must be fire - Isolated distal, non-displaced, intraarticular ulna fracture: A case report

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Isolated distal ulna styloid fractures are a rarity.

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Timely diagnosis and appropriate therapy reduce posttraumatic morbidity.

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High level of suspicion should be maintained in the presence of nonspecific pain, even if the initial X-ray is inconspicuous.

Introduction

Falling on the outstretched arm is a frequent trauma. The consequences can be isolated fractures of the distal radius, combined fractures of the distal radius and distal ulna - whereas the isolated fracture of the distal ulna is an uncommon trauma.

Presentation of case

We report on a 20- year- old male who presented at the emergency department after a motorcycle accident, suffering pain at his left forearm and left wrist. After an unremarkable x-ray in two planes, a CT- scan of the left wrist was performed and detected an isolated distal ulna fracture. The patient was treated with a forearm cast which led to a satisfying long term outcome.

Discussion

Based on the presented case the anatomical peculiarities of the distal radioulnar joint and the different trauma mechanisms as well as the resulting lesions, the diagnostic modalities and the treatment options are discussed.

Conclusion

We recommend performing an additional CT scan of the wrist in case of credible complaints after trauma to avoid baulking this very rare type of fracture.