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

Retroperitoneal Ganglioneuroma (GN): Case report in 14 years old boy

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Ganglioneuroma (GN) is a rare benign tumor.

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GN are usually asymptomatic found incidentally on abdominal imaging or having nonspecific symptoms related to mass effect.

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The cornerstone for the management its remain on complete surgical excision.

Introduction

The ganglioneuroma is a rare tumor arising from sympathetic nervous system, which is composed of gangliocytes and mature stroma.

Presentation of the case

A retroperitoneal ganglioneuroma was found in a 14 years old Saudi boy, presented with recurrent vomiting. CT image showing a retroperitoneal cyst near the inferior vena cava and right iliac vessels. Treated by laparoscopic cystic excision, histopathology of the cyst showing ganglioneuroma, completely excised.

Discussion

Ganglioneuromas arise from the sympathetic chain, The most common sites of presentation are the posterior mediastinum, retroperitoneum, head and neck region. GN are usually asymptomatic found incidentally on abdominal imaging. The treatment of retroperitoneal mass is complete surgical excision.

Conclusion

Ganglioneuroma (GN) is a rare benign tumor, usually asymptomatic. One of the most common site of presentation is retroperitoneum, the main treatment for that is complete surgical excision.

A new case of radiation-induced breast angiosarcoma

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A biopsy of any suspicious breast skin lesion after radiotherapy is recommended.

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Patients with clinical anomalies post-breast cancer surgery and RT need attention.

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The Angiosarcoma was cured due to surgery and high-dose neoadjuvant chemotherapy.

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A correct 6 month follow-up is needed: check-ups, chest X-rays and ultrasound.

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The survival of the patient suggests possible ways to manage this rare tumour type.

Introduction

Radiation-induced breast angiosarcoma is a severe but rare late complication in the breast-preserving management of breast cancer through surgery and radiotherapy. Often the initial diagnosis is complex given its relatively anodyne nature and the fact that it usually presents in the form of typically multifocal reddish-purple papular skin lesions.

Presentation of the case

We describe the clinical and pathologic findings of a 79-year-old woman, who developed a radiation-induced breast angiosarcoma after around 8 years. She initially refused a mastectomy leading to an adaptation in the management of this cancer.

Discussion

The average latency of secondary angiosarcoma of the breast following radiation therapy is around six years. Breast angiosarcoma is typically considered to affect the dermis, and is therefore cutaneous in origin. An incisional biopsy of the discoloured skin and underlying mass is necessary. The treatment is surgical resection. The role of chemotherapy has not been clearly defined. Most data originate from retrospective case series studies suggesting that angiosarcomas are relatively sensitive to taxanes and anthracyclines.

Conclusion

The preferred treatment is always aggressive surgical removal and, as our atypical clinical case suggests, neoadjuvant chemotherapy in very high doses is also needed. A biopsy of any suspicious breast skin lesion after radiotherapy is recommended. Despite the treatment challenges, our case provides enlightening details on the management of such a rare cancer even when faced with unplanned events which do not always allow for a textbook approach.

Transverse colonic volvulus after resection of sigmoid volvulus: Presentation of a case report

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Volvulus is a common cause of large bowel obstruction but its metachronous occurrence is an extreme rarity.

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Metachronous transverse colonic volvulus should be eliminated as a differential diagnosis.

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Gangrenous bowel is a life threatening condition and should be dealt with as an emergency situation with the adequate procedure.

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The elective surgical resection should follow optimization of the general condition and set-up.

Introduction

Colonic volvulus is the third leading cause of colonic obstruction in the world following colorectal cancer and complicated sigmoid diverticulitis. Transverse colon is the rarest among other colonic volvulus. Moreover synchronous/metachronous transverse colonic volvulus is extremely rare condition with only few case reported in the literature, we hereby report this case of metachronous transverse colonic volvulus years after sigmoidectomy for sigmoid volvulus

Case presentation

A case of transverse colon volvulus in elderly male with history of chronic constipation and a previous history of a sigmoid volvulus resection few years ago. He presented as an emergency with typical features of acute large bowel obstruction. He was successfully managed with a good out come

Discussion

We discuss the presentation, diagnosis and surgical management with a literature review of this case of a metachronous transverse colonic volvulus.

Conclusion

Metachronous colonic volvulus is an extremely rare cause of large bowel obstruction and should be considered as a differential diagnosis especially in geographic areas with high rate of volvulus or in those with underlying risk factor

Ectopic pheochromocytoma or paraganglioma of the ZUCKERKANDL organ: A case report and review of the literature

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EPIDEMIOLOGY: paraganglioma of the ZUCKERKANDL organ is a rare neuroendocrine tumour but must be known.

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DIAGNOSIS: The typical presentation which is the Menard Triad of symptoms, associating headaches, sweating and palpitation. Preoperative diagnosis can be difficult in pauci-symptomatic cases. The Clinical signs, Abdominal-pelvic CT scan and biology are the steps of the preoperative diagnosis.

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TREATMENT: Treatment is surgical. Preoperative medical preparation is aimed at reducing risks of peroperative hemodynamic instability. The anesthetist should therefore prepare himself to manage blood pressure peaks during the tumour’s dissection, but also the possible low blood pressure at the end of exeresis. Surgery remains the key element of treatment and consists in exeresis of the paragaglioma.

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PROGNOSIS: paraganglioma of the ZUCKERKANDL organ is often a benign tumor. The resuscitation determines the patient’s prognosis.

Introduction

Paraganglioma of the ZUCKERKANDL organ are rare. Diagnosis is based on clinical, radiological and biological arguments. We report a case to describe our surgical procedure and insist on the necessity of preoperative diagnosis.

Presentation of case

BA, 52-years-old male patient was seen in consultation for left hypochondrium pains. The clinical examination had revealed a painful tumefaction in the left flank and the left hypochondrium. A deep mass was observed, but was difficult to be assessed, due to pain. Abdominal-pelvic CT scan with contrast injection had revealed a tissue mass, suggesting a tumor of the tail of the pancreas. Laparotomy showed this mass was not attached to the tail of the pancreas, and was along the abdominal aorta up to the aortic bifurcation. Upon touching the mass, blood pressure raised up to 240 mmHg. A least mobilization of the mass and the use of nicardipine helped maintain blood pressure below 180mmhg. Dissection was carried out from the aortic bifurcation to the TREITZ’s angle and the mass was removed. The follow-ups were characterized by low blood pressure a few minutes following the resection of the mass.

Discussion

Pheochromocytoma is rare. The Clinical signs, Abdominal-pelvic CT scan and biology are the steps of the preoperative diagnosis. The surgery consists a lumpectomy. The resuscitation determines the patient’s prognosis.

Conclusion

Pheochromocytoma is an unusual mass. Preoperative diagnosis can be difficult in pauci-symptomatic cases. One should consider this in the face of any abdominal mass, so as to improve planning of resuscitation which determines the patient’s prognosis.

A case report of a midesophageal diverticulum mimicking a fibrovascular esophageal polyp

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Esophageal diverticula and esophageal fibrovascular polyps are uncommon entities.

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These anomalies often present with different symptomatology and may be associated with specific esophageal anatomy.

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We present a case of a midesophageal mass, which was suggestive of a fibrovascular polyp upon diagnostic workup.

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Operative exploration revealed the mass to be an esophageal diverticulum with a leading lipoma.

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Esophageal diverticula may arise in the midesophagus secondary to inflammation or traction, such as a leading lipoma.

Introduction

Esophageal diverticula and esophageal fibrovascular polyps are uncommon clinical entities. While an asymptomatic presentation is possible, symptoms, when present, may be dissimilar in their gastrointestinal or respiratory characteristics. Additionally, these findings typically occur in different segments of the esophagus, with polyps occurring most frequently in the cervical esophagus and the midesophagus being the predominant location of pathologic diverticula.

Presentation of case

We report the case of a 55-year-old patient who presented with a two-year history of progressive dysphagia secondary to a large proximal to midesophageal mass. Workup included esophagography, computed tomography, and endoscopy with ultrasound and was initially consistent with a diagnosis of a large esophageal fibrovascular polyp. Upon operative exploration, the mass was found to be a midesophageal diverticulum associated with a leading lipoma. The patient was successfully treated with transthoracic stapled diverticulectomy. At postoperative follow-up the patient was tolerating oral intake with no symptoms of dysphagia.

Discussion

Esophageal diverticula are typically found in the midesophagus and are thought to arise from radial traction secondary to mediastinal inflammation. Esophageal fibrovascular polyps may result from tracheobronchial compression, and esophagography typically identifies a mobile intraluminal mass.

Conclusion

Esophageal fibrovascular polyps and diverticula are rare, and a high index of suspicion is important in evaluation of these entities.

Pediatric fibroma in maxillary sinus following nasal trauma: A case report

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Fibroma and fibroma like lesions are rare and difficult to diagnose in pediatric ageas.

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In the Pubmed database, we did not encounter any large-scale study focused on this type of tumors except for some case reports of fibromyxoma.

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Management of fibroma in the maxillofacial area is surgical excision.

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If there is a persistent maxillofacial swelling and edema with history of trauma in the pediatric age you should be considered differential diagnosis for the soft tissue tumors like fibroma.

Introduction

Fibroma is a benign tumor of the connective tissue and is classified among the fibrous and fibrous histiocytic lesions. In the pediatric age group, both the differential diagnosis and surgery of maxillary swellings are difficult.

Case reports

A 26-month old girl applied with swelling and malformation in the nose. She complained of swelling in the right cheek, nasal obstruction and dyspnea during the night time. Her family stated that she had a head trauma 45 days before the application. We observed a rigid mass in the lateral side of the right nasal region consistent with severe edema. The pediatric endoscopic examination displayed a passage obstruction and an expansion of the lateral wall towards the septum. We performed right Caldwell-Luc approach with the endoscopic transnasal approach. The pathological examination with the light microscope displayed dense and thick collagen fibers and fusiform fibroblasts mixed up with these collagen fibers.

Discussion

Fibroma and fibroma like lesions are rare and difficult to diagnose. In the Pubmed database, we did not encounter any large-scale study focused on this type of tumors except for some case reports of fibromyxoma. In respect of the findings in the literature, along with the pathological criteria, the clinicopathological correlation and radiological imaging may facilitate the diagnosis. Furthermore, a good cooperation with the patient and his/her family and a reliable history like trauma are also critical.

Conclusion

The possibility of trauma should be definitively questioned during the history of pediatric patients, who applied with a maxillofacial swelling with the presence of persistent edema and differential diagnosis for the soft tissue tumors like fibroma should be considered.

Small bowel angiomyxoma causing intussusception: Case report and review of the literature

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Myxomas of the small bowel are very rare.

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They usually present with mechanical small bowel obstruction caused by an intussusception.

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They mainly occur in females in their forties.

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Surgical resection is always indicated.

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They are usually solitary and do not metastasize.

Introduction

Angiomyxoma-related intussusception in adults is extremely rare. Herein, we report an adult man who presented with mechanical small bowel obstruction caused by ileo-colic intussusception triggered by an angiomyxoma of the terminal ileum and review the literature on this topic.

Presentation of case

A-40-year-old man was referred to Al-Ain Hospital with a clinical picture of small bowel obstruction. He has no previous abdominal surgery. Clinical examination showed a distended soft abdomen, and hyperactive bowel sounds. Abdominal ultrasound and computed tomography scan showed a doughnut sign confirming the presence of ileo-colic intussusception as the cause for small bowel obstruction. At laparotomy, a mass was found in the right iliac fossa. Right hemi colectomy was performed with ileo-colic anastomosis. An ileal pedunculated mass triggered the intussusception. Histopathology of the mass was diagnostic of an angiomyxoma of small bowel. Echocardiogram showed no atrial synchronous myxoma. The patient was discharged home with good general condition. At three years follow up, the patient remained asymptomatic without evidence of recurrence.

Conclusions

Myxoma of small bowel should be included in the differential diagnosis of small bowel obstruction in the young age group particularly if the diagnosis of intussusception was made preoperatively.

Functional elbow range of motion 6 months after contracture release and ORIF K-wire in elbow stiffness with malunion capitellum and neglected radial head and ulnar dislocation: a case report

INTRODUCTION

Elbow stiffness is the most common complication following trauma of the elbow. This is because the elbow joint is susceptible to effusion, hemarthrosis, scarring, and capsule thickening due to its small intracapsular volume. Surgical treatment is therefore necessary to release soft tissue contracture.

CASE

A male teenager was unable to flex his elbow since 1 year prior to admission after falling down during football practice. He didn't seek any medical treatment and had his elbow massaged since 5 months ago. On physical examination, his right elbow was extended, with flexion-extension range of motion (ROM) of 30⁰ - 0⁰. On the radiograph, there was malunion fracture of left capitellum and neglected posterosuperior dislocation of radial head and ulna. Surgery was performed to release contracture and correct the malunion. Normal activity with functional elbow flexion-extension ROM of 110⁰ - 30⁰ was achieved in 6 months after operation.

DISCUSSION

Elbow stiffness is a challenging case for surgeon, especially in regards of developing good perioperative plan. The aim of treatment for elbow stiffness is to achieve a pain-free and functional elbow ROM.

CONCLUSION

To achieve functional elbow ROM, surgical treatment was necessary to release the contracture. In addition, the etiology of trauma must be thoroughly investigated and a good rehabilitation program must be integrative to the treatment.

Abdominal actinomycosis misconceived as intestinal lymphoma: Report of a case

INTRODUCTION

Abdominal actinomycosis is a rare clinical entity and it is difficult to make the correct preoperative diagnosis because of its nonspecific clinical symptoms and varied radiological findings. The diagnosis is usually made after the patient undergoes an operation and tissue is available for pathological evaluation. When the diagnosis is made, the patient should be treated with the appropriate long-term antibiotics.

PRESENTATION OF CASE

A 69-year-old male patient was transferred to our hospital complaining of a palpable mass, painful abdominal discomfort, weight loss, and night sweating. After colonoscopy and radiologic studies, our presumptive diagnosis was intestinal lymphoma combined with ileocecal intussusception. He was found to have abdominal actinomycosis after surgery and successfully treated with ampicillin for six months.

DISCUSSION

Pre-operative radiological imaging in abdominal actinomycosis is unlikely to allow a definitive diagnosis, but CT scanning is the single most useful imaging modality. Although we performed preoperative radiological studies, including CT, none led to a diagnosis of abdominal actinomycosis, we mistakenly considered the case as intestinal lymphoma combined with ileocecal intussusception.

CONCLUSION

Physicians should include abdominal actinomycosis in the differential diagnosis when an abdominal mass presents an irregular, infiltrative growth pattern, even though ileocecal intussusception is an extremely rare presentation in abdominal actinomycosis.

Cesarean section after laparoscopic hysterosacropexy with Richardson's lateral repair and Burch operation-Case report

INTRODUCTION

Pelvic floor disorders are common also in young patient population. Their quality of life is lessened because of their condition, but they would also like to avoid any complicated operations. The minimal invasive procedures and fertility sparing are very important.

CASE PRESENTATION

32 year old caucasian female (BMI: 22,6) was admitted to our clinic in August 2016 with the following symptoms: the feeling of a foreign body in the vagina, prolapse of the bladder and stage II stress urinary incontinence. She had 2 vaginal deliveries. A gynecological examination of the pelvic organ prolapse was classified as follows: prolapse of the uterus POP-Q II, and a cystocele with a lateral defect POP-Q III, after reposition of uterus cystocele POP-Q II, urethrocele, positive cough test. She underwent a laparoscopic hysteropexy with lateral repair and Burch operation. Effect of the operation was satisfied. It revealed an improvement in the QoL-Questionnaire PIFQ-7. Pregnancy in 2018 was delivered by cesarean section. The effect of the prolapse operation was not affected and the quality of life maintained.

CONCLUSION

Laparoscopic hysteropexy should be a standard procedure for the repair of a level I defect in young patients, particularly as a fertility sparing procedure.

Foreign body reaction simulating mandibular osteosarcoma-Case report

INTRODUCTION

This study aimed to report the case of a foreign body granuloma in a 34-year-old woman, presenting clinical and imaging characteristics, as well as to discuss the association of using alloplastic material for the lesion in question.

PRESENTATION OF CASE

Female patient seeking dental care for a routine treatment. The panoramic radiograph showed the presence of asymptomatic, radiolucent, and multiloculated lesion between teeth 31 and 34. Among the hypotheses diagnosed, central giant cell granuloma and osteosarcoma were suggested. When questioned, the patient denied any health changes or recent local procedures. After performing a histopathological examination and insisting on anamnesis, the case was diagnosed more accurately as "foreign body reaction" and the adequate therapy was determined.

DISCUSSION

The use of alloplastic material has been reported as an etiological factor of foreign body lesions, and dentists, either clinicians, radiologists or pathologists, should be aware of this because of the great increase of such procedures and the difficulties related to their diagnosis.

CONCLUSION

The foreign body granuloma associated with silicone prosthesis, based on its clinical and imaging characteristics, may be mistaken for neoplastic processes.

Medial clavicle pseudarthrosis successfully treated with an inverted distal clavicle locking plate

Introduction

Medial clavicle fractures are rare injuries. Symptomatic nonunion arises up to 8% of medial clavicle fractures when treated conservatively.

Presentation of case

A 53-year-old man sustained a left medial clavicle fracture and was treated conservatively at another hospital. Nine months after his initial injury, he was referred to our institution. We diagnosed pseudarthrosis of the medial clavicle. We performed open reduction and internal fixation using an inverted distal clavicle locking plate. At the 1-year follow-up, radiographs showed bone union.

Discussion

This is the first reported case of medial clavicle pseudarthrosis treated with an inverted distal clavicle anatomical locking plate. There are several advantages in using this plate.

Conclusion

This method is a good treatment option.

Perforated gangrenous ileo-colic intussusception in a 9 month old Nigerian infant presenting at a private hospital: A case report

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The current case presented late with complication of gangrene and perforation because it was first managed as a case of gastroenteritis.

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Gastroenteritis is among the various differential diagnosis of intussusception a high index of suspicion is required for timely diagnosis.

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Being available, cheap and free of radiation, using ultrasound more often in infants can aid diagnosis.

Introduction

Intussusception is the process of invagination of a bowel segment into the adjoining intestinal lumen which may cause bowel obstruction and gangrene. It commonly occurs in infants at a mean age of 9-months with male preponderance. The condition has excellent prognosis if diagnosis is made early and appropriate treatment commenced and mortality rate from intussusception in children can be less than 1%. However, if diagnosis or treatments are delayed it can be fatal in a few days.

Presentation of case

We present a case of Ileo-colic perforated ileum due to delayed diagnosis. It was initially misdiagnosed as gastroenteritis at another hospital. The infant was resuscitated with intravenous fluid and had laparotomy. A signed consent was obtained before the surgery and media consent was signed for publication. A gangrenous terminal ileum was resected and ileo-colic anastomosis was done. Post-operative course was uncomplicated and the patient was discharged after 5days.

Discussion

The index case presented late with complication of gangrene and perforation because it was first managed as a case of gastroenteritis. Gastroenteritis is among the various differential diagnosis of intussusception. Complications have been reported to increase numbers of surgical treatment and sometimes mortality, but rarely occur with good diagnostic acumen.

Conclusion

We conclude that high clinical suspicion, interaction with senior surgeons and regular use of ultrasound in infants with gastrointestinal symptoms will aid diagnosis. Although surgery was performed in the index case, non-surgical reduction is a very efficient treatment modality in uncomplicated cases.

Mature bony metaplasia in multinodular goiter: A case report

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Osseous metaplasia with ectopic bone formation is extremely rare in benign thyroid disorders.

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Only thirteen cases of sporadic goiter with heterotopic bone formation are reported.

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Osseous metaplasia can be a pitfall in the diagnosis of multinodular goiter.

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Ruling out comorbidities is mandatory.

Introduction

Various degenerative changes can be seen in multinodular goiter. These include cystic changes, hemorrhage, fibrosis and calcification. However, osseous metaplasia is extremely rare.

Presentation of the case

Here we present a 44-year-old lady with multiple ill-defined thyroid nodules upon physical examination. Thyroid ultrasound showed multiple variably sized nodules with cystic degeneration. The largest left lobe nodule showed macrocalcification. Further evaluation was advised by the radiologist. Total thyroidectomy was performed and it revealed histological osseous metaplasia with lamellar bone formation. The clinical course following resection was unremarkable.

Discussion

Osseous metaplasia with ectopic bone formation is extremely rare in benign thyroid disorders. To the best of our knowledge, only thirteen cases of sporadic goiter with heterotopic bone formation are reported.

Conclusion

Osseous metaplasia can be a pitfall in the diagnosis of multinodular goiter. Ruling out comorbidities is mandatory, and further genetic and follow-up studies are needed.

Valproic acid induced necrohemorragic pancreatitis: Case report and diagnostic approach in uncommon pancreatitis

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Is convenient to consider a medication induced necrohemorragic pancreatitis in patients without clear causative agent.

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Because progressive increase in AP incidence and the impact on morbidity and mortality is crucial determine an etiologic diagnosis in order to proceed to appropriate therapeutic interventions as for recurrence prevention.

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The valproic acid is a strong AP inducer (class Ia) in its evidence based classification and review of literature on medication induced AP, with the biomolecular evidence of pancreatic injury.

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An adequate initial approach with a complete clinical history and pharmacological background, good physical examination, and pertinent extension of laboratory tests are necessary in order to achieve a proper AP etiology.

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The etiologic diagnosis algorithm for AP proposed could be considered as a diagnostic exclusion tool, and is easy to apply for a timely therapeutic approach in medication induced AP.

Background

Acute pancreatitis (AP) is one of the most frequent gastrointestinal alterations in the United States. Medication induced AP has been undervalued in the surgical environment as etiologic entity of necrohemorragic pancreatitis (NHP). A case of NHP induced by valproic acid (VA) is presented, and an exclusion diagnostic algorithm is proposed.

Case report

A 29-year-old female with past medical history of migraine controlled with VA was admitted to our institute for acute abdominal pain and peritoneal irritation. An exploratory laparotomy was performed, finding pancreatic necrosis and a diagnosis of NHP was determined. The most frequent etiologies for AP were discarded. An exclusion diagnostic algorithm was performed reaching VA as etiologic gent. The treatment consisted on medication withdrawal, oral restriction, parenteral nutrition, hydration, analgesia and peritoneal wash-outs with a positive outcome.

Conclusion

Is convenient to consider a medication induced AP in patients without clear causative agent, such as the VA case presented. An etiological diagnosis algorithm of exclusion is proposed, for an adequate therapeutic approach in medication induced PNH. Algorithm validation is required.

Double direct hernia, triple indirect hernia, double Pantaloon hernia (Jammu, Kashmir and Ladakh Hernia) with anomalous inferior epigastric artey: Case report

INTRODUCTION

Double direct and triple indirect type hernia in unilateral inguinal hernia is unique. Anomaly of pathway traversed by inferior epigastric artery is always of surgical importance. Meticulous exploration of the groin is mandatory for diagnosis of rare hernia.

CASE REPORT

A 46 year old male presented with the right groin swelling. An inguinal hernia having two direct types separated by anamalous inferior epigastric artery and three indirect types of hernia were present. There was one bubonocele and two funicular types of indirect type of hernia present on the single cord. Anamalous inferior epigastric artery lying superficially at midpoint of inguinal canal was buttresed in the posterior wall to prevent its entrapping in mesh. Individual ligation of the indirect sacs and Lichtenstein repair was done. This is first kind of unique case report with the new type of hernia reported in the English literature after searching Pubmed, Medline, Google Scholar and Embase database. This new hernia, Double Pantaloon hernia, as a mark of respect and unity, is named after its State of origin, "Jammu, Kashmir and Ladakh" so called as "Jammu Kashmir and Ladakh Hernia".

CONCLUSION

Double direct and triple indirect type hernia in a unilateral inguinal hernia is unique. Presence of multiple hernia sacs in the inguinal hernia is a risk for recurrence, if not detected. Inferior epigastric artery in inguinal canal may traverse an aberrant course.

Quality of Randomized Controlled Trials Published By Plastic Surgeons: Long-Term Follow-Up

INTRODUCTION

In two previous studies, the quality of randomized controlled trials (RCTs) with the participation of at least one plastic surgeon was evaluated in two periods: 1966-2003 and 2004-2008.

OBJECTIVE

To evaluate the evolution of the quality of RCT publications by plastic surgeons in the subsequent 5-year period, from 2009 to 2013.

METHODS

RCTs published from 2009 to 2013 in English with the participation of at least one plastic surgeon were identified by electronic search and classified for concealment of allocation by two independent evaluators. The studies with adequate allocation concealment had their quality evaluated by two evaluators using the Delphi List and the Jadad Quality Scale.

RESULTS

Of the 6997 identified studies, 261 were classified as to concealment of allocation. Of these, 43 (16.47%) had adequate allocation concealment. According to the evaluation in the Delphi List, there was an improvement, in relation to 1966-2003, in the items "most important characteristics of the prognosis" (p < 0.001), "use of independent evaluator" (p = 0.0029), and "measures of variability and point estimate for the primary variable" (p = 0.0057); there was no difference in relation to 2004-2008. Regarding the Jadad Quality Scale, there was an increase in scores in relation to 1966-2003 (p < 0.0004) but not in relation to the 2004-2008 period.

CONCLUSION

There was no difference in the quality of publications of RCTs by plastic surgeons in the period 2009-2013 compared to the previous 5 years (2004-2008), but both periods presented higher quality than the period 1966-2003.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Laparoscopic cholecystectomy in situs inversus totalis: Case report with review of techniques

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SIT is a rare congenital anatomy with mirror image transposition of the viscera.

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The underlying anatomical variation poses a challenge in the diagnosis and management of cholelithiasis In patient with SIT.

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Laparoscopic cholecystectomy can be safely performed in these cases.

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It is considered technically challenging procedure and often requires alteration in the technique compared to the conventional laparoscopic cholecystectomy.

Introduction

Situs inversus totalis (SIT) is a congenital disorder in which the visceral organs are mirrored from their normal anatomical position. Diagnosis and management of cholelithiasis in patient with SIT poses a challenge due to the underlying anatomical variation.

Presentation of case

We report a case of a 40-year-old male patient who presented with an intermittent history of epigastric and left upper quadrant pain for one month. Clinical assessment and radiological investigations confirmed the presence of cholelithiasis with evidence of SIT. The patient underwent elective laparoscopic cholecystectomy with no complication and he had an uneventful recovery. Various intraoperative modification has been made to overcome the technical difficulties encountered due to the underlying anatomical variation.

Discussion

Since the first successful laparoscopic cholecystectomy in patient with SIT performed in 1991, 85 cases have been reporsted in the literature. Surgeons managed to overcome the technical difficulties by adopting various modification in the techniques compared to the conventional laparoscopic cholecystectomy.

Conclusion

The anatomical variation in SIT can influence the localization of symptoms in patient with cholelithiasis leading to a delay in diagnosis and management. Laparoscopic cholecystectomy can be safely performed in these cases. However, it is considered technically challenging procedure and often requires alteration in the technique.

Prednisolone-induced virginal mammary hypertrophy: Case report

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Virginal Mammary Hypertrophy is a rare condition.

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Virginal Mammary Hypertrophy can be physically and psychologically debilitating.

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A 17-year old with breast hypertrophy following prednisolone treatment is discussed.

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The patient was treated with a bilateral mammaplasty following appropriate counseling.

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Four years after the original procedure, there was no recurrence of hypertrophy.

Introduction

Virginal mammary hypertrophy (VMH) is a rare benign disorder of the breast characterized by excessive enlargement of one or both breasts. It usually presents during adolescence. Drug-induced VMH has been scarcely reported in case reports. Review of the literature showed that prednisolone-induced gigantomastia was reported in a single study on a 47-year-old female. In this study, a case of VMH in a 17-year-old girl following prednisolone treatment will be described. Clinical presentation, clinical findings, diagnostic work-up, management and follow up are discussed.

Presentation of case

A 17-year-old, single female presented to the plastic surgery department at our institute with progressive enlargement of both breasts, 2 months following treatment with prednisolone. Incisional biopsy excluded other breast differential diagnoses. The patient was managed surgically with bilateral mammaplasty with free nipple-areola graft. A total of 8.325 kg of breast tissue was resected. Follow-up 48 months postoperatively revealed good patient satisfaction with no recurrence of breast hypertrophy.

Discussion

Although the estrogen theory is regarded as the most credible explanation for VMH, several cases of drug-induced mammary hypertrophy have been reported. This study may be the first reported case of adolescent prednisolone-induced VMH. Mammaplasty is an accepted treatment despite its possible association with a higher recurrence rate.

Conclusion

VMH may be a rare complication of prednisolone treatment. It should be considered in patients presenting with breast hypertrophy following steroid administration.

STA-MCA bypass following sphenoid wing meningioma resection: A case report

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There were a few cases of skull base tumors requiring vessel revascularization. This is the first clinical report on this issue in Vietnam.

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Most of the vessel revascularization cases were meningiomas.

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Saphenous vein graft (SVGs) was the most commonly reported graft, followed by radial artery graft (RAGs).

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STA-MCA bypass was a safe and helpful choice, especially the collateral vessels were present and the need for blood flow augmentation was minimal.

Introduction

Sphenoid meningioma engulfed cerebral arteries has always been a challenge. To achieve a gross total resection, vessel sacrifice may be unavoidable.

Presentation of case

A 22-year-old man with a history of head trauma a week ago complained of a headache for one week. On examination, he was alert, denied paralysis and cranial nerves palsies. Preoperative MRI showed a hypervascular left sphenoid wing meningioma embedding left internal carotid artery and proximal segment of the middle cerebral artery. In operation, a branch of the MCA was divided when dissecting the tumor. The MCA was clipped but was still difficult to dissect vessel ends in the Sylvian fissure. We decided to extend craniotomy and did superficial temporal artery to M4 segment of MCA bypass. Then, the patient was resuscitated in surgical high dependency unit for 3 days. Surgical outcome in one year postoperative was good with KPS 90 out of 100 points and no neurological deficits. On postoperative MRA, STA-MCA bypass shown acceptable flow.

Discussion

There were a few cases of skull base tumors requiring vessel revascularization. Most of the revascularization cases were meningiomas. Saphenous vein graft (SVGs) was the most commonly reported graft, followed by radial artery graft (RAGs). In case of difficulty in dissecting the vessel ends due to the tumor infiltration, STA-MCA bypass was a safe and helpful choice, especially the collateral vessels were present and the need for blood flow augmentation was minimal.

Conclusion

STA-MCA bypass was effective surgical management for MCA injury in sphenoid wing meningioma resection.

A case of intra-articular fasciitis in the elbow joint

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Intra-nodular fasciitis is very rare and there are only two reported cases of intra-articular nodular fasciitis in the elbow joint.

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It is difficult to diagnose preoperatively, so a clear diagnosis can be obtained only after excisional biopsy.

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As local recurrence has not occurred in previously reported cases, we think that arthroscopic resection is suitable for treatment of this disease.

Introduction

Nodular fasciitis is a benign myofibroblastic proliferation arising from the fascia. Until now, there have been only two reported cases of intra-articular nodular fasciitis in the elbow joint.

Presentation of case

We report a case of a 19-year-old woman with a 3-month history of pain in the left elbow. Contrast-enhanced T1-weighted magnetic resonance imaging (MRI) showed an intra-articular lobulated mass on the anterior portion of the elbow joint, with accompanying effusion. The patient subsequently underwent arthroscopic excision of the mass. Histologically, intra-articular nodular fasciitis was the final diagnosis. At the most recent follow-up, 20 months after surgery, the patient had no subjective symptoms, including pain. The final MRI findings showed no tumor recurrence.

Discussion

As nodular fasciitis is not generally known to arise within a joint, the occurrence at such anatomical locations may lead to a misdiagnosis. Intra-articular nodular fasciitis is rarely encountered, and therefore, is not usually considered during the clinical investigation of joint symptoms.

Conclusion

Preoperative diagnosis was difficult in this case because of nonspecific preoperative clinical findings. Although histological examination is necessary to establish a diagnosis, we recommend that intra-articular nodular fasciitis should be included in the differential diagnosis of intra-articular mass lesions.

Giant symptomatic serous cystadenoma mimicking carcinoma: A case report and literature review

•

The diagnosis of serous cystadenoma is challenging.

•

Surgery may be indicated for select serous cystadenoma.

•

Serous cystadenocarcinoma is a rare entity and histologically indistinguishable from its benign counterpart.

Introduction

Advanced imaging has led to an increase in the incidental diagnosis of pancreatic cysts. Serous cystadenomas (SCAs) account for nearly 30% of cases. These are typically considered benign lesions but up to 16% of cases are resected for aggressive behavior and symptoms.

Presentation of case

A 64 year old female presented with a large incidental cyst in the pancreatic body. Pre-operative imaging conferred a diagnosis of SCA. After 2 years the cyst grew resulting in abdominal pain. Enlargement was associated with splenic vein occlusion and varices of the short gastric vessels. This change in behavior was concerning for malignant transformation. The cyst was resected by distal pancreatectomy and splenectomy. The patient recovered with minimal morbidity. Final pathology revealed a 15.5 × 10.3 × 8.5 cm SCA with negative margins.

Discussion

In this case a patient presents with aggressive radiographic features and new symptoms suggesting malignant transformation of a previously diagnosed SCA on imaging. Although malignant variants can be diagnosed by findings of metastatic deposits at the time of surgery or as recurrence years later, histologic findings cannot discriminate benign from malignant potential. Preoperative imaging is challenging with erroneous characterization in nearly 60% of cases.

Conclusion

Based on the low risk of malignancy, selective surgical resection for SCA appears warranted. Accepted indications for surgery include development of symptoms or concern for correct diagnosis in a medically fit individual. Routine resection for cysts >4 cm has been suggested however, prospective studies are needed to determine benefit over risk rationale.

Metastatic renal cell carcinoma to the pancreas, thyroid, & subcutaneous tissue 13 years after Radical nephrectomy: A case report

•

Renal cell carcinoma (RCC) is an aggressive cancer accounting for 3% of all malignancies.

•

RCC has been reported to be one of the most common malignancies to cause solitary pancreatic metastasis.

•

Metastasis to thyroid is reported to occur in 1% of patients, and can present as late as 20 years after the resection of the primary tumor.

•

A high index of suspicion is crucial to detect RCC metastasis, in addition to life-long follow-up.

Introduction

Renal cell carcinoma (RCC) accounts for 3% of all adult malignancies and is known for its poor prognosis. At the time of diagnosis up to 30% of patients will present with metastasis. We report multiple metastases of RCC to rare sites; twice to pancreases, thyroid, twice to subcutaneous tissue, and the other kidney- occurring years after the radical nephrectomy.

Case presentation

Our case is of a 51-year-old female who underwent a right radical nephrectomy for RCC. Upon 6 years post-operative surveillance for recurrence, multiple metastatic lesions were found in the head of the pancreas which were resected by a Whipple procedure. Four years later, she presented with a thyroid nodule and fine needle aspiration showed metastatic RCC. The patient underwent a total thyroidectomy. Months later, the patient presented with a right forearm mass. Biopsy showed metastatic RCC. Excision with negative margins was performed. A year later, a metastatic lesion was found in the tail of pancreas in addition to a recurrent metastatic mass over the right forearm. The patient underwent completion pancreatectomy and resection of the forearm mass. One year later, another metastatic lesion was found in the left kidney, for which the patient underwent left partial nephrectomy with negative margins.

Conclusion

RCC is one of the most aggressive malignancies. A high index of suspicion is crucial to detect its metastasis. As some lesions maybe missed because they lack the classical radiological findings or are found in atypical locations, in addition to the latent recurrence of RCC metastasis, a lifelong follow-up is recommended.

Prenatal gunshot wound, a rare cause of maternal and fetus trauma, a case report

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Trauma during pregnancy is an important cause of adverse fetal and maternal outcomes.

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Gunshot wounds to the gravid uterus are generally lethal for the fetus, and cause significant morbidity to the mother.

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Gunshot wounds in a pregnant woman must be handled by a multidisciplinary team.

•

Training in maternal and infant resuscitative measures and surgical techniques are vital.

Background

Gunshot wounds in pregnant women, although rare, represent an important cause of fetal and maternal mortality. Understanding the mechanism of injury is essential to identify the possible injuries and to adequately manage the complexity of these emergency scenarios.

Case presentation

We present a case of a 27-year-old woman and her 37 week fetus who were the victims of a gunshot wound. The trajectory of the bullet injured not only the mother but also the developing fetus. An emergency c-section was performed and the bullet was removed from the infant's abdomen. The two patients fully recovered and on follow up controls both patients are doing well.

Conclusions

Trauma events, and particularly gunshot wounds in pregnant women requires promptly and adequate intervention. Coordinated efforts from multidisciplinary clinical teams are needed as well as the appropriate training in maternal and infant resuscitative measures and surgical techniques.

Volvulus of the ascending colon due to failure of zygosis: A case report and review of the literature

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The ascending colon has been described as a retroperitoneal organ however it may occasionally have a long mesentery.

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The process of peritoneal zygosis is incompletely understood and is subject to perturbation leading to many abnormalities.

•

The excessive mobility may predispose to volvulus of this intestinal segment.

•

There is often a long symptomatic prodrome before volvulus occurs during which the observant surgeon may intervene.

•

The mesentery has gained new relevance with respect to its role in the contemporary management of surgical diseases.

Introduction

Volvulus of the mobile ascending colon is a serious complication of a subtle embryological abnormality that frequently goes unrecognised. There has been renewed interest in the development of the mesentery because of its relevance to the contemporary management of surgical diseases. This case is presented to illustrate the dire consequences of missing this diagnosis and to review the fascinating embryology of the condition as well as its clinical implications.

Presentation of case

We report on a 23-year-old male who presented with signs and symptoms of distal small bowel obstruction after a long prior history of intermittent right lower quadrant pain. At laparotomy, a 360-degree counter-clockwise volvulus of the entire right colon was noted as the result of an excessively long ascending mesocolon and unattached hepatic flexure. All gangrenous bowel was resected with primary ileocolic anastomosis performed thereafter. The patient did well post-operatively and was subsequently discharged.

Discussion

Interruption of the in-utero events of fixation known as peritoneal zygosis lead to a persistence of the mesocolon in parts of the bowel that ordinarily are retroperitoneal. The events that lead to this anomaly are poorly understood and have been subject to controversy for centuries. New insights have challenged surgical dogma and informed new surgical techniques. Its true incidence is probably underestimated because of its indolent clinical prodrome, and it requires a high index of suspicion.

Conclusion

Failure of peritoneal zygosis is implicated in a myriad of clinical conditions. Expeditious recognition and intervention in the prodromal period can avert potentially disastrous complications.

Supralevator abscess: New treatment for an uncommon aetiology: Case report

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Proper drainage of supralevantor abscess should be achieved for the fistulae path.

•

After supralevator abscess resolution the drain should be taken off and marsupialization with ENDO GIA® should be performed.

•

It is possible to adapt the length of ENDO GIA® to the length of the fistulae tract.

•

This treatment is a safe method for definitive treatment of traumatic supralevator abscess with intersphincteric fistulae.

Introduction

Supralevator abscess is the least common type of anorectal abscess. Its diagnosis can be hard and treatment difficult.

Presentation of the case

A 48-year-old men was diagnosed in the emergency department with a supralevantor abscess. Under general anaesthesia, the abscess drainage was accomplished after removal of a fish bone, who was perforating the rectum. Due to persistent rectal purulent discharge, a pelvic Magnetic Resonance (MRI) was performed: a supralevator abscess adjacent to the internal obturator muscle and an inter-sphincteric fistulae from the inferior margin of this collection were identified. A Pezzer® drain was placed through the fistula tract. After radiological resolution, under general anaesthesia, the patient was submitted to extraction of the drain and marsupialization of the path left using an ENDO GIA®. At two year follow up he remained asymptomatic.

Discussion

Despite of the abscess aetiology, the principles of treatment are the same: good radiological characterization and proper drainage. An adequate radiological characterization is important to avoid iatrogenic creation of a complex fistulae.

Conclusion

If a supralevator abscess diagnosis is made, fistulae trajectory should be studied. If no clear internal opening is evident, a pelvic MRI should be done followed by drainage of the abscess. After resolution the drain should be taken off and marsupialization with ENDO GIA® should be performed.

Retained gallbladder secondary to retrieval bag rupture during laparoscopic cholecystectomy-A case report

INTRODUCTION

Retrieval bags are used in laparoscopic cholecystectomies to reduce the risk of bile and gallstone spillage during removal of the gallbladder. Retrieval bag rupture is rare, and its complications have never been previously documented.

PRESENTATION OF CASE

A 17-year-old female presented three months post-laparoscopic cholecystectomy with a tender periumbilical mass. Her operative report noted difficulty removing the retrieval bag from the infra-umbilical port site. Imaging of the lump revealed an intra-abdominal fluid collection communicating with the umbilicus. A diagnostic laparoscopy uncovered significant pus in the peritoneal cavity and a gallbladder remnant with multiple gallstones. A combination of sharp and blunt dissections was used to free the gallbladder remnant from its adherent surroundings for removal. A peritoneal washout was performed following extraction of the retained gallstones. The patient's presentation could be traced back to her laparoscopic cholecystectomy where it was confirmed that the retrieval bag ruptured during removal. This would have transected the gallbladder, causing its remnants and associated gallstones to be retained in the peritoneal cavity.

DISCUSSION

Retrieval bag rupture can result in retained gallbladder remnants in the peritoneal cavity. Abdominal abscess can manifest months after the initial operation.

CONCLUSION

Retrieval bags should be inspected following removal to ensure it is completely intact. Surgeons should consider extending the fascial incision if there is any difficulty during removal. Any damage to the retrieval bag mandates immediate pneumoperitoneum for further exploration of retained products. Governance bodies should incorporate practice guidelines related to retrieval bag rupture as these are currently not present.

Lung cancer combined with methotrexate-associated lymphoproliferative disorder: A case report

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Methotrexate-associated lymphoproliferative disorder is known to occur in patients with rheumatoid arthritis treated with methotrexate.

•

FDG-PET/CT have showed FDG uptake in the nodule of methotrexate associated lymphoproliferative disorder.

•

In patients with lung cancer patients who were treated with methotrexate for rheumatoid arthritis, methotrexate-associated lymphoproliferative disorder should be considered as a differential diagnosis.

Introduction

Methotrexate (MTX)-associated lymphoproliferative disorder occurs in rheumatoid arthritis patients treated with MTX; however, patients with concomitant pulmonary lesions are rare. We present a case of lung cancer combined with MTX-associated lymphoproliferative disorder for which, for which it was necessary to differentiate these from possible pulmonary metastasis.

Presentation of a case

A 72-year-old man was referred to our hospital for treatment of squamous cell carcinoma in the left upper bronchus. He was receiving oral MTX and prednisolone for rheumatoid arthritis for 15 years. However, chest computed tomography performed 1 week before surgery revealed a 1-cm-sized pulmonary nodule in the right lung. Surgical pulmonary resection of the right lung tumor revealed substantial B-cell lymphoma-type lymphoproliferative disorder. Left upper lobectomy for the squamous cell carcinoma in the left upper bronchus was performed 5 weeks after the first surgery. Chest CT performed 2 weeks after the first surgery revealed a new 1-cm-sized nodule in the lower left lung lobe. However, after discontinuing oral MTX therapy, the new lesion in the left lower lobe disappeared.

Discussion and conclusion

In lung cancer patients treated with MTX for rheumatoid arthritis, MTX-associated lymphoproliferative disorder should be considered as a differential diagnosis.

Invasive carcinoma in accessory axillary breast tissue: A case report

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Accessory breast cancer is a rare entity with incidence of around 0.2%–0.6%.

•

Routine mammograms can miss accessory breast tissue due to its location.

•

General lack of awareness of accessory breast cancer among clinicians has potentially dangerous implications.

•

Accessory breast cancer does not require mastectomy unless involved by cancer.

Introduction

Accessory or ectopic breast tissue is an aberration of normal breast development. It is known to be a rare entity present anywhere along the embryologic mammary streak or milk line but more common in axilla.

Presentation of case

We report a case of 36 year old female with accessory breast carcinoma who presented with a progressive lump in her left axilla for 1 year. On examination a 2 cm solitary mass was palpable in axilla. Ultrasound confirmed a 19 mm mass with no other lesion in breast and axilla. Core biopsy showed invasive ductal carcinoma. She was discussed in multidisciplinary board meeting and was offered upfront surgery with excision of accessory breast tissue and sentinel lymph node biopsy. Axillary lymph node dissection was omitted following ACOSG Z0011 criteria. She was offered adjuvant chemotherapy and radiation post operatively along with endocrine treatment as she was hormone receptor positive.

Discussion

Accessory breast development is hormone dependent just like normal breast. Breast cancer in accessory breast tissue is very rare. The incidence is around 6%. Most common pathology is invasive ductal carcinoma (50–75%). The most common location is axilla (60–70%) although it can present in other less common locations like infra-mammary region (5–10%) and rarely in thighs, perineum, groin, and vulva.

Conclusion

Since accessory axillary breast tissue is out of the image of screening breast examination, it is necessary for the oncologists to be aware of this entity and associated pathologies. Their preventive excision in high risk women can also be considered.

Rare constellation of abdominal vascular injuries in blunt trauma: Left gastric artery pseudoaneurysms and dissection

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Traumatic visceral artery pseudoaneurysms and dissections are typically secondary to penetrating trauma involving splenic or hepatic vessels.

•

Solitary left gastric pseudoaneurysm and dissection in blunt trauma are rare, and best recognized using multi-detector multiphase CTA.

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Pseudoaneurysms measuring less than 2.0 cm without symptoms of persistent abdominal pain or peritoneal signs can be managed conservatively.

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Conservative management involves close observation, treatment with antithrombotic agents, and optimization of medical comorbidities.

Introduction

Abdominal visceral artery pseudoaneurysms and dissections in blunt trauma are uncommon, however, solitary vascular injury of the left gastric artery and development of multifocal dissections are extremely rare with only 5 reported cases in the literature.

Presentation of case

A 79-year-old male presents two days after a motor boating incident in profound hemorrhagic shock. Subsequent CT imaging revealed moderate hemoperitoneum, two pseudoaneurysms of the left gastric artery measuring 6 mm and 9 mm, as well as attenuation of the artery in keeping with a focal dissection and intramural thrombus, and no active extravasation. After stabilization with blood product resuscitation, he was managed conservatively with administration of ASA and close monitoring.

Conclusion

Abdominal visceral artery vascular injuries in blunt trauma can be managed safely with close monitoring, antithrombotic agent, and medical co-morbidity optimization. Instability or worsening/ persistent symptoms should be considered for endovascular treatment or surgical ligation Further research and reporting of management approaches are required.

Elevated PSA level as a warning of mesh rejection risk after combined laparoscopic totally extraperitoneal hernia repair and transurethral resection of prostate: Case report

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Mesh rejection after combined laparoscopic TEP and TURP.

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High PSA level before procedure.

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An abscess developed several months after operation.

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Might be caused by mesh erosion to viscera.

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Mesh evacuation and debridement had been performed.

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No recurrence of hernia was found after mesh evacuation.

Background

Prostate hypertrophy and inguinal hernia are common health issues in men aged more than 50 years. Recently, many studies showed that prostatectomy and laparoscopic inguinal hernia repair could be performed at the same time. This report depicts mesh rejection after concomitant repair of bilateral direct inguinal hernia with TEP and TURP.

Presentation of case

A 66-year-old man presented with bilateral direct inguinal hernia and enlargement of the prostate. Prostate biopsy shows atypical adenomatous hyperplasia accompanied by chronic inflammatory cells. Surgery was performed with laparoscopic TEP by using mesh and TURP. The patient underwent a combination of laparoscopic TEP and TURP. A single preoperative and postoperative dose of levofloxacin was administered. The laparoscopic TEP and TURP procedures were completed with no difficulty. Hematoma at the right inguinal occurred three weeks after the procedure. Bilateral inguinal abscess and sepsis occurred at 3-month follow-up. We performed laparotomy mesh evacuation and debridement, and found no recurrence of the hernia.

Discussion

Combined laparoscopic TEP hernia repair and TURP are feasible procedures. Bladder erosion caused by mesh might be the cause of mesh infection. However, the elevated PSA levels in this patient can be a warning sign of chronic infection in the prostate which can lead to complications of surgery.

Conclusions

Elevated PSA levels can be a warning before doing a combination of TEP and TURP surgery because they can show signs of infection. However, further research is needed to ascertain the relationship between elevated PSA levels and complications of combination TEP and TURP surgery.

Laparoscopic liver resection for hepatocellular carcinoma in Fontan-associated chronic liver disease. The first case report

INTRODUCTION

A well-recognized long-term complication after Fontan procedure (FP), a complex cardiac surgery performed in patients with univentricular hearts, is the development of chronic liver disease and hepatocellular carcinoma (HCC). Due to the risk of cardiac and liver decompensation, liver resection of HCC is challenging and the laparoscopic approach has never been reported.

PRESENTATION OF THE CASE

We present the first case of laparoscopic liver resection (LLR) of HCC in a 33-years-old girl with cardiac-related cirrhosis after FP. Intraoperatively, the pneumoperitoneum was established at 8-10 mmHg and adequate fluid infusion was given to maintain the cardiac preload. After an ultrasound-guided thermoablation along the free-tumor margin of the hepatic lesion, a full laparoscopic non-anatomical resection of the tumor in segment V was performed, without Pringle manouver and blood transfusion requirement. The cardiac function remained stable during the surgery and thereafter, and the post-operative course was uneventful.

DISCUSSION

HCC in chronic liver disease after FP is associated with high-risk mortality. Due to the complex hemodynamic changes after FP, open surgical resections often aren't feasible and loco-regional percutaneous treatment or combined liver-heart transplantation are the only therapeutic options. This case suggests that LLR in FP patients has low-risk of liver and cardiac decompensation, minimizing the pneumoperitoneum insufflation to ensure low intra-abdominal/intra-thoracic pressures and providing accurate anaesthetic management to maintain proper cardiac preload and output.

CONCLUSION

LLR for HCC after FP is safe and feasible, and might be considered an alternative treatment of HCC for which the best treatment has not been defined yet.

Perioperative management of polycythemia vera with advanced gastric cancer: A case report

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We report a case involving operation for gastric cancer after treatment for PV.

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Control of WBC and Plt counts during the perioperative period led to good results.

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Perioperative management for PV is important for complication-free surgery.

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Careful follow up should be performed for gastric cancer and PV recurrence.

Introduction

Polycythemia vera (PV) is a chronic myeloproliferative disorder with generally good prognosis. However, thrombotic and cardiovascular complications are among the leading causes of death in patients with PV and sufficiently effective management strategies are yet to be established. We report a case involving operation for gastric cancer in a patient being treated for PV.

Presentation of case

A 73-year-old man was diagnosed as PV on the basis of abnormal laboratory data eight years previously. Three months ago, he was referred to our department for anorexia and melena. The preoperative diagnosis was advanced gastric cancer, Stage IIB. To avoid perioperative thrombotic and hemorrhagic events, low-dose aspirin administration was continued with an additional dose of hydroxyurea. Emergent control was necessary because of the severity of gastric cancer symptoms, including pyloric stenosis and anemia. Distal gastrectomy with D2 lymph node resection was performed. The postoperative course was satisfactory, and the patient is currently doing well without any signs of recurrence or hematological complications.

Discussion

We described the successful management of a patient being treated for PV who underwent gastrectomy. As mentioned earlier, thrombotic complications and hemorrhage during the perioperative period are the major risk factors in patients with PV. In this case, control of white blood cell and platelet counts during the perioperative period led to good results.

Conclusions

Perioperative management for PV is important for complication-free surgery. Careful follow up should be performed for gastric cancer and PV recurrence.

A novel surgical approach with peritonectomy to extranodal multisystemic histiocytic sarcoma: A case report and literature review

INTRODUCTION

Histiocytic sarcoma (HS) is a very rare malignant histiocytic derivation cancer. The extranodal multisystemic HS has an aggressive clinical course and poor Disease-Free Survival (DFS) and Overall Survival (OS). There are no shared and effective therapeutic protocols; our approach aims to improve the prognosis for advanced diseases.

PRESENTATION OF THE CASE

53-year-old female patient admitted to hospital for intestinal obstruction in April 2016 with evidence of an ileal mass in the right iliac fossa and peritoneal metastases, undergoing urgent surgery of ileal resection, ileostomy and nodular peritoneal mass biopsy. Histological examination diagnosed HS. Staging exams excluded the involvement of other gastro-intestinal districts in the absence of concomitant lymphoproliferative disorders, and PET-CT revealed multiple abdominal and mediastinal nodes hyperplasia. The patient performed chemotherapy and, seeing the partial abdominal extranodal response, was performed cytoreductive surgery (CRS). Histological examination confirmed the diagnosis of HS with multiple peritoneal, ileal, colic and omental localisation. Adjuvant second-line chemotherapy treatment (4 DHAP cycles) was performed. Disease Free Survival at ten months from cytoreductive surgery, Overall Survival at 21 months from diagnosis.

DISCUSSION

Despite a multimodal therapy with surgery and chemotherapy, extranodal multisystemic HS has a poor prognosis. Up to now the role of surgery is limited to biopsies or complications treatment. Our results of DFS and OS show that cytoreductive surgery may be a valid therapeutic choice.

CONCLUSION

The surgical approach with major cytoreductive purposes could improve the prognosis in cases with prevalent abdominal extranodal localisation.

Laproscopic treatment for small bowel bleeding after detection by double-balloon endoscopy: A case report

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The frequency of small bowel bleeding due to an arteriovenous malformation is rare.

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Localization of the bleeding location is required prior to laparoscopic resection.

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Double-balloon endoscopy enabled direct observation and preoperative tattooing.

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Endoscopic marking followed by laparoscopic resection might be optimal option.

Introduction

The frequency of small bowel bleeding is relatively low and the process for the diagnosis and treaVtment remains difficult. Here, we report a case of massive small bowel bleeding due to arteriovenous malformation (AVM), treated by a combination of double-balloon endoscopy and laparoscopic resection.

Presentation of Case

A 59-year-old man was admitted to our hospital due to a hemorrhagic stool. The patient presented transient hemorrhagic shock and contrast-enhanced CT revealed a hyper-vascularized tumor in the small bowel. India ink tattooing for the responsible lesion with double-balloon endoscopy was performed. The tattooed lesion was easily confirmed during the subsequent laparoscopic observation and segmental resection was done. Pathological examination showed arteriovenous malformation of the small bowel.

Discussion

Prior to laparoscopic resection, the localization of the responsible area might be a significant consideration when the lesion is invisible. Endoscopic marking with DBE enables intraluminal detection and laparoscopic observation from the serosal side.

Conclusion

Preoperative marking with the use of double-balloon endoscopy followed by laparoscopic resection might be an optimal option for the treatment of massive small intestinal bleeding.

TFE3-expressing primary perivascular epithelioid cell tumor of the Lymph node mimicking nodal relapse of rectal cancer: A case report

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TFE3-expressing PEComa has unique morphological and immunohistochemical features.

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PEComa can mimic lymph node relapse of rectal cancer.

•

Surgical excision can aid a proper diagnosis of suspicious lesions in rectal cancer.

Introduction

Perivascular epithelioid cell tumor (PEComa) is a rare mesenchymal neoplasm.

Presentation of case

We treated a 50-year-old woman who underwent neoadjuvant chemoradiotherapy followed by low anterior resection and adjuvant chemotherapy for ystage IIIB rectal adenocarcinoma. The patient was diagnosed with metastatic rectal adenocarcinoma in the right lower lobe of the lung after 14 months of follow-up. Later, after 3 years of follow-up, a mass in the gastrosplenic area was revealed by computed tomography, which was considered indicative of metachronous mass relapse. The patient underwent partial omentectomy, and an enlarged mass measuring 2.2 × 1.3 cm was found. Microscopic findings revealed an alveolar-like collection of epithelioid cells surrounded by a thin-wall vascular channel within a lymph node (LN). These epithelioid cells were positive for HMB45 and TFE3 but negative for Melan-A, CK, and S100. The patient was finally diagnosed with TFE3-expressing primary PEComa of LN.

Discussion

We report a rare case of TFE3-expressing primary LN PEComa that mimicked nodal recurrence of rectal cancer. Thus, imaging results in patients affected by neoplasm present a clinical diagnostic dilemma, as the presence of newly onset PEComa of LN may lead to the erroneous diagnosis of tumor recurrence or progression.

Conclusion

Suspicious isolated recurrences of rectal cancer in unusual locations may require surgical excision to confirm definitive diagnosis.

Robotic right colectomy in a patient with ventriculoperitoneal shunt. Report of a case

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Laparoscopic surgery in patients with VPS tubes was previously contraindicated.

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Robotic right colectomy is associated with improved recovery.

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No need of VPS catheter manipulation is needed in robotic surgery.

•

The first reported case of a robotic right colectomy with an intracorporeal anastomosis in a patients with a VPS.

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Robotic right colectomy is safe also in patients with VPS, with short hospital stay and fast postoperative recovery.

Introduction: Ventriculoperitoneal shunt procedure has become the most common neurosurgical method for hydrocephalus because it considerably improves patients prognosis.

Pneumoperitoneum has been considered a contraindication to laparoscopic surgery because of risk for increased intracranial pressure during pneumoperitoneum and/or malfunction/infection of the VP shunt itself. Laparoscopic resection of the cecum and of the rectum for cancer has been reported.

Presentation of case: A 74-year old man with ventriculoperitoneal shunt for normal pressure hydrocephalus referred to the emergency medicine ward for COPD, lower limb oedema and severe anemia. CT Scan showed a substenotic tumor of the right colon and non-specific enlarged regional lymph nodes, with no distant metastases. Colonoscopy confirmed the presence of an ulcerated tumor of the right colon involving half of the colic lumen. A right colectomy with CME was carried out, with a stapled intracorporeal ileocolic side-to-side isoperistaltic anastomosis and without manipulating the VPS catheter.

Discussion: Laparoscopic surgery in patients with VPS tubes was previously contraindicated because of the possibility of shunt-associated complications, that may include shunt malfunction due to increased intra-abdominal pressure, damage or infection of the catheter. Some authors reported that intracranial pressure increased up to 25 mmHg at a pneumoperitoneum pressure of 12 mmHgHerein we report, to our knowledge, the first case report of robotic assisted right colectomy for cancer in a patient with a VP shunt.

Conclusion: Robotic assistance may allow to perform colorectal resection safely and with low risk also in patients with ventriculoperitoneal shunt.

Conservative management of delayed presentation of intraperitoneal bladder rupture following caesarean delivery: A case report

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Bladder injury is an uncommon complication of cesarean delivery with an incidence ranging from 0.0016% to 0.94%.

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Delayed blabber rupture post CD may present with urinary ascites and elevated serum creatinine mimicking acute kidney injury.

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Cystography is the diagnostic imaging of choice with the reported accuracy of 85%–100%.

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Surgical repair is the treatment of choice for intraperitoneal bladder injury.

•

Conservative management with intraperitoneal and urethral catheter may succeed in properly selected cases.

Introduction

Bladder injury is an uncommon complication of cesarean delivery (CD) with an incidence ranging from 0.0016% to 0.94%. The risk factors are emergency CDs, subsequent CDs, trial of normal delivery after CD and whether adhesions are present or not. The presentation is either immediate intraoperative event or delayed bladder rupture and urinary ascites.

Case presentation

A 35-year-old female presented with considerable abdominal distension, shortness of breath, oliguria, straining to void and elevated levels of blood urea and serum creatinine 11 days after an uneventful Caesarean delivery. Abdominal ultrasound showed marked ascites. Immediate resuscitation was done, a urethral catheter and percutaneous intraperitoneal pigtail catheter were inserted confirming urinary ascites. Next day cystoscopy was performed and revealed a perforation at the posterior wall of the bladder. She was kept on conservative treatment with adequate urine diversion through both urethral and intraperitoneal catheter. Her condition improved and responded well.

Discussion

To the best of our knowledge this presentation of delayed intraperitoneal bladder rupture post CD is the second case reported in literature. Although surgical repair is regarded as the treatment of choice for intraperitoneal bladder injury, conservative treatment may succeed in properly selected cases. Non-operative managements include indwelling transurethral Foley catheter alone, percutaneous peritoneal drain alone or combined Foley catheter and percutaneous peritoneal drain for complete urinary drainage.

Conclusion

Delayed urinary bladder rupture is a very rare complication of cesarean delivery. Non-operative treatment can be a viable alternative to surgical repair in carefully selected patients.

Parathyroid adenoma presenting as genu valgum in a child: A rare case report

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Primary hyperparathyroidism is a rare disease in children and adolescents.

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Genu valgum is a rare presentation in children with PHPT.

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Primary hyperparathyroidism may present as normocalcemic primary hyperparathyroidism if associated with vit. D deficiency.

•

Technetium99 M-sestamibi scan is most sensitive and specific for localization of parathyroid adenoma.

•

Surgery is the only curative treatment for PHPT and post-operative management for features of hypocalcemia is crucial.

Introduction

Parathyroid adenoma is the most common cause of primary hyperparathyroidism (PHPT). Patients typically present with elevated serum calcium levels and elevated serum parathyroid hormone levels. The incidence and prevalence is higher in adults but is rare in pediatric age group.

Case presentation

A 12-year-old, pre-pubertal female presented with pain in bilateral knee joints and gait abnormality since one year. Her past medical history and family history were insignificant. On general examination, no other congenital bony deformities were observed besides genu valgum. Laboratory tests showed hypocalcemia and elevated serum levels of intact parathyroid hormone. Radiograph of bilateral both knee joints was suggestive of genu valgum. Ultra sonogram of neck revealed enlarged parathyroid gland and a Technetium (99mTc) sestamibi scan was suggestive of right inferior parathyroid adenoma. Surgical resection was performed and post-operative hypocalcemia was seen. After necessary treatment was given and the patient was discharged when asymptomatic.

Discussion and conclusion

Parathyroid adenoma causing primary hyperparathyroidism is a rare disease in children. They typically present with nonspecific symptoms involving gastrointestinal, musculoskeletal, renal and neurological symptoms due to hypercalcemia. Moreover, Genu valgum is a rare presentation in children with parathyroid adenoma.

Laparoscopic surgery of a presacral epidermoid cyst: A case report

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The best approach for resecting epidermoid cysts is still controversial.

•

We successfully performed laparoscopic resection of an epidermoid cyst.

•

Laparoscopic resection may be a better option in carefully selected cases.

•

However, the tumor size and location must also be considered.

Introduction

The best approach for resecting epidermoid cysts is still controversial. We describe a case of an epidermoid cyst in which laparoscopic resection was performed successfully.

Presentation of case

63 × 55-mm well-defined cystic mass was incidentally detected by computed tomography in the presacral cavity of a 50-year-old woman during evaluation for upper abdominal pain. Magnetic resonance imaging showed a cystic tumor with a low signal intensity on T1-weighted images and, high signal on T2-weighted images in the left dorsal side of the rectum. This tumor was diagnosed as a developmental cyst, and laparoscopic resection was performed. Resection of the tumor was performed with negative margins. This tumor was histopathologically diagnosed as an epidermoid cyst. There was no evidence of malignancy, and no postoperative event or signs of recurrence occurred 6 months postoperatively.

Discussion

In our patient, there was no difficulty in the field of view and forceps operability during laparoscopic surgery. Furthermore, it is possible to perform laparoscopic surgery with minimal damage to the muscles, nerves, and rectum, leading to the preservation of anal function.

Conclusion

Laparoscopic resection of an epidermoid cyst may be a better option in carefully selected cases with consideration of the tumor size and location.

Successful utilization of angioembolization and delayed laparoscopy in the management of grade 5 hepatic laceration: Case report and literature review

INTRODUCTION

The liver is the most commonly injured solid organ in blunt abdominal trauma. Although the incidence of hepatic lacerations continues to rise, non-operative management with angioembolization is currently the standard of care. While active arterial hemorrhage is commonly embolized in grade 3 or 4 injuries, patients with grade 5 injuries frequently require operative intervention.

PRESENTATION OF CASE

A 30-year-old man presented to our level I trauma center following a motor scooter accident. CT abdominal imaging revealed a grade 5 right lobar hepatic laceration. He underwent successful angioembolization without further hemorrhage. The patient later developed abdominal discomfort that worsened to peritonitis and he was taken for laparoscopic drainage of massive hemoperitoneum with bile peritonitis. Postoperatively, the patient's abdominal pain abated and he tolerated oral dietary advancement.

DISCUSSION

Surgical management of blunt hepatic trauma continues to evolve in tandem with minimally invasive interventional techniques. Patients with high-grade lacerations are at higher risk for developing biliary peritonitis, hemobilia, persistent hemoperitoneum, and venous hemorrhage after angioembolization. Accordingly, the primary role of surgery has shifted in select patients from laparotomy to delayed laparoscopy to address the aforementioned complications.

CONCLUSION

While laparotomy remains crucial for hemodynamically unstable patients, angioembolization is the primary treatment option for stable patients with hemorrhage from liver trauma. The combination of angioembolization and delayed laparoscopy may be considered in stable patients with even the highest liver injury grades.

Safe resection margin in video-assisted left anterior and lingular segmentectomy for an impalpable lung nodule

INTRODUCTION

The nodule located at the left anterior segment near the lingular segment is traditionally resected by left upper lobectomy. We performed video-assisted thoracoscopic surgery (VATS) segmentectomy and could achieve a complete resection that is minimally invasive and oncologically sufficient.

PRESENTATION OF CASE

An 82-year-old woman was found to have a nodule in the left anterior segment of the lung on chest computed tomography (CT). The nodule was 1.9 cm in size and strongly suspected to be lung carcinoma. No suspicious regions of metastasis were observed; thus, we diagnosed stage IA2 and decided to perform anterior and lingular segmentectomy by VATS.

DISCUSSION

Because of the location, the tumor is traditionally resected by left upper lobectomy. However, we planned a minimally invasive intervention and performed anterior and lingular segmentectomy by VATS using a CT-guided nodule marking prior to the surgery.

CONCLUSION

This technique resulted in complete tumor resection with minimal adverse effects.

Genetic identification of endoscopic biopsies after unnecessary gastrectomy: Case report and medico-legal evaluation

INTRODUCTION

Forensic genetic laboratories analyse samples included in paraffin to verify the genetic correspondence of histological samples, from living subjects or cadavers, in cases where there is a suspicion of contamination of samples with tissues of other patients.

PRESENTATION OF THE CASE

A case of a man subjected to a gastrectomy as a result of a histological diagnosis of gastric adenocarcinoma after endoscopic biopsies is reported. The microscopic analysis on the gastric tissue after the gastrectomy excluded the presence of cancer. Having suspected a diagnostic error, a microscopic revision of the biopsies was performed and confirmed the presence of cancer cells but led to a hypothesis that there had been contamination with foreign intestinal tissue. The genetic analysis performed on various pieces of tissue, despite the reduced amount of biological material, succeeded in identifying the presence of two incomplete genetic profiles, one of which belonged to a subject of the opposite sex.

DISCUSSION

The case raised many questions about the process of setting up histological specimens. Even though it is impossible to identify the healthcare professionals responsible for contamination, the organizational error during the management of biopsies has significantly affected the clinical case of the patient, who underwent a gastrectomy for cancer that was not present.

CONCLUSION

This case is not simply an example of diagnostic error and related unnecessary surgery, but it has raised some doubts about patient management and it has led us to some medical-legal cause for reflection in the field of professional liability.

Giant sixteen kilogram lymphangioma mesenteric cyst: An unusual presentation of a rare benign tumour

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Mesenteric cysts may present as giant abdominal masses.

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It is the heaviest (16 kg) mesenteric cyst reported in the literature to date.

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In low incomes countries, the interval between the onset of symptoms and consultation is often significant, leading to unusual presentations.

Background

Mesenteric cysts are rare abdominal benign tumours with an incidence of 1:100.000–250.000 surgical admissions located in the mesentery. Theirs presentations may range from incidental asymptomatic discovery during imaging to non-specific abdominal symptoms.

Case presentation

We present the case of a 46 year old female who presented with 9 months history of progressive abdominal distension. CT scan showed a giant abdominal mass. After the necessary preoperative work up, a midline incision laparotomy was performed. Intraoperative findings were a mesenteric cyst originates from the transverse mesocolon. The cyst weighed 16 kg and histopathology analyses confirmed a lymphangioma mesenteric cyst.

Discussion

In low incomes countries like our own, the interval between the onset of symptoms and consultation is often significant, leading to unusual and sometimes spectacular presentations at the time of diagnosis. To our knowledge, it is the heaviest mesenteric cyst reported in the literature to date.

Conclusion

Mesenteric cysts may present as giant abdominal masses. The publication of this atypical case is a plea for us for the establishment of universal health coverage in our country in particular and in Africa in general.

Incomplete superficial palmar arch and bilateral persistent median artery

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Possible anatomical variations of the vascular supply for the hand.

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Screen patients for the presence of persistent median artery.

Introduction

The superficial palmar arch (SPA) is a major source of blood supply to much of the hand and is conventionally formed by the anastomosis of the ulnar artery with the superficial branch of the radial artery. The SPA has been classified into complete or incomplete based on the presence or absence of anastomosis between the arteries contributing to the formation of this palmar arch.

Case report

Reported here is a unilateral presentation of incomplete superficial palmar arch. The ulnar artery (UA) gave off one proper palmar digital artery, which supplied the ulnar side of the little finger, and two common palmar digital arteries, which supplied the little, ring, and the middle finger. The superficial palmar branch of the radial artery gave off a proper palmar digital artery to the thumb, and two common palmar digital arteries, which supplied the thumb, index, and middle fingers. Apart from the presence of the incomplete SPA, persistent median arteries were also observed bilaterally in this cadaver.

Discussion

The prevalence of incomplete SPA has been reported to vary between 3.6–54.76%. To the best of our knowledge, this is the first case report describing an incomplete palmar arch and bilateral persistent median artery in a cadaver.

Conclusion

Patients should be screened for the presence of complete or incomplete SPA before harvesting the radial artery either for myocardial revascularization or for radial artery forearm flap to prevent ischemic complications in the hand.

A new approach for severe aortic regurgitation in porcelain aorta with sutureless Perceval valve: A case report

INTRODUCTION

The association of pure aortic regurgitation and porcelain aorta represents a challenging situation. In the Transcatheter Aortic Valve Implantation (TAVI) era, porcelain aorta (PA) becomes an additional risk for patient treatment and sometimes serves as the primary indication for the TAVI approach, even in low-risk patients. Devices currently on the market are not yet validated for the treatment of pure aortic regurgitation (AR) in PA and mid/long-term results are still not available. Furthermore, small calcified sinotubular junction and the association of small Valsalva sinus with low origin of coronaries ostia represent a relative contraindication of TAVI.

PRESENTATION OF CASE

We report a case of severe symptomatic AR associated with a PA in a patient successfully treated with a sutureless Perceval valve.

DISCUSSION

The sutureless Perceval valve may represent an excellent option. This valve requires less manipulation of the ascending aorta and no manipulation of the aortic annulus except for the aortic valve leaflets removal. Furthermore, it can be implanted also in a small and calcified sino-tubular junction because the valve is collapsible before the implant.

CONCLUSION

The present case represents a proof that self-expandable cardiac valve technology can be employed to treat, either by surgery or by catheter, selected cases of AR. We have observed an excellent mid term result with no paravalvular leak at 2 years.

Distal ureteral stone formation over migrated Hem-o-lok clip after robot-assisted partial nephrectomy

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Foreign bodies, such as suture materials, mesh, cotton swab, Hem-o-lok clips, metallic clips, coils used for angioembolization etc. are rare causes of urinary tract stone disease.

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Clinicians should be aware of the possibility of migrated hem-o-lok clips serving as a nidus for urinary tract stone formation in patients who have undergone endoscopic PN.

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Attention to suture tension during endoscopic partial nephrectomy may reduce the risk of clip migration.

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Laser lithotripsy of the calculous cortical rim around the Hem-o-lok clip(s) and removal of the denuded foreign body under direct endoscopic visualization are strongly advisable, since Hem-o-lok clips are usually SWL-resistant.

Introduction

Hem-o-lok clip migration into the ipsilateral collecting system and formation of a distal ureteral stone after robot-assited partial nephrectomy (PN) is a rare condition of stone disease.

Presentation of case

A 48-year-old male presented with hematuria. Physical examination was unremarkable. Urinalysis showed presence of red blood cells. Serum multiple analysis and ultrasonography were within normal limits. Contrast enhanced abdominal computerized tomography scan revealed an 8-mm right distal ureteral stone, which was not associated with ipsilateral hydronephrosis.

Discussion

With the widespread adoption of minimally invasive surgery, it is not uncommon to utilize foreign bodies as surgical facilitators which also have the potential to migrate to the urothelium-lined urinary tract and act as a stone nidus when used for endoscopic PN

Conclusion

Clinicians should be aware of the possibility of migrated hem-o-lok clips serving as a nidus for urinary tract stone formation in patients who have undergone endoscopic PN.

Fluoroscopy-assisted posterior percutaneous reduction for the management of unilateral cervical facet dislocations after unsuccessful closed reduction: A case report

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Open reduction of cervical facet dislocation is needed when closed reduction fails.

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Anterior cervical discectomy and fusion after posterior percutaneous reduction was performed.

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Posterior percutaneous reduction can be useful for cervical facet dislocations.

Introduction

In some cases of cervical facet dislocations, open reduction becomes imperative when closed reduction fails. In these cases, posterior open reduction with subsequent posterior fixation has been favored in previous reports as reduction using the posterior approach is less challenging than that using the anterior approach. However, it invades the posterior cervical muscles, is associated with a high risk of postoperative axial neck pain, and is less likely to restore cervical lordosis than anterior surgery. In this report, we describe a novel reduction technique, posterior percutaneous reduction, which can address this dilemma.

Presentation of case

An attempt to perform closed reduction in a 19-year-old adolescent with a unilateral facet dislocation at the C4-C5 level was unsuccessful. To preserve the posterior cervical muscles and obtain good cervical alignment, we opted for posterior percutaneous reduction and subsequent anterior cervical discectomy and fusion instead of posterior open reduction and fixation. An elevator was inserted into the locked facet percutaneously with fluoroscopic assistance, and reduction was achieved by lever action. Seven days after the percutaneous reduction, anterior cervical discectomy and iliac bone grafting with plate fixation were performed. There were no complications or neurological deficits postoperatively.

Discussion

This report describes the case of a patient who underwent anterior cervical discectomy and fusion after posterior percutaneous reduction with preservation of the posterior cervical muscles for unilateral facet dislocation when closed reduction was unsuccessful.

conclusion

Posterior percutaneous reduction could be a useful option for the management of cervical facet dislocations.

Rescue surgery for advanced anal gland adenocarcinoma: A case report

INTRODUCTION

Extramucosal anal canal adenocarcinomas can arise in anorectal fistulas and the anal glands, the latter being rare. We present a rare case of anal gland adenocarcinoma treated with a combination of neoadjuvant therapy and radical surgical resection.

PRESENTATION OF CASE

A 56-year-old man presented with rectal bleeding and irritation, and a nodule that had been enlarging for 10 months. Rectal examination revealed a bleeding ulceroproliferative growth at the left lateral edge of the anus without apparent invasion of the anal mucosa. Histopathology and immunohistochemistry confirmed the diagnosis of anal canal adenocarcinoma CK7+,CDX2-, and focalCK20+). Endoanal ultrasound showed a lesion involving the anal canal, extending into the transition zone with the lower rectum, invading the external anal sphincter, with no cleavage plane with the urethra, measuring 89 × 33 × 57 mm, associated with lymphadenopathy in the lower mesorectum (uT4N1). PET/CT confirmed a hypermetabolic lesion on the anal edge and bilateral hypermetabolic inguinal lymph nodes suggestive of secondary involvement. Colonoscopy was normal. The patient was started on neoadjuvant therapy with oral capecitabine and radiotherapy (57.6 Gy). Twelve weeks, the patient underwent extralevator abdominoperineal excision, cystoscopy (free urethral mucosa), skeletonization of the urethra with partial resection of the corpus cavernosum, and pelvic floor reconstruction with a vertical rectus abdominis myocutaneous flap.

DISCUSSION

Treatment of anal gland adenocarcinoma remains to be established. A combination of radical surgical resection and neoadjuvant/adjuvant chemoradiotherapy has been suggested, as performed here.

CONCLUSION

Patients with advanced anal gland adenocarcinoma may benefit from neoadjuvant therapy followed by rescue surgery.

The ugly face of deep vein thrombosis: Phlegmasia Cerulea Dolens-Case report

INTRODUCTION

Phlegmasia Cerulea Dolens (PCD), a rare & life-threatening condition caused by a massive deep venous thrombosis that is associated with arterial occlusion caused by the subsequent compartment syndrome.

CASE PRESENTATION

A 56-year-old male was diagnosed as a case of extensive left femoral DVT & pulmonary embolism. Two days after being managed by systemic thrombolytics & heparin, his condition worsened as he developed cyanosis of the affected limb, compartment syndrome & foot drop so he was referred to our facility for further management. CT venogram showed a thrombosis of the left popliteal vein extending into the left common iliac vein confirming the diagnosis of PCD & May-Turner syndrome. We adopted a limb preserving approach using a pharmacomechanical catheter directed thrombolysis (PCDT). The patient recovered fully with a complete resolution of his foot drop.

DISCUSSION

Several treatment options have been suggested to improve the outcomes of PCD, but due to the rarity of this condition a gold standard treatment is still controversial. But regardless of the chosen approach, there is an urgent need to decrease the thrombus burden to prevent further adverse sequelae like amputation or even death which can be achieved by using PCDT as it was demonstrated in our case.

CONCLUSION

Our case shows that a rare entity of DVT as PCD could be a result of improper management of acute proximal DVT in the background of anatomical variabilities & that despite the late presentation of such a rare condition there still a role for a limb preserving approach with endovascular techniques.