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

Acellular dermal matrix for rhinophyma: Is it worth it? A new case report and review of literature

INTRODUCTION

nasal reconstruction after rhinophyma surgery could be challenging. In the last decade, some authors proposed the use of dermal substitutes, but only few case reports have been described throughout the Literature.

PRESENTATION OF CASE

we described a new case of severe and disfiguring rhinophyma treated by total excision and a two-step reconstruction by using acellular dermal matrix and subsequent full-thickness skin graft. Despite an overall improvement of the nasal shape and a good functional recovery were observed after 12 months of follow-up, the aesthetic outcome was not satisfactory and the patient required further surgical revisions.

DISCUSSION

the use of ADMs in rhinophyma poses some important aspects to be discussed. The resorption rate of the matrix and retraction rate of the skin graft make the final thickness of the neodermis unpredictable. Moreover the location of phymatous lesions and the extent of the surgical removal may strongly impact the final aesthetic outcome, often leading to a multistep procedure and patient dissatisfaction.

CONCLUSION

although we believe that ADM represents a simple and reliable alternative for surgical reconstruction after rhinophyma, basing on our clinical experience we suggested some important tips and tricks in order to avoid surgical revisions, and both surgeons and patients should be aware about the potential drawbacks of this technique.

Successful surgery localized to the infected lesion as diagnosed by 18F-fluorodeoxyglucose positron emission tomography/computed tomography for extended-aortic prosthetic graft infection

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Radical surgical treatment for prosthetic graft infections is still challenging.

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Especially so for patients with extended-aortic prosthetic graft infection.

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Redo total arch replacement while preserving prostheses with no abnormal FDG uptake.

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All the resected tissues were positive for methicillin-resistant Staphylococcus epidermidis.

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No signs of infection recurrence at 2 years postoperatively.

Introduction

We describe the successful treatment of a patient with extended-aortic prosthetic graft infection (PGI) by surgery limited to the infected lesion based on ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG-PET/CT) findings.

Presentation of case

A 54-year-old man, who had undergone three graft replacements (GRs) for extended-thoracic aortic aneurysms, was diagnosed with PGI complicated by an aorto-esophageal fistula. On the basis of ¹⁸F-FDG PET/CT findings, we performed a redo total arch replacement, preserving the other prosthesis where abnormal FDG uptake was not detected. All the resected tissues were positive for gram positive coccus. There were no signs of infection recurrence at 2 years postoperatively.

Discussion

Since activated inflammatory cells such as macrophages uptake FDG, FDG-PET/CT clarifies the localization of the infected prosthesis precisely.

Conclusion

Surgery localized to the infected sites detected by FDG-PET/CT can be an effective option for PGI in cases with previous multiple GRs.

Case report: A rare presentation of high risk epithelioid hemangioendothelioma on leg treated with surgical excision

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High risk type hemangioendothelioma (EHE) identified via pathology with characteristic nuclear pleomorphism and associated erythrocytes within vascular channels.

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CD31 membrane positivity with >3 mitosis/50 on high power field. Cytologic features of such a finding.

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Treated with surgical excision on leg (x2) with resolution of local site. Secondary site of EHE discovered at 7 month mark right groin mass which was also excised.

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Identified how to approach and treat a rare vascular tumor (EHE) type based upon limited literature review.

Introduction

A rare vascular tumor, epithelioid hemangioendothelioma (EHE), can be difficult to diagnose for physicians. Although uncommon, EHE has the potential to become malignant and cause patient death. The five year mortality rate with the diagnosis of the high risk type has been reported to be as high as 41. Thus this finding requires aggressive treatment to prevent amputation or death (Deyrup et al., 2008).

Presentation of case

In this case, a 60-year-old male patient was evaluated for a suspicious subepidermal nodule on the upper lateral aspect of the lower right leg just distal to the knee. It was excised to the level of muscle with appropriate margins of 1 cm circumferentially. The specimen underwent appropriate pathological testing and did reveal a high-risk-type epithelioid hemangioendothelioma with remaining tumor present at the deep margin. The patient had additional surgery by an orthopedic surgeon in order to obtain clear margins of the lesion and retain maximum function of leg. Despite surgical excision with ultimately clean margins, the lesion did metastasize to the right groin area seven months after surgery and the secondary metastatic site also required surgical excision.

Discussion

There is very little information available to the identification and treatment of a finding of EHE. The only definitive treatments to prevent malignancy is excision or amputation, possibly in conjunction with radiation therapy. The role of oncology intervention should be considered because the finding may be either a cause or an effect of malignancy.

Conclusion

The goal of this paper is to raise awareness of the importance of pathology for soft issue lesions even if there is initially a low clinical index of suspicion. Unique characteristics in the pathology is the cornerstone to the identification and treatment. Although surgical excision can appear to be a curative treatment, EHE may inevitably metastasize, so aggressive and definitive treatment is best.

Successful mesh plug repair using a hybrid method for recurrent inguinal hernia after laparoscopic transabdominal preperitoneal approach: A case report

INTRODUCTION

The HerniaSurge Group and the European Hernia Society guidelines recommend an anterior approach to treat recurrent inguinal hernias after a failed posterior approach. The hybrid method combining explorative laparoscopy and anterior open approach can provide the benefits of both approaches.

PRESENTATION OF CASE

A 79-year-old man presented with a recurrent inguinal hernia after primary repair for an indirect hernia using the laparoscopic transabdominal preperitoneal approach (TAPP) 5 years ago. The indirect hernia formed inferior to the lower edge of the previous mesh was diagnosed under laparoscopy. The hernia defect (2 cm) was fixed using a mesh plug via the anterior approach. Appropriate mesh overlap was confirmed using laparoscopy.

DISCUSSION

This minimally invasive method enabled us to choose the best treatment for recurrent hernia and prevent chronic pain due to possible nerve damage caused by extended dissection of the scar tissue. Furthermore, the final confirmation step using laparoscopy assures complete coverage of all defects within the myopectineal orifice.

CONCLUSION

This hybrid method facilitates the choice of an optimal approach for the treatment of recurrent hernia and may reduce surgical complications and re-recurrence rate.

Novel surgical approach without bowel resection for multiple gastrointestinal lipomatosis: A case report

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We experienced GI lipomatosis existing from the duodenum to the small intestine.

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In case of multiple lipomas, resection procedure and range cannot be determined.

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Intestinal lipomas were resected with local excision without any bowel resection.

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And duodenal lipoma was resected with ESD.

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Local excision + ESD seemed to be one of the methods in resecting lipomatosis.

Introduction

Asymptomatic lipoma only requires observation, whereas symptomatic lipoma requires treatment such as endoscopic or surgical resection. However, in case of multiple lipomas, with evident diffusion and malignancy, resection procedure and range cannot be determined.

We experienced GI lipomatosis (multiple lipomas) diffusely existing from the duodenum to the small intestine and involved recurrent intussusception.

Presentation of case

47 year-old female was a history of open bowel resection for intestinal obstruction caused by intussusceptions of multiple small intestinal lipoma 11 years ago. EGD showed duodenal lipoma, and CT showed diffuse multiple lipomas from the proximal jejunum to the distal ileum. Another CT also showed intussusception of small intestine, but no signs of intestinal obstruction. Surgical procedures performed included diagnostic laparoscopy. All intestinal lipomas were resected with local excision, and duodenal lipoma was resected with ESD without any bowel resection.

Discussion

Multiple local excision  ESD for multiple GI lipomatosis have not been reported. The most problematic thing is that if extensive resection is performed to cut off all multiple lipoma, short bowel syndrome may occur. Determining the range to be cut remains unclear.

Conclusions

Multiple local excision ± ESD seemed to be one of the methods in resecting multiple GI lipomatosis. In the future, cases and indications of surgery and resection method for GI lipoma should be accumulated and considered, respectively.

Laparoscopic detorsion of the ovary in ovarian hyperstimulation syndrome during the sixth week of gestation: A case report and review

INTRODUCTION

Ovarian torsion in ovarian hyperstimulation syndrome (OHSS) is a relatively rare but serious complication in pregnant women. A delay in treatment increases the risk for functional loss of the ovary and early termination of pregnancy. In this report, we present the case of a 40-year-old female with OHSS who experienced ovarian torsion that was successfully treated with laparoscopic detorsion.

PRESENTATION OF CASE

A 40-year-old pregnant woman in the 6th week of gestation who had conceived following in vitro fertilization presented to us with severe and persistent lower abdominal pain. Ultrasound examination revealed a viable singleton intrauterine pregnancy and bilateral enlarged ovaries with scanty ascites. Approximately 14 h after symptom onset, exploratory laparoscopy was performed. The right ovary was found to be twisted once around over the pedicle, and laparoscopic detorsion was completed. Postoperative follow-up was uneventful, and she successfully delivered a healthy infant at 38 weeks of gestation.

DISCUSSION

Although the reports on successful laparoscopic surgery for pregnant women with ovarian torsion are becoming more frequent, there are few reports on laparoscopic surgery for ovarian torsion in OHSS during the early first trimester. Optimal management of ovarian torsion during pregnancy needs to be explored for these patients.

CONCLUSION

Immediate explorative laparoscopic surgery is a potentially safe and useful strategy for treating ovarian torsion during the early first trimester of pregnancy.

Peritoneal dissemination of ascending colon cancer demonstrating relapse-free survival for 40 months with panitumumab monotherapy: A case report

INTRODUCTION

The prognosis of metastatic colorectal cancer (mCRC) patients receiving multiple cytotoxic agents and targeted therapies (CATT) has improved, but a complete cure by CATT is still very rare.

PRESENTATION OF CASE

We report the successful treatment of ascending colon cancer complicated by peritoneal disseminations (PDs) with panitumumab (Pmab) plus mFOLFOX6 therapy. A 67-year-old male patient was diagnosed with clinical stage IV cancer of the ascending colon with PDs, and underwent ileostomy. Eighteen courses of Pmab plus mFOLFOX6 caused remarkable tumor shrinkage and the disappearance of PDs on ECT. Laparotomy revealed tumor shrinkage and scarring at the PD sites. We performed right hemicolectomy, subtotal omentectomy, and ileostomy closure as curability B surgery. Seven months later, new PDs were detected by ECT so we resumed Pmab plus mFOLFOX6 therapy. After nine courses of treatment, the target lesion had completely disappeared. After a total of 20 courses, we changed to Pmab monotherapy as maintenance therapy because there was no recurrence. Forty months after the initiation of Pmab monotherapy, there has been no oncologic progression.

DISCUSSION

Pmab plus mFOLFOX6 treatment resulted in a complete response for PDs, which is extremely rare for CATT.

CONCLUSION

We consider that Pmab therapy should be introduced for the treatment of mCRC complicated by PDs.

Idiopathic intramural hematoma of the right colon. A case report and review of the literature

INTRODUCTION

Intestinal hematoma is usually observed after an abdominal trauma or in patients treated with anticoagulant therapy. Conversely, idiopathic bowel hematoma is very rare, being colon involvement sporadic with few reports in the Literature.

PRESENTATION OF CASE

The Authors report a case of idiopathic spontaneous large bowel hematoma. A 48-year-old man was admitted for a thoraco-abdominal pain and signs of acute abdomen and fever. After ruling out heart diseases, a CT scan revealed a marked thickening of the ascending colon wall, obstructing the bowel lumen. Leukocytosis was observed. In an emergency setting, an explorative laparotomy was performed. Hemoperitoneum and a large hematoma involving the caecum and the ascending colon were detected, together with intramesenteric and retroperitoneal blood effusion. A right hemicolectomy was accomplished. Histopathology confirmed the diagnosis of large bowel hematoma. Post-operative molecular diagnostic testing for coagulative disorders failed to demonstrate any genetic variation associate with hemorrhagic predisposition. In the post-operative course, the patient experienced a left basal bronco-pneumonia with increased unilateral pleural effusion, successfully treated by a thoracic drain and antibiotic therapy.

DISCUSSION

The reported case and Literature data show that diagnosis of idiopathic colon intramural hematoma is challenging, especially in the emergency setting. Although conservative therapy is the first line treatment, surgery still has an important role when the diagnosis is uncertain, medical treatment fails or a complication, such untreatable bleeding, perforation or occlusion occur.

CONCLUSION

The Authors report a very rare case of spontaneous intramural hematoma of the right colon. Surgery still has a role in selected cases.

A total laparoscopic treatment strategy for Amyand's hernia complicated with appendicitis: A case report

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An appendix incarcerated in the inguinal hernia is defined as Amyand’s hernia.

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Preoperative diagnosis of Amyand’s hernia is feasible with ultrasound and CT.

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Laparoscopy for diagnostic and therapeutic purposes has been on an upward trajectory.

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A potential total laparoscopy treatment strategy for Amyand’s hernia was proposed, with fair outcomes.

Introduction

The presence of a vermiform appendix in an inguinal hernia sac is known as Amyand’s hernia. It is even rarer with complicated appendicitis. Formerly it was treated via an open groin approach; recently there are new trends involving the use of laparoscopy for reduction and management of appendix. Conversely the role of laparoscopy in the following hernia repair was less discussed, with no standard care. We reported a case of Amyand’s hernia complicated with appendix which was managed via a total laparoscopic strategy.

Presentation of case

A 49-year-old male presented with right groin mass with progressive pain for 3 days. Physical exams revealed incarcerated right inguinal hernia. Amyand's hernia with acute appendicitis was diagnosed preoperatively via computed tomography (CT). Emergent diagnostic laparoscopy was performed. Appendix was reduced, with appendectomy justified for signs of appendicitis. An interval total extraperitoneal (TEP) hernioplasty was performed 3 month later, with no adverse events postoperatively.

Discussion

In virtue of previous literature, we proposed a total laparoscopic strategy for Amyand’s hernia which consists of transabdominal diagnostic laparoscopy, management of appendix, and either immediate or elective laparoscopic hernioplasty, based on status of appendix.

Conclusion

This laparoscopic treatment strategy is feasible for Amyand’s hernia, with minimized risk of surgical site infection (SSI), fair recovery and cosmesis.

Giant lipoma of the left mesocolon: Radiological and surgical aspects

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Epidemiology: Lipoma of the mesocolon is a rare tumour less described in the literature.

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Diagnosis: It generally involves large masses. Clinically, it is often asymptomatic. When they exist, these symptoms are less specific and generally due to the large size of the tumour (compression, invagination, hernia). Imaging, especially TDM and MRI are an important step of the preoperative diagnosis. In imaging as in anatomopathology, lipoma-like liposarcoma is the main differential diagnosis. A differential diagnosis with lipoma-like sarcoma must be done.

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Treatment: Treatment is surgical. However, there are variations in the surgical procedures. Some authors had carried out lumpectomy. In our case, we carried out a left colectomy removing the tumour and the mesocolon, as well as the satellite lymph nodes. Each approach has its arguments, i.e. a conserving treatment exposing to repetition if the histological and/or immunochemistry data come out less reassuring, and a more secure and less invasive treatment. There is no consensus on the procedure which depends on the teams.

Introduction

Abdominal masses are common in digestive surgery and gastro-enterology units. However, meso-intestinal lipomas remain rare and lipoma of the left colon uncommon. We report a case of giant lipoma of the left mesocolon whose diagnosis was highly guided by radiological examinations.

Presentation of case

A female patient aged 56, consulted for left subcostal abdominal pains. The clinical examination showed an abdominal mass occupying the left hemiabdomen. The abdominal-pelvic CT scan highlighted a large abdominal-pelvic mass in the left abdomen. Abdominal-pelvic MRI revealed a large fatty mass spreading from the front subphrenic space up to the level of the left iliac fossa, non-suspected and compatible with lipoma. FDG-Pet Scan had not revealed pathological fixing. The mass appeared like a total gap space. Exploratory surgery revealed a lipoma mass in the left mesocolon. Hemicolectomy was performed taking away the mass. Histology confirmed the diagnosis of lipoma and the outcome was favourable.

Discussion

Our case represents the fourth case of mesocolon lipoma described in the literature. Imaging, especially TDM and MRI are an important step of the preoperative diagnosis. The surgery consists of either a lumpectomy or a colectomy.

Conclusion

Lipoma of the left mesocolon is exceptional. Radiological examinations provide most arguments to suggest lipoma. However the organ’s diagnosis is provided by surgical exploration and the certainty diagnosis by pathological examination. Treatment is surgical.

Complete resolution of obstructive colonic amebic pseudotumor with conservative treatment: A case report and literature review

INTRODUCTION

Entamoeba histolytica is a well-known cause of infectious colitis, it has a worldwide distribution. Presentation ranges from mild diarrhea to occasionally frank dysentery and may spread to involve extra intestinal sites such as the liver, lung, and other organs, in the form of amebic abscesses.

CASE PRESENTATION

Herein, we report a case of amebic pseudotumor wherein the diagnosis was revealed after 2 months of diarrhea.

DISCUSSION

Colonic amebiasis, may rarely form a segmental mass called amebic pseudotumor in patient untreated or inadequately treated during the course of proven amebic colitis. Due to the rarity of colonic amoebic pseudo tumor it is usually discovered incidentally during surgical interventions. However if discovered earlier it responds well to medical treatment and usually resolves within few weeks.

CONCLUSION

So surgical intervention is reserved for complications of this entity manifested by fulminant colitis or colonic perforation.

Malignant adenomyoepithelioma of the breast: A rare case report

INTRODUCTION

Adenomyoepithelioma of the breast is a rarely reported and mostly benign disease that seldom undergoes malignant transformation.

PRESENTATION OF THE CASE

Here, we present a case of malignant adenomyoepithelioma of the breast in a patient who initially presented with pain following an excision procedure at local clinic. The condition was finally diagnosed after a third surgical procedure, pathologic analysis with hematoxylin and eosin staining, and immunohistochemistry analysis to detect smooth muscle actin and S100 expression.

CONCLUSION

The patient developed no complications or recurrences after a total mastectomy with sentinel node dissection.

Adenoid cystic carcinoma of the breast - Discordant size on imaging and pathology: A case report and review of literature

Introduction

Adenoid cystic carcinoma (ACC) is an uncommon tumour of the breast. It is known for its rare lymph node involvement and distant metastasis. A triple-negative breast cancer that has a favorable prognosis compared to other triple negative ductal carcinomas, it accounts for approximately 0.1-1% of all breast cancers.

Presentation of case

We report a case of a 69-year-old female with a palpable left breast mass who underwent multiple imaging modalities with significant size variance between the studies. Breast conserving therapy (BCT) was performed with axillary sentinel lymph node biopsy (SLNB) followed by radiation therapy (RT). Pathological examination confirmed the tumour as ACC.

Discussion

ACC, known as an persistent if low-grade malignant tumour of salivary gland, is considered to have low-malignant potential in the breast. It is a very rare subtype and from this scant data, there is minimal mention about size discrepancy between imaging modalities such as ultrasound and MRI.No consistent MRI features have been demonstrated, with the exception of T2 hyperintensity in larger lesions and T2 iso-intensity in smaller lesions. Ultrasound demonstrates primarily a hypoechoic or heterogenous mass with minimum vascularity, consistent with our radiographic findings.

Conclusion

ACC is a rare entity in breast cancer pathology. Its size can be highly variable as measured by various radiographic modalities, and final Pathology from the surgical specimen is, as always, required for an accurate tumoral diameter. With that caveat, careful utilization of pre-operative imaging modalities is critical in pre-surgical planning to choose the appropriate surgery.

An isolated congenital absence of nasal columella: A case report and review of literature

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The absence of nasal columella has functional and esthetic consequences.

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The etiology of isolated congenital absence of nasal columella is still unknown.

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Reconstruction of absent columella is challenging due to its complex anatomy.

Introduction

The nasal columella is an important aesthetic and functional entity of the midface. Congenital absence of the nasal columella as an isolated anomaly is extremely rare.

Presentation of case

We present a case of total congenital aplasia of the nasal columella in a 3-month-old female infant. The deformity was not associated with any other anomalies and with no obvious underlying cause.

Discussion

Isolated congenital absence of the nasal columella is an extremely rare anomaly and its etiology is still unknown. Surgical reconstruction of absent nasal columella is challenging as a result of its complex anatomy, and different surgical techniques have been described in the literature to reconstruct the nasal columella with varying advantages and disadvantages.

Conclusion

The variety in available surgical techniques for the reconstruction of nasal columella necessitates a thorough preoperative evaluation in order to choose the most suitable surgical technique and achieve the best outcome, both functionally and esthetically.

Pneumoperitoneum, pneumatosis intestinalis and portal venous gas: Rare gastrostomy complications case report

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Open gastrostomy lethal complications include intestinal pneumatosis and portal venous gas.

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Intestinal necrosis, disruption of mucosa, increased permeability of mucosa, and pulmonary disease, can cause complications.

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There are several theories describing pathophysiology of intestinal pneumatosis. one of them, secondary to surgery or trauma.

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Medical versus surgical management of the complications depend on the patient’s comorbidities and physician’s consideration.

Introduction

The gastrostomy is one of the most common procedures performed in general surgery. Although a simple procedure, it is not exempted from potential complications, specifically portal venous gas and intestinal pneumatosis being some of the ones with higher rates of mortality. The following case report presents a pneumoperitoneum due to extensive pneumatosis from esophageal, gastric, intestinal and portal gas. These rare complications were managed medically without undergoing emergency surgical intervention.

Presentation of Case

A 19-year-old male patient, with previous history of cerebral palsy, chronic malnutrition and severe physical deconditioning, required a nutritional access. Due to co-existing pathologies, an open gastrostomy was chosen as the best intervention, which was performed without complications. On the tenth postoperative day, patient presents abdominal pain and diarrhea; laboratory results were within normal limits, and the abdominal computed tomography scan reported extensive pneumatosis compromising esophagus, stomach, small intestine, part of the colon, pneumoperitoneum and gas in the portal venous system. Medical management was carried out with an adequate recovery.

Discussion

Intestinal pneumatosis and portal venous gas are rare and potentially lethal complications. Surgical intervention as well as severe malnutrition impairs carbohydrate digestion and promotes bacterial fermentation forming large volumes of gas and dissection of the intestinal mucosal wall, causing the intestinal pneumatosis evidenced in this case report.

Conclusions

This case report presents a rare open gastrostomy complication, as well as a differential diagnosis to pneumoperitoneum. Additionally, the medical management poses a successful alternative to an emergency surgical intervention.

The challenges of diagnosing idiopathic ovarian vein thrombosis: Case report

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Ovarian vein thrombosis is rare, but a life-threatening condition.

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It is rarer in non-pregnant women and in patients without history of recent pelvic surgery as the case in our patients.

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The most commonly involved vein is the right ovarian vein, although in our case the left ovarian vein was affected.

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Diagnosis of ovarian vein thrombosis can be by CT scan or MRI but the initial modality should be doppler ultrasound.

Introduction

Abdominal pain is a common clinical challenge presenting to the emergency department. The challenge lies in the wide differentials particularly in females due to the addition of potential gynecological conditions. Ovarian vein thrombosis (OVT) is one of the uncommon differentials requiring rapid recognition & treatment to avoid serious complications or even death.

Case presentation

We report a 42-year-old healthy female, post normal vaginal delivery 1- year prior to presentation. She presented with left iliac fossa and periumbilical pain for 1-day with no other symptoms. She was vitally stable. Abdominal & pelvic examinations revealed left lower tenderness with guarding. Laboratory investigations were within normal. Abdominal Doppler showed a dilated left ovarian vein with absent flow and Computed tomography (CT) scan confirmed the presence of a thrombus. Therefore, the diagnosis of OVT was made and she was started on anticoagulation.

Discussion

OVT is a rare, life-threatening condition occurring mainly during the post-partum period (0.18% post vaginal delivery). Diagnosing ovarian vein thrombosis can be challenging because of the overlapping presentation with other differentials. A high index of suspicion should be kept in females presenting with abdominal pain. Standard guidelines for managing OVT are lacking. However, lower limb DVT guidelines have been suggested in the literature to be applicable.

Conclusion

The initial modality of diagnosing OVT is Doppler ultrasound. However, CT and MRA confirm the diagnosis in case of uncertainty. The mainstay of treatment is the conservative approach while the surgical approach is reserved for persistent OVT despite appropriate conservative therapy.

An anatomic aberration and a surgical challenge: Mediastinal parathyroid adenoma anterior the pericardium. A case report

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Ectopic parathyroid adenomas located deeper in the mediastinum remain a surgical challenge.

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Their incidence reaches up to 20% of the general population and they tend to constitute a severe cause of failed primary surgery for PHPT.

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Such aberrations seem to be more common than described in the literature and there are possible anatomic aberrations that have not been described yet.

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Preoperative detection of the mediastinal parathyroid adenoma and detailed exposure of the operative field are essential for a safe mid-sternal thoracotomy.

Introduction

Ectopic parathyroid glands occur in 6–16% of cases of PHPT and they constitute a potential cause of failed primary surgical therapy. In particular, aberrant adenomas located deeper in the mediastinum, as in the presented case, remain a severe challenge for the surgeons.

Presentation of case

A 54-year-old Caucasian female proceeded to our institution with signs and symptoms of PHPT. Imaging studies performed identified a large mass localized in the lower anterior mediastinum, on the left of the median line. A mid-sternal thoracotomy was performed and the aberrant adenoma was finally detected anterior to the pericardium and the left pericardiophrenic vessels and the left phrenic nerve. The operation was uneventful. A meticulous review of the literature was conducted as well.

Discussion

Single parathyroid adenomas are the key culprits of PHPT. Anatomic aberrations of the location of the parathyroid glands and their adenomas are more common than described in the literature and there are possible anatomic aberrations that have not been described yet. All these anatomic variations constitute major risk-factors of thoracic bleeding and of nerve injury.

Conclusion

Detailed preoperative detection in addition to meticulous exposure of the operative field are fundamental in order to perform a safe adenoma excision without harmful impacts to the patient.

Juvenile polyposis syndrome: A case report

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The development of polyps is a rare genetic defect.

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juvenile polyposis syndrome are at greater risk of colorectal and gastric cáncer.

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The only treatment to avoid the risk of malignancy is total resection.

Introduction

Juvenile polyposis syndrome it is an uncommon autosomal dominant inherited condition. Hamartomatous polyps can affect the entire gastrointestinal tract but usually predominates in the colon. We introduce a case of juvenile polyposis syndrome presented with massive gastric polyposis that requires a total gastrectomy.

Case presentation

A 22-year-old man presented symptoms of chronic upper gastrointestinal bleeding. Gastroscopy showed massive gastric polyposis. Initially endoscopic polypectomy was performed, but due to the progressive symptoms, a total gastrectomy was then performed. Histology confirmed massive gastric juvenile polyposis.

Conclusion

Massive gastric polyposis it is an uncommon manifestation of juvenile polyposis syndrome.

A giant cell rich osteosarcoma of the proximal ulnar bone treated by elbow arthroplasty: A case report

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Osteosarcoma of the proximal ulnar bone is a malignant progressive bone tumors.

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Diagnosis of these cases needs a comprehensive history taking physical examination and additional diagnostic test.

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Limb salvage surgery using wide excision and reconstruction with elbow arthroplasty by our institution was a challenging procedure.

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Latissimus dorsi flap is important to close the defect left by wide excision.

Introduction

Osteosarcoma is a malignant tumor of the bone. The treatment and prognosis have changed dramatically these days. Limb salvage surgery is a widely accepted alternative to amputation in patients with sarcoma. In most cases, the diagnosis of osteosarcoma is not difficult. We reported a rare location and a rare type of osteosarcoma case treated by elbow arthroplasty along with the challenging diagnostic and treatment.

Case presentation

We reported 46 years old female complained of pain on her left elbow for 5 months. An x-ray showed lytic lesion on the medial side of the elbow while the MRI examination suggested a malignant bone tumor in the epi-meta-diaphyseal of left ulnar bone. Core biopsy showed a Giant Cell containing lesion. The histology of resected tumor and Ki67 staining confirmed the diagnosis of giant cell-rich type osteosarcoma.

Discussion

Giant cell rich osteosarcoma is an uncommon variant of osteosarcoma which characterized by an abundance of osteoclastic giant cells and lack of tumor osteoid. Involvement of forearm in conventional osteosarcoma is extremely rare. This was the epidemiologic reason why the osteosarcoma was not the first diagnosis of our case. Being a very rare location of the osteosarcoma, the management poses a special challenge. They are the surgical technique, which is not well described, and the implant that need to be custom made.

Conclusion

Giant cell rich osteosarcoma is difficult to diagnose because its histology and radiologic feature mimic a benign giant cell tumor.

Inguinal bladder hernia: A case report and literature review

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Inguinal bladder hernia is an unusual condition that requires a high index of clinical suspicion for diagnosis.

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This case demonstrates the importance of preoperative diagnosis in avoiding surgical complications including bladder injury.

Introduction

Cases of inguinal bladder hernia are rare, with bladder involvement seen in 1–4% of inguinal hernias. The majority of cases are diagnosed intraoperatively, with only 7% of bladder hernias identified prior to surgery. Diagnosis may be challenging as patients are often asymptomatic or have nonspecific symptoms. Surgical repair is currently the standard treatment, and careful surgical planning is necessary to avoid complications including bladder injury.

Presentation of case

A 58-year-old man presented to our Emergency Department with 2-day history of progressively worsening left lower quadrant pain, groin bulge, and dysuria. Physical exam revealed an irreducible left inguinal hernia associated with urinary urgency on attempted reduction. Plain CT was ordered and demonstrated inguinal hernia with bladder protrusion into the left scrotum. The patient underwent open surgical reduction and hernia repair and made a quick postoperative recovery without complications.

Discussion

Inguinal bladder hernia most often presents in older, obese males and clinicians should have a high index of suspicion when assessing patients with inguinal hernia. Preoperative diagnosis based on history, physical, and radiologic imaging allow for careful surgical planning and prevention of severe complications including bladder injury and leakage.

Conclusion

We present a case report of inguinal bladder hernia in a middle-aged man that presented as left lower quadrant pain, groin pain, and dysuria. Diagnosis was confirmed preoperatively with radiographic imaging. The hernia was surgically reduced and the defect repaired without complications.

Modified total humeral replacement on unusual osteosarcoma of the humerus: A case report

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The patient underwent a neoadjuvant chemotherapy before surgery, but the mass became more expanded.

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Limb salvage surgery by wide excision of the humerus and reconstruction using modified total humeral replacement was done.

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Total Humeral Replacement for the treatment of humerus malignancy was feasible by using this modification.

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This procedure yielded good functional outcome.

Introduction

Osteosarcoma of the humerus is an unusual case. In order to salvage the limb, resection followed with total humeral replacement is preferred. In situations where those prostheses are not available, a technique of modified total humeral replacement could be used.

Case presentation

A 20-year-old female patient came with osteosarcoma of the right humerus accompanied by pathological humeral shaft fracture, with the onset of six months. The lesion extended along the proximal to distal part of humerus. The patient underwent a neoadjuvant chemotherapy before surgery and a limb salvage surgery by wide excision of the humerus and reconstruction using modified total humeral replacement was performed. Modifications to the shoulder hemiarthoplasty and total elbow prostheses were made, so both prostheses could join as one unit.

Discussion

After the surgery, no disturbances of hand function were seen, and functional outcome was evaluated by using Musculoskeletal Tumour Society Score (MSTS) score with score of 83% (excellent). After 3 years of follow up, patient could work and resume daily activity with improved MSTS score. There were neither sign of tumor recurrence nor distant metastasis on follow up.

Conclusion

Total Humeral Replacement for the treatment of humerus malignancy was feasible by using this modification. This procedure yielded good functional outcome.

Anatomical variation of the trajectory of the brachiocephalic artery encountered during parathyroid adenoma excision. A rare case report and a surgical challenge

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BCT may present anatomical variations concerning its origin and its trajectory.

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Preoperative observation of these anatomical variations has vital clinical and surgical importance, since they constitute risk-factors of severe bleeding.

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Fundamentals to avoid iatrogenic injury are: (1) exposure of the trajectory and the origin of BCT, since it is quite evident that probable novel anatomic variations could be unexpectedly detected during the operation (2) good haemostasis and (3) preoperative utilization of diagnostic ultrasound.

Introduction

The brachiocephalic trunk (BCT), also known as the “anonymous artery” constitutes the first branch of the aortic arch that bifurcates at the level of the right sternoclavicular joint into the RCCA and the RSA. Anatomical variations of the origin and the trajectory of BCT are of vital clinical significance since they constitute major risk-factors of hemorrhage when performing tracheotomy, surgeries at the anatomic area of the neck as in the presented case.

Presentation of case

A 64-year-old Caucasian female proceeded to our institution with signs and symptoms of PHPT. Imaging studies performed identified a large mass localized posterior to the right thyroid lobe. During the operation, surgeons incidentally detected anterior to the trachea aberrant trajectory of the BCT. The operation was uneventful. A meticulous review of the literature was conducted as well.

Discussion

Anatomical anomalies of the origin and the trajectory of BCT are vaguely described in the literature. However, these anatomic variations constitute major risk-factors of accidental bleeding and subsequent complications when performing surgeries of the thyroid and parathyroid glands, tracheotomy and invasive radiological interventions.

Conclusion

Deep knowledge of such variations of the trajectory of the BCT in addition to detailed exposure of the operative field constitute the cornerstone in order surgeons to perform a safe intervention.

Apical periodontitis associated with a calculus-like deposit: A case report of a rare fan-shaped manifestation

Introduction

Bacterial biofilms can be calcified. Granulomas or cystic lesions are the most commonly found entities in endodontics. Surprisingly, this case report presents a rare radiopaque image, in a fan shape, of a calculus-like deposit in the periapical region of the maxillary left central incisor.

Case presentation

A 34-year-old male, with a history of trauma, presented with apical periodontitis associated with an uncommon image, similar to a calculus-like deposit adhered to the apical region of the maxillary left central incisor. Nonsurgical endodontic intervention was performed, followed by apicoectomy and histopathological analysis of the collected material. The results of the biopsy were not compatible with a cyst or granuloma but showed fibrous connective tissue with calcified areas.

Discussion

Correct diagnosis in endodontics is possible with a well-conducted anamnesis, complementary imaging exams and, in some cases, histopathological analysis. The periapical calculus-like deposit, associated with a periapical radiolucent lesion, was a result of the body's fight for healing, producing unusual radiopacity.

Conclusion

The presence of the calculus-like deposit in a fan shape at the root surface represented dystrophic calcification as a manifestation of the attempt to heal. In the present case, apicoectomy and tissue biopsy for histological evaluation were fundamental for the correct diagnosis.

•

Root canal is critical area for biofilm development.

•

Extraradicular biofilm on the surface of the root may cause persistent periapical lesions.

•

Uncommon radiopaque image association with endodontic periapical lesions was related.

•

Persistent periapical lesions associate with extraradicular biofilm represents a challenge for Endodontic treatment.

•

Only surgical resection was capable to repair the injury.

Closure of subarterial ventricular septal defect with minimally invasive surgical technique: A case report

•

Minimally invasive cardiac surgery for closure of subarterial ventricular septal defect.

•

The approach using left parasternal thoracotomy via third intercostal space.

•

Excellent exposure of subarterial ventricular septal defect without special instruments.

Introduction

Minimally invasive cardiac surgery has been applied for the treatment of ventricular septal defect (VSD) with various approaches. However, closure of subarterial VSD with minimally invasive technique via left parasternal thoracotomy is rarely reported.

Case presentation

A 22-year-old man, weighing 65 kg, with a diagnosis of subarterial VSD underwent successful repair with minimally invasive technique via left parasternal thoracotomy through third intercostal space. The peripheral perfusion was performed with femoral arterial and venous cannulation. Myocardium was protected by warm blood cardioplegia injected directly into aortic root by a long needle and aortic clamp introduced through the thoracotomy incision.

Discussion

The left parasternal thoracotomy through third intercostal space (ICS) allows to expose both the subarterial VSD and ascending aorta. Myocardial protection and repair of this defect can be performed merely without requirements of video assistance or unique instruments. The patient recovered rapidly and was satisfied with the cosmetic result. The primary concern of this technique is mammary tissue which can be injured by a transverse incision in female patients. In this case, we can transform into the longitudinal incision.

Conclusion

This minimally invasive technique is feasible for the surgical treatment of subarterial VSD. Long-term follow-up and additional cases will be needed for validation of the safety and efficacy of this approach.

1st report of unexpected true left-sided gallbladder treated with robotic approach

•

For left-sided gallbladder, no change of port setting is needed using the robot.

•

ICG helps to recognize associated vascular and biliary anomalies.

•

Anatomical variations assessment is crucial to avoid biliary or vascular injuries.

Introduction

True left-sided gallbladder (T-LSG) occur when the gallbladder is positioned to the left of the ligamentum teres and falciform ligament and under the surface of the left liver lobe.

Presentation of case

Patient is 29-year-old caucasian male, presenting with 9-month history of epigastric right upper quadrant (RUQ) colic pain. RUQ Ultrasound reported cholelithiasis, gallbladder wall thickening, and no intrahepatic biliary dilation.

Discussion

Robotic cholecystectomy was the chosen approach. When visceral surface of the liver was exposed, anomalous location of the gallbladder was noted, left to the round ligament. A cystic duct with a “hairpin” configuration and a very cephalad cystic artery were identified. Cholecystectomy was performed safely and uneventfully.

Conclusion

No change of port setting was required with the robotic approach. The ICG-aided cholangiography improved surgeon’s ability to recognize the concomitant vascular and biliary anomalies. However, no definitive conclusion can be drown until further experience and volume are achieved.

Total lower lip reconstruction by bilateral Fujimori technique-A case report

Squamous cell carcinomas are the most common type of lower lip cancer. In cases where the tumour involves less than on third of the lower lip, direct suture maintains the physical appearance of a normal mouth with few adverse effects. Squamous cell carcinomas involving more than half or even most of the lower lip are not common. We report a successful case of complete lower lip reconstruction after recurrent squamous cell carcinoma involving most of the lower lip by use of bilateral Fujimori technique.

CASE

We present a case of full-thickness squamous cell cancer located to the vermillion border initially, but progressing rapidly in two months during radiotherapy to a state in which most of the lower lip, including the angles of the mouth, were affected.

DISCUSSION

Surgical management ensuring a functional and aesthetic acceptable outcome is a challenge in patients with large tumours including all of the lower lip. Several methods for reconstruction of the entire lower lip are discussed.

CONCLUSION

Bilateral Fujimori one-stage flaps can be used in cases of squamous cell carcinomas involving most of the lower lip, including the commissures of the mouth. A limitation of the method is an eventual lack of local tissue when preparing the flap.

Endolymphatic sac tumor at the cerebellopontine angle: A case report and review of literature

INTRODUCTION

Endolymphatic sac tumors may present as sporadic or may be associated with Von Hippel-Lindau disease. Patients generally present with hearing loss, tinnitus and vertigo. The tumor is highly vascular which may lead to erosion of the adjacent bony and vascular structures, resulting in heavy bleeding during surgery.

PRESENTATION

A twenty-five year-old female presented with a five year history of chronic ear discharge, left sided facial weakness, and recent onset of ataxia.

DISCUSSION

The unusual clinical presentation made management challenging, in large part due to profuse bleeding. Pre-operative embolization of the vessels supplying the tumor may reduce blood loss during surgical excision. Radiotherapy could be considered for any residual tumor.

CONCLUSION

The patient was diagnosed with an endolymphatic sac tumor of sporadic origin which presented at the cerebellopontine angle and was managed with a multidisciplinary approach.

Corrective osteotomy of distal radius malunion after IIIB open fracture: Palmar approach - Case report

BACKGROUND

Despite the fact that distal radius fractures are the most common, open fractures are relatively uncommon. The aim of this study is to present the case with severe malunion of extra-articular left distal radius after open fracture grade IIIB (Gustillo). The treatment was done with open correctuve osteotomy and ostosynthesis with volar low profile plate.

CASE PRESENTATION

A 32-years old man was admitted to our departement because of severely malunited left distal radius extra-articular metaphyseal fracture after treatment of an open fracture. He was primary treated in a Regional Hospital with irrigation, debridement, antimicrobial cover, and immediate skeletal management through fixation with Kirschner's wires. No external fixator was used. He developed volar metaphyseal angulation after loss of primary reduction of K-wires fixation; therefore it required corrective surgical treatment. Because of malunion, open corrective osteotomy and bone grafting of distal radius with volar plating were done. Follow-up 20 months after surgery show deformity correction of radial volar inclination, height, and restitution of distal radioulnar joint.

CONCLUSION

This case report offers an informative overview on this uncommon case of distal radius open fracture malunion treated successfully with volar approach corrective osteotomy. Corrective surgery is the primary therapy of choice in the this case. This method have shown to be safe and effective in treatment of distal radius malunion with volar angulation.

Jejuno-ileal diverticulitis: A disorder not to underestimate

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In the paper a rare case of complete and well documented jejunal diverticulitis complicated with perforation and peritonitis is described.

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Interesting radiological and intraoperative imaging are attached.

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A carefull and recent literature review has been performed in order to discuss diagnosis and management of jejuno-ileal diverticula and our clinical behavior.

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From the discussion emerges that the possibility of the presence of small bowel diverticula must be considered in case of occult bleeding non-indentifiable with gastroscopy or colonoscopy.

•

Therapeutic behavior is suggested in case of acute peritonitis due to jejunal diverticula or in case of incidental diagnosis.

Introduction

Jejuno-ileal diverticulitis is an uncommon, acquired clinical entity, with higher prevalence among patients aged between 60 and 70. The condition is usually silent and has been regarded as relatively innocuous. Sometimes patients complain chronic vague symptoms like malabsorption, pain or nausea, that easily lead to misdiagnosis. Acute complications are rare, however, they have been reported and can result in major surgery and high overall mortality.

Case report

We are presenting a case of a 67-year-old patient who presented to our department with abdominal pain and signs of peritonitis. The CT scan displayed an inflammatory mass with a fair amount of free liquid in the abdomen, as well as multiple diverticula at different levels of the intestine. The patient had to underwent immediate surgery, during which a resection of 25 cm jejunum and 80 cm of ileum has been performed.

Conclusion

Jejuno-ileal diverticula are a very uncommon finding that can present formidable challenges in diagnosis and treatment. The course can be completely asymptomatic, however, in rare cases, the condition can lead to severe complications that often require surgery. Multi detector CT (MDCT) with intravenous contrast should always be the modality of choice for investigating a suspect of small bowel diverticula. There are no specific guidelines respect the management of jejuno-ileal diverticulitis, nevertheless, in the acute setting, bowel resection is the treatment of choice.

As well as setting out the rarity of this case, our work intends to review the current literature regarding the epidemiology, natural history, diagnosis and management of jejuno-ileal diverticula

Tuberculous peritonitis in a cerebral palsy patient: A challenge in diagnosis and management

•

Mental retardation caused by cerebral palsy results in difficult examination.

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Spasticity in cerebral palsy can mimic acute abdomen.

•

Diagnosis of tuberculous peritonitis constitutes difficult task in cerebral palsy.

Introduction

Diagnosis of tuberculous peritonitis (TBP) in a normal person, although possible, is often difficult to make because of its non-specific symptoms and signs. However, establishing a diagnosis of TBP in a patient with cerebral palsy (CP) does not seem to be possible due to impaired mental development accompanied by communication problems.

Presentation of case

A 19-year-old spastic man diagnosed with CP presented with fever and a nonverbal complaint of abdominal pain. The conditions were hard to evaluate due to his mental status. Abdominal radiography showed dilatation of both small and large bowels, and a subsequent computed tomography (CT) scan did not provide any additional information. With respect to a common suspected cause, a diagnosis of perforated appendicitis was established. However, at the theatre, there was only bowel dilatation with multiple small nodules at the serosa of small and large bowels. Postoperatively, polymerase chain reaction and culture revealed Mycobacterium tuberculosis, thereby leading to a diagnosis of TBP.

Discussion

Due to spasticity caused by CP, on examination, the patient presented with board-like rigidity, from which a diagnosis of a surgical condition was established. The misdiagnosis of an acute abdomen situation had let the patient to undergo an unnecessary exploration. To our knowledge, there has not been a report of TBP in a CP patient.

Conclusion

The diagnosis of TBP had been complicated by the presence of CP in the reported case. The underlying CP not only preclude the diagnosis of TBP, but also produced symptoms that mimicked a condition requiring surgery.

Extensive epithelioid hemangioendothelioma of the maxillary sinus: A case report

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Epithelioid haemangioendothelioma is a rare vascular tumor which can originate from the maxillary sinus.

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Surgical excision is the treatment of choice for local tumors.

•

Exclusive radiation therapy with chemotherapy can be an option for extensive forms.

Background

Epitheliod hemandioendothelioma (EHE) is a rare vascular tumor which was first reported by Weiss and Enzinger in 1982. It can be seen in many locations whose paranasal sinus is extremly rare. Its main treatment is surgery. To our best knowledge, no report of EHE treated by radiation therapy and chemotherapy has been described.

Case summary

A 18 years old man presented to our hospital with a 3 months history of right intermittent epistaxis, permnanent nasal obstruction and right hearing loss. The physical exam found a right exophtalmia, swelling deformatted right hemifacia and a bulky whitish tumor filling the right nasal cavity. The magnetic resonance imaging (MRI) showed an extensive hyperascularized nasopharyngeal process filling the right nasal cavity whose histopathological exam revealed an epitheloid hemangioendothelioma. Due to intracranial extension, surgery was contraindicated. The patient received 65 Gy of radiation therapy and chemotheray (cisplatin). After 18 months of follow up, the exopthalmous regressed and the MRI showed a 50% regression of the tumour size.

Conclusion

Extensive EHE can be treated by radiation therapy and chemotherapy when surgery can’t be perfomed.

Lymphaticovenular anastomosis for Klippel-Trenaunay-Weber syndrome

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To the best of our knowledge, this is the first report on lymphaticovenular anastomosis (LVA) for the Klippel-Trenaunay-Weber syndrome.

•

We performed seven LVA procedures for the right lower limb with the intention of preventing recurrent bouts of cellulitis.

•

The patient has been cellulitis-free for 1 year post-operatively, having previously had such infection every other month.

•

We suggest that LVA may be effective for the management of similar cases.

Introduction

Since we performed lymphaticovenular anastomosis (LVA) for Klippel-Trenaunay-Weber syndrome and obtained relatively good results, we report the adaptation, effect of treatment, and mechanism of LVA.

Presentation of case

Case is a 28-year-old man with an increase of the circumference and pigment changes on the whole right leg and gluteal region from the time he was born. He exhibited signs of right leg cellulitis with a fever about 40° at frequency of the degree once a month. We planned to perform LVA of the right leg to prevent cellulitis of the lower limbs.

Discussion

This case presented with repeated, severe cellulitis occurring once a month prior to treatment. This symptom greatly reduced the quality of life of the patient. Postoperatively, he lived his daily life with no particular limits, and significant improvement quality of life was due to LVA. Therefore, it is inferred that the protective efficacy of inflammation was obtained by anastomosing lymphatics and the vein around the skin lesions and a return current of the lymph flow was promoted.

Conclusion

The possibility that LVA could become an excellent therapy for similar cases is suggested.

Microwave ablation of splenic cyst: A case report

Introduction

Non-parasitic spleen cyst (NSC) is a relatively rare and difficult to diagnose disease, which rapture due to a traumatic impact to the spleen, can lead to the peritonitis.

Case presentation

We present the case of a 30-year-old woman with a 7.5 × 7.5 × 5 cm NSC, who underwent the microwave ablation (MWA) of the splenic cyst.

Results

The procedure was performed under intravenous anesthesia. MWA of the cysts was performed using a probe placed in the cavity of the cyst, with the frequency of 902-928 MHz delivered during 15 minutes. The postoperative period was uneventful, and the patient was discharged after 2 days.

Conclusion

We demonstrated that MWA can be utilized as a novel, minimally-invasive, and cost-effective approach in NSC treatment.

Total nasal reconstruction for nasal defect after treatment for extranodal natural killer/T cell lymphoma, nasal-type: A case report

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Total nasal defect after chemoradiation was complex and difficult to rebuild.

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The surgery was divided into 3 stages with each stage to prepare for the next stage.

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With the multiple facial unit defects, reconstruction is based on aesthetic unit.

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After using multiple local flaps to reconstruct the defect, the result was improved.

Introduction

Nasal-type extranodal natural killer (NK)/T-cell lymphomas are a rare type of clinical condition. Reconstruction of the complex nasal defect after chemoradiation is extremely challenging for plastic surgeons.

Presentation of case

Here we present the case of a 56-year old female with the condition of a nasal-type NK/T-cell lymphoma which had caused complex nasal disfigurement. The patient had undergone chemoradiotherapy. Lesions after treatment were present all over the nasal defect (nasal septum, mucosa, support frame and skin) and the left cheek medial subunit. The surgery was subdivided into 3 stages. First, we removed the infectious tissue and restored the wall of nasal cavity by the left forehead – scalp flap. Second, we used the pedicle of the left forehead flap to rebuild the nasal mucosa defect, the rotational flap to rebuild the cheek defect, and the right forehead flap to recovered skin defect of the nose. Finally, we divided the pedicle of right forehead flap.

Discussion

The complex nasal defect is difficult to reconstruct and has a higher risk of failure in patient who received chemoradiotherapy. It is crucial to choose the right materials and have a confident plan in order to achieve successful results for the sake of the patient.

Conclusion

Our case report shows that the nasal defect caused by a nasal-type NK/T-cell lymphoma is complex. After our 3 stages plan for the surgery, as well as using multiple flaps for reconstruction from the forehead skin, the result was significant reduction in the disfiguration of the patient’s nose.

A case report of a thymic neuroblastoma associated with syndrome of inappropriate secretion of antidiuretic hormone: Ten-year follow-up results after surgical treatment

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A rare case of thymic neuroblastoma in an adult associated with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

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Histologically and hormonally confirmed for a thymic neuroblastoma in an adult associated with SIADH.

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Long-term follow-up CT scans reveal his free of disease.

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The thymic neuroblastoma is most effectively treated with surgical resection and follow-up examinations.

•

Complete surgical removal is considered to be one of options for treatment of this tumor that is clearly separated from the surrounding tissue with no invasion.

Introduction

Thymic neuroblastoma with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in adults is an extremely rare and malignant neoplasm. Although the tumor is known to grow rapidly and have a poor prognosis, its etiology is still uncertain. In 2009, we described a case of thymic neuroblastoma with SIADH. We report here the clinical course over the last 10 years.

Presentation of case

A 70-year-old Japanese male with a history of thymic neuroblastoma with SIADH was regularly followed up on an out-patient basis after complete surgical resection for more than 10 years. He remains free of the disease and asymptomatic.

Discussion and conclusion

Complete surgical removal is considered as one of the treatment options for this tumor if clearly separated from the surrounding tissue with no invasion.

Midgut volvulus is a rare cause of intestinal obstruction in adults: A case report

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Midgut volvulus is usually diagnosed in first weeks of life, or even, in many cases, before birth.

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Incidence of midgut malrotation among pediatrics is 1 in 500 livebirths.

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Incidence of adult midgut malrotation is reported between 0.0001% and 0.19%.

•

This is case rare presentation in which a 34 year old man was presented. With diagnosis of midgut volvulus underwent laparotomy.

Introduction

The incidence of midgut vovulus is rare in adults. However, a significant number of cases were seen in infant and children.

Presentation of case

We report a case of a 34-year-old male who presented to the emergency room with persistent periumbilical abdominal pain without any other symptoms. Contrast-enhanced CT showed clearly the typical finding of midgut volvulus like whirlpool sign, corkscrew sign, and the superior mesenteric vein to the left of superior mesenteric artery. The patient was planned for Ladd’s procedure and emergency laparotomy performed successfully with an uneventful postoperative recovery.

Discussion

Managing midgut volvulus is based on presentation. In symptomatic cases surgery is the treatment, but in asymptomatic cases, treatment is controversial.

Conclusion

Although midgut volvulus is rare in adults, it should be considered as an intestinal obstruction.

Submucosal mucoid as a late complication after appendectomy-A case report

INTRODUCTION

Shortly after an operation infection, intraabdominal abscess, seroma, haemorrhage or development of paralytic ileus may occur. Postoperative adhesions, nonspecific abdominal pain without signs of obstruction, incisional hernia and appendicitis or mucocele in appendiceal stump present common late complications. We present a unique case of a late complication after appendectomy.

PRESENTATION OF CASE

The case report describes a unique expansion in the ascending colon of a young athlete with long-lasting abdominal pain in the lower right quadrant. Colonoscopy showed a lesion in a wall of the ascending colon. Computed tomography (CT) confirmed a cystoid formation of high content density in a wall of the caecum. A right hemicolectomy was performed. Histology showed a lesion located in the submucosa with intestinal lining and stroma rich in lymphoid cells. These are the typical attributes of the wall of the appendix. Other parts of the wall were not demonstrated, and there was no communication with the lumen of the native bowel.

CONCLUSION

A submucosal cavity filled with acellular matter, which were probably disintegrated epithelioid structures, and calcifications were found in the ascending colon, while no intestinal cell atypia or dysplasia was found. The case cannot be classified under any previously presented diagnosis.

Laparoscopic splenectomy for isolated splenic sarcoidosis: A case report

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Isolated splenic sarcoidosis is difficult to diagnose due to its rarity.

•

Laparoscopic splenectomy has become the gold standard in patients presenting with solid splenic lesions.

•

Laparoscopic splenectomy is less invasive and useful as part of the diagnostic approach.

Introduction

Isolated splenic sarcoidosis is difficult to diagnosis due to its rarity. Laparoscopic splenectomy has become the gold standard for therapeutic diagnosis in patients presenting with solid splenic lesions because needle biopsy can lead to bleeding and tract seeding.

Presentation of case

A 59-year-old female was referred to our hospital due to abnormal accumulation in the spleen on abdominal ultrasonography. Enhanced computed tomography showed three heterogeneously enhanced nodules. Magnetic resonance imaging showed hypointense nodules on T2-weighted images. The initial diagnosis was a fibrous hamartoma or an inflammatory pseudotumor. At follow-up 4 months later, the splenic nodules had increased in size, and diagnostic laparoscopic splenectomy was performed without complications. Histopathologically, the splenic nodules contained noncaseating granulomas comprising epithelioid cells, multinucleated giant cells, and asteroid inclusion bodies. Postoperatively, examinations found no other organ involvement, and the final diagnosis was isolated splenic sarcoidosis. There was no evidence of recurrence at 2 years postoperatively, and systemic treatment was not required.

Conclusion

Radiological imaging studies are insufficient for the differential diagnosis of splenic lesions in sarcoidosis from other diseases, whereas laparoscopic splenectomy is less invasive and useful as part of the diagnostic approach.

Tibial tubercle avulsion fractures in school sports injury: A case report

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Most injuries in school occur during sport. Avulsion fractures of the tibial tubercle are uncommon school sports injuries.

•

X-ray is the key to diagnosis. Then CT scan is needed to evaluate the fracture extension to the articular joint.

•

Many cases are misdiagnosed and progress to recurvatum deformity especially in open physis individuals after neglected tibial tuberosity fractures.

•

These injuries cause significant disruption to school and sport, but fortunately, complications are rare and functional recovery is usually complete.

Introduction

Most injuries in adolescent occur during school sports like volleyball, football or basketball. Tibial tubercle avulsion fractures (TTAF) are an unusual condition, resulting from a forced extension of the knee opposed to fixed leg.

Presentation of the case

A 16 years old male was hurt during school basketball, X-rays displayed avulsion fracture of tibial tuberosity of left knee, the treatment was operative using two cancellous screws, results were good including complete knee mobility and early coming back to school sport at 6 months.

Discussion

TTAF remains rare accounting for <3% of all epiphyseal injuries, it is frequent in teenage boys with open physis during school sport. We review the pathophysiology, mechanism, classification, diagnosis, and management of this injury.

Conclusion

complications are occasional and functional recuperation is common after closed reduction and cast immobilization for slightly or no displaced fractures, otherwise open reduction and internal fixation for displaced fractures.

Boerhaave's syndrome: A case report of damage control approach

INTRODUCTION

Boerhaave's syndrome is a life-threatening oesophageal perforation that carries a high mortality rate (20-50%). Diagnosis is difficult by its rarity and the absence of typical symptoms. Treatment of this condition usually requires surgical intervention.

PRESENTATION OF CASE

We report the case of a 77-year-old man that resorted to the emergency room with dyspnoea and thoracic pain after vomiting. CT scan revealed pneumomediastinum, left collapse lung and loculated pleural effusion. A left intercostal chest tube was inserted with food drainage. Hence, Boerhaave's syndrome was suspected. Thoracotomy with mediastinum debridement, pleural drainage and oesophageal T-tube drainage was performed. Patient was admitted on the Intensive Care Unit with septic shock, with need for ventilatory support and vasopressor therapy. Two days later, a second look thoracotomy was done with definitive oesophageal repair and pleural patch. The post-operative course was complicated by pneumonia and stroke. Patient was discharged home on the 38th day and remains well at 3 month of follow-up.

DISCUSSION

Delayed diagnosis and treatment are the principal causes of high mortality in Boerhaave's syndrome. The classic Mackler's triad (vomiting, lower thoracic pain and subcutaneous emphysema) is present in less then 50% of cases. A thoracic drainage may be useful to confirm diagnosis promptly. There is no standard treatment option. In this case report, the authors used a damage control approach to control sepsis, allowing for a delayed definitive oesophageal repair.

CONCLUSION

Prompt diagnosis with thoracic drainage and a damage control treatment plan might lead to good prognosis for patients with this rare and potentially fatal condition.

Stress fracture of the midshaft clavicle associated with sternocostoclavicular hyperostosis-Case report

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Stress fractures of the midshaft of the clavicle caused by sternocostoclavicular hyperostosis are very rare.

•

The differential diagnosis of sternocostoclavicular hyperostosis might be difficult.

•

Sternocostoclavicular hyperostosis in the patient was suspected of having either SAPHO syndrome or ankylosing spondylitis.

•

The patient was treated conservatively and the shoulder function was satisfactory at the final follow-up.

Introduction

Stress fracture is generally a result of cumulative and repetitive stress in athletes, which accelerates the normal remodeling process of bones, and the most frequently involved areas are the tibia and metatarsal bones. Therefore, stress fractures of the midshaft of the clavicle are very rare.

Presentation of case

A 58-year-old female was admitted to our hospital because of pain in the middle of the right clavicle. Based on laboratory and radiographic inspection, it was concluded that the stress fracture of the midshaft of the clavicle in this case was caused by sternocostoclavicular hyperostosis (SCCH). Because the clavicular fracture had no displacement or callus formation, conservative treatment with a clavicle band was undertaken. Shoulder function at the final follow-up visit was satisfactory.

Discussion

SCCH is a rare chronic inflammatory disorder of the axial skeleton and ossifying diathesis associated with a predominantly osteogenic response. Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome and ankylosing spondylitis (AS) should be considered in the differential diagnosis of SCCH. If a patient with this type of fracture has no history of traumatic injury or sports activity, the differential diagnosis might be very difficult.

Conclusion

We report the case of a female who had a stress fracture of the midshaft of the clavicle associated with SCCH in SAPHO or AS. Although the patient was treated conservatively, and the shoulder function was satisfactory at the final follow-up visit, re-fracture may occur in the future.

Case report of a laryngotracheal reconstruction with anterior and posterior costal cartilage graft and stent placement - Surgical technique

•

Subglottic stenosis is defined as airway narrowing below the true vocal folds.

•

Subglottic stenosis commonly occurs after endotracheal intubation in newborns.

•

The incidence of subglottic stenosis has decreased to 1–2% of premature patients.

•

The single-stage procedure avoids prolonged hospitalization.

•

The two-step procedure allows for treatment of a more extensively stenosed area.

Objective

The purpose of this report is to examine a grade III subglottic stenosis case with double-stage laryngotracheal reconstruction using a costal cartilage graft and to explore the relevant literature regarding these topics.

Context

In this report, the authors examine a severe grade III subglottic stenosis pediatric case and its subsequent laryngotracheal reconstruction with costal cartilage graft. This case demonstrates a surgical intervention which has become infrequently utilized since neonatologists began using noninvasive positive pressure airway support rather than intubation; thus, the incidence of acquired subglottic stenosis is decreasing. Features of the case and its surgical correction are discussed in detail.

Case Report Summary

The patient is a 3-year-old African-American female born prematurely at 30 weeks by emergent cesarean section complicated by placenta previa, twin gestation and absent end diastolic flow. The patient has a past medical history significant for apnea of prematurity, necrotizing enterocolitis, bronchopulmonary dysplasia, hyaline membrane disease, pneumonia, abnormal electroencephalogram, cardiac arrest due to respiratory disorder, parainfluenza infection, chronic respiratory failure, laryngomalacia and grade III subglottic stenosis. The patient’s surgical history is significant for supraglottic laryngoplasty, tracheostomy placement, gastrostomy tube placement and laryngotracheal reconstruction with anterior and posterior costal cartilage graft and stent placement with subsequent stent removal. As of March 2019, the patient continues to have follow up laryngoscopy/bronchoscopy with dilation. Ultimately, the patient will maintain her own airway with tracheostomy tube removal.

Data sources and overall comparisons

A PubMed literature review of subglottic stenosis and laryngotracheal reconstruction with costal cartilage graft was performed. Twenty sources were reviewed leading to greater understanding of the evidence supporting the laryngotracheal reconstruction with graft treatment modality.

Conclusion

Optimal management and correction of subglottic stenosis is possible via laryngotracheal reconstruction with cartilage graft. The reconstruction procedure, first utilized in the 1970’s, allows correction of severe (grades III and IV) subglottic stenosis. After healing is complete, the patient regains function of her own airway.

Esophageal schwannomas: A rarity beneath benign esophageal tumors a case report

•

Esophageal Schwannoma is a rare tumor with only few cases reported in the literature.

•

In general, Schwanommas are rarely found in the gastrointestinal tract.

•

Esophagic schwanommas is the least common gastrointestinal form of presentation.

•

The knowledge about a new case of esophagic schwanomma, impacts in obtaining more information about the clinical course and surgical treatment of this tumor.

Introduction

Esophageal Schwannoma is a rare tumor that represents the least frequent mesenchymal tumor of the esophagus and represents a condition with only a few cases reported in the literature

Presentation of a case

We report a 40-year-old female with a 5 years history of gastroesophageal reflux, repeated history of pharyngitis, odynophagia that culminated in progressive oropharyngeal dysphagia to solids. A barium esophagogram revealed a filling defect in the superior and middle thirds of the esophagus. Upper gastrointestinal endoscopy showed a smooth elevated lesion in the upper third of the esophagus, impossible to resect by this mean. An open left cervical approach revealed an 80 × 45 × 20 mm large tumor, which was resected.

Discussion

In general, Schwanommas are rarely found in the gastrointestinal tract (GI), while the great majority occur in the stomach, esophagic is the least common GI form of presentation.

Conclusion

The knowledge about a new case, impacts in obtaining more information about the clinical course and surgical treatment of this tumor.

Revision Roux-en-y hepaticojejunostomy for a post-cholecystectomy complex vasculobiliary injury with complete proper hepatic artery occlusion: A case report and literature review

INTRODUCTION

Complete proper hepatic arterial [PHA] occlusion due to accidental coil migration during embolization of cystic artery stump pseudoaneurysm resulting from a complex vasculobiliary injurie [CVBI] post laparoscopic cholecystectomy [LC] is an extremely rare complication with less than 15 cases reported. We present a case depicting our strategy to tackle this obstacle in management of CVBI and review the relevant literature.

PRESENTATION OF CASE

A 35 year old lady presented on sixth postoperative day with an external biliary fistula following Roux-en-y hepaticojejunostomy [RYHJ] for biliary injury during LC. She developed a leaking cystic artery pseudoaneurysm, during angioembolisation of which, one coil accidentally migrated into left hepatic artery resulting in complete PHA occlusion. Fourteen months later, cholangiogram revealed a worsening RYHJ stricture despite repeated percutaneous balloon dilatations. Multiple collaterals had developed. Revision RYHJ was fashioned to the anterior wall of biliary confluence with an extension into left duct. Minimum hilar dissection ensured preservation of collateral supply to the biliary enteric anastomosis. Postoperative recovery was uneventful. The patient is doing well at 1 year follow up.

DISCUSSION

Definitive biliary enteric repair should be delayed till collateral circulation is established within the hilar plate, hepatoduodenal ligament and perihepatic/peribiliary collaterals to provide an adequate arterial blood supply to biliary confluence and extrahepatic portion of the bile duct.

CONCLUSION

Assessment of hepatic arteries should be part of investigation of all complex biliary injuries. Delayed definitive biliary enteric repair ensures a well-perfused anastomosis. Minimum hilar dissection is the key to preserve biliary and hepatic neovasculature.

Pneumoretroperitoneum with subcutaneous emphysema after a post colonoscopy colonic perforation

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Colonic perforation after colonoscopy could be intraperitoneal, extraperitoneal or a combination of both.

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Majority of the perforations are intraperitoneal.

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Risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and colonic strictures.

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Extraperitoneal perforations can manifest as pneumoretroperitoneum, pneumomediastinum, pneumothorax and/or subcutaneous emphysema.

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Non operative management in isolated retroperitoneum while surgery required in majority of peritoneal perforation.

Introduction

Colonoscopy is considered as one of the most common performed procedures for both diagnostic and therapeutic purposes. Serious complication after colonoscopy could occurs like bleeding or perforation. Majority of the perforations are intraperitoneal, while extraperitoneal perforations are very rare and it may cause pneumoretroperitoneum, pneumomediastinum, pneumothorax and subcutaneous emphysema.

Presentation of the case

A case report was described of 80-year-old female who underwent a diagnostic colonoscopy for recurrent abdominal pain who presented with severe abdominal pain and tenderness with CT findings of pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema. The patient successfully treated surgically with laparoscopic Hartman procedure.

Discussion

Colonic perforation is rare complication of colonoscopy that can manifest intraperitoneal, extraperitoneal or a combination of both. Patient risk factors include advance age, female sex, diverticulosis, previous abdominal surgery and pre-existing colonic strictures. Technical risk factors includes excessive shearing forces during endoscopic insertion, dilation, biopsy and using electrocautery. Majority of the intraperitoneal perforation warrant a surgical intervention whereas isolated extraperitoneal perforation may be managed conservatively.

Conclusion

Combined intraperitoneal and extraperitoneal colonic perforation are rare presentations following diagnostic colonoscopy and often difficult to diagnose based on the clinical manifestation only. Understanding the manifestation of extraperitoneal perforation will help to properly identify the condition and preventing morbidity and mortality in these patients.

Synchronous mixed germ cell tumor of testis and renal cell carcinoma: A rare presentation

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Synchronous presentation of mixed germ cell tumor of testis and renal cell carcinoma is a rare presentation and has not been reported in literature.

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During the metastatic work up to mixed germ cell tumor we found the mass in the left kidney which was diagnosed to be renal cell carcinoma.

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Treatment strategies for both malignancies depend on accurate clinical staging and should be integrated to provide best results.

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The management of both the malignancies depend on their merit and is a real challenge for a surgeon.

Introduction

Synchronous presentation of mixed germ cell tumor of testis and renal cell carcinoma is a rare presentation and has not been reported in literature. RCC accounts for 3% of all adult malignant neoplasms (Marzouk et al., 2014). It is the most lethal urologic cancers. Testicular cancer is of generally aggressive form and is the most common form of cancer in young men aged 15–35 years.

Presentation of case

We report a case of incidental finding of left renal cell carcinoma with mixed germ cell tumor of right testis in our patient.

A 36 years old male patient came with complaints of painless swelling in the right side of the scrotum since 1 year. On palpation a hard swelling of size 5 x 4 cm was palpable in right scrotum. Ultrasonography suggested likelihood of a neoplastic etiology. On Contrast enhanced CT of abdomen, a well defined mass in the lower pole of left kidney likely to be an Oncocytoma, which was not palpable. CT guided biopsy of renal mass, was suggestive of epithelial renal tumor probably oncocytoma or low grade renal cell carcinoma.

Discussion

In literature there are very few cases reported of metachronous mixed germ cell tumor of testis and renal cell carcinoma. There are 12 reports of patients having metachronous testicular and renal malignancy. During the metastatic work up to mixed germ cell tumor we found the mass in the left kidney which was ultimately diagnosed to be renal cell carcinoma. The management of both the malignancies depend on their merit and is a real challenge for a surgeon.

Conclusion

Treatment strategies for both malignancies depend on accurate clinical staging and should be integrated to provide optimal results.

Malignant rhabdoid tumor in a solitary kidney arising in an adult patient with chronic obstructive renal calculi

INTRODUCTION

Malignant rhabdoid tumor (MRT) is one of the most aggressive and lethal malignancies in pediatric oncology, MRT of the kidney is an uncommon renal tumor in children and it's extremely rare in adult patients. With only seven previously reported adult cases in the English-literature, to our knowledge this is the first case that is associated with renal calculi.

PRESENTATION OF CASE

We present the case of a 65-year-old man with an MRT arising in a solitary kidney with multiple enlarged lymph nodes that compressing the inferior vena cava.

DISCUSSION

Malignant rhabdoid tumor of the kidney was originally described as a "rhabdomyosarcomatoid" variant of Wilm's tumor due to the resemblance of cells to rhabdomyoblasts, now this type of tumor is recognized as distant and unique malignant renal tumor. It affects usually children before the age of 2 years. Tumor tissue sampling is required to make the diagnosis of MRTK, based on either nephrectomy, core biopsy, or autopsy specimens. There is no established standard of care due to the paucity of cases. Surgery is considered to be the first choice of treatment if possible.

CONCLUSION

This case report reinforces the importance of recognizing this entity in the adult population, and discuss the possible treatment options of this rare and highly aggressive tumor.

Successful conservative treatment of multiorgan infiltrating placenta percreta by uterine embolization and followup with serial magnetic resonance. A case report

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Morbidly adherent placenta presents sever maternal complications including death.

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This report presents a case of placenta percreta treated with conservative management without complications.

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Serial MRI was performed to evaluate the course of conservative management.

Introduction

Conservative management was recently adopted as an option with an aim to reduce surgical complication and improve maternal outcome. We present a case of placenta percreta that invaded the urinary bladder, sigmoid colon, rectum, and vagina of a patient treated with conservative management successfully.

The work has been reported in line with the SCARE criteria (Agha et al., 2018 [1]).

Case presentation

A 32-year-old woman, gravida 4, para 3. She had previously had 3 caesarean sections. At 36 week of gestation patient referred to our centre with a diagnosis of placenta praevia with a high suspicion of placenta percreta. Ultrasound and MRI repeated and confirmed the diagnosis with invasion to the rectum/sigmoid colon, urinary bladder, and upper vagina. Patient treated successfully by uterine embolization and follow up without any complication and we performed serial MRI to evaluate the course of conservative management.

Discussion

Placenta percreta is a serious condition with high maternal morbidity and mortality rate. Cesarean hysterectomy is the standard treatment for now. However, conservative management was recently adopted as an option. Many case reports were published with placenta percreta that invaded the urinary bladder and treated conservatively but this is a placenta percreta that invaded the urinary bladder, sigmoid colon, rectum, and vagina. We opted conservative management and performed serial MRI to evaluate the course of conservative management.

Conclusion

We believe that this case is the first case of placenta percreta that invaded the urinary bladder, sigmoid colon, rectum, and vagina. That treated successfully by conservative management and publishing this case will improve the clinical information about the course of the conservative management of placenta percreta.

Ingested metallic foreign body impacted in the vermiform appendix presenting as acute appendicitis: Case report

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Foreign body appendicitis in children may be caused by a variety of ingested foreign bodies.

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Pins are the most common cause of foreign body appendicitis.

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The reported incidence of bowel perforation is less than 1%, especially with sharp, thin, pointed or long objects.

Introduction

Ingestion of foreign bodies and their impaction at the lumen of the appendix is a very rare finding and only few cases have been reported all over the world. A variety of metallic foreign bodies when ingested may be lodged in the lumen of the appendix such as screws, bird shots, and needles. This is called in most literatures as foreign body appendicitis.

Case presentation

A 4-year-old boy with history of an accidental ingestion of a metallic nail presented to the emergency department one week later with right iliac fossa pain and one attack of vomiting. During abdominal examination there was tenderness and rebound tenderness at the right iliac fossa. Plain abdominal X-ray showed the metallic nail in the region of the right iliac fossa. Ultrasound examination was normal apart from tenderness of putting the probe on the right lilac fossa. The white blood cell counts were 14,000 cell per microliter.

During surgery the nail was found to be impacted inside the lumen of the vermiform appendix causing inflammation of the appendix. Appendicectomy done and the patient discharged on the third day in a good general condition.

Conclusion

Acute appendicitis may be caused by a variety of causes including ingested foreign bodies if impacted in its lumen. When the patient has signs of generalized peritonitis it is important to exclude bowel perforation. The surgery can be done by the open surgery or laparoscopically.

Ultrasound guided lipofilling as a suggested method for implant salvage in implant based breast reconstruction: A case report

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A 27-year-old case of breast cancer underwent skin sparing mastectomy and implant reconstruction.

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The patient presented with an exposed but not infected implant during her follow up.

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After antibiotic irrigation and secondary suture, ultrasound guided lipofilling was performed for implant coverage.

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The patient had a smooth course and received radiotherapy with no other recorded implant - related complications.

Background

Implant based reconstruction is one of the well-established methods to restore shape and volume after total mastectomy. Exposure of an implant is a serious complication that could lead to failure of the whole process of breast reconstruction. There are no uniform guidelines on the management of such complication. Several methods have been described including antibiotic irrigation, implant replacement and flap coverage. This case report describes the use of ultrasound guided lipofilling for implant salvage in case of an exposed non-infected implant.

Case presentation

A 29-year-old patient with T3N1 post neoadjuvant chemotherapy breast cancer underwent skin sparing mastectomy and immediate subpectoral implant based reconstruction. She presented a week post hospital discharge with an exposed non infected silicone implant.

Antibiotic irrigation and secondary sutures were done with satisfactory wound healing within eight days. However, ultrasound examination revealed a sizeable area where the implant was in direct contact with the skin.

Utrasound guided lipofilling was done in the same setting as contralateral mastopexy to achieve symmetry. The patient had a smooth postoperative course. She was referred to radiation therapy department where she received adjuvant chest wall irradiation according to her pathological result.

Follow up after radiation therapy by clinical and ultrasound examination revealed no implant related complications.

Conclusion

Lipofilling is a very useful tool that could help in cases of an uninfected exposed implant. It could also be used primarily as an adjunct procedure to implant based reconstruction to optimize the outcome.