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

Septic arthritis following femoral neck fracture: A case report

INTRODUCTION

Femoral neck fracture is common in the elderly, especially in the era of aging populations. Septic arthritis of the hip after femoral neck fracture is a rare complication. There are limited reports on this complication especially in patients without a severe medical condition and there is no consensus on the method of treatment of this complication.

CASE PRESENTATION

A 75-year-old male had right hip pain for two weeks after falling on his right hip. The patient was diagnosed as pathological fracture with hematologic malignancy. He was scheduled for bipolar hemiarthroplasty. However, an intraoperative finding found that the hip joint was filled with pus. The treatment was successful with a two-stage procedure. The first stage was implantation of an antibiotic cement spacer and the second stage was total hip replacement.

CONCLUSION

Septic arthritis following femoral neck fracture is a complication which requires special attention for the diagnosis and treatment. Increasing hip pain or the developing signs of infection in patients awaiting surgery may indicate infection in the hip. The two-stage procedure is the treatment of choice in this condition.

Pancreatoduodenectomy in patient with perforated duodenal diverticulum and peritonitis: Case report

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Duodenal diverticulum is present in 5–22% of population.

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Complicated diverticulum can lead to perforation, bleeding, obstruction, pancreatitis.

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Pancreatoduodenectomy is an option when all other surgical approaches are not usable.

Introduction

Duodenal diverticula are quite prevalent in general population, seen on up to 5% of radiology studies and up to 22% of autopsy examinations.

Presentation of the case

70 years old female was admitted to the hospital with epigastric pain, fevers and elevated white cell count. Abdominal CT scan demonstrated evidence of perforated duodenal diverticulitis which failed to improve with IV antibiotics. Emergent pancreatoduodenectomy was performed with full recovery and uncomplicated hospital stay.

Discussions

Conservative therapy with antibiotics and bowel rest is successful in majority cases of perforation. Failure of conservative therapy demands surgical management. Variety of surgical approaches ranging from simple diverticulectomy to segmental resection, duodenal exclusion/bypass to pancreatoduodenectomy are available.

Conclusion

Pancreatoduodenectomy is an option when complicated duodenal diverticulum is not resolved with conservative or interventional therapy. This report has been written in concordance with the SCARE criteria Agha et al. [1].

Successful outcome after Pancreaticodoudenectomy in an elderly cirrhotic patient: A case report

INTRODUCTION

Cirrhosis is a risk factor for poor outcomes in non-hepatic oncological resections. There are only a handful of cases demonstrating outcomes of pancreaticoduodenectomy (PD) in patients with pancreatic cancer and underlying cirrhosis. Moreover, pushing the limits of PD to elderly cirrhotic patients and demonstrating its safety remains under reported.

CASE PRESENTATION

Here, we report successful management of a 71 year-old-lady with HCV related liver cirrhosis, obstructive jaundice and poor performance status, who was medically optimized and then underwent PD for adenocarcinoma of the head of pancreas. There was no major post-operative morbidity except minor chyle leak which resolved spontaneously. On her last follow up, she was doing well and undergoing adjuvant chemotherapy.

DISCUSSION

Preoperative medical optimization and careful patient selection can yield successful outcomes even after a major abdominal surgery like PD in elderly patients with underlying liver cirrhosis.

CONCLUSION

Liver cirrhosis is not a contra indication to PD in elderly patients with good performance status.

Appendiceal mucocele-A rare case report

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A Mucocele appendix with wide base communicating with caecum is a rare presentation.

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Presentation is same as acute appendicitis.

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Pre-operative diagnosis even with the help of USG & CT is really a challenging issue.

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Diagnosis of wide base mucocele appendix (preoperatively/intraoperatively) changes whole course of surgical management.

Introduction

Appendiceal mucocele is a rare disease and has a clinical picture that resembles acute appendicitis. A correct diagnosis before surgery is very important for the selection of surgical technique(appendicectomy/colectomy)to avoid severe intraoperative and postoperative complications. The work has been reported in line with the SCARE criteria (Agha et al. [23]).

Presentation of case

We present a case of 70 year old female admitted with chief complaints of right iliac fossa pain intermittent in nature with nausea and generalized weakness since 1 month. With the help of USG and CECT preoperative diagnosis of Appendiceal Mucocele was made. Midline incision Laparotomy was performed. Preoperative diagnosis of Appendix Mucocele changing the course of management has been reported rarely in literature.

Discussion

Intraoperatively a cystic mass of appendix with dimensions 8 cm × 5 cm with broad base and inflamed walls communicating with caecum but without perforation was discovered in right iliac fossa. Extended right hemicolectomy with ileotransverse anastomosis was done. Histopathological diagnosis of Mucinous Cystadenoma with Mucocele was reported. After 6 months of surgery patient is doing well with no postoperative complications.

Conclusion

In our opinion every patient more than 50 years old presenting in emergency department with clinical symptoms of acute appendicitis must undergo CT and open surgery should be favoured against laparoscopic surgery.

Rapid recurrence of primary gastric choriocarcinoma after complete resection

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A 78-year-old man was diagnosed with stage cIB primary gastric choriocarcinoma.

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Total gastrectomy with spleen-preserving D2 lymphadenectomy was performed.

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Early recurrence was diagnosed 3 months postoperatively.

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The patient underwent a standard nongestational choriocarcinoma chemotherapy.

Introduction

Primary gastric choriocarcinoma (PGC) is a rare and rapidly invasive tumor. We report a case of PGC diagnosed by endoscopic biopsy and treated with gastrectomy and chemotherapy.

Presentation of case

A 78-year-old man was referred to our hospital because esophagogastroduodenoscopy showed a tumor at the fornix of the stomach. Pathologic examination of biopsy specimens revealed choriocarcinoma. Abdominal computed tomography (CT) revealed no enlarged abdominal lymph nodes or distant metastases. Robot-assisted total gastrectomy with spleen-preserving D2 lymphadenectomy was performed on the basis of a diagnosis of cT2N0M0, stage cIB PGC. The pathologic diagnosis was pT2, ly0, v1, pN0, PM0, DM0, stage pIB PGC. The postoperative course was uneventful, and the patient was followed carefully without adjuvant chemotherapy. Three months after gastrectomy, blood tests indicated that serum β-human chorionic gonadotropin (β-hCG) levels had increased, and CT revealed multiple liver metastases. The patient underwent a standard nongestational choriocarcinoma chemotherapy regimen with etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine. Although β-hCG levels temporarily decreased with chemotherapy, the patient experienced tumor recurrence with ascites and his serological test demonstrated an elevated level of β-hCG (120 ng/mL). The patient died 10 months postoperatively.

Conclusion

We report a case of stage pIB PGC with poor prognosis, recurring at only 3 months postoperatively despite curative surgery and chemotherapy.

A case report of an asymptomatic male child with multiple entero-enteric fistulae post multiple magnet ingestion

INTRODUCTION

Foreign body ingestion cases are very common in children. They usually present with obvious symptoms allowing proper diagnosis and management; however, magnet ingestion can be asymptomatic. This disorder is considered uncommon as well as challenging to diagnose before complications of intestinal obstruction or peritonitis occur due to entrapment of intestinal walls in the magnetic field.

CASE PRESENTATION

An asymptomatic four-year-old male child was admitted to our centre after passing two bullet-shaped magnets in stool that were noticed by his mother. The child was asymptomatic. An abdominal X-ray revealed five bullet-shaped magnets in the lower abdomen. Laboratory investigations were normal except for a mild leukocytosis. Surgery was performed with excision of seven entero-enteric fistulae and two intestinal anastomoses.

DISCUSSION

Between 2003 and 2006, the Centers for Disease Control and Prevention reported 20 complicated cases of magnet ingestion in children aged 10 months to 11 years among whom 75% had bowel perforations, and 20% suffered from generalized peritonitis. Half that number of patients required emergency laparotomy. As a result, the Consumer Product Safety Commission (CPSC) issued the first warning announcing the hazards of high-powered magnets used in children's toys, which had been increasing exponentially. It is clear that the diagnosis of magnet ingestion is made commonly due to complications, such as peritonitis or death. However, the patient in this case was completely asymptomatic and had no complications.

CONCLUSION

A high index of suspicion regarding complications is recommended in asymptomatic cases of suspected magnet ingestion. Avoid delaying intervention once a diagnosis has been made.

Recurrent gastric volvulus associated with a gastrointestinal stromal tumor: A case report

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A 7-cm gastrointestinal stromal tumor (GIST) caused recurrent abdominal pain, apparently through gastric volvulus (GV).

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The risk of GV based on the size and location of a tumor is unknown.

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Prompt surgical intervention is indicated in cases of recurrent GV.

Introduction

Gastric volvulus (GV) is defined as a rotation of the stomach along its short or long axis leading to variable degrees of gastric outlet obstruction. Rotation of the stomach >180° may cause closed loop obstruction and possible strangulation, which often causes acute abdominal pain. Strangulation and gangrene of the twisted stomach sometimes occurs, which demands immediate surgical intervention. We report a case of acute gastric volvulus due to a gastrointestinal stromal tumor (GIST), with multiple recurrences, that eventually required emergency gastrectomy.

Presentation of the case

A 71-year-old woman with a history of recurrent epigastric pain, nausea, and anorexia was diagnosed to have a 70-mm sized submucosal tumor (SMT) in the lesser curvature of the stomach. An elective gastrectomy was planned; however, before the procedure, she visited the emergency room with acute recurrent epigastric pain associated with postural variations. Computed tomography (CT) revealed a GV and the tumor had shifted to the greater curvature. An emergency gastrectomy was performed. The postoperative course was uneventful and pathological examination revealed features consistent with that of GIST.

Discussion

GV with GIST has rarely been reported and risk factors such as size or localization are unknown. In this case, GV was probably caused by GIST of the stomach, which was large and heavy enough to rotate the gastric body around the mesenteroaxis.

Conclusion

Surgical intervention without delay should be planned in similar scenarios accounting for the risk of GV in GIST.

A successful combined laparoscopic cholecystectomy and laparoscopic exploration of common bile duct for acute gangrenous cholecystitis and choledocholithiasis during pregnancy: A case report

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Complicated gallstone disease during pregnancy can be successfully managed by combined laparoscopic cholecystectomy and exploration of common bile duct through trans-cystic duct approach.

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This approach is safe and can cure cholecystitis and choledocholithiasis in one goal.

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This approach avoids ionizing radiation to the developing fetus.

Introduction

Choledocholithiasis during pregnancy is relatively uncommon but it can be life-threatening. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of ionizing radiation exposure to the developing fetus. Other strategies are thus needed to tackle this problem.

Presentation of case

A 38-year-old 8 weeks’ pregnant lady presented with acute onset of right upper quadrant pain. Ultrasonography showed features of acute cholecystitis and choledocholithiasis, which was later confirmed by magnetic resonance cholangiogram. Emergency combined laparoscopic cholecystectomy (LC) and laparoscopic exploration of common bile duct (Lap ECBD) were performed. Lap ECBD through trans-cystic duct approach was adopted. The patient recovered uneventfully and was discharged on postoperative day 4. A healthy baby boy was delivered at 40 weeks’ gestation without developmental problem.

Conclusion

Lap ECBD avoided ionizing radiation for choledocholithiasis during pregnancy, and can combined with LC as an effective minimally invasive procedure for complicated gallstone disease.

Intestinal ischemia due to methamphetamine use: A case report

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Methamphetamine is associated with non-occlusive intestinal ischemia.

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Splanchnic vasocontriction of mesenteric and colonic vessels is the most likely cause of methamphetamine-induced intestinal ischemia.

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Surgeons should have a high index of suspicion for intestinal ischemia in methamphetamine users who present with acute abdominal pain.

Introduction

Methamphetamine use is a rare cause of intestinal ischemia but is of clinical significance due to its high morbidity and mortality. Knowledge of methamphetamine-induced intestinal ischemia has been limited to few case reports.

Case presentation

We describe the case of a 48-year-old man who presented with ischemic bowel related to methamphetamine use. With concern for intestinal infarction the patient was taken to the operating room for emergency laparotomy, which found a segmental gangrene of small bowel and colon. The patient subsequently underwent right hemicolectomy and small bowel resection for damage control, followed by second-look laparotomy and anastomosis. The patient recovered well from the surgery and was discharged without complications.

Conclusion

This case report alerts surgeons to have a high index of suspicion for intestinal ischemia in methamphetamine users who present with acute abdominal pain.

Left sided PAPVC with intact IAS-Surgically managed with vertical vein anastomosis to LA appendage: A rare case report

INTRODUCTION

Partial anomalous pulmonary venous connection (PAPVC) is a rare entity. Only 10% of these are left sided. An intact atrial septum is further uncommon.

PRESENTATION OF CASE

We present a case of left sided PAPVC with no atrial septal defect (ASD), who presented with effort intolerance and an unremarkable physical examination. Computed tomography pulmonary angiography (CTPA) confirmed the primary diagnosis as suggested by an initial 2-D echocardiography, and aided in better understanding of the anatomy.

CONCLUSION

Patient underwent successful surgery through a simple & reproducible technique of anastomosis of vertical vein to left atrial appendage. Patient recovered uneventfully and was discharged on day 10.

Preoperative diagnosis and surgical treatment for giant retroperitoneal liposarcoma: A case report

INTRODUCTION

The purpose of this article is to present the diagnostic and surgical approach for a giant retroperitoneal sarcoma and to highlight the difficulty of a precise preoperative diagnosis and the extention of surgical resection.

PRESENTATION OF CASE

A 63-year-old female patient was admitted at our department with light diffuse abdominal pain, fever and gradual increase of abdominal girth. A CT scan showed a giant fatty tumor occupying left hemiabdomen and indirect findings of renal damage, probably sustained by ureter stretching and urine stasis. At surgical exploration, no cleavage plane was discovered between the mass and the surrounding organs. The severe pielonephritis and the apparent intraoperatively involvement of surrounding tumour structures lead to an aggressive surgery. An "en-bloc" resection of tumor mass, left colon, spleen, pancreatic tail, left annex, left kidney and adrenal gland was performed. Histology revealed a well differentiated liposarcoma with large areas of high grade of dedifferentiation.

DISCUSSION

Liposarcoma is an histologic subtype of soft tissue sarcoma and the most common type of sarcoma arising in retroperitoneum. It is difficult to make an accurate preoperative diagnosis through a percutaneous biopsy. Although it is required to obtain negative resection margins, literature shows that surgical radicality is not a primary endpoint if noble structures are strictly close. In some cases surgery must be more aggressive because of the apparent organ involvement or damage.

CONCLUSION

This is a rare case of a giant liposarcoma involging many organs. Surgery should be tailored according to intraoperative findings and organ damage.

Myxoid esophageal liposarcoma: A case report of a rare tumor

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Esophagealliposarcoma represent a rare cause of esophagealtumor.

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We present a case of liposarcomain the low oesophagus treated by surgical resection.

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There is no conventional treatment of this pathology.

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The curative treatment requires surgical resection orendoscopic approach for selected tumor.

Introduction

Esophageal liposarcoma represent a rare cause of esophageal tumor. According to the literature, since the first case reported in 1983, only 42 cases of esophageal liposarcoma were reported.

Presentation of case

We present a case of liposarcoma in the lower oesophagus treated by surgical resection.

Discussion

Liposarcoma in the oesophagus gastrointestinal tract is an uncommon. An analysis of the literature reports 42 cases.In many cases the diagnosis was established in postoperative period.Surgery is the standard treatment including polypectomy, total or subtotal oesophagectomy.

Conclusion

There is no conventional treatment of this pathology. The curative treatment requires surgical resection or endoscopic approach for selected tumor.

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

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Leiomyosarcoma of the spermatic cord is a rare entity.

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The diagnosis of spermatic cord leiomyosarcoma is difficult based on imagery alone.

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The standard treatment is radical orchidectomy with high ligation of the spermatic cord.

Background

Leiomyosarcoma of the spermatic cord is a rare entity. It presents as a firm and painless intrascrotal mass. For diagnosis radiological methods such as ultrasound, CT or MRI are necessary. Radical orchiectomy is the gold standard of treatment.

Case description

We reported a one case of a 66-year-old man that he has suffered from a painless hard mass in the right hemiscrotum since three years. Ultrasound revealed a paratesticular mass. Further workup revealed no distant metastasis before surgery. Right radical orchiectomy was performed, the final pathologic examination showed a leiomyosarcoma of the spermatic cord. The patient remained disease-free twelve-month during follow up after surgery.

Discussion

Leiomyosarcoma of the spermatic cord is a rare condition, it arises from mesenchymal cells of the spermatic cord and occurs mainly in elderly patients. The diagnosis of spermatic cord leiomyosarcoma is difficult if based only on imaging procedures, it is revealed by histological examination post surgery. No treatment protocol has yet been established for paratesticular leiomyosarcoma due to the rarity of the disease. Standard treatment is radical orchidectomy with high ligation of the spermatic cord. The benefit of adjuvant chemotherapy, radiotherapy, and retroperitoneal lymphadenectomy are not well understood and may differ according to the surgeon's preferences.

Conclusion

The lack of such cases results in the challenging nature of the diagnosis and treatment of leiomyosarcoma of the spermatic cord. Additional studies are needed to better define optimal management strategies.

Idiopathic segmental infarction of the omentum mimicking acute appendicitis: A case report

INTRODUCTION

Omentum is a well vascularized organ. Omentum infarction is uncommon. Most of the cases are secondary due to torsion, intra-abdominal infections and vascular thrombosis. Primary idiopathic segmental omental infarction is rare.

PRESENTATION OF CASE

A 26-year-old male presented with acute onset right iliac fossa pain mimicking acute appendicitis. On radiological imaging, early acute appendicitis was suspected. On diagnostic laparoscopy, appendix appeared normal and there was idiopathic infarction of a part of the greater omentum lying close to the cecum. Patient underwent laparoscopic appendectomy with excision of the diseased segment of the omentum and had uneventful recovery.

CONCLUSION

Idiopathic omental infarction should be included in the differential diagnoses while treating patient with acute abdomen.

Concomitant primary ovarian paraganglioma neuroendocrinal differentiated urothelial tumor in a BOTOX-injected bladder: A case report

INTRODUCTION

There is no reported data for patients with malignant bladder Botox^® injection related outcomes. Herein, we reported effect of Botox^® injection in case of BCG cystitis. In addition, reporting of rare incidence of both primary neuroendocrine differentiation of bladder tumor and primary ovarian paraganglioma post cystectomy.

PRESENTATION OF CASE

A-64 years old female presented with sever irritative lower urinary tract symptoms (LUTS) post vesical BCG installation for carcinoma in situ. Patient's symptoms were relieved after Botox^® bladder injection after anticholinergics failure. One year later, she came back with hematuria. Cystoscopy showed nodular bladder lesion. Hypertension episodes were noticed during cystoscopic resection. Pathological examination showed presence of muscle invasive transitional cell carcinoma (TCC) with neuroendocrine differentiation. Patient underwent radical cystectomy and pathology was associated with incidentally discovered primary ovarian paraganglioma.

DISCUSSION

Intravesical BCG is a standard adjuvant treatment for carcinoma in situ with 75% induced cystitis as a local side effect. The International Bladder Cancer Group's recommendation for BCG cystitis included many agents, these treatment options had very limited outcomes. The existence of paraganglioma in the female genital tract described rarely <1% in the vagina, uterus, vulva and ovary with only few reports. The same as paraganglioma small cell differentiation of vesical urothelial tumor is a rare entity with no reported cases of simultaneous occurrence and to differentiate each other as primary or metastatic.

CONCLUSION

Bladder Botox^® injection could be offered as a treatment for overactive bladder-like symptoms in malignant cystitis. Neuroendocrine tumors are with a rare entity could be happened instantaneously in urogenital tract.

Surgical treatment of gastric outlet obstruction from a large trichobezoar: A case report

INTRODUCTION

Bezoars are concretions of foreign indigestible material accumulating in the gastrointestinal tract leading to intraluminal mass formation that impairs the gastrointestinal motility and can lead to gastric obstruction of the small or the large bowel. There are different types of bezoars, named according to the material they are made of. These include phytobezoar, lactobezoar, pharmacobezoar, trichobezoar, and polybezoar. Trichobezoars (hair ball) are usually located in the stomach but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome).

CASE PRESENTATION

Herein, we report a case of a young adult female known to have a long-standing trichophagia who presented with gastric outlet obstruction due to a large trichobezoar. Endoscopy revealed a large and hard gastric trichobezoar not amenable to endoscopic retrieval leading to surgical extraction as a last resort.

DISCUSSION

They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. Trichobezoar can be treated either surgically by laparotomy/laparoscopy or by endoscopic intervention.

CONCLUSION

Treatment should be coupled to psychiatric evaluation and therapy to prevent recurrence.

Hydatid cyst involving Right Pectoralis Major Muscle: A case report

BACKGROUND AND AIM

Hydatid disease is caused by Echinococcus granulosus; a tapeworm. They rarely affect the musculoskeletal system of the body (<5% of cases). The objective of this case report is to discuss about hydatid cyst disease involving the right pectoralis major muscle.

CASE PRESENTATION

Herein, we report a case of a 35 years old lady who came to the outpatient department with a gradually increasing soft swelling at the right upper chest below the clavicle. The final diagnosis was made with the help of a CT scan. The cyst was excised and the area was washed with a scolicidal agent. There was no recurrence after six months of follow up and the patient was doing well.

CONCLUSION

Hydatid cyst of the Pectoralis Major is rare and must be considered in the differential of any muscular swelling in the body in endemic areas. These cysts should be treated with enucleation/excicion followed by irrigation of the area with a scolicidal agent.

General anaesthesia for caesarean section in a patient with neuromyelitis optica spectrum disorder (NMOSD)

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We report the anaesthetic management of a patient with pre-existing NMOSD undergoing a caesarean delivery.

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Multidisciplinary collaboration and careful patient counselling were essential to optimize maternal and foetal outcomes.

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The use of neuromuscular monitoring and sugammadex reversal might play an important role in anesthetic management of patients with NMOSD.

Introduction

Neuromyelitis optica spectrum disorder (NMOSD) is a rare demyelinating disorder affecting the spinal cord and optic nerves. The anesthetic management in parturient women with NMOSD are controversial and remains challenging.

Presentation of case

A 35-year-old G2P1 woman at 36 weeks of gestation with NMOSD presented for pre-anesthesia assessment prior to caesarean section. Her NMOSD had been diagnosed four years previously and was treated with intravenous methylprednisolone (IVMP) and plasma exchange (PLEX). She underwent general anesthesia without developing adverse respiratory events or signs and symptoms of muscle weakness.

Discussion

Both neuraxial and general anaesthesia for NMOSD have been described in previous case reports. Risk factors of general anesthesia in pregnancy with NMOSD must be weighed against the likely risk of NMOSD relapse and the potential deteriorating neurological symptoms after neuraxial anesthesia.

Conclusion

A multidisciplinary collaboration together with careful anesthetic consideration is required for the anesthetic and perioperative management of these patients.

Solitary contralateral adrenal metastasis of renal cell carcinoma 15 years following radical nephrectomy: A case report and review of literature

INTRODUCTION

Renal cell carcinoma (RCC) is known to metastasize to almost every organ. A well-recognized phenomenon in RCC is late metastatic recurrence after nephrectomy which is arbitrarily defined as more than 10 years. The incidence of solitary ipsilateral and contralateral adrenal metastasis is 3% and 0.7% respectively in patients who have underwent radical nephrectomy.

CASE REPORT

A57-year-old female presented with an incidental ultrasonic finding of a right adrenal mass 15 years after radical nephrectomy for left side renal cell carcinoma. Further evaluation with abdominal contrast enhanced CT scan revealed a right adrenal mass suggestive of metastatic lesion. The results of laboratory examinations showed the mass to be nonfunctional. Open right adrenalectomy was performed. She was discharged home on 4th postoperative day. Pathological examination revealed morphological and immunohistochemical findings in line with metastatic renal cell carcinoma of the left kidney. During the last 2 years she has being on regular follow up, neither local recurrence nor distant metastasis anywhere have been detected by whole body Positron Emission Tomography(PET) scan.

DISCUSSION

Late metastatic contralateral adrenal recurrence from RCC is very rare and to the best of our knowledge, 5 similar cases have been reported 10 years after radical nephrectomy. Early diagnosis of adrenal metastasis is challenging because they are usually silent both anatomically and functionally.

CONCLUSION

Solitary contralateral adrenal metastatic recurrence of RCC is extremely rare event. Surgical removal is a wise option in these cases that may improve survival.

Surgical management of a large calcifying epithelial odontogenic tumor in the maxilla: A case report

INTRODUCTION

The calcifying epithelial odontogenic tumor (CEOT), also known as Pindborg tumor, is a locally invasive benign neoplasm. Histogenesis is controversial.

PRESENTATION OF CASE

A 26-year-old male presented asymptomatic swelling on the right side of the face, with approximately six months of evolution. At intraoral examination, a hard nodule localized in the right posterior region of the maxilla, measuring approximately 5.0 x 3.0 cm was observed. The computed tomography images showed hypodense lesion with points of calcification associated with two non-erupted teeth. We suspect of odontogenic lesions. The final diagnosis of CEOT was established based on the histopathological aspects.

DISCUSSION

This tumor is more frequent in adult men, usually develops in the posterior region of the mandible and may present clinical-pathological similarities with others odontogenic lesions. The radiological aspects observed in the CEOT are variable and depend on the time of evolution of the tumor. The histopathological examination is mandatory to establish the final diagnosis.

CONCLUSION

Our case was treated with simple enucleation without signs of recurrence in five years of follow-up. Further studies are needed to understand the aetiology and the biological behaviour of this tumor.

Multidisciplinary management of CDH1 germinal mutation and prophylactic management hereditary lobular breast cancer: A case report

INTRODUCTION

Germline CDH1 mutations, classically associated with hereditary diffuse gastric cancer (HDGC), also imply an increased lifetime risk of developing lobular breast cancer (LBC) in a highly penetrant autosomal dominant manner.

PRESENTATION OF CASE

We report a 44-year-old woman CDH1 mutation carrier with a strong family history of cancer, who previously had prophylactic total gastrectomy. We registered normal findings at the breast and axilla assessment. Mammography, ultrasonography and breast MRI scans were negative for cancer. In our Institute a bilateral prophylactic mastectomy followed by breast reconstruction was performed. Foci of atypical lobular hyperplasia(ALH) and lobular carcinoma in situ (LCIS) were histologically shown.

DISCUSSION

The current consensus guidelines for women with pathogenic CDH1 mutations recommend annual mammography, ultrasound, breast MRI scans and clinical breast examination starting at the age of 35. Due to the well-documented aggressive behavior of this particular type of cancer, bilateral mastectomy and reconstruction would be more beneficial for this kind of high-risk patients.

CONCLUSION

Conflicting evidences and lacking data about the benefits in terms of overall survival, disease-free survival and the long-term outcomes related to prophylactic bilateral mastectomy for CDH1 mutation carriers restrict the instruction for this type of procedure to selected cases, which should always be managed by a multidisciplinary team.

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

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Massive localized lymphedema (MLL) constitutes a rare benign clinical disorder, presenting in obese patients, characterized by chronic accumulation of lymph and adipose tissue due to lymphatic flow obstruction.

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MLL may mimic an abundance of soft tissue tumors.

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Nevertheless, surgical excision of the soft-tissue mass, seems the most favorable therapeutic approach, as performed in the presented case.

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.

A hepatic sclerosing hemangioma emerged in the postoperative course of multiple gastric carcinoid tumors masquerading as metachronous liver metastasis

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The authors present an unusual case of newly appearing hepatic sclerosing hemangioma newly emerged in the postoperative course after the resection of multiple gastric carcinoid tumors.

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Hepatic sclerosing hemangioma is often misdiagnosed as malignant lesion for its resemblance on the imaging studies.

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Although preoperative diagnosis is still difficult, hepatic sclerosing hemangioma must be included into the differential diagnosis of hepatic tumors.

Introduction

Hepatic sclerosing hemangiomas are rare tumors whose appearance on imaging is similar to that of malignant tumors. The resulting difficulties in preoperative diagnosis frequently lead to surgical resection in order to accurately identify the tumor.

Case presentation

A 68-year-old man was diagnosed with multiple gastric carcinoid tumors (T1N1M0, pStage IIIB) after total gastrectomy with D2 lymph node dissection. Enhanced computed tomography of the abdomen 2 years after the initial surgery revealed a novel solid lesion with ring enhancement measuring 22 × 15 mm at S5 of the liver. Metachronous liver metastasis from multiple gastric carcinoid tumors was suspected, and partial hepatectomy of S5 was successfully performed. Histopathological diagnosis was sclerosing hemangioma with no malignant findings.

Discussion

Ours is the first reported case of a newly appearing sclerosing hemangioma excised and diagnosed histopathologically. Hepatic sclerosing hemangiomas are rarely observed, but they are often resected under a preoperative diagnosis of malignant lesion due to the similarity on imaging studies.

Conclusion

Surgeons must consider that a hepatic tumor may be a sclerosing hemangioma, particularly when the lesion appears to be ring enhanced.

Incidental Morgagni hernia found during laparoscopic repair of hiatal hernia: Case report & review of literature

Introduction

Morgagni hernia is rare clinical entity accounting for 3% of all surgically treated diaphragmatic hernias. Similarly, paraesophageal hernia constitutes only 5% of all hiatal hernia. The co-existing of these two hernias is extremely rare with only 10 cases reported in the literature.

Presentation of case

We present a case of 53-year-old female patient with 6-year history of reflux disease. Her symptoms were poorly controlled by medications and she was seeking a surgical treatment. Preoperative assessment revealed a giant paraesophageal hernia for which a laparoscopic repair was planned. During the surgery, left-sided Morgagni hernia was discovered and both hernias were repaired at the same time. The patient tolerated the procedure well without complications.

Conclusion

The co-existence of Morgagni and Hiatal hernia is rare and the simultaneously laparoscopic repair of both hernias is safe and feasible.

Surgical repair of a large ventral hernia under spinal anaesthesia: A case report

BACKROUND

Secondary ventral hernias are incisional hernias developed in former postoperative scars. Up to 30% of all patients undergoing laparotomy develop an incisional hernia. Open ventral hernia repair is often performed under general anaesthesia but can also be performed under regional anaesthesia.

CASE REPORT

We report the case of an elderly man, who underwent open surgery of a large incisional hernia in spinal block. Regional anaesthesia was chosen due to the patient's additional diseases and disorders.

CONCLUSION

Open surgery of large ventral hernia in spinal anaesthesia can be performed because the spinal anaesthesia provides adequate conditions for ventral hernia repair. The patient has to be in good physical condition in order for the surgery to be successful. During the surgery the patient has to be watched over vigilantly by the anaesthesiologist.

A case report of ten-month-neglected anterior shoulder dislocation managed by open reduction combined with Latarjet procedure

INTRODUCTION

Neglected shoulder dislocation is a rare case and may be accompanied by pathological changes in bony and soft tissue structure. Therefore, it requires extensive surgical procedure. Until now, there is no standard treatment protocol to overcome this case and it is still a challenging case.

PRESENTATION OF CASE

We presented a 27-year-old male patient with deformity on his left shoulder. The patient has suffered a ten-month-neglected anterior shoulder dislocation with a Hill-Sachs lesion. The treatment was open reduction combined with Latarjet procedure. Evaluation of treatment was performed three months after surgery.

DISCUSSION

Management of a neglected shoulder dislocation, especially with significant bony defects, is challenging and cannot be managed with standard surgical technique because of severe soft-tissue contracture and imbalance as well as bone deficiency. Chronic locked anterior shoulder dislocation is a difficult condition for both patient and clinician. In addition to that, the treatment results can be unsatisfactory. Latarjet procedure has been shown to be effective for the treatment of recurrent anterior shoulder dislocation with a large glenoid osseous defect which might justify the application of this procedure for the treatment of neglected anterior shoulder dislocation.

CONCLUSION

Open reduction combined with Latarjet procedure performed for treatment of neglected anterior shoulder dislocation was found to have a high rate of successful in preventing further dislocation of the shoulder joint although the high risk of osteoarthritis of the shoulder joint can still persist.

Retroperitoneal space-occupying lesion with displacement of the inferior vena cava

•

Exact preoperative diagnosis and surgery of retroperitoneal schwannoma (RS) is sophisticated.

•

Due to heterogeneity of the entity, preoperative negative biopsy does not exclude malignancy.

•

A curative (R0) resection must be achieved in order to avoid local recurrence, always under consideration of multivisceral resections.

Introduction

The differential diagnosis and therapy of retroperitoneal masses suspicious for soft tissue tumors remains difficult and needs individual decisions as to the best management of patients. We report an unusual case of retroperitoneal schwannoma (RS).

Presentation of case

We report on a 57-year-old female patient with a retroperitoneal space-occupying lesion with displacement, but no infiltration of surrounding vessels, especially the inferior vena cava. As presence of malignancy could not be completely excluded by imaging and biopsy, we performed an open resection of the tumor with plastic reconstruction of the right renal vein. Curative resection of the tumor could be achieved and benign RS verified.

Discussion

Preoperative work-up, including a broad spectrum of differential diagnoses, and consecutive appropriate surgical resection are challenging. Characteristic features of the pre-therapeutic diagnostics of retroperitoneal schwannomas are discussed and differential diagnostic considerations as well as surgical therapeutic options are outlined.

Conclusion

Deeper understanding of retroperitoneal schwannomas gained from preoperative radiologic diagnostics may serve to underline the need for targeted biopsy. This and its histopathological examination necessitate expert interventional radiologists and pathologists. Thus, even the pre-therapeutic diagnostic management should be performed in a specialized center. If doubts remain regarding the entity of the retroperitoneal lesion and findings are still controversial after thorough assessment, surgical oncologic resection represents the therapy of choice, if the surgical risk is adequate.

Efficiency of fluorescent cholangiography during laparoscopic cholecystectomy for subvesical bile ducts: A case report

•

The subvesical bile ducts are important from the potential risk for bile leakage.

•

It is difficult to identify the subvesical bile ducts intraoperatively.

•

Fluorescent cholangiography visualized the subvesical bile ducts clearly.

Introduction

The subvesical bile ducts are located in the peri-hepatic connective tissue of the gallbladder fossa. Injury of the subvesical bile ducts provokes the severe complication of bile leak. Until now, fluorescent cholangiography has been employed during hepatobiliary surgery. Herein, we report the detection of subvesical bile ducts by fluorescent cholangiography during laparoscopic cholecystectomy.

Presentation of case

A 63-year-old female was admitted to our department for surgery for symptomatic cholelithiasis. The subvesical bile ducts were not observed on drip-infusion cholangiography with computed tomography. Immediately following induction of anesthesia, 2.5 mg of indocyanine green was intravenously injected. Fluorescent cholangiography demonstrated two thin aberrant bile ducts during dissection of Calot’s triangle. We considered them to be subvesical bile ducts. We ligated them with clips, divided them, and then performed laparoscopic cholecystectomy using a standard procedure. The patient had a good post-operative recovery without bile leakage. Postoperative laboratory test results were all within normal limits. Computed tomography revealed no dilatation of the intrahepatic bile duct after laparoscopic cholecystectomy. The patient was discharged on postoperative day 4.

Discussion

Injury to the subvesical bile ducts is one of the most common causes of bile leakage associated with cholecystectomy. Fluorescent cholangiography enabled real-time identification of the thin subvesical bile ducts, which were undetectable by drip-infusion cholangiography with computed tomography.

Conclusion

Fluorescent cholangiography during laparoscopic cholecystectomy may be useful for preventing postoperative bile leakage.

Thymic papillary adenocarcinoma coexisting with type A thymoma: A case report

INTRODUCTION

Thymic papillary adenocarcinoma is rare. Further, thymic papillary adenocarcinoma coexisting with type A thymoma is extremely rare. Surgery remains the only effective treatment for this disease.

PRESENTATION OF CASE

An 84-year-old Japanese woman presented to our institute due to abnormal chest computed tomography (CT) findings showing a 45 × 40 × 40-mm tumor located in the anterior mediastinum. A malignant tumor was suspected based on the CT findings and high serum levels of carcinoembryonic antigen. Mediastinal tumor resection was performed via video-assisted thoracic surgery through the left thoracic approach. This patient was discharged from our institute without any problems at six days post-operation.

DISCUSSION

This report has three major implications. First, one of the tumors was papillary adenocarcinoma. Primary papillary adenocarcinoma of the thymus is exceedingly rare. Second, papillary adenocarcinoma and type A thymoma coexisted in this tumor. Third, epithelial thymic tumor should be resected completely, since complete resection has been reported to be associated with an improved prognosis.

CONCLUSION

We encountered a rare case of thymic papillary adenocarcinoma coexisting with type A thymoma.

Successful manual reduction for ureterosciatic hernia: A case report

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Manual reduction was successfully performed for a patient with sciatic hernia.

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There were no report of closed manual reduction previously.

•

A sciatic hernia in women may be manually reduced without surgery.

Introduction

Sciatic hernias are the least common type of pelvic floor hernias. The purpose of this study was to present a novel technique for manual reduction and to conduct a systematic review of previous reports of sciatic hernias to characterize them and review the outcomes.

Presentation of case

An 86-year-old female presented with left-sided lumbar pain. She had a past medical history of rheumatoid arthritis and was treated with prednisolone and methotrexate. Her left abdomen and left lumbar area were tender. An unenhanced abdominal computed tomography scan revealed invagination of the left ureter into the left sciatic foramen and a dilated left proximal ureter and renal pelvis. Ultrasonography showed an invaginated left ureter viewing from the left buttock. She was diagnosed with a sciatic hernia. Ultrasound-guided manual transvaginal reduction was performed. Post-procedure unenhanced abdominal computed tomography scan confirmed reduction of the ureter. After 10-months of follow-up, there is no evidence of recurrence.

Discussion

Previous reports of patients with sciatic hernia were identified. Clinical data associated with the hernia, reduction technique and clinical outcomes were collected for 72 patients. Open reduction was performed in 24 patients. A ureteral stent was placed in eight patients when the hernia contained the ureter. Four postoperative complications including one death were reported in adults. There were no reports of closed manual reduction.

Conclusion

A sciatic hernia in women may be manually reduced without surgery. Further reviews of this rare entity are needed to determine the best management strategy.

Interlaminar stabilization and decompression for the treatment of bilateral juxtafacet cysts: Case report and literature review

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Lumbar juxtafacet cysts are typically treated by resection alone or resection combined with posterior instrumentation.

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Resection with instrumentation is associated with a lower rate of recurrence but also with increased cost and morbidity.

•

We present a case of bilateral juxtafacet cysts causing neurogenic claudication treated with decompression and interlaminar stabilization.

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Complete symptom resolution was sustained at one-year follow-up.

•

Decompression followed by interlaminar stabilization may be a reasonable alternative for some patients.

Introduction

Lumbar juxtafacet cysts (JFCs) are a common cause of lumbar radiculopathy which tend to occur in areas of increased facet mobility. While resection alone is a possible treatment, recent publications suggest that laminectomy alone for JFCs may not yield as favorable an outcome as laminotomies reinforced with posterior dynamic hardware. The Coflex^® is a novel interlaminar stabilization device that has been shown to achieve comparable results to rigid fusion in the management of lumbar stenosis in patients with no more than grade one anterolisthesis, and superior performance compared to laminectomy alone when a combined outcome score was used. We describe the combined use of dynamic posterior element fusion with primary cyst resection in the management of bilateral JFCs.

Presentation of case

A 71-year-old man who developed a progressive left L4 radiculopathy along with new urinary incontinence was found to have bilateral L3/4 JFCs causing significant lumbar stenosis and neurogenic claudication. After treatment with primary cyst resection and interlaminar stabilization, the patient experienced complete symptom resolution and was discharged to inpatient-rehabilitation on post-operative day 1.

Discussion

While current recommendations for the management of juxtafacet cysts causing progressive neurologic symptoms include surgical cyst removal and lumbar decompression with or without fusion, the role of dynamic interlaminar stabilization has not been explored.

Conclusion

Direct decompression followed by interlaminar stabilization may represent an alternative for patients to simultaneously benefit from a decompression of their juxtafacet cysts while affording posterior element reconstruction.

Surgical management for an infected urachal cyst in an adult: Case report and literature review

INTRODUCTION

Incomplete urachal obliteration during fetal development gives rise to distinct malformations of the median umbilical ligament. Most anomalies are asymptomatic and resolve during early infancy, but some go unrecognized until adulthood. These rare cases can present with acute abdominal symptomatology secondary to infected urachal remnants.

PRESENTATION OF CASE

A 20-year-old man presented with periumbilical pain. Physical exam showed a warm, erythematous infra-umbilical mass that was tender to palpation. CT revealed an infected urachal cyst. The patient underwent urachal abscess incision and drainage with cyst excision. The patient returned home on postoperative day two. Two-week outpatient follow-up confirmed an uncomplicated recovery.

DISCUSSION

Surgical excision of urachal anomalies in adults is curative and preventive against recurrent infection and malignancy, but preoperative management is currently unstandardized. Current literature recommends a two-stage approach characterized by preoperative antibiotics and cyst incision and drainage followed later by complete surgical excision. Our patient underwent a single therapeutic approach with preoperative antibiotics and definitive operative excision. Our patient had a comparable outcome with no complications and a short hospitalization.

CONCLUSION

Preoperative antibiotics with excision of urachal remnants was effective in our case. Staged approaches are appropriate in complicated cases as a means to reduce post-operative infection rates and hospital stays. Urachal remnant excision is recommended in adults to prevent future malignancy.

Small gastrointestinal stromal tumour of the duodenum causing a life-threatening bleeding - A case report and review of the literature

INTRODUCTION

Duodenal gastrointestinal stromal tumors (DGISTs) are mesenchymal tumors. Main presenting symptoms are gastrointestinal bleeding and non-specific abdominal pain. Surgical treatment is golden standard for treatment of DGISTs. Tumour location and size determine the surgical strategy. Recurrence rate depends on tumour location and completeness on removal.

PRESENTATION OF CASE

75 years old male fell ill with hematemesis, hemohesia and dizziness. Oesophagogastroduodenoscopy (EGD) did not reveal the source of bleeding. Upon admission, a second EGD was performed due to loss of consciousness and anaemia, which revealed only approximate source of bleeding in the third portion of the duodenum. The exact bleeding spot could not be reached and bleeding could not be controlled endoscopically. Patient was transferred to the operating room for an emergency explorative laparotomy. After extensive mobilisation of the duodenum a 2 × 2 cm intraluminal tumour with central bleeding ulceration was found in D3. The diseased part of the duodenum was excised and the duodenotomy was closed with interrupted sutures. Final pathohistological report confirmed gastrointestinal stromal tumour, pT1. Postoperative period was uneventful.

DISCUSSION

Gastrointestinal stromal tumours are most common in males aged 60-65 years. Surgical treatment is a golden standard. Surgical approach depends upon tumor location and size. In case of major bleeding surgical procedure is lifesaving and diagnostics for staging purposes are omitted.

CONCLUSION

Gastrointestinal stromal tumors are a potential source of life-threatening bleeding. In such cases an emergency operation is often indicated with aim to remove the tumour en bloc and achieve hemostasis as soon as possible.

Acute pancreatitis as a complication of routine colonoscopy-A rare case report

INTRODUCTION

Abdominal pain after colonoscopy is a relatively common symptom and usually benign. Colonoscopy-induced pancreatitis is an extremely rare phenomenon that can sometimes be missed leading to delayed diagnosis and treatment.

PRESENTATION OF CASE

A 53 year old woman presented to the Emergency Department with abdominal pain, a significantly raised lipase and a CT scan revealing pancreatitis. She had no previous history of pancreatitis or any aetiological risk factors. Her pain started 2 h after having a routine outpatient colonoscopy for polyp surveillance. The endoscopist had no difficulty during the procedure and the findings were unremarkable. She developed a Systemic Inflammatory Response Syndrome (SIRS) and an ileus requiring a prolonged hospital admission. However with conservative management she improved and was discharged on day 11 post-admission in stable condition.

DISCUSSION

The mechanism of colonoscopy-induced pancreatitis is not well understood. Hypotheses include mechanical trauma to the pancreas caused by the endoscope particularly at the splenic flexure, over-insufflation of the colon, external abdominal pressure, and transmural colonic burns via electrocautery causing irritation to the pancreas.

CONCLUSION

Pancreatitis should be considered in the differential diagnosis of abdominal pain post-colonoscopy after the more common explanations are excluded.

Liver transplantation with a normothermic machine preserved fatty nonagenarian liver: A case report

INTRODUCTION

The use of organs from expanded criteria donors for Liver Transplantation (LT) represents a major challenge. In the current era of Normothermic Machine Perfusion (NMP), donor age boundaries are often overcome and may contribute to reduce the gap between supply and demand of organs suitable for transplantation. We report on a unique case of nonagenarian liver successfully transplanted after NMP.

PRESENTATION OF CASE

A fatty previously declined liver graft from nonagenarian male brain death donor underwent NMP (OrganOx Metra®, UK, Oxford) perfusion at University of Rome Tor Vergata on April 2018. The histology assessment showed 15% macro and 35% micro vescicular steatosis. Liver fulfilled viability criteria after NMP and was thus transplanted. The recipient was a 53 years old male with hepatocellular carcinoma who underwent two previous trans-arterial chemo-embolization. The post-LT AST peak was 1556 U/L; post operative course was characterized by hepatic artery thrombosis that required re-laparotomy and successful thrombectomy. Recipient experienced biliary stricture three months after discharge successfully treated by endoscopic retrograde cholangiopancreatography. At 7 months of follow-up patient has good clinical status and graft function.

DISCUSSION

NMP represents a safe approach in order to increase the usage of very old fatty livers, that otherwise would be declined because of the high risk of primary non function and death.

CONCLUSION

Nonagenarian liver recruitment after NMP seems to be feasible but a major attention is advisable on the manipulation and cannulation of hepatic artery in order to avoid intimal damage that can lead hepatic artery thrombosis.

Simultaneous small bowel and colon obstruction due to splenosis. A case report and review of literature

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Splenosis is an autotransplantation of splenic tissues throughout the body post splenic rupture or splenectomy.

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Symptomatic when hematological diseases have recurred.

•

Abdominal splenosis may rarely be associated with abdominal pain and/or gastrointestinal symptoms.

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Further evaluation and treatment is mandatory when bowel obstruction is present.

•

Treatment consists of resection of problematic splenic nodules.

Introduction

Splenosis, an autotransplantation of splenic tissues in another compartment of the body, is only symptomatic when hematologic diseases have recurred or compression of other adjacent structures have occurred. Therefore, we report a clinical case of a patient with bowel obstruction due to splenosis.

Case presentation

A patient with a history of splenectomy, presented to the emergency room for abdominal pain and obstipation, suggesting intestinal obstruction which is also seen on CT scan. During laparotomy, multiple splenic nodules were seen on the mesentery of the small bowel and colon, with vascular bridges between them, resulting in bowel obstruction. Resection of splenic nodules was performed. The post-operative course was uneventful and the patient was discharged a week after.

Discussion

Although very rare, gastrointestinal symptoms may sometimes be described in patients with splenosis. Bleeding or obstruction can occur because of intramural grow or external compression, respectively. Treatment consists of resection of these nodules.

Conclusion

Splenosis should always be thought in patients with previous splenic rupture and presenting with incidental nodules seen on imaging, with further investigations when symptoms are present.

An inexpensive and rapid method for removal of multiple stripped locking screws following locking plating: A case report

INTRODUCTION

Removal of stripped or jammed locking screws involves several difficulties. Especially when two or more screws are involved, their removal is a more challenging and time-consuming process because the various reported techniques have certain limitations.

CASE PRESENTATION

Herein, we report a case in which five stripped screws were removed using a novel technique.

DISCUSSION

Many techniques to remove damaged locking head screw were introduced, however in case with multiple screws were involved, they are limited to use. In the case, screw extractor, although it is not a medical device, is helpful in terms of time and cost.

CONCLUSION

In case with the failure of removal of multiple locking screws, our technique using non-medical screw extractor can be a good option.

Lymphangiomatosis of the ileum with perforation: A case report and review of the literature

Lymphangiomatosis is a benign proliferation of lymph vessels. Lymphatic diseases can vary from small lymphangioma to generalized lymphangiomatosis, which is a rare condition and can have several clinical manifestations. The gastrointestinal tract may be affected, but the incidence in the intestinal wall is very low. We propose in our study a case of ileal lymphangiomatosis presenting with perforation, in which the diagnosis was made after the pathological analysis of the resected intestinal tract. Although rare and not described in the literature, intestinal lymphangiomatosis could manifest itself with acute abdomen and could be a surgical urgency. This disease should be considered when intestinal perforation is observed.

•

Lymphangiomatosis is a multisystemic disorder.

•

The GI tract may be affected, but the incidence of lymphangioma of the intestinal wall is very low.

•

Lymphangiomatosis of the small bowel is a rare disease, so it is easy for a clinician to make a misdiagnosis.

•

Intestinal lymphangiomatosis could manifest itself with an acute abdomen and surgical urgency.

•

The pathologist should keep it in mind in the differential diagnosis, when he analyses a case of perforation.

Isolated myeloid sarcoma of the temporal bone: As the first clinical manifestation of acute myeloid leukemia in a patient of down's syndrome

•

MS are extremely rare tumors with an aggressive clinical course.

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Morphologically, they can mimic small round cell tumors. This problem is further complicated by the lack of clinical suspicion in patients without any hematological disorder.

•

Accurate diagnosis of isolated MS requires a multifactorial approach including histopathology, immunophenotyping, immunohistochemistry and cytogenic abnormalities.

•

A high level of suspicion is necessary, because early, accurate diagnosis is important to avoid delaying appropriate chemotherapy. A delay in the diagnosis may result in unwarranted fatality particularly so in pediatric patients.

•

Here, we report an unusual case of MS initially presenting as a tumor of the temporal bone and first manifestation of AML, in a pediatric patient suffering from Down’s syndrome. This case illustrates the challenges associated with offering a rapid diagnosis with an early initiation of treatment.

Introduction

Leukemia is the most common malignancy of childhood but myeloid sarcoma is a rare presentation of underlying leukemic disorder. Myeloid sarcoma (MS) is a rare tumor composed of proliferation of myeloid precursors at extramedullary sites.

Presentation of case

We report an unusual case of myeloid sarcoma involving the temporal bone in a young male child who presented with a large mass involving the left temporal region. This lesion was the initial presentation which led to further diagnosis of acute myeloid leukemia in our case. This case report brings awareness to the diverse extramedullary manifestations of isolated myeloid sarcoma, as well as the importance and difficulties that are associated with establishing a rapid diagnosis and initiating treatment.

Discussion

They can arise de novo or in association with hematological malignancies, most commonly acute myeloid leukemia (AML-M2). Clinically, it can masquerade as an abscess, cutaneous ulcer, or as a mass lesion. Morphologically, MS can mimic a variety of small round cell tumors including lymphomas, neuroblatoma and rhabdomyosarcoma. The occurrence of this tumor usually heralds AML or the onset of the blastic phase of chronic myeloid leukemia. Early recognition of this rare entity is important, because early aggressive chemotherapy and focal irradiation can cause regression of the tumor and thus improve patient longevity.

Conclusion

The possibility of MS should be considered when dealing with unusual lymphoma like neoplasms that cannot be categorized as any of the Non-Hodgkin lymphoma subtypes and small blue round cell tumors.

Dedifferentiated retroperitoneal large liposarcoma and laparoscopic treatment: Is it possible and safe? The first literature case report

INTRODUCTION

Soft tissue sarcomas are rare neoplasms often characterized by local invasiveness and distant metastasis with poor prognosis for affected patients. Among the most frequent sarcomas we find well-differentiated and dedifferentiated liposarcomas characterized by a better survival compared to the other histological types. When it is possible the only curative treatment for these neoplasms is surgical resection.

CASE REPORT

We report a case of a 62-year-old caucasian woman with CT abdominal scan that demonstrated a voluminous solid oval mass in the left perirenal space with dislocation of the kidney and in continuity with the anterior renal fascia. After a percutaneous CT-guided biopsy of the mass the histopathological diagnosis was a dedifferentiated retroperitoneal liposarcoma. We performed a laparoscopic surgical resection of the retroperitoneal mass in block with kidney and left adrenal gland.

DISCUSSION

When possible, surgical resection with adequate margins represents the only curative therapeutic option for this pathology. Only a few papers are available in literature which take into consideration the possibility of laparoscopic approach for retroperitoneal masses with better vision of surgical field, reduction of post-operative pain and better cosmesis.

CONCLUSION

A retroperitoneal mass represents a serious diagnostic challenge. The choice of the best surgical procedure can benefit to the patient prognosis. To our opinion laparoscopy can be a safe and successful treatment and it can represent a valid alternative to open surgery. However, we have no randomized controlled trials that compare laparoscopic versus open resection for retroperitoneal liposarcomas.

Necrotizing fasciitis of the neck and head complicated with chronic osteomyelitis: Case report presentation

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Necrotizing fasciitis of the head and neck in children is very rare.

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Proper early diagnosis and adequate antibiotic therapy played an important role.

•

Early aggressive surgical treatment is crucial for an adequate outcome.

•

The vacuum-assisted closure and hyperbaric oxygen therapy are very useful to accelerate wound healing.

•

A multidisciplinary management is fundamental to increase treatment success.

Introduction

Necrotizing fasciitis (NF) is a severe infectious condition associated with significant morbidity and mortality and characteristically has a higher incidence in adults; pediatric cases are very rare. In this case report we describe, the clinical presentation, management and outcome of a patient with necrotizing fasciitis of the neck and head complicated with chronic osteomyelitis.

Presentation of the case

An 18 month-old, latin, male, diagnosed with rickets and Crouzon syndrome, twenty-four hours post- craniofacial remodeling surgery presented tissue edema, indurated skin and violaceous and well delimited lesions in the neck and head. The patient developed septic shock, acute osteomyelitis and infection of the cranial grafts. Multiple surgical lavages, debridation of the necrotic tissue and resection of the affected bone, in combination with multiple antibiotics, laboratory test methods, VAC therapy and hyperbaric oxygen were required for successful treatment and full recovery of the patient.

Discussion

Although early antibiotic therapy and critical care are basic for the treatment of patients with NF, early aggressive surgical treatment is crucial for an adequate outcome. Adjuvant treatment for NF such as the Vacuum-assisted closure and the hyperbaric oxygen therapy are very useful to accelerate wound healing. Moreover, special laboratory test methods such as the checkerboard can be used to determine the adequate antimicrobial combination of drugs in the case of multi resistant organisms.

Conclusions

Early diagnosis, adequate antibiotic therapy and aggressive surgical debridement of the necrotic tissue combined with VAC and hyperbaric oxygen therapy played an important role in the successful treatment of NF.

Male DCIS diagnosed after use of over-the-counter hormonal supplement

INTRODUCTION

Male breast cancer is a rare disease. Although epidemiologic and genetic factors are associated with male breast cancer, hormonal factors may also play a role.

CASE PRESENTATION

We report the case of a 39-year-old BRCA negative male patient taking a sexual performance enhancement supplement who presented with worsening asymmetric gynecomastia and unilateral spontaneous bloody nipple discharge and was found to have ductal carcinoma in-situ.

DISCUSSION

The altered cellular environment related to the hormone contents of the supplement coincided with the rapid worsening of his gynecomastia and may have played a role in the development of the ductal carcinoma in-situ, or growth of an existing focus.

CONCLUSION

The use of hormonal male enhancement supplements can lead to higher levels of androgens in users. It is possible for this altered hormonal environment to cause the growth of tumor or promote the progression of an existing focus.

A case of an elderly patient with high-grade colorectal cancer in poor general condition who showed near complete response to chemotherapy and achieved long-term survival

•

Systemic therapy can achieve good treatment outcomes in advanced CRC.

•

Suitable chemotherapeutics can markedly improve the prognosis of unresectable CRC.

•

Unresectable CRC can now be treated with systemic chemotherapy instead of BSC.

Introduction

Chemotherapy is difficult to administer in patients with poor performance status (PS), advanced metastatic lesion, and unresectable colon cancer. We report herein our experience of a patient who showed complete response to chemotherapy and marked PS improvement. The patient presented with the following adverse factors poor PS, advanced progression of metastatic lesions, advanced unresectable colorectal cancer with severe stricture, and old age.

Presentation of case

The patient was an 80-year-old male diagnosed with occlusive cancer of the descending colon with multiple metastases in the liver, Stage Ⅳb (National Comprehensive Cancer Network guidelines version 2. 2018). A 5-fluorouracil, leucovorin, and oxaliplatin (mFOLFOX6) + panitumumab (Pmab) regimen was successfully administered and led to decreased tumor marker levels; oral intake also became possible. Additional examinations showed that the primary lesion and distant metastatic lesions had almost disappeared; the patient had achieved a near complete response (CR). Currently, 35 cycles of mFOLFOX6＋Pmab have been administered, and his near CR has been maintained for 32 months.

Discussion

Best supportive care (BSC) is the recommended option for elderly patients with advanced unresectable colon cancer. This is the first case in which an elderly patient with poor PS and advanced unresectable colorectal cancer was treated with combination chemotherapy of mFOLFOX6 + Pmab.

Conclusion

Although the use of chemotherapy for elderly with advanced unresectable colorectal cancer or those with poor PS is limited, this case shows that systemic chemotherapy is now an option for such cases previously managed with BSC.

Rare case of gallbladder mucocele causing gastric outlet obstruction treated with cholecystectomy

INTRODUCTION

Gallstone(s) impacted at the distal small bowel causing intestinal obstruction as a result of cholecystoenteric fistula is a well-known, albeit uncommon surgical condition. The rare Bouveret's Syndrome, which refers to the proximal impaction of gallstone(s) in the duodenum or pylorus resulting in the gastric outlet obstruction (GOO), has also been described in the literature. However, gallbladder mucocele with extrinsic compression of the duodenum and/or pylorus causing GOO is a separate entity that is extremely rare.

PRESENTATION OF CASE

A patient who presented with loss of appetite and weight, with intermittent vomiting over a course of eight months was found to have GOO secondary to extrinsic duodenal compression from a large gallbladder mucocele. Surgical intervention in the form of cholecystectomy was performed, and the patient's symptoms resolved post-operatively.

DISCUSSION

We describe an extremely rare case of GOO, which can be easily corrected with cholecystectomy. Removal of the gallbladder removes the root cause of the issue, and should be first line therapy unless the patient is unfit for surgery.

CONCLUSION

This extremely rare cause of GOO should be recognized, and treated promptly with surgery if possible.

An ileo-ileal intussusception secondary to polypoid lipoma in a child, a case report and review of the literature

•

Small intestinal lipoma is a rare reason for ileoileal intussusception but should be included in the differential diagnosis for lead points causing intussusception in children.

•

Dexamethasone as an adjuvant treatment may improve the outcome in cases of intussusceptions but this point needs future researches.

•

Intermittent attacks of small intestinal intussusception may lead to dilation of the distal segment (Intussuscipiens). This mechanism may delay vascular compromise.

•

High level of clinical suspicion needs to diagnose intussusception with unusual presentation.

Background

Intramuscular intestinal lipoma is one of the rare benign tumours of the small intestine in children and acts as a lead point of intussusception.

Presentation of case

We describe a case in which a 4-year-old boy presented with recurrent attacks of colicky abdominal pain and non-bilious vomiting. Abdominal examination was irrelevant. Per rectum (PR) examination indicated an empty rectum without red currant jelly stool and non-palpable mass. Abdominal ultrasonography revealed a target sign of intussusception. After a period of conservative treatment, the child passed normal coloured and well-formed stool. Exploratory laparotomy referred to a long segment ileo-ileal intussusception with a polypoid lipoma as a lead point. Microscopic examination showed a benign non-capsulated intramuscular ileal lipoma.

Discussion

Small bowel lipoma produces symptoms of intermittent bowel obstruction. Herein, the child presented with non- bilious vomiting, we attribute this to reflex sympathetic stimulation of the pylorus leading to pylorospasm.

Conclusion

Small intestinal lipoma is a rare finding in children that may cause intussusception which does not resolve spontaneously.

Pancreatic tail splenunculus: Case report and review of the literature

•

Solitary pancreatic tail lesion should undergo nuclear scintigraphy to assess whether the lesion is compatible with a splenunculus.

Introduction

Mass lesions in the pancreatic tail are increasingly identified upon radiological imaging. However the diagnosis of these lesions can be challenging and impact significantly upon patient management.

Presentation of case

We report a case of an intrapancreatic accessory spleen initially diagnosed as a neuroendocrine tumour of the pancreas tail following nuclear scintigraphy.

Discussion

The investigation of solitary pancreatic tail lesions and the potential management paradigms are discussed.

Conclusion

Solitary lesions within the pancreatic tail should have splenunculus included in the differential diagnosis.

Retroperitoneal lipoma; a benign condition with frightening presentation

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Lipoma is the most frequent soft tissue tumor in adults.

•

Its occurrence in the retroperitoneal region is extremely rare.

•

It presents with various clinical scenarios.

•

We present a case of retroperitoneal lipoma with a brief literature review.

Introduction

lipoma is the most frequent soft tissue tumor in adults. Its occurrence in the retroperitoneal region is extremely rare. The aim of this study is to report a case of retroperitoneal lipoma with a literature review.

Presentation of case

A 34-year-old female presented with abdominal distension and severe back pain for one year duration. She also reported weight loss and constipation. The examination revealed asymmetrical abdominal distension and everted umbilicus. There was a big irregular mass occupying the whole abdomen reaching into the xiphisternum, firm in consistency, smooth surface, and well defined borders. Abdominal ultrasound demonstrated a large retroperitoneal heterogeneous mass. Computed tomography (CT) scan showed a large well defined hyperechoic mass with fibrous septa extending from the left ovary up to the diaphragm. Exploratory laparotomy revealed a giant clearly demarcated fatty tumor adherent to the retroperitoneal fatty tissues. The histopathological examination of the specimen confirmed the diagnosis of the retroperitoneal lipoma.

Discussion

Retroperitoneal lipomas have been reported in various age groups; namely children, middle and old age patients. Based on the characteristic radiological features of the tumor, enormous diagnostic work-up is not justified.

Conclusion

Retroperitoneal lipoma is a very rare variant of lipoma, presents with various signs and symptoms that may be misleading. Radiologic imaging especially CT scan is the diagnostic tool of choice. Surgical resection is the main modality of management.

Case report: Intraoperative thrombosis cardiac arrest in extended right hepatectomy involving use of local haemostatic agent in intraoperative cell salvage (ICS) and administration of recombinant activated factor VII (rFVIIa)

•

Intractable intraoperative haemorrhage is a result of both surgical and coagulopathic (nonsurgical) components.

•

There is increasing off-label use of rFVIIa for ceasing refractory bleeding aside from its application in patient with haemophilia.

•

rFVIIa use may be associated with increased thromboembolic events according to some literature.

•

The use of topical haemostatic agent in conjunction with ICS may potentially lead to systemic clot formation upon re-infusion of the chemical.

•

Avoid use of cell saver suction while the surgical field is contaminated with topical clotting factors before irrigation with 0.9% sodium chloride.

Introduction

In modern surgical era, local haemostatic agents and blood components such as recombinant activated factor VII (rFVIIa) have expanded surgeons’ armamentarium in controlling “surgical” and “nonsurgical bleeding”. We report a case of intraoperative thrombosis and cardiac arrest involving use of local haemostatic agent in intraoperative cell salvage and rFVIIa administration in extended right hepatectomy.

Presentation of case

A 46-year-old lady underwent extended right hepatectomy using cardiopulmonary bypass (CPB) and autotransfusion with ICS for metastatic gastrointestinal stromal tumour. She became extremely coagulopathic following weaning of CPB despite an array of fluid and blood products replacements. Decision to administer rFVIIa as a measure to arrest bleeding was unsuccessful. Extensive systemic thrombosis occurred which resulted in cardiac arrest and mortality.

Discussion

The thromboembolic event was unclear but likely multifactorial. Two important hypotheses were the administration of rFVIIa and use of local haemostatic agent in ICS.

Conclusion

Reported incidence of thromboembolism with use of rFVIIa in refractory bleeding is variable. More randomised controlled trials are needed to ascertain the efficacy and safety profile of the haemostatic agent. At present, off-label use of rFVIIa should be guided by the risk:benefit profile on a case-to-case basis. The authors also feel strongly against the use of local haemostatic gel in conjunction with ICS due to potential systemic circulation of the thrombin.

A rare case of rectal prolapse after Deloyers procedure in a patient with Hirschsprung's disease: A case report

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Deloyers procedure reported as a colonic salvage procedure after extensive left colon resection.

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Deloyers procedure has been used in long segment Hirschsprung’s disease.

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First case of rectal prolapse after Deloyers procedure for Hirschsprung’s disease.

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Potential complication after Deloyers procedure for colorectal cancer in adult patients.

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Further study required to ascertain long term sequelae in this group of patients.

Introduction

Deloyers procedure has been reported in the literature as a viable alternative to the more commonly performed Swenson, Soave and Duhamel methods. As of yet, the long term sequelae of this procedure for patients with Hirschsprung’s disease have not been studied in depth.

Presentation of case

We report the first case in the literatures of a 27-year-old man presenting with rectal prolapse due to colorectal anastomotic intussusception after Deloyers procedure for Hirschsprung’s disease.

Discussion

Few studies with low case volume have been performed investigating the long term sequelae of Deloyers procedure as a mainstay in patients undergoing operative treatment for Hirschsprung’s disease. This procedure allows for preservation of a longer segment of colon, in turn potentially improving absorption and continence compared to other methods. Studies are limited and as of yet the viability of Deloyers as a mainstay of treatment for Hirschsprung’s disease is inconclusive.

Conclusion

We report the first adult case of prolapsed colorectal anastomotic intussusception after Deloyers procedure for Hirschsprung’s disease. Further study is required to delineate long-term complications and viability of this method in these patients.

Gallbladder volvulus: A case report and review of the literature

INTRODUCTION

Gallbladder volvulus (GV) is a rare disease with less than 400 cases reported in the English literature. The pre-operative diagnosis of GV is difficult as none of the imaging modalities are accurate. Once diagnosed, the mainstay of treatment is emergency surgical derotation and cholecystectomy.

PRESENTATION OF CASE

A 83-old lady presented with right upper quadrant pain and fever for 3 days. Abdominal imaging revealed the presence of a distended, floating gallbladder located outside its normal fossa with thickened non-enhancing wall and a twisted pedicle suggestive GV. The patient underwent emergency laparotomy because the laparoscopic approach was refused by the anesthetist due to the history of pulmonary emphysema. Intraoperatively, the gallbladder was found be gangrenous and rotated in anti-clockwise direction around the cystic pedicle. The gallbladder was de-rotated followed by cholecystectomy.

DISCUSSION

GV is an uncommon cause for abdominal pain and occurs due to rotation of gall bladder on its mesentery along the axis of the cystic duct and the cystic artery. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging. This case is one of the rare cases diagnosed with pre-operative imaging. It is often misdiagnosed as acute cholecystitis before surgery. However, critical constellation of presenting signs and symptoms along with radiological findings may guide the surgeon to accurate and timely diagnosis of GV before surgical intervention.

CONCLUSION

Although rare, it is important to consider GV as a differential diagnosis in an elderly patient with acute cholecystitis.