Pretracheal tuberculous abcess mimicking a thyroid swelling-A case report

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Tuberculous cervical lymphadenitis is the most common extra pulmonary manifestation (Das et al., 2016 [1], Sharma and Mohan, 2004), posterior group of cervical nodes (Baskota et al., 2004 [2]) being the most common.

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Pre tracheal lymph node involvement in the neck is very rare.

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A high degree of suspicion for tuberculosis is needed while diagnosing a lower midline swelling in the anterior neck, especially in TB- endemic areas.

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Tuberculous abscess can be easily treated with incision and drainage along with anti tuberculous drugs, thus avoiding major surgery.

Introduction

Pretracheal tubercular abscess is a rare presentation of extra pulmonary tuberculosis even in TB- endemic areas (WHO, 2014 [3]). It usually presents in posterior triangle group of lymph nodes (Baskota et al., 2004 [2]).

Presentation of case

We report a case of a lower midline swelling in anterior part of the neck of 6 months duration, with dysphagia of 1 month duration. Radiological diagnosis was established as tuberculous abscess and was drained. Patient was started on anti tuberculous treatment.

Discussion

Swellings anatomically located in the area of anterior group of lymph nodes should be dealt with high degree of suspicion for tubercular etiology especially in TB-endemic areas (WHO, 2014 [3]). Anterior group of lymph node involvement is very rare. To differentiate, proper radiological assessment is needed to differentiate between thyroid nodule and lymph node pathology.

Conclusion

Pre operative assessment is often under estimated. Adequate evaluation will avoid major surgery for a benign pathology like tuberculosis.

Subcutaneous metastases from early stage esophageal adenocarcinoma case report

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Subcutaneous metastases from esophageal adenocarcinoma are rare.

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Associated risk factors have not been clearly elucidated and prognosis is poor.

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We present three cases of subcutaneous metastases from esophageal adenocarcinoma.

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These metastases can occur even after resection of early stage disease.

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They can occur at various intervals of time and various locations.

The identification of subcutaneous metastatic lesions from primary visceral malignancies has increased over time, probably due to an increase in the awareness of their presentation and an increase in cancer survival times. Although the rate of subcutaneous metastases from breast,lung and colon cancer is more significant, the incidence of subcutaneous metastases from esophageal carcinomas is very low. These metastatic lesions usually present metachronously and may signify advanced disease and poor prognosis. We report three cases with early stage esophageal adenocarcinoma treated with surgery with curative intent presenting with subcutaneous metastases two months, two years and three years after their esophagectomy.

A case of obturator hernia leading to right thigh abscess in China

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This article introduces a case of obturator hernia leading to right thigh abscess on 68-year-old woman of china.

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Patients have been successfully operated, but she died because of severe infection.

The purpose of this case is to investigate a case of obturator hernia leading to right thigh abscess on 68-year-old woman of China. A 68-year-old Chinese woman was referred to China-Japan Friendship Hospital of Jilin University with abdominal pain, bloating, exhaust, stop defecation in 2011. She had chronic bronchitis, emphysema with a history of 20 years. This patient did not have any bad habits, such as smoking, alcohol consumption, etc. In this surgery, CT was used to diagnose the basic condition of the patient. Surgery was used for treatment of patients with diseases. In addition, this operation was performed by the china-Japan Friendship Hospital of Jilin University. The results of this case showed that the cervix of rectal right anterior wall can hit a funicular neoplasm, toughening, smooth, with tenderness, considering for the external pressure bowel loops. The inside of the right thigh showed obvious swelling, skin slightly bruising, and tenderness. Chest radiographs showed that patients had emphysema, multiple planes of fluid and air in the abdomen. Patients had been successfully operated, but she died because of severe infection.

Surgery for chronic mesh infection occurred 10 years after sacrectomy - Mesh resection and mesentric leaf repair: A case report

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An 83-years old woman underwent sacrectomy combined with mesh reconstruction for chordoma suffered chronic mesh infection and bowel penetration 10 years after surgery.

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This is the first report of mesh infection after sacrectomy and its surgical strategy.

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We performed subtotal mesh resection and Mesenteric leaf repair for pelvic reconstruction.

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Mesentric leaf repair might be a useful procedure for pelvic reconstruction when the use of a mesh has to be avoided.

Introduction

Sacrectomy to treat malignant tumors is often results in large pelvic defects to require reconstruction, using a prosthetic mesh. Importance is to avoid its direct contact of mesh with intestine to prevent adhesion between them.

Presentation of case

An 83-year old woman who was diagnosed with a mesh infection caused by a small bowel penetration 10 years after sacrectomy combined with mesh reconstruction for chordoma. In the first operation, because of incomplete re-peritonealization due to a large defect in the retroperitoneum, a mesh unavoidably was compelled to contact with the small intestine. We subtotally removed the mesh and performed mesentric leaf repair of the pelvic defect.

The postoperative course was complicated by infection of the pelvis. She was discharged 59 days after surgery with a little purulent discharge from perineal wound, which was persisted for two years after operation.

Discussion/Conclusion

We used the mesenteric leaf to repair the pelvic defect at the operation. This procedure might be the best alternative, when the use of mesh has to be avoided like present case. To our knowledge, this is the first report of mesh infection after sacrectomy, so we report herein.

Thyroid carcinoma with extensive tumor thrombus in the superior vena cava: A case report

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This is an uncommon surgical case report of thyroid carcinoma with extensive tumor thrombus in the superior vena cava.

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Management criteria for thyroid carcinoma with venous tumor thrombus is considered for safe and effective operation.

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Treatment and natural history for pulmonary infarction that occurred for drop off of the tumor thrombus are recognizable.

Introduction

Venous tumor thrombus of thyroid cancer that extend to the great vein is rare, and management criteria for venous thrombus have not been established yet. We report a surgical case of thyroid carcinoma with extensive tumor thrombus in the superior vena cava (SVC) and consider the appropriate treatment strategy for venous thrombus.

Presentation of case

A 75-year-old woman consulted our hospital because of thyroid carcinoma with an extensive tumor thrombus. Computed tomography (CT) revealed a solitary thyroid mass with extensive continuous tumor thrombus in the left internal jugular vein, innominate vein, and SVC. We planned complete tumor resection. During operation, the tumor thrombus in the SVC disappeared, suggesting that pulmonary embolism occurred. Therefore, she underwent total thyroidectomy with extensive phlebectomy (the innominate and internal jugular veins). Although she had some morbidities during her postoperative course, she was followed up for 6 months without progression of thyroid cancer.

Discussion and conclusion

Intravascular tumor extension of thyroid carcinoma is rare, but is a life-threatening complication. For patients with thyroid tumor with venous tumor thrombus, segmental resection and thrombectomy should be considered if radical operation is possible. Therefore, preoperative correct imaging evaluation and operative planning are necessary to perform safe and effective operations. We suggest a management criteria for patients with thyroid carcinoma with venous tumor thrombus.

Report of a case with gallbladder carcinoma: P53 expression of the peritumor epithelium might predict biliary tract recurrence

INTRODUCTION

The over-expression of P53 protein in gallbladder carcinoma is a biomarker correlating with a poor survival. However, the significance of P53 expression in peritumor tissues is unknown. We experienced a case of gallbladder carcinoma where the operative specimen showed over-expression of P53 on the peritumor epithelium, and early recurrence developed at the biliary tract.

PRESENTATION OF CASE

A 74-year-old female patient was referred to our hospital due to wall thickening of the gallbladder on ultrasonography. Radiographic examinations revealed wall thickening at the fundus of gallbladder and no abnormalities of the biliary tract or surrounding lymph nodes. We performed open cholecystectomy and lymph node dissection without extrahepatic bile duct resection, as a frozen section of the surgical stump of the cystic duct was cancer-free. However, a pathological examination revealed over-expression of P53 protein in the epithelium of the peritumor to the cystic duct, which were diagnosed as normal on hematoxylin eosin staining. The patient developed bile duct metastases, two and half years after the operation. She underwent endoscopic stenting for the obstruction of bile duct with no additional therapy, and died 6 months later.

DISCUSSION AND CONCLUSION

The immunohistochemical staining of the GB wall or surgical stump for a surgical specimen of GBC may be crucial to predict the bile duct recurrence.

Severe trachea compression caused by Riedel's thyroiditis: A case report and review of the literature

Background

Riedel's thyroiditis (RT) is a rare form of chronic thyroiditis, associated with fibroinflammatory process involving the thyroid and surrounding cervical tissues, leading to compressive symptoms.

Case presentation

We present a case of RT in a 73-year-old female with dyspnoea caused by severe trachea compression. She had reported dyspnoea during physical stress, and had noticed a large mass on the front of the neck. Despite the combination of various imaging modalities, the thyroid mass was not differentiated from thyroid malignancy and other thyroid disorder. Total thyroidectomy and tracheotomy were performed. During surgery, the thyroid had severe adhesion to surrounding tissue and the pathology revealed RT.

Conclusions

Clinicians should be aware of RT. It is important to differentiate this condition from other thyroid disorders, especially malignant lesions. Thyroidectomy is indicated for patients with compressive symptoms, suspicious malignancy and failure of conservative management.

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Riedel's thyroiditis (RT) is a rare form of chronic thyroiditis, associated with fibroinflammatory process involving the thyroid and surrounding cervical tissues, leading to compressive symptoms.

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It is important to differentiate this condition from other thyroid disorders, especially malignant lesions.

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Thyroidectomy is indicated for patients with compressive symptoms, suspicious malignancy and failure of conservative management.

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Clinicians should be aware of RT.

Preferred reporting of case series in surgery; the PROCESS guidelines

INTRODUCTION

Case series have been a long held tradition within the surgical literature and are still frequently published. Reporting guidelines can improve transparency and reporting quality. No guideline exists for reporting case series, and our recent systematic review highlights the fact that key data are being missed from such reports. Our objective was to develop reporting guidelines for surgical case series.

METHODS

A Delphi consensus exercise was conducted to determine items to include in the reporting guideline. Items included those identified from a previous systematic review on case series and those included in the SCARE Guidelines for case reports. The Delphi questionnaire was administered via Google Forms and conducted using standard Delphi methodology. Surgeons and others with expertise in the reporting of case series were invited to participate. In round one, participants voted to define case series and also what elements should be included in them. In round two, participants voted on what items to include in the PROCESS guideline using a nine-point Likert scale to assess agreement as proposed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group.

RESULTS

In round one, there was a 49% (29/59) response rate. Following adjustment of the guideline with incorporation of recommended changes, round two commenced and there was an 81% (48/59) response rate. All but one of the items were approved by the participants and Likert scores 7-9 were awarded by >70% of respondents. The final guideline consists of an eight item checklist.

CONCLUSION

We present the PROCESS Guideline, consisting of an eight item checklist that will improve the reporting quality of surgical case series. We encourage authors, reviewers, editors, journals, publishers and the wider surgical and scholarly community to adopt these.

Our experience with surgery in situs inversus: Open peptic perforation repair and laparoscopic cholecystectomy in 1 patient and 3 patients respectively

INTRODUCTION

Situs inversus is a rare autosomal recessive condition associated with complete transposition of abdominal+/- thoracic organs. Surgical diagnosis and surgical procedures in patients with situs inversus is tricky because of the mirror image anatomy of intra-abdominal organs.

MATERIALS AND METHODS

A retrospective analysis of 2152 and 1497 patients who underwent laparoscopic cholecystectomy and open peptic perforation repair respectively from June 2014-June 2016 was done. 1 patient and 3 patients with situs inversus underwent open peptic perforation repair and laparoscopic cholecystectomy respectively. A 10mm left para-median port 5cm caudally from xiphoid was used for grasping the infundibulum. Two 5mm ports placed 10cm caudally from costal margin in the mid-clavicular and anterior axillary line were used for dissecting and retracting fundus respectively. A 10mm supra-umbilical camera port was used.

RESULTS

A 40year male with situs inversus totalis underwent open peptic perforation repair. Laparoscopic cholecystectomy was done in 3 female patients with situs inversus aged 33-46year (mean 41year). Mean operative time for laparoscopic cholecystectomy was 59min (39-93). There were no intraoperative or post-operative complications. Histopathology revealed chronic inflammation in peptic perforation and cholecystitis.

CONCLUSION

Perforation peritonitis in situs inversus can cause diagnostic confusion with free gas under the left hemi diaphragm. Laparoscopic cholecystectomy in situs inversus is ergonomically inconvenient and technically difficult for right handed surgeons. We describe an ergonomically convenient port placement for right handed surgeons in situs inversus.

Papillary carcinoma of hyoid

INTRODUCTION

Thyroglosal duct cyst is a common anomaly with an incidence of 7% in adults, the rate of carcinoma in TGDC is 0.7-1.6%, and are extremely rare those originated in the hyoid bone.

PRESENTATION OF CASE

A 60 years old male patient, had a hard mass in the anterior neck. CT revealed a hyoid tumor. Hyoid bone resection was performed, the pathological report show a conventional papillary carcinoma in bone tissue. We rule out primary tumor in thyroid gland. Five years later, he developed a neck node recurrence. Total thyroidectomy and a selective left neck dissection (II-IV levels) was performed. He received radioiodine adjuvant treatment.

DISCUSSION

Hyoid cancer originates of a persistent thyroglosal duct remnants inside hyoid bone.

CONCLUSION

We propose to add a new subdivision to pathology derived from thyroglosal duct remnants). The diagnostic approach with ultrasound and CT are necessary. A primary in te hyoid gland mustang be discorded, and then the entire hyoid bone must be removed. Treatment of the thyroid gland and neck should be considered when there are significant risk factors of recurrence, similarly to thyroid cancer based on the risk assessment.

Capsular nevus versus metastatic malignant melanoma - a diagnostic dilemma

INTRODUCTION

A positive finding of metastatic melanoma in a sentinel lymph node is an ominous sign and a strong predictor of overall survival. In contrast, current data trends have shown that patients with benign nevus cells in the sentinel nodes do not require additional therapy since their prognosis has been shown to be similar to that of patients with negative lymph nodes. Distinguishing between benign capsular nevi and metastatic melanoma often proves to be diagnostically problematic.

CASE PRESENTATION

In this case report we present two cases of melanoma in which sentinel lymph node biopsies proved to be difficult in distinguishing metastatic melanocytes from capsular nevus cells. In both cases, further workup was necessary for accurate diagnoses.

DISCUSSION

A lack of standardized distinctions of benign nevus cell from melanoma pose a diagnostic pitfall. Assigning a diagnosis of malignant melanoma might seem like the safer approach to avoid a false negative, but the resultant treatment, including the possibility of additional surgical complications, may cause anxiety, discomfort, and financial instability for the patient. Current methods of distinguishing the two based solely on histology may be insufficient due to similar pathologic patterns.

CONCLUSION

To avoid misdiagnosing a patient and performing unnecessary therapy, it would be beneficial to get a second opinion by additional histopathologists at a high volume center. Additionally, immunohistochemical staining should be carefully employed due to some overlap in commonly used markers. Using tissue morphology in conjunction with immunohistochemical staining may be the best way to make the most accurate diagnosis.

Fondaparinux for intra and perioperative anticoagulation in patients with heparin-induced thrombocytopenia candidates for peripheral vascular surgery: Report of 4 cases

INTRODUCTION

Intra and perioperative anticoagulation in patients with heparin induced thrombocytopenia (HIT), candidates for peripheral vascular surgery remains a challenge, as the best alternative to heparin has not yet been established. We evaluated the off-label use of fondaparinux in four patients with HIT, undergoing peripheral vascular surgery procedures.

PRESENTATION OF CASES

Four patients of whom 3 men of a mean age of 66 years, with proven heparin induced thrombocytopenia (HIT) underwent two axillo-femoral bypasses, one femoro-popliteal bypass and one resection of a splenic artery aneurysm under fondaparinux. No intra or perioperative bleeding or thrombosis of new onset was observed.

DISCUSSION

In the absence of a valid alternative to heparin for intra and perioperative anticoagulation in HIT, several other anticoagulants can be used in an off-label setting. However, no general consensus exist on which should be the one of choice. In this small series fondaparinux appeared to be both safe and effective.

CONCLUSIONS

These preliminary results seem to justify the off-label use of fondaparinux for intra and perioperative anticoagulation in patients with HIT, candidates for peripheral vascular surgery interventions.

Ewing sarcoma/primitive neuroectodermal tumor of the kidney: A report of three cases

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Ewing sarcoma/primitive neuroectodermal tumor of the kidney (ES/PNET) is a member of Ewing’s sarcoma family, occurring in young adults.

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The clinical course and prognosis of ES/PNET are different from renal cell carcinoma (RCC).

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For definite diagnosis, in addition to cytogenetic analysis; other techniques may be needed; such as fluorescent in situ hybridization (FISH), reverse transcriptase-polymerase chain reaction (RT-PCR) of the t (11; 22) translocation [1].

Introduction

Ewing sarcoma/Primitive neuroectodermal tumor of the kidney (ES/PNET) is a member of Ewing’s sarcoma family, occurring in young adults and has aggressive clinical behavior and poor prognosis. However, its discrimination from the renal cell carcinoma (RCC) is very difficult preoperatively. We present three cases of this rare disease that were managed in two academic centers.

Presentation of cases

Herein we report three cases of ES/PNET of the kidney, 2 young men complaining of right flank pain and gross hematuria and one young woman complaining of left subcostal pain. In two cases computerized tomography (CT) scan revealed huge renal masses which were excised by radical nephrectomy. Microscopic examination of the nephrectomy specimen showed primitive neuroectodermal tumor features which confirmed by immunohistochemistry (IHC).

Two of 3 patients were treated with adjuvant chemotherapy and the third patient with neoadjuvant chemotherapy. They were symptom-free until now.

Discussion

The clinical course and prognosis of ES/PNET are different from renal cell carcinoma (RCC) and definite pathologic diagnosis is necessary for optimum treatment. For definite diagnosis, in addition to cytogenetic analysis; other techniques may be needed; such as fluorescent in situ hybridization (FISH), reverse transcriptase-polymerase chain reaction (RT-PCR) of the t (11; 22) translocation or the EWS-FLI and related gene fusions [1].

Conclusion

Up to our knowledge and search in English literature, this is the first case series that was reported from a major referral center from our country, Iran.

Atraumatic diplaced bilateral femoral neck fracture in a patient with hypophosphatemic rickets in postpartum period: A missed diagnosis

INTRODUCTION

Simultaneous bilateral femoral neck fracture is an uncommon condition. There are very few cases reported in the literature and most of these cases have underlying bone pathologies such as renal osteodystrophy and osteomalacia. In some cases bilateral femoral neck fractures occur due to generalized seizures or high-energy trauma.

PRESENTATION OF CASE

In this case report "atraumatic bilateral femoral neck fracture in a 26year old woman in postpartum period with hypophosphatemic rickets disease" is presented.

DISCUSSION

Femoral neck fractures are more frequently seen in elderly because of the reduction of bone quality and developing osteoporosis. In the literature generalized epilepsy, osteomalacia, hypovitaminosis D and chronic renal failure are shown as facilitating causes of bilateral femoral neck fractures. In patients without any additional pathology electric shock, electroconvulsive therapy, and high-energy trauma can lead to femoral neck fractures. In our patient there was also an underlying pathology, she has been followed due to autosomal recessive hypophosphatemic rickets disease since she was one year old. In the treatment of bilateral femoral neck fractures open/closed reduction internal fixation or hip arthroplasty are applied.

CONCLUSION

For patients with bone metabolic diseases and/or the patients in pregnancy and postpartum period, preventive measures should be increased to reduce the risk of pathologic fracture. Admitting to the hospital physicians must be more careful about detecting fractures in these patients.

Inferior vena cava aneurysm presenting as deep vein thrombosis - A case report

INTRODUCTION

Throughout history, venous aneurysms have seldom been heard of or even reported, especially since they have no specific symptoms unless complicated by their various manifestations, one being deep vein thrombosis.

PRESENTATION OF CASE

Here we report a case of a 33-year-old male patient who presented with idiopathic Deep vein thrombosis, and upon further investigation was found to have an IVC Aneurysm.

DISCUSSION

Thrombosis due to flow dynamics resulting in venous stasis is more prominent in Type II- IV IVC aneurysm, making their presentation as deep vein thrombosis common. Management of IVC aneurysm is highly controversial, with options of both medical and surgical interventions, each with its own merits and demerits.

CONCLUSION

Therefore, it is important to include IVC aneurysm as a differential when patients present with unprovoked DVT.

Scrotal dartos-fascio-myo-cutaneous flaps for penis elongation after catastrophic iatrogenic skin shaft sub-amputation: A case of recovery using an extremely adaptable flap

INTRODUCTION

Genitalia are linked to self-esteem and male sexual identity, especially among young men, who sometimes require a surgical procedure to acquire more confidence. Among the surgical procedures requested for aesthetical purposes, circumcision is one of the most popular. Although it can be considered to be a simple surgical practice, it may cause severe complications such as penile skin necrosis.

PRESENTATION OF CASE

We report a case of a catastrophic situation after a circumcision performed on a 27-year-old HIV positive man resulted in a drastic reduction in the length of the penile shaft due to extensive skin loss; this was subsequently restored using dartos-fascio-myo-cutaneous flaps. Primary healing occurred in 10days. No infection, dehiscence or flap ischemia were reported. Donor site morbidity was minimal. An adequate aesthetical appearance and satisfactory functional results were obtained.

DISCUSSION AND CONCLUSION

Various techniques are available for penile skin covering, such as skin grafts or cutaneous flaps. The skin of the scrotum seems to be the most suitable tissue to be used to reconstruct the skin covering of the shaft as it is the most similar. Dartos-fascio-myo-cutaneous flap is a single stage procedure that is easy and safe to perform. It can provide satisfactory cosmetic and functional results, offering a large amount of tissue, with minimal donor site morbidity.

Surgical sponge forgotten for nine years in the abdomen: A case report

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Gossypiboma consist in retained surgical sponges are more usual than the reported.

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A young patient nine years after cesarean section with abdominal pain and fever.

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An abscess was diagnosed in the lower abdomen by CT.

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During laparotomy, a sponge was extracted from a large abscess.

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She had a normal post-operative course.

Introduction

Retained surgical sponge or other items in patients’ bodies happens more frequently than is reported. Healthcare personnel can forget to remove textile material or instruments during complicated, extended, or emergency surgery. In addition, changes in the operating team can influence the occurrence of such errors.

Presentation of case

We present a case with a symptomatic gossypiboma nine years after a previous cesarean section. A 34-year-old woman was admitted to the emergency room having experienced abdominal pain and fever for the previous month. An abdominal computed tomography revealed an abscess in the lower abdomen.

A laparotomy was performed, and a resection and block were carried out. A surgical sponge was extracted from an omental abscess.

Discussion

Surgical sponges are the most common foreign materials retained (70%) in the abdominal cavity because of their frequent usage and small size. Moreover, a blood-soaked sponge in a hemorrhagic abdomen can be difficult to distinguish from blood.

Conclusion

Whenever the accounting for material depends on humans, mistakes will continue to be committed.

A falsely correct sponge count was reported in 71.42% of cases [14]; therefore, a new count system must be developed for post-surgical situations.

Deep venous thrombosis as the single sign of unexpected metastatic urinary tract cancer in a patient with a history of cutaneous melanoma: A case report

INTRODUCTION

Cancer is a recognized risk factor of venous thromboembolism (VTE) as it induces a prothrombotic state through various mechanisms of activation of coagulation. Recognizing occult cancer as a risk factor is equally important. In patients with no known thromboembolic risk factors, utilizing PET/CT as a screening tool may be considered in order to reveal occult malignancy associated with otherwise unexplainable VTE.

METHODS

This case report has been reported in line with the SCARE criteria.

PRESENTATION OF CASE

We describe a case of deep venous thrombosis of the lower leg as the single sign of metastatic urinary tract cancer. The patient had a history of cutaneous melanoma but no thromboembolic risk factors. Following treatment for deep venous thrombosis, the patient was referred directly to the plastic surgery department for further examination including PET/CT due to suspicion of metastatic melanoma.

DISCUSSION

Screening for occult cancer in patients with unprovoked VTE has so far not been shown to benefit survival. As new treatments emerge, significant improvement in prognosis might be expected with early diagnosis of occult cancer and initiation of treatment. Thus an open mind should be kept towards utilizing advanced diagnostic tools such as PET/CT to screen for occult cancer in patients presenting with unprovoked VTE.

CONCLUSION

This case highlights the importance of considering all possible causes and utilizing targeted diagnostic tools when assessing a patient with seemingly unprovoked deep venous thrombosis. A whole-body PET/CT scan ultimately proved significant in revealing occult metastatic cancer of a completely different origin than expected.

Isolated hydatid cyst of spleen: A rare case with rare presentation

Hydatid cyst is a common health problem of world in sheep grazing area. Liver is the most commonly involved organ. Splenic hydatid cyst is uncommon and its isolated involvement is very rare. We are presenting a case of isolated hydatid cyst of spleen in a sixty one year old female patient with complaints of pain in the left hypochondrium, dyspepsia and features of gastritis for the last 1 year. The diagnosis was confirmed by Contrast enhanced CT scan (CECT). Laparoscopic splenectomy was performed. The aim of this case report is to emphasize that the most important factor in diagnosing splenic hydatid cyst is the awareness of its possibility and the intraoperative precautions which will decrease morbidity and mortality in the postoperative period.

A multidisciplinary approach to giant soft tissue sarcoma of the chest wall: A case report

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Chest wall sarcomas most commonly present as painless slow growing masses.

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Resection is often precarious due to involvement of important structures.

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The multidisciplinary approach is crucial for the optimal management of this tumor.

Introduction

Soft tissue sarcomas of the chest wall are exceptionally rare entities that present as painless slow growing masses. Resection is often precarious due to involvement of vital structures, and patients are left with large chest wall defects postoperatively requiring extensive reconstruction.

Presentation of case

We present a case report of a 29 year-old man who presented with a giant soft tissue sarcoma of the chest that had been growing slowly for one year prior to presentation. The patient had a biopsy that was positive for sarcoma, and PET CT demonstrated a large lobulated mass in the left chest wall with an SUV of 6.7. He received 50 Gy of radiation therapy; however, the mass continued to grow in size. He subsequently underwent an en-bloc resection of the mass with latissimus and serratus muscle primary reconstruction. Final pathology showed a 27 cm high-grade fibrosarcoma with prominent myxoid component. To our knowledge, this is the largest soft tissue sarcoma of the chest wall reported in the literature. Postoperatively, the patient received 6 cycles of adjuvant chemotherapy.

Discussion

Surgery is the mainstay of treatment, and chemotherapy and radiation are used in specific circumstances. Risk of recurrence is dependent on many factors, including histologic subtype, grade, and size of tumor. Long term surveillance with physical exam and imaging is recommended.

Conclusion

We feel that the multidisciplinary approach is crucial for optimal management of large soft tissue sarcomas. We recommend this approach to all patients with chest wall sarcomas.

Extreme oncoplastic breast surgery: A case report

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Many oncoplastic approaches have been proposed for breast cancer surgery but few have been described for multicentric cancers.

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“Extreme oncoplastic surgery” allows successful breast conservation in selected patients with multicentric tumors.

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We present an application of oncoplastic breast surgery in a case of multicentric breast cancer with optimal outcomes.

Introduction

So called “extreme oncoplastic surgery” is emerging as a new promising concept in breast cancer surgery allowing successful breast conservation in selected patients with multicentric tumors.

Presentation of case

We report the case of a 48-year-old woman presenting with a multicentric breast cancer and successfully treated with an oncoplastic technique consisting in three radical lumpectomies followed by breast reshaping and simultaneous contralateral symmetrization.

Discussion

According to our experience, oncoplastic conserving breast surgery could represent a better option than the combination of mastectomy, reconstruction and radiation therapy, in terms of quality of life for selected patients affected by multicentric breast cancer.

Conclusion

The surgical treatment for multicentric breast cancers remains controversial even though emerging evidences show good oncological and aesthetic outcomes following oncoplastic conserving breast surgery.

Aneurysmal degeneration of vein conduit used for vascular reconstruction-Case report and literature review

INTRODUCTION

Popliteal artery aneurysms (PAA) are the most prevalent form of peripheral arterial aneurysms. Greater saphenous vein grafts and endoaneurysmorrhaphy remains the mainstay therapy for open repair of PAA. True aneurysmal degeneration of lower extremity infrainguinal autologous vein grafts are relatively rare and its etiology is not completely understood.

CASE PRESENTATION

We present a case of a 57-year-old man with recurrent autologous venous graft aneurysmal dilatations following a surgical popliteal artery aneurysm repair.

DISCUSSION

The pathogenesis of true aneurysmal graft dilatation remains speculative with possible pathogenesis including progression of underlying atherosclerosis, systemic dilating diathesis, autologous venous graft varicosities, low-grade infections and post-stenotic dilatations. Management of venous graft aneurysms should be subjected to the same criteria as other aneurysms. Diagnosis requires a high index of suspicion. The initial study of choice is duplex ultrasonography as it can diagnose the aneurysm and distinguish it from other popliteal masses, provide accurately measurements and identify thrombus within the aneurysm. Once diagnosed, surgical repair should be performed as soon as possible as graft dilatation tends to occur overtime and is typically followed by a rapid increase in size over a short period of time.

CONCLUSION

Aneurysmal degeneration of autologous saphenous venous graft following PAA repairs occur infrequently. Its etiology remains largely speculative. Accurate diagnosis and early surgical intervention can prevent progression of aneurysmal dilatation and minimize the potential of complications.

Computer-assisted preoperative simulation for positioning and fixation of plate in 2-stage procedure combining maxillary advancement by distraction technique and mandibular setback surgery

INTRODUCTION

Computer-assisted preoperative simulation surgery is employed to plan and interact with the 3D images during the orthognathic procedure. It is useful for positioning and fixation of maxilla by a plate. We report a case of maxillary retrusion by a bilateral cleft lip and palate, in which a 2-stage orthognathic procedure (maxillary advancement by distraction technique and mandibular setback surgery) was performed following a computer-assisted preoperative simulation planning to achieve the positioning and fixation of the plate. A high accuracy was achieved in the present case.

PRESENTATION OF CASE

A 21-year-old male patient presented to our department with a complaint of maxillary retrusion following bilateral cleft lip and palate. Computer-assisted preoperative simulation with 2-stage orthognathic procedure using distraction technique and mandibular setback surgery was planned.

DISCUSSION

The preoperative planning of the procedure resulted in good aesthetic outcomes. The error of the maxillary position was less than 1mm.

CONCLUSION

The implementation of the computer-assisted preoperative simulation for the positioning and fixation of plate in 2-stage orthognathic procedure using distraction technique and mandibular setback surgery yielded good results.

Urological injuries associated with pelvic fractures: A case report of a detached bone segment inside the bladder

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A 45-year-old pedestrian male was hit by a car.

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Gross hematuria was evident upon inserting Foley’s catheter.

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CT revealed multiple stable pelvic fractures.

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CT cystogram showed intraperitoneal and extraperitoneal extravasation of contrast.

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A detached pubic bone fragment was found inside the urinary bladder.

Introduction

Urological injuries in pelvic fractures are noticed in 6–15% of the cases. The bladder, due to its anatomical position, is prone to rupture in pelvic fractures. The majority of urinary bladder injuries are either extraperitoneal or intraperitoneal. Nonetheless, both types can occur simultaneously in 6% of the cases.

Presentation of the case

A 45-year-old male was brought to our emergency department after being struck by an automobile. In the absence of signs of urethral injury, a Foley’s catheter was inserted revealing gross hematuria. The radiological assessment showed bilateral non-displacement sacral wing fractures, bilateral non-displacement anterior column fractures and bilateral comminuted superior and inferior pubic rami fractures, with a detached pubic bone fragment displaced posteriorly. A CT cystogram was performed showing intraperitoneal and extraperitoneal extravasation of contrast. The patient was taken to surgery. A sharp-edged bony fragment was discovered inside the bladder. A two-layer closure of the bladder was performed.

Discussion

Pelvic fractures with concomitant lower urinary tract injuries are associated with high morbidity and mortality. The signs indicative of bladder rupture include a more than one centimeter diastasis of the symphysis pubis and a displaced fracture of more than one centimeter involving the obturator ring. However, the signs may not be present as in our case.

Conclusion

This unusual case illustrates the potential risk of bladder injury following stable pelvic fractures through a detached bone segment. It also emphasizes on having a high index of suspicion. The teamwork and multidisciplinary approach are essential for an optimal outcome.

Granular cell tumour developing in the background of a previous mandibular giant cell lesion: Case report

INTRODUCTION

Granular cell tumours of the mandible are very rare. We present a unique case which has developed at the site of a previous giant cell lesion.

PRESENTATION

51 year old Caucasian lady had excision of a recurrent giant cell lesion of the anterior mandible. Follow up showed evidence of radiographic recurrence. However, further biopsies from the same site showed granular cell tumour with soft tissues extension. The patient remains well on long term follow up with no evidence of recurrence.

DISCUSSION

This case is unique because the granular cell tumour has evolved from the site of a recurrent giant cell lesion. Conservative surgical excision was an adequate treatment option.

CONCLUSION

Within the limitations of our case study, a correlation between granular cell tumour and giant cell lesion is possible. However, more research is needed to prove this.

Biventricular transient systolic dysfunction after mitral valve replacement: Pericardial decompression syndrome

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Pericardial Decompression Syndrome is an unexpected clinical scenario with an incidence less than 5% in all surgically or percutaneously managed pericardial tamponade patients.

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Yet, in the majority of cases there is no obvious cause for the development of paradoxical ventricular dysfunction after decompression.

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Close postoperative monitoring for the first 24 h, preferably in the ICU, and aggressive heart failure treatments should be managed even if low cardiac output develops.

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We recommend gradual removal of pericardial effusion under hemodynamic monitoring, especially in patient with postcardiotomy tamponade.

Background

Pericardial decompression syndrome is defined as paradoxical hemodynamic instability, left ventricular or bi ventricular systolic dysfunction and pulmonary edema after pericardial fluid drainage. Pericardial Decompression Syndrome is an unexpected clinical scenario with an incidence less than 5% in all surgically or percutaneously managed pericardial tamponade patients. The aim of this manuscript was to describe a case with cardiac tamponade in whom acute biventricular heart failure and pulmonary edema developed after surgical creation of a pericardial window, and to discuss this case in light of the literature.

Case report

A 43-year-old woman who underwent mitral valve replacement three weeks ago admitted to our hospital with dyspnea, tachycardia, and atrial fibrillation. Large quantity of pericardial fluid (35 mm in the posterior wall, 25 mm in the anterior wall) with partial compression of the right ventricle and 50% left ventricle ejection fraction (LVEF) was determined via transthoracic echocardiography (TTE). After creation of pericardio-pleural window, more than 1000 ml of serosanguineous fluid were quickly removed from the pericardial space. During the following hours of the decompression, the patient’s condition deteriorated and overt pulmonary edema developed. On the second day, biventricular systolic dysfunction, global diffuse hypokinesia and 15–20% LVEF was observed via TTE. High-dose inotropic support and diuretics was continued. During follow up she was progressively weaned off inotropes, LVEF were raised to 35%. Two weeks later, repeated TTE showed normal biventricular systolic function and LVEF was 50%.

Conclusion

We recommend gradual removal of pericardial effusion under hemodynamic monitoring, especially in patient with postcardiotomy tamponade.

Basal cell carcinoma mimicking pilonidal sinus: A case report with literature review

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Basal cell carcinoma (BCC) is the most common malignancy of the sun-exposed area. About 80–85% occur on the head and neck [2] (Lorenzini et al., 2005). It occur rarely in the other area.

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On the other hand, Pilonidal sinus (PNS) is a common benign disease that accounts for almost 15% of anal suppurations.

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We report a case of BCC presented with signs and symptoms of PNS.

Introduction

Pilonidal sinus is a common benign disease that accounts for almost 15% of anal suppurations while basal cell carcinoma is the most common malignancy of the sun-exposed area occurring mainly on the head and neck. We report a case of basal cell carcinoma presented with signs and symptoms of PNS. A 40-year-old male presented with swelling of the lower back for 2 years. On examination, there was a round, mobile, soft 4 × 2.5 cm mass on the sacrococcygeal area. Ultrasound showed subcutaneous cystic lesion. Clinical diagnosis of PNS was done and excisional biopsy was performed under local anesthesia. The result of the histopathological examination was suggestive for basal cell carcinoma.

Conclusion

Basal cell carcinoma should not be forgotten in differential diagnosis of superficial mass and abscesses.

Is the fourth port routinely required for laparoscopic cholecystectomy? Our three-port laparoscopic cholecystectomy experience

BACKGROUND

There have been many changes in number and place of trocars that have been described, since the first laparoscopic cholecystectomy (LC), but, in fact, all authors agree that laparoscopic procedure is accepted as gold standard. However, four trocars use in standard laparoscopic cholecystectomy, it has been argued that the fourth port is not necessary for grasping fundus of gallbladder so as to expose Calot's triangle. The aim of this study is to establish the safety of three-trocar LC in symptomatic gallbladder disease and also to determine the ratio of technical requirements of the fourth trocar.

METHODS

Between August 2010 and January 2016, 291 cases were operated in Kocaeli Derince Education and Research Hospital, department of general surgery for symptomatic gallbladder disease with three-port LC, and their records were examined retrospectively.

RESULTS

Two hundred and twenty patients were female (75.6 %) and seventy one (24.4 %) were male. Two hundred and eighteen of two hundred and ninety-one cases (74.92 %) were operated with three- port LC in a secure way. In seventy-three cases (25.08 %), one more port was needed to use. Mean operative time was 33.76 ± 11:18 min. (15-90 min). In these cases, major complications, such as main bile duct injury or bile leakage, that may increase the mortality and morbidity, did not occur. Only in one case (0.34 %) postoperative bleeding was seen from the liver bed, which was required exploration.

CONCLUSION

We concluded that in experienced hand, LC with three ports is safe and feasible technique if it is not endanger the course of the surgery.

Lactic Acidosis: An Update

Lactic acidosis is an etiologically and biochemically heterogeneous disorder that is due to the overproduc tion of lactic acid or the underutilization of lactate. It occurs with disorders in which tissue oxygenation is impaired (Type A) and with disorders in which it is not (Type B). Lactic acidosis is an anion-gap metabolic acidosis in which the lactate concentration is greater than or equal to 5 mM and the systemic pH is less than 7.30. Treatment is largely empiric and generally unsatis factory. The use of sodium bicarbonate in lactic acidosis is currently controversial. The adverse effects of bicar bonate and the beneficial effects of dichloroacetate in experimental models of lactic acidosis are reviewed.

Role of Histamine Release Test for the Evaluation of Patients with Immediate Hypersensitivity Reactions to Clavulanic Acid

BACKGROUND

Immediate hypersensitivity reactions to clavulanic acid (CLV) seem to be on the increase. Diagnosis is mainly based on skin testing and the drug provocation test (DPT), procedures that are not risk free. The aim of this study was to evaluate whether the histamine release test (HRT) could help evaluate patients with selective hypersensitivity to CLV.

METHODS

Eighteen patients with immediate selective hypersensitivity reactions to CLV (positive skin tests to CLV but negative to the major and minor determinants of benzylpenicillin and amoxicillin; negative DPT to benzylpenicillin and amoxicillin) and 21 controls with tolerance to CLV were included. Direct and passive HRT, using patient whole blood or 'IgE-stripped' donor blood sensitized by patient serum, respectively, were performed by stimulating the blood with CLV, and basophil histamine release was detected by fluorometric determination.

RESULTS

The clinical symptoms were anaphylaxis (n = 6), urticaria (n = 9) and urticaria-angioedema (n = 3). The median time interval between the reaction and the study was 225 days (interquartile range, IQR: 120-387.5) and between drug intake and the development of symptoms 30 min (IQR: 6.25-30). We obtained similar data for both the direct and passive HRT, with a sensitivity and specificity of 55 and 85%, respectively, a positive predictive value of 76% and a negative predictive value of 69%.

CONCLUSIONS

The sensitivity of both the direct and passive HRT for diagnosing patients with immediate allergy to CLV is less than 60%. However, the passive HRT has the advantage that it is based on the testing of serum samples that can be handled more easily than fresh blood samples.

Pore formation by actinoporins, cytolysins from sea anemones

Actinoporins (APs) from sea anemones are ~20 kDa pore forming toxins with a β-sandwich structure flanked by two α-helices. The molecular mechanism of APs pore formation is composed of several well-defined steps. APs bind to membrane by interfacial binding site composed of several aromatic amino acid residues that allow binding to phosphatidylcholine and specific recognition of sphingomyelin. Subsequently, the N-terminal α-helix from the β-sandwich has to be inserted into the lipid/water interphase in order to form a functional pore. Functional studies and single molecule imaging revealed that only several monomers, 3-4, oligomerise to form a functional pore. In this model the α-helices and surrounding lipid molecules build toroidal pore. In agreement, AP pores are transient and electrically heterogeneous. On the contrary, crystallized oligomers of actinoporin fragaceatoxin C were found to be composed of eight monomers with no lipids present between the adjacent α-helices. This article is part of a Special Issue entitled: Pore-Forming Toxins edited by Maur Dalla Serra and Franco Gambale.

Engineered nanoparticles mimicking cell membranes for toxin neutralization

Protein toxins secreted from pathogenic bacteria and venomous animals rely on multiple mechanisms to overcome the cell membrane barrier to inflict their virulence effect. A promising therapeutic concept toward developing a broadly applicable anti-toxin platform is to administer cell membrane mimics as decoys to sequester these virulence factors. As such, lipid membrane-based nanoparticulates are an ideal candidate given their structural similarity to cellular membranes. This article reviews the virulence mechanisms employed by toxins at the cell membrane interface and highlights the application of cell-membrane mimicking nanoparticles as toxin decoys for systemic detoxification. In addition, the implication of particle/toxin nanocomplexes in the development of toxoid vaccines is discussed.

The effect of cholesterol on the long-range network of interactions established among sea anemone Sticholysin II residues at the water-membrane interface

Actinoporins are α-pore forming proteins with therapeutic potential, produced by sea anemones. Sticholysin II (StnII) from Stichodactyla helianthus is one of its most extensively characterized members. These proteins remain stably folded in water, but upon interaction with lipid bilayers, they oligomerize to form a pore. This event is triggered by the presence of sphingomyelin (SM), but cholesterol (Chol) facilitates pore formation. Membrane attachment and pore formation require changes involving long-distance rearrangements of residues located at the protein-membrane interface. The influence of Chol on membrane recognition, oligomerization, and/or pore formation is now studied using StnII variants, which are characterized in terms of their ability to interact with model membranes in the presence or absence of Chol. The results obtained frame Chol not only as an important partner for SM for functional membrane recognition but also as a molecule which significantly reduces the structural requirements for the mentioned conformational rearrangements to occur. However, given that the DOPC:SM:Chol vesicles employed display phase coexistence and have domain boundaries, the observed effects could be also due to the presence of these different phases on the membrane. In addition, it is also shown that the Arg51 guanidinium group is strictly required for membrane recognition, independently of the presence of Chol.

Mutagenesis and functional analysis of the pore-forming toxin HALT-1 from Hydra magnipapillata

Actinoporins are small 18.5 kDa pore-forming toxins. A family of six actinoporin genes has been identified in the genome of Hydra magnipapillata, and HALT-1 (Hydra actinoporin-like toxin-1) has been shown to have haemolytic activity. In this study, we have used site-directed mutagenesis to investigate the role of amino acids in the pore-forming N-terminal region and the conserved aromatic cluster required for cell membrane binding. A total of 10 mutants of HALT-1 were constructed and tested for their haemolytic and cytolytic activity on human erythrocytes and HeLa cells, respectively. Insertion of 1–4 negatively charged residues in the N-terminal region of HALT-1 strongly reduced haemolytic and cytolytic activity, suggesting that the length or charge of the N-terminal region is critical for pore-forming activity. Moreover, substitution of amino acids in the conserved aromatic cluster reduced haemolytic and cytolytic activity by more than 80%, suggesting that these aromatic amino acids are important for attachment to the lipid membrane as shown for other actinoporins. The results suggest that HALT-1 and other actinoporins share similar mechanisms of pore formation and that it is critical for HALT-1 to maintain an amphipathic helix at the N-terminus and an aromatic amino acid-rich segment at the site of membrane binding.

Cholesterol stimulates and ceramide inhibits Sticholysin II-induced pore formation in complex bilayer membranes

The pore forming capacity of Sticholysin II (StnII; isolated from Stichodactyla helianthus) in bilayer membranes containing 1-palmitoyl-2-oleoyl-sn-glycero-3-phosphocholine (POPC), palmitoylsphingomyelin (PSM) and either cholesterol or palmitoyl ceramide (PCer) has been examined. The aim of the study was to elucidate how the presence of differently ordered PSM domains affected StnII oligomerization and pore formation. Cholesterol is known to enhance pore formation by StnII, and our results confirmed this and provide kinetic information for the process. The effect of cholesterol on bilayer permeabilization kinetics was concentration-dependent. In the concentration regime used (2.5-10nmol cholesterol in POPC:PSM 80:20 by nmol), cholesterol also increased the acyl chain order in the fluid PSM domain and thus decreased bilayer fluidity, suggesting that fluidity per se was not responsible for cholesterol's effect. Addition of PCer (2.5-10nmol) to the POPC:PSM (80:20 by nmol) bilayers attenuated StnII-induced pore formation, again in a concentration-dependent fashion. This addition also led to the formation of a PCer-rich gel phase. Addition of cholesterol to PCer-containing membranes could partially reduce the inhibitory effect of PCer on StnII pore formation. We conclude that the physical state of PSM (as influenced by either cholesterol or PCer) affected StnII binding and pore formation under the conditions examined.

Sphingolipids as modulators of membrane proteins

The diversity of the transmembranome of higher eukaryotes is matched by an enormous diversity of sphingolipid classes and molecular species. The intrinsic properties of sphingolipids are not only suited for orchestrating lateral architectures of biological membranes, but their molecular distinctions also allow for the evolution of protein motifs specifically recognising and interacting with individual lipids. Although various reports suggest a role of sphingolipids in membrane protein function, only a few cases have determined the specificity of these interactions. In this review we discuss examples of specific protein-sphingolipid interactions for which a modulator-like dependency on sphingolipids was assigned to specific proteins. These novel functions of sphingolipids in specific protein-lipid assemblies contribute to the complexity of the sphingolipid classes and other molecular species observed in animal cells. This article is part of a Special Issue entitled New Frontiers in Sphingolipid Biology.

Biological functions of sphingomyelins

Sphingomyelin (SM) is a dominant sphingolipid in membranes of mammalian cells and this lipid class is specifically enriched in the plasma membrane, the endocytic recycling compartment, and the trans Golgi network. The distribution of SM and cholesterol among cellular compartments correlate. Sphingolipids have extensive hydrogen-bonding capabilities which together with their saturated nature facilitate the formation of sphingolipid and SM-enriched lateral domains in membranes. Cholesterol prefers to interact with SMs and this interaction has many important functional consequences. In this review, the synthesis, regulation, and intracellular distribution of SMs are discussed. The many direct roles played by membrane SM in various cellular functions and processes will also be discussed. These include involvement in the regulation of endocytosis and receptor-mediated ligand uptake, in ion channel and G-protein coupled receptor function, in protein sorting, and functioning as receptor molecules for various bacterial toxins, and for non-bacterial pore-forming toxins. SM is also an important constituent of the eye lens membrane, and is believed to participate in the regulation of various nuclear functions. SM is an independent risk factor in the development of cardiovascular disease, and new studies have shed light on possible mechanism behind its role in atherogenesis.

Characterization of a novel proteinous toxin from sea anemone Actineria villosa

The sea anemone Actineria villosa expresses a lethal protein toxin. We isolated a novel 120-kDa protein, Avt120, from partially purified toxin and found it to possess extremely strong lethal activity. The 3,453-bp Avt120 gene translates to a 995-amino acid protein. The 50% lethal dose (LD(50)) of purified Avt120 in mice was 85.17 ng. Among several tested cell lines, Colo205 cells were most sensitive to Avt120: 50% of them were damaged by 38.4 ng/mL Avt120. Avt120 exerted ATP degradation activity (10 μmol ATP h(-1) mg(-1)), which was strongly inhibited by ganglioside GM1 to decrease the cytotoxicity of Avt120.