The SCARE 2020 Guideline: Updating Consensus Surgical CAse REport (SCARE) Guidelines

Endoscopic lateral decompression of calcaneo-fibular impingement: Case Report and literature Review

INTRODUCTION AND IMPORTANCE

The calcaneo-fibular impingement syndrome is frequent after calcaneal fracture. The impinging lesion could be in bone and/or in soft tissue. The operative treatment aims to remove the impinging lesions either by open or endoscopic surgery.

CASE PRESENTATION

We report a case of a 33-year female patient with calcaneo-fibular impingement syndrome. The condition was managed using endoscopic bone resection, soft tissue debridement and peroneal tendons release.

CLINICAL DISCUSSION

Endoscopic treatment of calcalneo-fibular impingement syndrome has gradually been broadened as a safe, minimally invasive, and effective procedure. This endoscopic approach could reduce the wound complications associated with the open procedure and ensure early return to activity, better cosmetic and better patient satisfaction. The lateral approach could reduce nervous and tendinous complications associated with posterior approach.

CONCLUSION

The endoscopic surgery using lateral approach is a reliable and a minimally invasive technique to address calcaneo-fibular impinging. However, this procedure is less useful for advanced cases of calcaneal malunion (Stephens and Sanders II and III).

Successful conservative treatment of a poly-4-hydroxybutyrate mesh infection: A case report

Introduction and importance

An infection of an abdominal wall prosthesis can be a real disaster for the patient. A conservative treatment might be an option if biological or slowly resorbable synthetic meshes were used. However, adequate research of their use in contaminated and dirty wounds lacks.

Case presentation

Herein we report the case of a 69-year-old patient with a heavily infected poly-4-hydroxybutyrate mesh that was successfully treated conservatively.

Clinical discussion

Despite promising results of poly-4-hydroxybutyrate meshes, their use remains controversial and studies in contaminated wounds are scarce.

Conclusion

Our case report shows the potential benefits of a poly-4-hydroxybutyrate mesh in a very high-risk patient with active infection.

Two case of bilateral approach in laparoscopic pancreas-sparing distal duodenectomy for duodenal neoplasms arising from the distal duodenum

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Surgical procedures for duodenal tumors at third and fourth portion of duodenum.

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The procedures do not require either Kocher’s maneuver and Cattell–Braasch maneuver.

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Preferable approach for laparoscopic pancreas sparing distal duodenectomy.

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Pancreas was safely preserved during the procedures.

Introduction

Laparoscopic pancreas-sparing distal duodenectomy is a less invasive surgical therapy; however, the anatomical complexity of the duodenum increases the difficulty of laparoscopic procedures. We introduce our technique for laparoscopic pancreas-sparing distal duodenectomy for distal duodenal tumors.

Presentation of cases

A first patient was 47-year-old woman who had 30 mm of duodenal tumor which located in third portion of duodenum. A second patient was 66-year-old man who had 35 mm of submucosal tumor which located in the third portion of duodenum. Laparoscopic pancreas-sparing duodenectomy was performed using bilateral approach for both cases. We began by dissecting an avascular area on the right side of the transverse mesocolon to mobilize the second and third portions of the duodenum with the uncinate process of the pancreas. Next, from the left side, the jejunum and the fourth portion of the duodenum were fully mobilized orally from the surrounding tissue, connecting the dissection plane with the right-side area. The jejunum and duodenum were cut with a linear stapler. Intracorporeal reconstruction was performed in an overlapped manner. We performed this procedure in two patients. Operative time was 326 and 370 min, respectively. Patients were discharged on postoperative days 9–12 without postoperative complications.

Discussion

Duodenal tumors are found increasingly often because of developments in endoscopic technology and techniques; therefore, establishing safe surgical procedures for duodenal tumor excision is imperative. Our surgical approach was simple and safe procedure.

Conclusion

Laparoscopic pancreas-sparing distal duodenectomy with a bilateral approach is a useful approach without wide mobilization of duodenum.

Carpal tunnel syndrome caused by a giant lipoma of the hand: A case report

INTRODUCTION AND IMPORTANCE

Lipomas are common benign tumours which occur in up to 2% of the population. They are classified as giant when larger than 5 cm. Although they are usually asymptomatic, giant lipomas of the hand may cause compression of the underlying tissues.

CASE PRESENTATION

A 62-year-old Caucasian male presented to the Plastic and Reconstructive Surgery outpatient clinic with numbness and pain in his left hand. The numbness in his fingers pointed to compression of the median nerve, as well as the ulnar nerve. He presented with a rapidly progressive swelling in his left palm. An MRI scan of the hand was made, which showed a lipoma of approximately 8,5 cm in diameter. The swelling was surgically removed and sent for histopathological analysis, which confirmed the diagnosis of benign giant lipoma of the hand. Two weeks postoperatively, pain and numbness significantly decreased.

CLINICAL DISCUSSION

Neural injury in carpal tunnel syndrome is related to the duration and degree of compression. A giant lipoma is considered malignant until proven otherwise since variants with high potential for metastasizing exist. Distinguishing between a benign tumour and a malignant lipoma is essential, since a more radical treatment plan might be required.

CONCLUSION

Giant lipomas of the hand are a rare cause of carpal tunnel syndrome and a malignant variant should always be suspected. A preoperative MRI scan should be performed. Rapid en bloc excision is necessary in case of compression of the underlying tissues.

Bilateral shoulder septic arthritis due to suspected bacterial endocarditis: A case report

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Septic arthritis of the shoulder is rare but potentially devastating. Bilateral shoulder septic arthritis is even more rare of a diagnosis.

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Patients can often present with unimpressive physical examination findings, so it is of utmost importance to keep septic arthritis as a differential diagnosis.

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It is paramount that patients be promptly treated with surgical intervention and the appropriate antibiotic therapy for preservation of life and limb, regardless of the chronicity or severity of the septic joint.

Introduction

Septic arthritis is an orthopedic emergency that requires rapid diagnosis and treatment. It is typically caused by occult bacteremia which allows bacteria to seed the joint or local invasion of a soft tissue infection. Most cases of septic arthritis are caused by gram-positive bacteria, with the most common culprit being Staphylococcus Aureus. The reason septic arthritis is an orthopedic emergency is because of rapid destruction to cartilage. The mechanism of injury to cartilage is two-fold: bacterial enzymes are directly toxic to joint cartilage, and buildup of exudate can tamponade blood flow and cause anoxic injury. Typically, the knee is the most commonly involved joint. This is followed by the hip, ankle, elbow, wrist, and shoulder in descending order of occurrence. Polyarticular disease makes up a small percentage of these cases and if present, it is usually asymmetric and will involve at least one knee joint.

Presentation of case

Bilateral joint septic arthritis is relatively rare. We present an uncommon case of atraumatic bilateral septic shoulders in an elderly man with a history of heart disease and insidious bilateral shoulder pain after golfing 18 holes. This presentation is unique not only in its rarity but also in its impact on our understanding of septic arthritis in the setting of medical comorbidities and a relatively unimpressive presentation. With a recent golfing day just prior to presentation, differential diagnoses other than septic arthritis included deltoid/rotator cuff muscle strain, acute on chronic rotator cuff tendinosis, acute on chronic rotator cuff tearing, acute flare up of osteoarthritis, rheumatoid arthritis, or crystalline arthropathy. With elevated inflammatory markers and an equivocal physical examination, our patient underwent advanced imaging via MRI and subsequent bilateral glenohumeral joint diagnostic aspirations that were consistent with septic arthritis due to his complaining of contralateral shoulder pain shortly after his admission. Immediately after said diagnosis was made, the patient was taken back for emergent bilateral open irrigation and debridement, as septic arthritis is an orthopedic emergency, and went on to recover appropriately on culture-directed intravenous antibiotic therapy.

Discussion/conclusion

This case report is impactful with regard to clinical practice for multiple reasons. First and foremost it is a cautionary tale for all clinicians with regard to the level of suspicion one must have for polyarticular septic arthritis in the setting of the multiply painful patient. Second, it demonstrates the utility of advanced imaging in the equivocal patient. Lastly, it underscores the importance of prompt diagnosis and treatment, validating the existing algorithm for septic arthritis.

Synovialosarcoma of the pharynx: A case report and literatture review

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Synovial sarcoma is a rare malignant neoplasm.

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The location in pharynx is extremely rare.

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The diagnosis of synovial sarcoma is confirmed by surgical biopsy.

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The objective of this study is to describe the clinical, radiological and histological features of pharyngeal synovial sarcoma and to discuss its therapeutic management.

Introduction

Synovial sarcoma is a rare tumor to be encountered in the head and neck region and is always a challenge in terms of diagnosis, treatment, as our case.

Presentation of case

We present a 23-year old female patient with synovial sarcoma of posterolateral pharyngeal wall. The radiological and clinicopathological features along with various diagnostic tests and treatment options are discussed.

Discussion

The objective of this study is to describe - from a clinical case reported from our institution, and from literature review- the clinical, radiological and histological features of pharyngeal synovial sarcoma and to discuss its therapeutic management.

Conclusion

Synovial sarcoma of pharynx is extremely a rare tumor in current practice.

The malignant degeneration of a phyllode tumour in man: A case report

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Through this case report and a review of the literature, we wish to highlight the difficulties of clinical and paraclinical diagnosis as well as the therapy.

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Malignant phyllodes tumour is a separate entity from breast cancer, it is rare, it is completely different from epithelial cancer and it can exist in man.

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The three pathological types (benign, borderline and malignant) were reported in men.

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Very few cases of phyllodes tumour were reported in men.

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Malignant phyllodes tumour of the breast show clinical and mammographic signs comparable to those of benign lesions.

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Its epidemiology is particular and it has particular difficulties in clinical and paraclinical diagnosis. The treatment is based on surgery, which may be a large lumpectomy or mastectomy, lymph node removal is unnecessary, and the prognosis depends on several factors, the most important of which are margins of surgical exeresis.

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Wide local excision is the standard of care for phyllodes tumours (with or without adjuvant radiotherapy in malignant lesions). The combination of adjuvant treatment with radiotherapy or chemotherapy is still under discussion.

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There is a risk of local relapse and distant metastases, in particular to the lung.

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The higher rate of distant metastases is found when the resection margins are less than 10 mm.

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After resection, the prognostic factors for phylloid sarcoma correspond to the histological grade, surgical margins and the presence of tumour necrosis. tumour size may also be a pejorative factor.

Introduction

Malignant phyllodes tumours of the breast represent less than 1% of all breast cancers.

Few cases of phyllodes tumours have been reported in men.

Case presentation

We present the case of a 60-year-old man who was operated on one year ago for a breast tumour that had undergone a lumpectomy with an anatomopathological study in favour of a grade 2 phylloid tumour. He was admitted to hospital with a palpable mass in his right breast. The lumpectomy enlarged to the right pectoralis major muscle was then performed with clear surgical margins.

Microscopic examination revealed high-grade malignant phyllodes.

Postoperatively, after 3 months, the patient was given a breast MRI and a PET/CT scan which returned without abnormalities.

The patient is followed for eight months and has shown no signs of recurrence.

Discussion

Malignant phyllodes tumours of the breast show clinical and mammographic signs comparable to those of benign lesions.

The diagnosis is confirmed by histology, treatment is based on surgery, which may be a large lumpectomy or mastectomy, and the prognosis depends on several factors, the most important of which is the margin for surgical resection.

Conclusion

The best treatment is a wide local excision with a safety margin of 1 cm, unless it is metastatic.

Early diagnosis and surgery improves the prognosis.

Intrahepatic intraductal papillary cystic neoplasm of the bile duct: A case report

Introduction and importance

Intraductal papillary neoplasm of the bile duct (IPNB) is a tumour with a very low incidence in the Western world, characterised by a high risk of malignant transformation and unknown prognosis. It is a new entity which was adopted by the WHO in 2010 as a precursor lesion of cholangiocarcinoma. Intrahepatic bile duct is the most common site of origin for IPNB.

Case presentation

Hereby, we present a case of an asymptomatic 63- year-old man, referred to our department after routine ultrasonography showing a multifocal cystic lesion on the left hepatic lobe. Further screening modalities (CT, MRI abdo) confirmed a complex cystic liver lesion with atypical features. The patient underwent left hepatectomy. Histopathology showed a cystic type intrahepatic IPNB, which was completely resected (R0). The follow up in 2 yrs post-operation showed no signs of recurrence.

Clinical discussion

The diagnosis and management of IPNB remain challenging. A multimodality imaging approach is essential in order to diagnose IPNB, assess tumour location and extent and plan the optimal treatment strategy.

Conclusion

Complete surgical resection (R0) with close postoperative follow-up offers long-term survival.

Impalement injury of the perineum with an iron rod with a minimal injury: A near miss: A case report

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Perineal impalement injuries are often fatal.

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We report a perineal impalement injury by an iron rod piercing the perineum with minimal external and internal injuries.

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Urgent laparotomy to manage all the potential injuries along with effective resuscitation and prehospital care are critical.

Introduction and importance

Penetrating perineal injury in children is uncommon. However, the injury is serious and life-threatening with significant morbidity and mortality.

Case presentation

We report an unusual case of a 13-year-old boy with an accidental perineal impalement injury by an iron rod, which pierced through the perineum and exited through the left loin, however with minimal external and internal injuries.

Clinical discussion

Multiple vital organs in the pelvic space are vulnerable to damage in perineal impalement injury. Vital organ injury, amount of blood loss, and effectiveness of the resuscitation determine the outcome of an impalement injury. Urgent laparotomy forms the cornerstone in management as all the potential injuries can be identified and managed immediately.

Conclusion

Effective resuscitation and accurate assessment of the associated injuries along with proper pre-hospital care with a multidisciplinary approach is crucial for the survival and optimum outcome of the victim.

Peliosis lienalis with atraumatic splenic rupture in a patient with chronic myelomonocytic leukemia: A case report

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Peliosis lienalis is a rare pathological entity which may be associated with chronic myelomonocytic leukemia.

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Increasing splenomegaly in patients with hematological malignancies should rise suspicion of impending splenic rupture.

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Peliosis lienalis may be suspected with new inhomogeneous splenic parenchyma on sonography.

Introduction

Atraumatic splenic rupture is a rare but life-threatening condition which may be associated with hematological malignancies.

Presentation of case

We present the case of a 63-year-old male patient with a history of chronic myelomonocytic leukemia and sarcoidosis under therapy with prednisone, who suffered an atraumatic splenic rupture with hemodynamic instability. He was managed with proximal splenic artery embolization and secondary open splenectomy. On pathology the diagnosis of peliosis lienalis was established.

Discussion

Peliosis is a rare pathological entity, which presents with multiple blood-filled cavities within parenchymatous organs and is of unknown etiology and pathogenesis. In retrospect a rapid increase in splenomegaly and inhomogeneous parenchyma of the spleen on sonography was realized.

Conclusion

Sonographic changes in size and parenchyma of the spleen in patients with hematological malignancies might help suspecting peliosis lienalis with impending splenic rupture and could alter clinical management towards a prophylactic splenectomy.

Rebellious headache revealing an extensive rhinoscleroma: A case report and review of the literature

and importance: this case report aimed at an unusual case of extensive rhinoscleroma with a literature review, We report this case to bring attention to the patients with immunodeficiency problem regardless of presenting symptoms. Case presentation: a 70 -year-old patient with diabetes and hypertension, consulted for chronic median and posterior headaches have not improved with symptomatic treatment. She reported cacosmia without rhinorrhea and right otalgia. The examination of the nasal cavity showed a bleeding lesion on the lateral wall of the nasopharynx. CT-scan of the facial showed tissue lesion on the posterior and lateral walls of the nasopharynx, with infiltration of the parapharyngeal space and bone lysis right edge of the clivus. The biopsy confirmed the diagnosis of rhinoscleroma. The patient started the ciprofloxacin for 3 months, and the evolvement has noticed with the disappearance of the lesion during the first month of treatment. The patient started the ciprofloxacin for 3 months, and the evolvement was noticed with the disappearance of the lesion during the first month of treatment. Cilinical discussion: rhinoscleroma is a chronic and progressive granulomatous disease of the nasal cavities. The diagnosis is confirmed by the search for bacteria and an anatomopathological assessment of MIKULICZ cells. The medical treatment of choice has a high concentration in macrophages such as rifampicin and fluoroquinolone. Conclusion: rhinoscleroma is a granulomatous disease caused by klebsiella rhinoscleromatis, you must think about in front a nasopharyngeal lesion imitating a malignant pathology.

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A rebellious headache may be indicate an extensive rhinoscleroma.

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We report this case to bring attention to the patients with immunodeficiency problem regardless of presenting symptoms.

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The possibility of an aggressive benign lesion like rhinoscleroma.

Management of a broken modular femoral stem following total hip arthroplasty in a patient with sickle cell disease using an endofemoral trephine reamer: A case report

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Using a trephine reamer to extract a broken femoral stem is a safe technique that preserves the femoral cortical integrity postoperatively in comparison with other techniques.

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Complications of a trephine reamer include heat necrosis and iatrogenic fractures.

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Intra-operative measures can be taken to limit possible complications of trephine reamer such as using new sharp reamers with the appropriate size, regularly irrigating the intramedullary canal while reaming to avoid heat necrosis, and involving a C-arm to avoid any cut-through in the cortex.

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SCD patients who require arthroplasty at young age are prone to a higher risk of aseptic loosening due to the increased physical activity and functional demands which increases the stress on the implant-bone interface hindering implant-bone integration

Introduction and importance

Breakage of the femoral stem with intact bone is a rare complication that has only been reported once. Sickle cell disease (SCD) patients are more prone to variable complications due to the nature of their disease. We discuss how to safely remove a fixed broken stem using an intramedullary trephine reamer to achieve optimal outcome in a SCD patient. It is important to keep an intact femoral cortex during arthroplasty to achieve stable prostheses.

Case presentation

We report a 35 years old SCD male, who complains of left hip pain and decreased activity 18-months following total hip arthroplasty with no history of trauma nor infection. Lab work and radiography showed signs of aseptic loosening and breakage of the femoral stem with no signs of cortical fractures. A trephine reamer was used to extract the stem during revision arthroplasty. Two years post-operative follow up showed improved Harris hip score (HHS) and apparent clinical improvement in function and pain.

Discussion

Multiple femoral stem extraction techniques have been reported in the literature. However, these approaches have variable disadvantages. Using the trephine reamer intramedullary helped to extract the distal femoral stem fragment and preserve the integrity of the femoral cortex. However, caution should be taken to avoid iatrogenic injuries.

Conclusion

Using the trephine reamer to extract a broken femoral stem is a safe technique that preserves the cortical integrity. Complications of the trephine reamer include heat necrosis and iatrogenic fractures. Intra-operative measures can be taken to limit those complications.

Trapped fourth ventricle: A case report and review of literature

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In this patient the diagnosis was missed. Initially we thought it was shunt infection or malfunction. A shunt series and septic work up were both normal.

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CT scan of the brain was delayed for 10 days due to financial constraints.

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The only option available for treatment was a fourth ventriculoperitoneal shunt.

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However, the patient did well and was fine by 12 month of follow up.

Introduction and importance

Trapped fourth ventricle (TFV) also known as isolated fourth ventricle (IFV) is a rare clinico-radiologic entity with only a few cases reported in the literatures.

The aim of this article is to present the first case of this condition in our center and highlight the challenges of arriving at clinical diagnosis and treatment in a resource limited setting.

Case presentation

An 18 months old girl who had ventriculoperitoneal shunt insertion for post meningitic hydrocephalus 4 months earlier presented with restlessness, ataxia, fever and inability to control her neck of one-week duration. On examination she was restless and had retro-colis with a Glasgow Coma Scale (GCS) score of 11/15 (E4V2M5).

She had an associated facial and abducent nerve palsies with global hypertonia, hyper-reflexia and muscle power of 3/5.

She was initially treated for shunt infection and malfunction. However, shunt series and CSF analysis were within normal limits and CSF culture yielded no growth of microorganisms. A CT scan of the brain which was ordered earlier was delayed for 10 days due to financial constraints. The CT scan revealed a trapped fourth ventricle and slit lateral and third ventricle.

She had emergency fourth ventriculoperitoneal shunt inserted on the left because of the pre-existing supratentorial shunt on the right.

She did well after the surgery and was discharged on the 10th postoperative day. She was doing well 12 months after the surgery.

Relevance and impact

TFV may occur after insertion of VPS for post-meningitic hydrocephalus. This may present a diagnostic dilemma. Insertion of a second VPS may be an option in a resource limited setting.

Enterocele manifesting as recurrent anterior rectal prolapse: A case report

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There should be a low threshold to complete dynamic imaging for anorectal pathology.

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Defecography is particularly useful to identify enteroceles presenting as prolapse.

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Surgical approaches to rare pelvic floor defects must be individualized.

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Consult Urogynecology or Colorectal surgery for management of pelvic floor defects.

Introduction and importance

An enterocele is a true herniation of small bowel through the rectovaginal septum, most commonly occurring transvaginally. Although the prevalence of enterocele is not as low as previously thought, enteroceles manifesting transrectally or with rectal prolapse are exceedingly rare and without established surgical guidance.

Case presentation

A medically complex, oxygen-dependent patient presented with full fecal incontinence and transrectal enterocele associated with recurrent anterior rectal prolapse. This was diagnosed via defecography and repaired under regional anesthesia through an open transabdominal approach of posterior cul-de-sac obliteration, uterosacral ligament vaginal vault suspension and simplified ventral suture rectopexy. Surgical planning was determined through a multidisciplinary care-conference, with preference for an approach with minimal respiratory compromise and repair durability. Short-term, this patient has complete resolution of bulge symptoms, and improved fecal continence.

Clinical discussion

In addition to history and examination, dynamic imaging of the pelvic floor, specifically defecography, is particularly useful in identifying enteroceles that present as a component of pelvic organ or anorectal prolapse. As there are no established standard surgical treatment approaches for these rare conditions, surgeons must consider several points prior to proceeding: the repair of the defect, the symptoms the repair targets, and repair durability.

Conclusions

Complete assessment and specialist consultation should be pursued prior to surgical repair for anorectal pathology. For this patient, an open transabdominal native tissue repair under regional anesthesia was successful, emphasizing that approaches to surgical correction of such rare presentations must be individualized.

Jejunal gastric heterotopia presenting as perforation peritonitis in a middle-aged adult: A case report

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Jejunal gastric heterotopia rarely occurs and is usually congenital.

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Jejunal gastric heterotopia can be a rare cause of perforation peritonitis in adults.

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Our case is the presumed oldest jejunal gastric heterotopia patient presenting with perforation peritonitis ever reported.

Introduction

Gastric heterotopia rarely occurs in the small intestine beyond ligament of Treitz. Most cases of jejunal gastric heterotopia have been reported in children and young adults. Herein we report a case of jejunal gastric heterotopia presenting as a perforation peritonitis in a middle-aged adult.

Presentation of case

A 51-year-old male presented with abrupt onset abdominal pain of 1 day duration. Physical examination revealed abdominal tenderness and rebound tenderness as well as costovertebral angle tenderness. Abdominal computed tomography revealed pneumoperitoneum, suggestive of hollow viscus perforation. At emergency laparotomy, a perforation site was discovered in the jejunum 100 cm distal to the ligament of Treitz. On macroscopic examination, the mucosa contained a 3 × 4 cm ill-defined, shallow ulceration next to the perforation site. Microscopically, the mucosa surrounding the perforation site revealed gastric heterotopia which consisted of gastric foveolar epithelium along with abundant pyloric glands and a few fundic glands.

Discussion

To the best of our knowledge, this case is the presumed oldest jejunal gastric heterotopia patient presenting with perforation peritonitis ever reported.

Conclusion

Jejunal gastric heterotopia should also be considered in the differential diagnosis of perforation peritonitis in adults.

Pancreatic pseudocyst extending into psoas muscle mimicking acute complicated diverticulitis: A case report

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Pancreatic pseudocysts (PP) are known sequelae of acute and chronic pancreatitis.

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Pseudocyst extension into the psoas muscles have been rarely described.

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Pancreatic pseudocyst can also masquerade as complicated diverticulitis.

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This is a rare case of PP successfully managed with percutaneous drainage.

Introduction and importance

Pancreatic pseudocysts (PP) are known sequelae of pancreatitis. In this case, we present a patient with a pancreatic pseudocyst extending to the left psoas muscle, initially masquerading as acute complicated diverticulitis.

Case presentation

A 43-year-old male with previous episode of pancreatitis presented with a one-week history of abdominal pain. Physical examination revealed left lower quadrant tenderness. A computed tomography (CT) showed a large intraperitoneal fluid collection extending to the left psoas muscle with segmental inflammation of the descending colon. The patient was managed medically with empiric antibiotic therapy for concern of complicated diverticulitis. Ultrasound-guided percutaneous drainage was performed and fluid analysis showed lipase >20,000 U/L. The patient was discharged home with the drain. At one month follow up a repeat CT showed resolution of the left psoas fluid collection. The drain was removed and the patient remained asymptomatic at two month follow-up.

Clinical discussion

Pancreatic pseudocysts are well-known complications of pancreatitis. In this case, we describe extension of a pseudocyst to the left psoas muscle. We identified twelve previously reported patients diagnosed with PP involving the psoas muscles. Our case is unique as there is no previously published case in which a pseudocyst masqueraded as complicated diverticulitis. In analysis of the literature, most patients were managed with percutaneous drainage. Only 50% had documented complete resolution on follow up; of those 75% had undergone percutaneous drainage.

Conclusion

Pancreatic pseudocysts that extend to the psoas muscle can mimic acute complicated diverticulitis upon presentation. These may be effectively managed with percutaneous drainage.

Usefulness of 18F-fluorodeoxyglucose positron emission tomography for assessment of tumorviability after resection of granulocyte-colony-stimulating-factor -Producing cholangiocarcinoma-a case report

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Surgical case of Granulocyte-Colony-Stimulating-Factor -Producing Cholangiocarcinoma is limited.

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¹⁸F-fluorodeoxyglucose positron emission tomography is reported to be useful in diagnosis.

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¹⁸F-fluorodeoxyglucose uptake in bone marrow is characteristic in this disease.

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We used FDG uptake not only diagnosis but assessing tumor viability and determining the surgical indication after postoperative recurrence.

Introduction and importance

Granulocyte colony-stimulating factor (G-CSF)-producing intrahepatic cholangiocarcinoma is rare. Surgical cases with postoperative clinical course have rarely been reported.

Case presentation

A 63-year-old woman complained upper abdominal pain. Computed tomography (CT) showed intrahepatic mass measuring 9 × 9 × 9 cm in the left lateral segment. ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed high uptake by the tumor, with diffuse uptake in the bone marrow. An extended left lobectomy was performed to achieve complete resection. Histopathological examination showed poorly differentiated adenocarcinoma with no lymph node metastasis. Immunohistochemical analysis revealed that tumor cells produced G-CSF. After chemotherapy with S-1 regimen at 10 months after the operation, CT and FDG-PET detected lymph node metastasis in the peri-duodenal area and left kidney metastasis, with no FDG uptake in the bone marrow. Serum G-CSF was normal. Combination chemotherapy with gemcitabine plus cisplatin was administered, and, 12 months after liver resection, metastases were enlarged and FDG uptake in the bone marrow was detected again. Serum G-CSF was elevated at 71.6 pg/mL. The patient was enrolled in a clinical trial of chemotherapy with another regimen and was alive at 19 months after liver resection.

Clinical discussion

Because of rapid progression, rapid diagnosis and resection are important. FDG uptake in the bone marrow is characteristic in G-CSF producing tumor. In this case, FDG uptake in the bone marrow reappeared after the enlargement of recurrent lesions, followed by tumor enlargement.

Conclusion

FDG-PET was useful for differential diagnosis and to assess tumor viability and determine the surgical indication.

Emergency laparoscopic ileocecal resection for a low-grade appendiceal mucinous neoplasm with impending rupture: A case report

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Appendiceal mucinous neoplasms account for less than 1% of all cancers.

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LAMNs have an aggressive biological potential.

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Preoperative diagnosis of appendiceal mucinous neoplasms is difficult.

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Here, we used emergency MRI to identify nodules in the appendix before operation.

Introduction and importance

We report the case of a patient with a low-grade appendiceal mucinous neoplasm (LAMN) who underwent emergency laparoscopic ileocecal resection to avoid the metastatic spread of tumor cells due to an impending rupture.

Case presentation

A 55-year-old woman presented to our hospital with pain in the right lower quadrant of the abdomen. Computed tomography revealed a markedly tense appendiceal mucinous tumor with surrounding inflammation, and laboratory test results showed elevated serum C-reactive protein (7.47 mg/dL), indicating impending rupture of the appendix. Magnetic resonance imaging revealed nodules inside the appendix, suggesting the possibility of appendiceal cancer. We performed emergency laparoscopic ileocecal resection with regional lymph node dissection. The tumor was pathologically diagnosed as a LAMN without rupture.

Clinical discussion

LAMN is classified as a clinically malignant tumor because it can cause pseudomyxoma peritonei due to perforation or the presence of residual tissue. Although an appendectomy would be appropriate for LAMN if the tumor margin is secured, ileocecal resection with lymph node dissection is necessary when preoperative discrimination of appendiceal cancer is impossible.

Conclusion

Further studies of preoperative imaging for appropriate differential diagnosis were necessary.

Case report of a skip segment Hirschsprung's disease: A real phenomenon

INTRODUCTION AND IMPORTANCE

Hirschsprung's disease is a congenital anomaly that results from an incomplete craniocaudal migration and maturation of intestinal ganglion progenitor cells leading to distal intestinal aganglionosis. Skip segment Hirschsprung's disease is an extremely rare phenomenon. We report a case involving only the small bowel with confirmed colonic ganglionosis.

CASE PRESENTATION

A case report of a 14-month-old with a skipped segment involving the distal 50 cm of the small bowel associated with colonic ganglionosis is presented. A current review of the literature is discussed.

CLINICAL DISCUSSION

Our patient had persistent obstructive symptoms despite undergoing a technically good, ganglionic pull-through operation at an outside institution. A laparoscopic-assisted pull-through might have documented a small bowel wall diameter discrepancy.

CONCLUSION

Although rare, skip segment Hirschsprung's disease is a real phenomenon that paediatric surgeons should be aware of and could involve small and large bowels.

Metastatic renal cell carcinoma involving colon with unusual histologic features and diagnostic challenges: A case report

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Metastatic RCC in the colon, although very rare, should be kept in the differential diagnosis of patients with lower GI bleeding, particularly patients with a prior history of kidney mass or nephrectomy

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Most common type of primary or metastatic RCC is Clear-cell-type.

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We reported the first case of rhabdoid-RCC metastasizing to colon.

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In the absence of IHC-stains, rhabdoid-RCC may be misdiagnosed as soft-tissue-sarcoma or other poorly differentiated carcinomas.

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Our case exclusively occurred in a woman while colonic metastasis of RCC commonly occurring in males.

Introduction and importance

Renal cell carcinoma (RCC) accounts for 3% of all malignancies in adults, on its own being the 3rd most common urologic malignancy. Commonly RCC metastasizes to lung, bone, liver, brain but rarely to colorectum. Here we present the metastasis of RCC to colon with unusual histologic features.

Case presentation

A 40-year-old woman presented with abdominal pain and constipation. Colonoscopy showed an ulcerative mass 30 cm from anal verge. Subsequently, she underwent abdominoperineal resection of the involved portion of colon and the biopsy was sent to us for histopathological analysis. Grossly, it was a large fungating mass. Microscopic examination revealed a malignant neoplasm with polygonal cells, abundant eosinophilic cytoplasm, eccentric nuclei and prominent nucleoli. Immunohistochemistry confirmed the diagnosis of RCC.

Clinical discussion

Colon rarely infiltrated by metastasis from RCC and so far, around 25 of such cases have been reported in the literature. Most common metastatic type of RCC to gastrointestinal tract is clear cell type. In our patient, the type of the metastatic RCC to colon was RCC with rhabdoid features. RCC with rhabdoid features is rare (3–5% of all RCC), but it is highly aggressive with higher chance of metastasis, extra renal invasion and poorer prognosis.

Conclusion

RCC should be considered as one of the differential diagnosis of colorectal cancers. Appropriate immunohistochemical workup would then reveal the correct diagnosis.

Malignant haemangiopericytomas of omentum presenting as left inguinal hernia: A case report

Background

Hemangiopericytomas (HPC) are vascular tumors and can be found at any place where vessels are present. These were previously known as ‘extrapleural Solitary Fibrous Tumour’. These tumors may reoccur and metastasize after surgical excision. We present herein a HPC of the greater omentum, diagnosed as left inguinal hernia preoperatively.

Case presentation

A 61-year-old male, presented with a huge painless mass in his left inguinoscrotal region secondary to weigh-lifting associated with malaise and vague abdominal pain. A well-defined, non-tender, and firm mass was found at the left lower abdomen extending to the left inguinoscrotal region. Based on the examination, a diagnosis of indirect inguinal hernia was made. Abdominal ultrasound showed a heterogeneous, hyporeflective, and vascularized mass. Contrast-enhanced computed tomography scan identified a localized, extraperitoneal, heterogeneously hypodense, well-defined, and lobulated mass, with marked contrast enhancement. On exploration, an encapsulated large mass originating from the omentum with enormously dilated blood vessels was excised. On histopathology, a neoplastic lesion, composed of spindle-shaped cells and moderate cytoplasm was identified. The blood vessels appeared thin-walled with a staghorn appearance in hemangiopericytic pattern. Omental sections showed fibro adipose tissue with dilated lymphatics and thick-walled blood vessels. Features were consistent with a malignant HPC of 20 × 14 × 10 cm.

Conclusion

We present an unusual presentation of primary omental malignant HPC as an inguinal hernia, treated by complete surgical resection. These tumors are rare therefore, timely diagnosis is important for proper evaluation, diagnosis, and treatment. It also requires long-term follow up for better survival.

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Hemangiopericytoma (HPC), previously known as ‘extrapleural Solitary Fibrous Tumor’, is a vascular tumor.

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A well-defined, non-tender, and firm mass was found at the left lower abdomen extending to the left inguinoscrotal region.

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Based on the examination, a diagnosis of indirect inguinal hernia was made.

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CT scan showed a contrast enhancing, localized, extraperitoneal, heterogeneously hypodense, and lobulated mass.

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On exploration, an encapsulated large mass originating from the omentum with enormously dilated blood vessels was excised.

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On histopathology, features were consistent with a malignant HPC of 20 × 14 × 10 cm.

Endovascular management of contralateral gate maldeployment during EVAR: Case report of interventional technique

INTRODUCTION

Endovascular repair of infra renal aortic aneurysm is becoming the preferable method of intervention compared to open surgery due to the lower early morbidity rates. One of the complications during the procedure is contra-lateral gate (CLG) maldeployment. Learning the endovascular salvage options is necessary to avoid the morbidities of open surgical conversion.

PRESENTATION OF CASE

we present a case of maldeployment during an endovascular exclusion of aortic aneurysm in a high cardiac risk patient for whom an endovascular management was successful.

DISCUSSION

We discuss the detailed technical aspect in managing CLG maldeployment in our case as well as variable options from literature.

CONCLUSION

Despite the available possibility to convert to open, there are multiple endovascular bail out alternatives to manage maldeployment that can be successfully performed by experienced interventionalist.

Anaesthesia mumps after laparoscopic right hemicolectomy under general anaesthesia: A case report

INTRODUCTION

Anaesthesia mumps is an extremely rare postoperative complication that occurs following various surgical procedures after general anaesthesia. We aimed to contribute to the growing knowledge of potential clinical presentations, outcomes, and possible causes.

PRESENTATION OF CASE

A 93-year-old man experienced acute swelling of a unilateral parotid gland 1 day after laparoscopic right hemicolectomy under general anaesthesia. The symptoms he presented with were acute, non-tender swelling in the left preauricular and submandibular triangle with well-marginated, circular swelling of the buccal mucosa. Amylase level was within the normal range. Computed tomography showed left preauricular soft tissue swelling and enlargement and an enhanced left parotid gland exhibiting inflammation. The swelling subsided after 3 days of conservative treatment.

DISCUSSION

Anaesthesia mumps have been associated with a variety of surgeries, including colorectal surgery, and is a rare complication after the induction of general anaesthesia. Despite the few cases presenting with airway obstruction, the outcome for swelling of the parotid or submandibular gland is generally good.

CONCLUSION

Early awareness of anaesthesia mumps and close evaluation lead to a fair prognosis for scar presentation.

An unusual case of gardening ocular injury during Covid-19 lockdown

Introduction

Facial trauma are an important cause of serious ocular morbidity. In particular domestic trauma are a small part of total.

COVID-19 pandemic has been influencing our life in a way never seen before, people need to remain at home due to lockdown restrictions. In this scenario we are seeing an increase in the percentage of domestic facial trauma. In other hand pandemic has influenced the possibility of hospitalization, so daily based procedures increased their importance in global treatment planning.

Case presentation

A 58 yo man presented to our ward with a foreign body in left eyebrow. Trauma happened during gardening.

Clinical discussion

The importance of imaging to perform the right procedure has become more important during pandemic to reduce time of hospitalization.

Conclusion

CT scan and ophtalmology consult have been the guideline to avoid a more invasive treatment which was performed in an outpatient regimen with local anesthesia.

Innovative continuous-irrigation approach for wound care after deep neck infection surgery: A case report

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Deep neck infection is a life-threatening disease that invades deep neck space.

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Treatment for deep neck infection consists of antibiotics and surgical drainage with manually postoperative wound irrigation.

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The authors present a case in which an innovative continuous-irrigation approach was applied for wound care.

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This approach is an alternative approach for wound care in patients with deep neck infection.

Introduction

Deep neck infection is a life-threatening disease that invades deep neck space and potentially causes airway obstruction. Treatment for deep neck infection consists of antibiotic administration and surgical drainage with manually postoperative wound irrigation. We herein present a case in which an innovative continuous-irrigation approach was applied for wound care following surgical drainage.

Presentation of case

A 65-year-old woman presented with neck swelling and fever for 5 days. Computed tomography of the head and neck revealed a deep neck infection with abscess formation. The patient underwent surgical incision and drainage of the deep neck abscess. We employed an innovative continuous-irrigation approach for wound care after surgery using a double-lumen tube consisting of an inlet tube and an outlet tube. Saline water was continuously injected through the irrigation tube and suctioned from the draining tube. After 5 days of intensive irrigation, wound swelling and discharge was considerably reduced, and the wound had been closed.

Discussion

This patient with deep neck infection was successfully treated using an innovative continuous-irrigation approach for wound care after surgery. This approach exhibited several advantages. First, compared with intermittently manual irrigation, a continuous-irrigation device can more effectively keep a wound clean. Second, the automated design of this device can reduce the workload for clinical staff. Third, our device does not require expensive materials or complex technology.

Conclusion

This innovative continuous-irrigation approach is an alternative approach for wound care in patients with deep neck infection.

About an unusual penetrating cervical wound:Iron bar

Introduction

The majority of cervical wounds are linked to aggressions and attempted autolysis by knives or firearms.

Case presentation

the story is about a 35 -year-old man admitted to the emergency room for a penetrating cervical wound following an accidental fall in the workplace. The extremely long iron bar (concrete)has penetrated its neck on the right side.upon admission, the patient was conscious,hemodynamically and respiratory stable without sensory-motor deficit.

Surgical exploration is urgently decided under general anesthesia, from wich the foreign body is successfully removed.A follow -up examination at 4 months was without particularity.

Discussion

Penetrating neck injuries caused by objects such as rods or iron bars pose a significantly high risk of serious neurological damage.

Penetrating neck injuries can be life-threatening and functional.the extent of the lesions must be assessed precisely before removing the foreign body.

Conclusion

we report an exceptional case of a penetrating neck wound caused by a concrete iron bar.treatment should always be multidisciplinary and giving priority to vital structures and function.

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The majority of cervical wounds are linked to aggressions and attempted autolysis by knives or firearms.

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The management of trauma to the penetrating neck has gone from compulsory exploration of the neck to selective management.

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The care is multidisciplinary because it calls upon several stakeholders to know: the surgeon of head and neck, vascular surgeon and anesthesiologist and only an early appropriate treatment can reduce the sequel.

Cutaneous metastasis from esophageal basaloid squamous cell carcinoma: A case report

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Cutaneous metastasis of esophageal cancer is rare.

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Basaloid squamous cell carcinoma (BSCC) of the esophagus is a relatively rare histologic variant of squamous cell carcinoma.

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We reported a case of cutaneous metastasis from esophageal BSCC and was successfully treated with multidisciplinary treatment.

Introduction and importance

Basaloid squamous cell carcinoma (BSCC) of the esophagus is a relatively rare histologic variant of squamous cell carcinoma. Here, we reported a case of solitary cutaneous metastasis as the first symptom of esophageal BSCC and was successfully treated with multidisciplinary treatment.

Case presentation

A 67-year-old man visited a local hospital with symptoms of dysphagia and cutaneous nodules on his left shoulder. Fluorine-18 fluorodeoxyglucose positron emission tomography revealed hypermetabolic accumulations in the middle thoracic esophagus, right recurrent laryngeal nerve lymph node, and epidermis of the left shoulder. Esophagogastroscopy revealed an ulcerative and infiltrating type tumor in the middle thoracic esophagus. Based on histopathologic examination of the endoscopic biopsy and the resected cutaneous tumor, the patient was diagnosed as esophageal BSCC with cutaneous metastasis. The patient was treated with chemotherapy followed by chemoradiotherapy. The therapeutic effect was a complete response, which was sustained for 39 months.

Clinical discussion

Review of previous literature in the PubMed database revealed only been two case reports on cutaneous metastasis of BSCC. Advanced BSCC of the esophagus with distant metastasis has a poor prognosis. Therefore, in our case, future careful follow-up is required.

Conclusion

Esophageal BSCC with cutaneous metastasis can be successfully managed by multidisciplinary treatment, including local resection of the cutaneous metastasis, systemic chemotherapy, and chemoradiotherapy.

Case report--mechanical bowel obstruction with appendicitis without strangulation and leukocytosis

Intestinal obstruction is a common surgical emergency caused by varied conditions. Acute appendicitis is considered as one of the unusual cause of intestinal obstruction especially functional and very few cases of mechanical obstruction. Here we report a Case of 62-years-old male who presented here with a clinical picture of small bowel obstruction. On laparotomy, there was a dilated gut with long appendix having inflamed tip buried into adjoining mesentery and then appendectomy was done and obstruction was relieved. Also, bowel was found to be viable hence simple appendectomy was found to be sufficient treatment. Histopathological findings was suggestive of chronic fibrosing appendicitis. Hence, in cases of bowel obstruction in an elderly patients with clinical examination which was not typical for appendicitis can be managed with laparotomy and simple appendectomy when early intervention is made to avoid the risk of ischemia and gangrenous changes in intestinal mesentery which may require resection in later stages.

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Acute appendicitis is considered as one of the unusual cause of intestinal obstruction especially functional and very few cases of mechanical obstruction.

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A case of 62-years-old male who presented here with a clinical picture of small bowel obstruction.

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Bowel obstruction in an elderly patients with clinical examination which was not typical for appendicitis can be managed ---with laparotomy and simple appendectomy when early intervention is made to avoid the risk of ischemia and gangrenous changes in intestinal mesentery.

Acute colonic occlusion over endometriosis: About a case

The gastrointestinal tract is the most common site of extra pelvic endometriosis, with the rectum and sigmoid colon being the most frequently affected areas. Its diagnosis is still very difficult, especially when it manifests itself as an acute occlusion. We report the case of a patient admitted to the emergency room for an occlusive syndrome on a sigmoid process and who was operated on with colorectal resection and it was the anatomopathological examination that led to the diagnosis of endometriosis.

Sub-acute transverse colon volvulus an exceptional cause of large bowel obstruction: Case report

Introduction

The sub-acute form of transverse colon volvulus manifests with signs and symptoms of large bowel obstruction. The diagnosis is most often done intraoperatively. We report a rare case of transverse colon volvulus in a 65-year-old female patient with no particular pathological or surgical history.

Case presentation

Sub-acute transverse colon volvulus in an elderly woman with no pathological or surgical history. Manifested with signs and symptoms of colonic obstruction. Surgically treated by a two-stage procedure with good postoperative outcomes.

Discussion

The transverse colon volvulus represents only 2-4% of all colonic volvulus. We discuss the diagnostic and therapeutic approach of our case of transverse colon volvulus through a literature review.

Conclusion

Transverse colon volvulus should be considered as a differential diagnosis in the face of large bowel obstruction. Early diagnosis and treatment improve the prognosis.

Aneurysm of anomalous splenic artery arising from a splenomesenteric trunk: Review of the literature with a report of a new case

INTRODUCTION

Aneurysm of splenic artery arising from splenomesentric trunk is an extremely rare condition. The aim of this study is to report a new case with literature review.

PRESENTATION OF CASE

A 52-year-old housewife presented with mild central abdominal pain for two month duration. Abdomen was soft. Abdominal ultrasound examination showed a focal aneurysmal dilatation in the splenic artery (SA) near the portal vein. Abdominal computed tomographic angiography (CTA) revealed presence of the splenomesentric trunk with fusiform aneurysm (45 × 33 mm) of the proximal part of the SA. In supine position, through upper midline laparotomy incision, exploration of both superior mesenteric artery (SMA) and SA was performed, total excision of the aneurysm was done, the SMA was side-repaired and SA was ligated. The post-operative period was uneventful.

DISCUSSION

It is interesting to note that orthotopic SA aneurysms, most commonly present in the distal third of the artery, followed by the middle third, while in cases of splenomesentric trunk, all reported cases of anomalous SA aneurysms including the current one, showed the aneurysms to be located in the proximal portion or root of the SA.

CONCLUSION

Splenomesentric trunk is a rare anatomical anomaly, aneurysm of which is even rarer. It can be managed either by endovascular intervention or open surgery.

The diagnostic dilemma of a gallbladder volvulus: An unusual case report and review of the literature

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Gallbladder volvulus is a challenging radiological diagnosis.

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Hepatobiliary iminodiacetic acid (HIDA) scans demonstrate no filling of the gallbladder in gallbladder volvulus.

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Persisting cholecystitis symptoms in the absence of gallstones can be indicative of gallbladder volvulus.

Introduction and importance

A gallbladder volvulus is a rare medical condition requiring emergency surgery. There are 500 cases reported in the literature, and only 10 % have ever been diagnosed preoperatively. Gallbladder volvulus occurs when the gallbladder torts around the cystic duct and cystic artery resulting in occlusion of both structures and consequently, ischemia of the gallbladder. The diagnosis is challenging because the symptoms mimic cholecystitis without distinct radiological features specific for a volvulus.

Case presentation

In this article, we report the case of a 77-year-old female who underwent ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and cholescintigraphy, which all reported features of cholecystitis. She underwent a cholecystectomy on admission day 5 because of refractory pain despite treatment with intravenous antibiotics. Intraoperatively, she was discovered to have complete gallbladder torsion with gangrene. Post-operatively, she had immediate and complete resolution of pain, and made a rapid recovery.

Clinical discussion

We review the available literature to determine radiological characteristics specific to a gallbladder volvulus. Patients without cholelithiasis and incomplete filling of the gallbladder in a nuclear medicine scan should be evaluated for gallbladder volvulus.

Conclusion

Through this report, we suggest a high index of suspicion for gallbladder volvulus in elderly female patients with signs and symptoms of acalculous cholecystitis that have no resolution in symptoms with conservative management.

Salvage esophagectomy for local recurrent esophageal cancer after definitive chemoradiotherapy followed by photodynamic therapy: A case report

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We report a case of esophageal cancer treated with PDT followed by esophagectomy.

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We assessed the PDT effect on adjacent tissues based on surgery and pathology.

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PDT can cause intense inflammation in tissues adjacent to the tumor.

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The location should be considered when performing salvage esophagectomy after PDT.

Introduction

Photodynamic therapy (PDT) is performed as a salvage treatment for patients with residual or recurrent esophageal cancer after chemoradiotherapy (CRT). Although PDT is considered less invasive than salvage surgery, it is unclear how deep its effects are and whether it causes damage to adjacent tissues. Herein, we report a case of esophageal cancer treated with PDT followed by esophagectomy. In this case, we evaluated the effect of PDT on adjacent tissues based on surgical and pathological examination.

Presentation of case

A 58-year-old man with dysphagia was diagnosed with esophageal squamous cell carcinoma (SqCC; T1N0M0, Stage I) in the upper thoracic esophagus. He underwent definitive CRT with two courses of 5-fluorouracil and cisplatin every 4 weeks with 60 Gy of radiation. Twelve months after CRT, endoscopic examination revealed local recurrence, and PDT using talaporfin sodium was performed. The tumor recurred again 6 months after PDT, and robot-assisted thoracoscopic esophagectomy was performed as a definitive treatment. Tissues around the left side of the esophagus and thoracic duct were tightly adherent with severe fibrosis and were successfully removed by extended resection. Histopathological examinations showed that the esophageal wall and peri-esophageal tissue were replaced by fibrous tissue and this extended even beyond the tumor.

Discussion

The primary tumor was limited to the submucosal layer, and the target for irradiation had some longitudinal margins. Therefore, PDT can cause intense inflammation in tissues adjacent to the tumor.

Conclusions

It is necessary to consider the location when performing salvage esophagectomy after PDT.

Solid pseudopapillary epithelial neoplasm (SPEN) of the pancreas involving the distal body and proximal tail: A case report

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Presentation, diagnosis and management of SPEN of the pancreas, a rare pancreatic tumor.

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SPEN is more common in women and can be more locally invasive and aggressive in men.

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Treatment involves surgical resection of the tumor and follow-up for recurrence.

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It has an excellent prognosis following resection; hence early identification and treatment are essential.

Introduction and importance

Solid Pseudopapillary Epithelial Neoplasm (SPEN) of the pancreas is a rare cystic exocrine tumor of the pancreas most commonly occurring in women between 30 and 40 years of age. This case report aims to demonstrate the clinicopathological findings encountered and the management of a patient diagnosed with SPEN.

Case presentation

An 18-year-old woman with gradually progressive and intermittent abdominal pain in the epigastric region presented to our outpatient department. Physical examination elicited tenderness to palpation in the epigastric area, and imaging findings suggested SPEN of the pancreas involving distal body and proximal tail region of the pancreas. The tumor was resected, and the diagnosis was confirmed on histopathology examination.

Clinical discussion

SPEN is a slow-growing tumor with a low-grade malignant potential, found incidentally in asymptomatic patients and symptomatic patients present with abdominal pain. The average tumor size is about 4 to 6 cm in diameter. Imaging is essential for diagnosis, and distal pancreatectomy with splenectomy was the most commonly reported procedure.

Conclusion

It is crucial to consider a diagnosis of SPEN in women with abdominal pain in the epigastric region as early surgical resection of the tumor results in resolution and excellent prognosis.

Gossypiboma-an unusual cause of surgical abdomen and surgeon's nightmare: A rare case report

INTRODUCTION

The term Gossypiboma is used to describe a retained surgical sponge in body after surgical procedure. It is an infrequent but serious surgical complication which is seldom reported because of the medicolegal implications. It can present within days as a surgical emergency or years after the operation.

CASE PRESENTATION

We report a case of 30-year-old female who presented in emergency with acute pain abdomen and severe distention of abdomen. She had history of caesarean section 15 days ago at another hospital. On clinical examination and investigation, it appeared like a surgical abdomen. Contrast enhanced computed tomography suspected an intrabdominal Gossypiboma. On exploratory laparotomy there was a lump in left side of abdominal cavity. Retained surgical sponge was removed that confirmed the diagnosis of Gossypiboma.

DISCUSSION

Gossypiboma is a real, serious but preventable surgical complication. It affects the patient safety, cost of treatment and may cause mortality if there is delay in diagnosis and treatment. It is commonly seen in emergency and difficult surgeries. Its clinical presentation is extremely variable. It can cause acute surgical abdomen, that needs urgent surgical intervention.

CONCLUSION

Meticulous counts of surgical items with careful inspection of surgical site can lessen these complications. Radio frequency chip identification verification by barcode scanner can reduce the error rate.

A gastrointestinal stromal tumor of stomach presenting with an intratumoral abscess: A case report

Introduction

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract, GISTs of the stomach presenting as an intratumoral abscess are extremely rare, which necessitates emergency surgery, we report a case of a stomach GIST developing an intratumoral abscess, in whom emergency surgery was performed.

Presentation of case

A 68-year-old man presented with severe abdominal pain and a fever. Laboratory data showed an elevated white blood cell count and C-reactive protein level. Computed to mography scan showed a 15 × 10 cm cystic mass adjacent to greater curvature of the stomach, which contained air. Emergency laparotomy revealed A giant cystic gastric mass was observed. Sleeve gastrectomy were performed. Immunohistochemically, the tumor was diagnosed as a Gastric high risk GIST,and imatinib mesylate was initiated, The patient had an uneventful postoperative course and remains well.

Discussion and conclusion

Such rare cases can be diagnosed and treated properly with careful clinical evaluation, surgical resection and adjuvant chemotherapy with imatinib mesylate is still the mainstay and most effective treatment for GISTs to date.

Giant renal pseudoaneurysm complicating angiomyolipoma in a patient with tuberous sclerosis complex: An unusual case report and review of the literature

Introduction

Angiomyolipomas (AMLs) are uncommon benign lesions, which are composed of dysmorphic blood vessels, adipose tissue, and smooth muscle components. They tend to bleed because of the hypervascularity and the presence of small aneurysms, leading to life-threatening complications.

Presentation of case

A 31-year-old female was presented to the emergency service of our hospital, complaining of left flank pain for 1 week followed by hematuria for one day. Radiologic imaging showed the features of a giant renal pseudoaneurysm. Superselective embolization was applied and she had an uneventful recovery.

Discussion

The blood vessels in AML are tortuous and thick-walled with the absence of supportive elastic tissue, which tend to the formation of the intralesional pseudoaneurysm. The risk of bleeding is higher with tumors larger than 4 cm, rapid tumor growth, and aneurysms larger than 0.5 cm. Early detection and treatment are essential for the prevention of bleeding and improving patient outcomes.

Conclusion

Giant pseudoaneurysm in a renal angiomyolipoma associated with tuberous sclerosis complex is a rare entity, often leading to potentially life-threatening bleeding. Selective angioembolization is recommended as firstline therapy for bleeding AML and is increasingly used as a preventive treatment for AML at risk of bleeding. However, a high incidence of the recurrence requires caution and a close longtime follow-up. Surgical intervention is indicated if the hemorrhage is not responsive to embolization or if there is suspicion of malignancy.

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Renal pseudoaneurysm is a rare, but potentially life-threatening complication of tuberous sclerosis-related angiomyolipoma.

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Early detection is essential for the prevention of bleeding and improving the patient outcomes.

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Selective angioembolization is recommended as firstline therapy for bleeding angiomyolipoma.

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Surgical intervention is indicated if the hemorrhage is not responsive to embolization.

Malignant glomus tumor of the foot. Case report

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Malignant glomus tumor is exceedingly rare.

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Diagnosis is based on the histopathological examination.

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The group of glomangiosarcomas arising de novo considered the most aggressive.

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Wide local excision remains the treatment of choice.

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These tumors had high potential risk of metastasis.

Introduction and importance

Glomangiosarcoma or is an extremely rare tumor. Few cases are published in the literature.

Case presentation

We present a rare case of 64-year-old female patient presented small reddish subcutaneous nodules on the sole of the foot. Surgical resection revealed malignant glomus, the evolution was marked by an infiltrating local recurrence leading to amputation, without notable metastases after six months.

Clinical discussion

Malignant glomus tumor exhibit unusual characteristics, notably deep localization, large size and infiltration, mitotic activity, nuclear pleomorphism and mitonecrosis. The wide excision and possible amputation for infiltrating local type unresecable was the adequate treatment.

Conclusion

Glomangiosarcoma arinsing de novo are exceedingly rare and must be considered the most aggressive and with high potential risk of metastasis.

Catastrophic appendicitis operation, successful repair in tertiary limited resources hospital: A case report

INTRODUCTION

Acute appendicitis is one of the most common surgical diseases. Perforated appendicitis resulting in catastrophic complication because of a burst abdomen with necrotizing fasciitis of the abdominal wall is exceedingly a rare case.

PRESENTATION OF CASE

A 13-year-old girl with perforated appendicitis who had undergone laparotomy had to experience a burst abdomen with necrotizing fasciitis of the abdominal wall. The patient has temporarily closed the abdominal cavity with a urine bag (modified Bogota bag). After 23 times replacement of the Bogota bag and the condition of the sepsis and nutrition had improved, the abdominal wall reconstruction was performed by carrying out two random rotational flaps to close the abdominal defect. One year later, the patient came for ileocolostomy closure; then the patient was sent home with uneventful condition.

DISCUSSION

Perforated appendicitis is a type of acute appendicitis with a low morbidity rate. Compared to other complications, burst abdomen and necrotizing fasciitis (NF) in perforated appendicitis are exceptionally rare events. Surgery with sepsis and recurrent intra-abdominal abscesses as a result of previous surgery are the causes of burst abdomen. The use of abdominal drainage has also been shown to cause NF. Both of these conditions will increase the cost and length of stay, and reduce the quality of life. The rotational flap procedure is the procedure of choice for a large burst abdomen.

CONCLUSION

Surgeons should and have to perform a meticulous operation to prevent catastrophic complication and to increase the quality of life.

Gallstone ileus after recent cholecystectomy. Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Gallstone ileus in cholecystectomized patients is very infrequent and when it happens shortly after surgery is even rarer. We report the case of a patient who presented Gallstone ileus few days after open cholecystectomy which has not been reported before in literature.

CASE PRESENTATION

A 52-year-old male with a history of recent open cholecystectomy was referred to our center due to a presumable surgical complication. During his hospitalization while trying to restart the oral route he presented abdominal pain and nausea. He evolved toward a bowel obstruction. We suspected gallstone ileus based on medical history as well as preoperative image study. We confirmed the diagnostic using a Computed Tomography. Surgical management was performed and a large gallstone was extracted from the bowel. The patient progressed favorably and was discharged. He was asymptomatic during the follow-up.

CLINICAL DISCUSSION

Cholecystectomized patients who have been reported with Gallstone ileus demonstrate different pathophysiological mechanisms or extraordinary presentations. This case describes a unique presentation illustrating relevant aspects of this pathology such as showing that acute cholecystitis can be its clinical manifestation or that it could happen after a cholecystoenteric fistula is found during a cholecystectomy.

CONCLUSION

Gallstone ileus in cholecystectomized patients is very rare. Clinical suspicion remains the cornerstone of diagnosis.

Phytobezoar: An unusual cause of small bowel obstruction

Phytobezoars are concretions of indigested fruit and vegetables fibers in the gastrointestinal tract. The past of gastric surgery is most common risk factor of phytobezoar. We present the case of a 39-year-old female was admitted to the emergency department and who presented with small bowel obstruction due to phytobezoar, her past medical history was marqued by truncal vagotomy and simple suture recurrent perforated gastric ulcer 15 years earlier. Her postoperative recovery was uneventful.

Broad ligament pregnancy in the presence of an intrauterine contraceptive device: A case report

INTRODUCTION

Abdominal pregnancy though scarce is associated with considerable morbidity and mortality. Few cases till now have been diagnosed or managed by laparoscopy.

CASE PRESENTATION

In this study, a case of an abdominal pregnancy in a woman with intrauterine contraceptive device (IUD) in situ and a history of cesarean section is described.

CLINICAL DISCUSSION

Our case was a brief description of a broad ligament pregnancy as a subcategory of abdominal pregnancy .It was located medial to the pelvic sidewall, lateral to the uterus, inferior to the fallopian tube and superior to the pelvic floor.

CONCLUSION

The pregnancy was in the location of the left broad ligament which was diagnosed on laparoscopic evaluation.

Acute intestinal infarction caused by initially unexplained splanchnic venous thromboses in a patient with protein C deficiency: A thought-provoking emergency case

INTRODUCTION AND IMPORTANCE

Splanchnic venous thrombosis (SVT) originating in the superior mesenteric vein (SMV) is rare and may cause acute intestinal infarction (AII). Protein C deficiency (PCD) results in thrombophilia.

PRESENTATION OF CASE

Acute unexplained SVT originating in the SMV and portal vein was detected in 68-year-old man. Pan-peritonitis and AII were diagnosed and emergency surgery performed. Part of the small intestine was necrotic and partial resection without anastomotic reconstruction was performed. Heparin was administered intravenously continuously from postoperative day (POD) 1. Hereditary, heterozygous, type 1 PCD was diagnosed postoperatively. The anastomosis was reconstructed on POD 16. Warfarin was substituted for heparin on POD 22. No recurrent thrombosis occurred during 2 years of follow-up.

CLINICAL DISCUSSION

Patients with the rare condition of SVT require prompt diagnosis and treatment and may have underlying disease. PCD can cause SVT even in intact veins and anticoagulation therapy should be administered immediately postoperatively. Misdiagnosis and/or delayed treatment of SVT can result in AII, a life-threatening condition with a high mortality rate. Insufficient clinician awareness can result in serious mismanagement of patients with PCD and SVT; emergency patients with AII caused by unexplained SVT should therefore be further investigated for prothrombotic states and assessment of coagulation-fibrinolysis profiles to clarify the underlying mechanism.

CONCLUSION

We here present a thought-provoking emergency case of AII associated with acute SVT caused by underlying PCD that was successfully treated by two-stage surgery and anticoagulation therapy. This case provides a timely reminder for emergency clinicians and gastrointestinal surgeons.

A case report of primary isolated extrahepatic hydatid cyst of the soft tissues of the breast and thigh

INTRODUCTION

Hydatid Disease (HD), or hydatidosis or echinococcosis, is an endemic infection and a major public health concern in the Mediterranean region. At times it involves the primary soft tissues, such as in the breast and muscle, though this is quite uncommon even in endemic areas.

PRESENTATION OF CASES

A. A 31 year-old woman complained of a gradual progressive, painless lump in the left axillary tail of spence for two years. Examination revealed a firm lump measuring 5cm × 5cm, non-mobile, in the left axillary tail of Spence. B. A 32 year-old woman presented with mild and continuous pain in lateral aspect of left thigh. On examination, there was a round, non-tender, non-mobile mass in the lateral aspect of her left thigh. Preoperative imaging studies in both patients revealed evidence of HD. Both of the patients underwent surgery and received Albendazole twice per day for 10 days, before and three months after surgery.

DISCUSSION

The disease can be diagnosed by serological and radiological modalities, both of which are not definitive. Ultrasonography should be the first diagnostic modality of soft tissue HD, however, MRI can be used to understand clearly the surgical involvements of structures. The standard treatment of soft tissue HD is surgery using pericystectomy techniques, as well as anthelmintic therapy.

CONCLUSION

HD should be suggestive in soft tissues if mass is slowly developing and presenting with local extension, particularly in endemic countries. Excision of HD using pericystectomy technique is the first choice of intervention for HD of soft tissues.

Congenital bilateral dacryocystocoele: A neonatal emergency

INTRODUCTION AND IMPORTANCE

Bilateral congenital dacryocystocoele with intranasal extension is very rare and may lead to mild to severe respiratory distress, depending on the degree of obstruction, in an otherwise healthy newborn. If severe, an urgent surgical intervention may be life saving. Our aim is to alert paediatric surgeons to this rare condition. Early detection and early treatment with a minimally invasive surgical procedure may be life saving and prevent severe sequelae due to respiratory distress.

CASE PRESENTATION

We present a healthy newborn girl who was admitted to neonatal intensive care with progressive respiratory distress. After a full work-up, she was diagnosed with bilateral dacryocystocoele with intranasal extension and complete obstruction of the anterior nasal cavity. Emergency bilateral endoscopic marsupialization of the cysts with probing of the nasolacrimal duct was performed. The girl recovered without sequelae.

CLINICAL DISCUSSION

In congenital dacryocystocoele, coexistent obstruction of the valve of Rosenmüller and the valve of Hasner is observed. Subsequent intranasal protrusion with obstruction of the inferior nasal cavity may occur. The incidence is unknown, but if bilateral, it is very rare. In most cases, a dacryocystocoele is uncomplicated and may be treated conservatively. However, if intranasal protrusion occurs, and especially if the involvement is bilateral, it is a surgical emergency.

CONCLUSION

Early diagnosis with subsequent minimally invasive surgical treatment of bilateral congenital dacryocystocoele with intranasal protrusion may prevent serious complications due to respiratory distress.

Eighteen years lasting bronchial foreign body: A case report in Cameroon, sub-Sahara Africa

INTRODUCTION

Foreign body aspiration represents an important cause of morbidity and mortality during childhood. A neglected aspirated foreign body can last for years, leading to complications that are sometimes difficult to manage, dramatically affecting the quality of life of the patient.

CASE REPORT

We report the case of a 29-year-old female who presented with eighteen-year history of recurrent cough, choking, and respiratory infections following a foreign body aspiration. The course was complicated by a chronic secondary lung abscess, successfully managed by combined medical and surgical treatment.

DISCUSSION

In low-income countries like ours, foreign body aspiration is often misdiagnosed. The often delayed management due to low socioeconomic status can lead to serious complications. To the best of our knowledge, it is the longest period of bronchial foreign body retention reported in the medical literature in Africa.

CONCLUSION

Foreign body aspiration is common in childhood and requires early recognition and treatment, in order to avoid complications that can be very serious or even fatal.

Double central ray amputation of the third and fourth digits for recurrent giant cell tumors of the hand: A case report

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Recurrent giant cell tumor of bone of hand treated by double central ray amputation.

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Double central ray amputation results in acceptable functional outcome of the hand.

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Double ray amputation aims to decrease re-recurrence rates of recurrent GCT of hand.

Introduction and importance

Recurrent giant cell tumor of the bone (GCTB) of the hand is very rare to be encountered. Our aim is to alert the surgeons to such condition and double central ray amputation of the third and fourth digits could be an option which may reduce the chance of a re-recurrence and provide an acceptable functional outcome.

Case presentation

We presented a 25-year-old woman with a recurrent GCTB of the proximal phalanx of the middle finger of the right hand. Considering the recurrent case, a high suspicion of malignancy, and apparent soft tissue extension, the lesion was treated with double central ray amputation of the third and fourth digits through metacarpals.

Clinical discussion

Extraosseous soft tissue invasion of recurrent GCTB of the hand had an important role in the treatment recommendation. A balance must be considered between the risk of re-recurrence and the impact of radical resection on function. Double central ray amputation surgery was performed in order to decrease the risk of additional recurrences. Acceptable functionality of the hand as she scored 26/30 (86 % rating) evaluated by Musculoskeletal Tumor Society (MSTS) Scoring System and no signs of local re-recurrence were found for 6 months follow up.

Conclusion

Double central ray amputation of the third and fourth digits is a good option for management of recurrent GCTB of proximal phalanx of the third digits with gross soft tissue extension to adjacent fourth digits region.

Hajdu Cheney Syndrome due to NOTCH2 defect - First case report from Pakistan and review of literature

INTRODUCTION AND IMPORTANCE

Hajdu Cheney Syndrome (HCS) is a rare skeletal disease characterized by severe, progressive focal bone loss with osteoporosis, variable craniofacial, vertebral anomalies and distinctive facial features. It is inherited as an autosomal dominant disease although sporadic cases have been described in literature. Identifying these cases in clinical practice is important for proper diagnosis and management.

CASE PRESENTATION

We report a case of a 36-year-old male patient presented at metabolic bone disease clinic at the Aga Khan University Hospital with history of multiple fragility fractures and juvenile osteoporosis since childhood. DNA sequence analysis of the NOTCH2 coding sequence revealed a pathogenic variant in NOTCH 2, Exon 34, c.6426_6427insTT (p.Glu2143Leufs*5), consistent with a NOTCH2 related conditions including HCS.

CLINICAL DISCUSSION

The multitude of presentations associated with HCS are linked to the NOTCH2 gene, as Notch signaling is one of the core signaling pathways that control embryonic development. Hence, mutations in the Notch signaling pathway cause developmental phenotypes that affect various organs including the liver, skeleton, heart, eye, face, kidney, and vasculature.

CONCLUSION

To the best of our knowledge, nucleotide mutations of c.6933delT, c.6854delA, c.6787C.T, and c.6424-6427delTCTG were all determined to be novel, with c.6428T > C being the most common mutation found in literature. The c.6426_6427insTT mutation our patient was found to have via gene sequencing too appears to be a novel mutation, which has not previously been reported in literature.

Bartsocas-Papas syndrome: The first case report of severe autosomal recessive form from Indonesia

INTRODUCTION

Bartsocas-Papas syndrome (BPS) is an autosomal recessive form of Popliteal Pterygium syndrome (PPS). It is a very rare disease characterized by congenital craniofacial anomalies, popliteal webbing, and genitourinary and musculoskeletal anomalies. Almost all of the cases were reported in dead intrauterine pregnancies.

PRESENTATION OF CASE

We present a 10-month-old boy with bilateral complete cleft lip and palate, abnormal scalp hair, an absence of both upper eyelids, choanal atresia, syndactyly of the third and fourth fingers of the right hand, agenesis fingers on the left hand, bilateral popliteal pterygia, bilateral talipes equinovarus, agenesis of the toes of both lower extremities, intercrural webbing, an absence of testis, and scrotal anomaly. Multistage surgical correction was performed for the multiple congenital malformations.

CONCLUSION

We report the first case of BPS from Indonesia. Gradual management should be performed according to the patient's age and available facilities.

Bile leakage test in emergency hydatid liver cyst surgery

INTRODUCTION AND IMPORTANCE

In liver cyst hydatid surgery, presence of cysto-biliary communication (CBC) is important for the prevention of postoperative morbidity. If cysto-biliary connections are not obvious, diagnosis is not easy. Intraoperative bile leakage test has been shown to reduce postoperative biliary complications by revealing occult CBCs. However, bile leakage testing in emergency conditions such as hydatid cyst perforation has not been experienced so far.

CASE PRESENTATION

Here, a bile leakage test performed in a 23-year-old male patient undergoing emergency surgery due to the perforation of the hydatid liver cyst was presented. Following the treatment of perforated hydatid liver cyst and biliary peritonitis, a bile leakage test was performed. The common bile duct was cannulated with a 22G catheter, normal saline and parenteral lipid solution were given to demonstrate the CBCs, and leakage areas were suture ligated. The patient was discharged postoperatively without any problem.

CONCLUSION

We recommend detection and treatment of the CBCs even in emergency hydatid liver cyst surgery for prevention of postoperative biliary complications.