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

Acute abdominal syndrome revealing an intestinal amoebiasis: Report of two cases in Tunisia

Amoebiasis is a parasitosis, mainly caused by Entamoeba histolytica (E. histolytica). It is a common disease in tropical and subtropical regions. E. histolytica possesses different mechanisms of pathogenicity, and might lead to the invasion and lysis of the intestinal epithelium. Outside of the high-risk regions, acute intestinal amoebiasis is a very rare condition, often leading to misdiagnosis and death, if not promptly treated. We discuss the cases of 18 and 43 year-old men without medical history, who presented to the emergency department complaining of acute abdominal pain along with fever. Following imaging features and clinical presentation, appendicitis and a complicated form of Crohn's disease were respectively suspected. Given the severity of the symptoms, an explorative laparotomy was performed showing in both cases an inflammatory aspect of the intestine. Histological examination concluded intestinal amoebiasis, a diagnosis that wasn't suspected at first. The learning point of these cases is considering invasive intestinal amoebiasis in patients presenting with an acute abdominal syndrome, even with no history of traveling abroad or immunodeficiency.

GIST associated with von recklinghausen disease: Report of two cases and review of literature

INTRODUCTION AND IMPORTANCE

Neurofibromatosis type 1 (NF1), or Von Recklinghausen's disease, is an autosomal dominant condition that affects the central nervous system. Gastrointestinal stromal tumor (GIST) refers to non-epithelial tumors of the gastrointestinal tract lacking smooth muscle structural features and schwann cell immunohistochemical characteristics. The risk of patients with NF1 to develop a GIST is 7%.

CASE PRESENTATION

GIST is a soft tissue sarcoma that probably arises from the interstitial Cajal cells of the intestine. GIST associated with NF1 syndrome appears to have a distinct phenotype, occurring in younger patients compared to sporadic GIST.

CLINICAL DISCUSSION

The clinical presentation can be highly variable, the association of gastrointestinal tumors associated with Von Recklinghausen's disease is up to 7%, postoperative treatment with imatinib is reserved for patients with a high risk of recurrence.

CONCLUSION

The treatment of primary GIST is complete surgical resection with free microscopic margins and an intact pseudocapsule.

Retrograde intussusception causing small bowel obstruction in a 35 year old Female patient following a Roux en Y Bypass. Case report

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RI is a mysterious pathophysiology that is still uncommonly present post Roux en Y gastric bypass.

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Exploratory laparoscopy is a more confirmative diagnostic option.

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The state of the intussuscepted intestine determines the plan of treatment.

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The most adequate surgical treatment technique is still debatable.

Introduction

Intestinal intussusception is an uncommon entity when preceded by Roux en Y gastric bypass. Retrograde intussusception is an enigmatic phenomenon characterized by reversely intussuscepted intestinal loop that may involve any piece of the Roux en Y limbs. Computed Tomography is gold standard for diagnosis. Surgical management is highly debatable.

Case presentation

A 35 years old female known for morbid obesity, post roux en Y gastric bypass since 5 years with 100 % excess weight loss presenting for on-off episodes of small bowel obstruction symptoms. She was diagnosed laparoscopically for retrograde intussusception that was reduced easily with closure of Peterson’s pouch due to high suspicion of an internal hernia. She did well postoperatively and followed up adequately with no recurrence of her symptoms.

Conclusion

Retrograde intussusception remains an interesting uncommon phenomenon in the horizon of the roux en Y gastric bypass surgeries. Several surgical options were discussed in the last 12 years and they are still debatable.

Acute pancreatitis as an uncommon complication of hydatid cyst of the liver: A case report and systematic literature review

Hydatid disease is a major health problem worldwide. The liver is the most frequent location of hydatid disease. Acute pancreatitis secondary to liver hydatid cyst ruptured in the biliary tract is scarce and fewly described in literature. The management of this pancreatic complication of liver hydatid disease is challenging and includes a combination of surgical and endoscopic approaches. We report herein a rare case of hydatid cyst of the liver with cysto-biliary communication revealed by acute pancreatitis. A systematic literature review of similar cases reported was provided to compare surgical and endoscopic techniques. A thirty-year-old woman was referred to our emergency unit for acute pancreatitis. The CT-scan findings revealed a liver hydatid cyst ruptured in the biliary tract and daughter vesicles within were found, responsible for C-grade acute pancreatitis. We decided then to perform an emergency surgery through a bisoucostal incision. We performed a cholecystectomy and a peroperative cholangiogram that showed the communication between the cyst and left biliary tracts and the presence of daughter vesicle within the common bile duct. We conducted an exploration of the common bile duct with extraction of vesicle daughters. We left behind a T-tube in the common bile duct and we sutured the cysto-biliary fistula. Drainage was left in the remnant cavity after unroofing the cyst. Postoperative course was uneventful. Six months follow-up showed no recurrence. Cysto-biliary communication of liver hydatid disease revealed by acute pancreatitis is uncommon. We chose to perform emergency open surgery. However, through a systematic literature review, we noticed that endoscopic treatment is an efficient therapeutic and diagnostic tool to delay a morbid surgery of the liver and the common bile duct.

Gangrenous appendicitis in Amyand's hernia: Surgical approach under local anesthesia. Case report and review of the literature

INTRODUCTION AND IMPORTANCE

Amyand hernia is a rare disease seen in approximatively 1% of all hernias, complications of it, like acute appendicitis, or perforated appendicitis are even more rare, about 0.1%. Its diagnosis is very difficult in the preoperative period: it is usually an incidental finding.

CASE PRESENTATION

We report an unusual case of perforated gangrenous appendicitis with peri-appendicular abscess occurring in an irreducible Amyand's hernia. An 80-year-old male, with chronic obstructive disease and pulmonary emphysema, atrial fibrillation, acute myocardial infarction, underwent urgent surgery, under local anesthesia, for right incarcerated inguinoscrotal hernia. He was found to have a perforated gangrenous appendicitis with peri-appendicular abscess within a right indirect inguinal hernia sac. Appendicectomy and Bassini's hernia repair were performed under local anesthesia without any complications.

CLINICAL DISCUSSION

The treatment of Amyand's hernia is not standardized. The current generally accepted algorithm for Amyand's hernia is essentially contingent on the appendix's condition within the hernia sac.

CONCLUSION

Appendectomy and primary herniorrhaphy, under local anesthesia, for type 3 of Amyand's hernia, is a safe procedure and easy to perform and, if confirmed by further study, could be part of every surgeon's knowledge.

Giant cell tumor of distal ulna treated using en-bloc resection combined with extensor carpi ulnaris and flexor carpi ulnaris tendon stabilization: A case report

INTRODUCTION

Giant Cell Tumor (GCT) is a form of bone tumor which is rare, benign, and locally invasive. To date, there have not been many case reports regarding cases of GCTs on the distal ulna which made the optimum strategy in management remain controversial. In some reported cases, the patient was treated with wide excision followed by reconstructive procedure resulting in ulnar translation of the carpal bones and dynamic convergence of the ulna towards the radius.

PRESENTATION OF CASE

We documented a case of 29-year-old male with distal ulna GCT, treated with en-bloc resection combined with extensor carpi ulnaris and flexor carpi ulnaris tendon stabilization. The key objectives of GCT treatments are to avoid local recurrence with sufficient resection and to maintain the function of the limbs. Specific treatment options have been suggested for en-bloc resection with or without the need for ulnar reconstruction or stabilization, even prothesis. In this case, we excised the distal portion of the ulna with some soft tissue procedure for added stability.

CLINICAL DISCUSSION

Three weeks after the surgery, the patient was able to perform wrist flexion and extension, fingers abduction, adduction, and opposition with slight limitation. The DASH and PRWE score had improved gradually within 3 weeks and 6 months after the surgery.

CONCLUSION

In the subsequent evaluation after six months of the surgery, the patient achieved full restoration of forearm function without any limitation.

COVID-19 and active primary tuberculosis in a low-resource setting: A case report

INTRODUCTION AND IMPORTANCE

Most people infected with the COVID-19 virus will experience mild to moderate respiratory illness. But there are few studies that explain the clinical features of COVID-19 patients with active primary tuberculosis. In a low-resource setting, it is difficult to distinguish the clinical characteristics of COVID-19 from other respiratory diseases. Here, we briefly report the first case of COVID-19 with active primary tuberculosis in our low-resource institution.

CASE PRESENTATION

A fourty two year old diabetic Indonesian male was admitted to emergency department in November 2020 due to vertigo-like dizzines for one week, tension type headache, shivering, cough with sputum, abdominal pain, and night sweats. Xpert MTB-RIF Assay G4 detect Mycobacterium Tuberculosis Bacteria (MTB) without rifampicin resistance, but the Tubex test for antibody IgM anti-O9 was negative. Patient admitted to isolation ward for suspected COVID-19 with separate rooms due to tuberculosis, until 24 hours evaluation of nasopharyng and oropharyng swab test performed. On the second day, the evaluation swab test was positive for COVID-19.

CLINICAL DISCUSSION

Limited or no protection against COVID-19 is one of the problems that leads to co-infection. Now, there is no recommendation treatment for COVID-19 sufferer with tuberculosis co-infection or vice versa. Ventilation support and intensive care for infectious patient must be accessible, yet still unavailable in our institution.

CONCLUSION

A low resource setting has its own challenges in handling COVID-19. Further studies are needed to address the clinical characteristics, diagnosis and management in COVID-19 patients with active tuberculosis.

Emergency high ligation in a suspected COVID-19 pediatric patient with incarcerated inguinal hernia: A case report

BACKGROUND

SARS-Cov-2 infects not only adults, but also children, including pediatric surgery patients with acute abdomen. Here, we report a pediatric surgery case with incarcerated inguinal hernia and suspected COVID-19.

CASE PRESENTATION

A 11-month-old male was brought to our emergency department with the main complaint of recurrent yellowish-green vomiting that was experienced from one day before admission. High fever and shortness of breath were also reported. This patient was also suffering from moderate dehydration. Neither history of contact with a confirmed case of COVID-19 nor traveling from any local transmission area were found. However, a SARS-CoV-2 rapid antibody test revealed a positive result. A lump in the left scrotum that persisted during admission was found. Fluid resuscitation and nasogastric tube placement for decompression was performed. Manual reduction was attempted but failed to reduce the lump. Accordingly, we decided to perform an emergency high ligation using tertiary protection regulations, i.e., full personal protective equipment (PPE) for COVID-19. Intraoperatively, we found a small intestine loop trapped in the scrotum and stuck in the inguinal canal. Postoperatively, the baby was continued to be managed as a patient with COVID-19 while waiting for the real-time reverse transcription polymerase chain reaction (RT-PCR) results.

DISCUSSION

Manual reduction is standard treatment for incarcerated inguinal hernia in children. The successful rate of manual reduction is about 70%, therefore, if the manual reduction fails, an emergency surgery is mandatory.During the COVID-19 pandemic, all medical procedures require clarity of the patient's status including whether infected with COVID-19. Along with proper precautions, great care must be taken during surgery to minimize the risk of cross infection to health workers.

CONCLUSIONS

During the COVID-19 pandemic, surgeons should always be aware of the possibility of cross-transmission from the patient, since children are also susceptible to SARS-CoV-2 infection. When and wherever possible, surgeons should perform the procedure in the quickest and most effective manner to shorten exposure time with patient and anesthetic aerosols as well as using appropriate PPE.

Presentation and surgical management of a superficial temporal artery pseudoaneurysm: A case report

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Raise awareness of pseudoaneurysms as an uncommon but important differential diagnosis for masses in the head and neck region.

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Highlight the importance of excluding pseudoaneurysm prior to diagnosing a simple post traumatic haematoma.

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Discuss treatment strategies for superficial temporal artery pseudoaneurysms.

Introduction and Importance

A Superficial Temporal Artery Pseudoaneurysm is an uncommon, but important, differential diagnosis for masses in the head and neck region.

This work has been reported in line with SCARE 2020 criteria [1].

Case Presentation

An 81-year-old male presented to the Oral and Maxillofacial Department with a facial swelling that had been present for a duration of three weeks. A provisional diagnosis of a haematoma was made and an ultrasound carried out to confirm diagnosis. Ultrasonography and CT Angiography confirmed a pseudoaneurysm arising from the left superficial temporal artery.

Clinical Discussion

Although this is a relatively uncommon diagnosis it is important to be aware of the key diagnostic tools used to identify a pseudoaneurysm. Specifically, their potential to exclude a pseudoaneurysm prior to diagnosing a simple post-traumatic haematoma. This is important as the treatment strategies for the two pathologies differ considerably. Useful learning points from this case include diagnostic aids such as the unique pulsatile nature of the mass and the role of ultrasonography and CT Angiography in confirming diagnosis and guiding surgical management.

Conclusion

Pseudoaneurysms are an important consideration as a differential diagnosis of masses in the head and neck region. This case report may impact upon management of future similar cases by highlighting significant aspects of their clinical diagnosis and surgical management, enabling early identification and appropriate management.

Unusual Richter's Hernia: Impacted foreign body leading to incarceration and perforation - A rare clinical entity

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The knowledge about this type of hernia has especially gained importance in the context of laparoscopic surgery as majority of the laparoscopic port site hernias are characteristically Richter’s type in configuration.

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Clinical suspicion, prompt radiological diagnosis and timely surgery can lead to an uneventful recovery.

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Surgery is the only treatment, but timely surgery remains the golden opportunity.

Introduction & Importance

Richter’s hernia is a clinically deceiving entity as is particularly associated with high morbidity and mortality which can be can be abated by timely diagnosis and surgery. Direct inguinal hernias having a wide neck have lesser chances of incarceration and strangulation when compared to indirect inguinal hernias. The knowledge about this type of hernia is especially important in the context of laparoscopy as majority of the laparoscopic port site hernias are characteristically Richter’s type in configuration. The objective of this report is to highlight the unusual presentation of the case and sine quo non of prompt diagnosis and timely surgery remains the cornerstone of management.

Case presentation

We report a case of Richter’s hernia incarcerated due to an impacted foreign body (match stick) through a direct inguinal hernia. Patient presented with a painful, non-expansile, tender swelling in left groin. Patient was diagnosed with a complicated inguinal hernia and underwent exploration with resection of involved bowel segment and primary repair of hernia.

Clinical discussion

Richter’s hernia is a rare abdominal wall hernia specifically known for its unusual and delayed presentation leading to high rates of morbidity and mortality. Direct inguinal hernias are less prone to complications like obstruction, strangulation and incarceration owing to presence of a wide neck. Clinical suspicion, prompt radiological diagnosis and timely surgery can lead to an uneventful recovery.

Conclusion

Surgery is the only treatment, but timely surgery remains the golden opportunity. Critical in repair is the evaluation of intestinal viability.

Osteofibrous dysplasia-like adamantinoma versus osteofibrous dysplasia in children: A case report of challenging diagnosis

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Challenging diagnostic regarding diagnosis of Osteofibrous dysplasia and Osteofibrous dysplasia-like adamantinoma.

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There is controversy spectrum disease between adamantinoma and OFD-like adamantinoma and OFD in children.

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Histopathology and immunohistochemical staining for diagnostic OFD, OFD-like adamantinoma and adamantinoma.

Introduction

Osteofibrous dysplasia (OFD) and Osteofibrous dysplasia-like Adamantinoma have a similar appearance both in clinical and radiography, but different in its histopathology. Despite this similarity, the treatment and prognosis are different, therefore the diagnosis should be established precisely.

Case illustration

A three-year-old boy was admitted to hospital after falling on his lower leg. A bead size lump appeared on his tibia with pain and swelling, which later became enlarged. Diagnosis of osteofibrous dysplasia and adamantinoma was considered. We performed limb-salvage procedure by curretage, bone grafting, and internal fixation application. The histology section showed woven bone rimmed by polygonal osteoblast cell with intervening fibrous stroma and small nests of tumour cells raised the possibility of epithelial differentiation. The positivity for cytokeratin immunostaining confirmed the diagnosis as osteofibrous dysplasia-like adamantinoma. In this case it is a very rare spectrum of malignancy in children.

Discussion

These two tumor entities have identical radiographic characteristics, histopathology features the distinction between classic adamantinoma and OFD-like adamantinoma based on the predominant epithelial component. The relationship of osteofibrous dysplasia with adamantinoma is unclear. Several authors considered possible calling relationship osteofibrous dysplasia as “juvenile adamantinoma”. However, does not rule out the possible existence of de novo osteofibrous dysplasia not related to adamantinoma.

Conclusions

OFD-like adamantinoma and Osteofibrous Dysplasia had similar histopathology pattern, a pathologist must be aware of this feature and perform immunohistochemical staining for keratin particularly when the histopathological feature of osteofibrous dysplasia showed small nests of tumor cells within the fibrous stroma. diagnostic challenging and require multidisciplinary approach.

Giant Juvenile Fibroadenoma of the breast in a 13-year-old Pakistani girl with excellent cosmetic outcome after subareolar enucleation - A case report

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Diagnosis and management of giant juvenile fibroadenoma can be challenging.

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Maintaining symmetry after complete excision is tougher in developing breasts.

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Periareolar approach for subareolar fibroadenomas provides good cosmetic results.

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Benign tumor to breast size ratio up to 70% provides excellent cosmetic outcome.

Introduction

Fibroadenoma is the most common benign lesion of breast in young women, characterized by an aberrant proliferation of both epithelial and mesenchymal elements. It is termed giant fibroadenoma when it is larger than 5 cm or weighs more than 500 g with an incidence of 0.5–2% of all fibroadenomas.

Presentation of case

In this report, we discuss a case of a 13-year-old Pakistani girl who presented with a giant juvenile fibroadenoma in left breast and was treated by a subareolar lump excision through a periareolar incision with excellent cosmetic outcome. To the best of our literature search, this is the first case of giant juvenile fibroadenoma in an adolescent being reported from Pakistan.

Discussion

Surgical management of giant juvenile fibroadenoma in immature breast is challenging as it may either result in asymmetric defect or damage to developing breast tissue resulting in long term poor outcomes. Surgical decision should be carefully undertaken and reported for future reference in such cases.

Conclusion

The diagnosis and management of giant juvenile fibroadenoma can be challenging because these tumors clinically and histologically mimic phyllodes tumor due to their rapid growth and large size. Excision through a periareolar approach for fibroadenomas located in subareolar region provides good cosmetic results in these patients with minimal scar visibility.

Adults Hirschsprung's disease, a call for awareness. A Case Report and review of the literature

Hirschsprung's disease (HD) is an uncommon condition in adulthood; the term adult HD denotes diagnosis after the age of ten. Patients suffer from constipation for many years before the diagnosis is established. They have very characteristic radiologic findings; however, the diagnosis is confirmed with full thickness biopsies. We describe the case of a 19-year-old Caucasian female patient from Southeast Missouri with a history of chronic constipation who was referred to the General Surgery Department by her primary care provider (PCP) due to massive colonic and rectal dilation in an abdominal CT scan. After rectal biopsies were performed the diagnosis of Hirschsprung's disease was confirmed. She was referred to a tertiary center where she underwent a colo-anal pull through procedure. She has been doing well for three years. Diagnosis of this condition can be very challenging, hence the need for clinical suspicion, good quality biopsies and inter-specialty communication among PCPs, gastroenterologists, surgeons and pathologists. Surgery aiming to remove or bypass the aganglionic colonic or rectal segment is the standard of care; quality of life can be significantly improved after surgery.

Spontaneous colo-vesical and colo-cutaneous fistula complicating a sigmoid diverticulitis: A case report

INTRODUCTION

Diverticular disease is a challenge in western countries. The occurrence of fistula complicating diverticulitis is uncommon. As a result, spontaneous and synchronous colo-vesical and colo-cutaneous is an even rarer situation.

CASE PRESENTATION

We report the case of a 68 years old patient with medical history of bilateral inguinal hernia surgery and diverticular disease. He was admitted for fecal fistula through to the left inguinal area and recurrent urinary tract infections evolving for 2 months. Clinical examination revealed fecaluria and colo-cutaneous fistula. Abdominal CT scan revealed the presence of air in the bladder associated with fistula tract between the sigmoid colon and the inguinal abdominal wall. Surgical management was realized in two stages. The first stage, consisting to an end-colostomy, was performed. The second stage will be laparoscopic colectomy and is not yet realized. In the follow-up, the patient is doing well with a good quality of life.

CONCLUSION

Spontaneous colo-vesical and colo-cutaneous fistula is an uncommon complication of diverticulitis. There is no guidelines about the management and the treatment should be tailored according to each patient characteristics. Laparoscopic surgery is a feasible and safe approach in the treatment.

Parathyroid lipoadenoma: The particularities of a rare entity a case report and review of the literature

Parathyroid lipoadenoma is a rare and anusual cause of primary hyperparathyroidism. The clinical presentation usually resembles other causes of primary hyperparathyroidism and the imaging is not always contributory considering its location. However, the histologic criteria are specific. We present a case that supplements and supports the rare literature data concerning the clinical and therapeutic aspects of parathyroid lipoadenoma. The case is about a 73 years old female with a right inferior parathyroid lipoadenoma that caused biological primary hyperparathyroidism. Initially followed and treated in Rheumatology department for hypercalcemia and osteoporosis, she was sent to our structure to diagnose and possibly treat the causal etiology. After non-contributory clinical examination and ultrasound imaging, the tumor was diagnosed in the cervical CT scan. The patient underwent successful surgical removal of the lipoadenoma, confirmed postoperatively on histological analysis. The follow up showed rapid normalization of the parathormon level. Even if it's a rare condition, the diagnosis of lipoadenoma should always be considered in front of primary hyperparathyroidism with a parathyroid lesion.

An arcane case report of primary intramuscular hydatid cyst of thigh

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Intramuscular hydatidosis is an extremely rare manifestation of hydatid disease which is endemic in India.

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Patient presented with a large swelling over the left thigh and was diagnosed in a timely manner using a multimodal approach.

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The rare location of the disease is confounding and required thorough and meticulous evaluation.

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Upon surgical exploration, the presence of multiple cysts and daughter cysts proved to be challenging but complete pericystectomy was achieved.

Introduction

Hydatid diseases are a cystic parasitic infestation caused by Echinococci which are endemic to parts of India and commonly occur in agricultural workers. Primary intramuscular hydatidosis is a rare manifestation of hydatid disease.

Presentation of case

Our case report describes a rare case of primary intramuscular hydatidosis in an agricultural worker with no involvement of any other viscera. This was diagnosed with clinical evaluation, radiological modalities and managed surgically.

Discussion

Hydatid disease is endemic in parts of India. Primary intramuscular hydatidosis is uncommon because the lactic acid in the muscle and muscle contractility hinders the development of cysts making it improbable diagnosis on first presentation. Hydatid cyst demonstrates a wide variety of imaging features, which can vary according to growth stage, associated complications and affected tissue. The treatment of choice is complete surgical excision of the cyst along with thorough irrigation of the surrounding soft tissues combined with the use of systemic antiparasitic drugs after surgery.

Conclusion

In a patient of an agricultural background of cattle rearing living in an endemic region and presenting with a swelling in the musculoskeletal system, a suspicion of hydatidosis should always be kept in the clinicians mind, so that it can be diagnosed using a multimodal approach and managed properly in a timely manner.

Persistent Hypokalemia post SARS-coV-2 infection, is it a life-long complication? Case report

Introduction and importance

SARS-CoV-2 is a novel infection that has affected millions of people around the world. Complications of the infection may affect multiple systems including cardiovascular, neurological, gastrointestinal, urinary, and pulmonary systems. Hypokalemia, which is a life-threatening condition that may lead to arrhythmia and possibly death, has been noticed in more than half of the COVID-19 patients. Further understanding of the disease process and its complications is necessary to guide in preventing the complications from happening in the first place and finding treatment for patients with an already established complications.

Case presentation

A 34-year old male from Philippines who lives in Saudi Arabia - Riyadh and works as health care provider with no previous history of any medical illness. Presented by himself to the emergency department (ED) with dry cough, shortness of breath, fever, malaise, and fatigability for five days. On examination (RR 25), (T 38.6 °C) and (O2 89% Room air), on auscultation there was a decrease on air entry bilaterally with scattered crepitations, no wheezing or stridor. Covid-19 swab was positive, (Day 1) potassium 2.91 (mmol/L) magnesium (mmol/L) with normal baseline before getting infected.

Clinical discussion

Patient while in the hospital was on daily potassium oral and IV replacement with IV magnesium replacement. Investigation showed 24Hr urine potassium 47.3 (mmol/L), 24Hr urine magnesium 5.52 (mmol/L), 24Hr urine Creatinine 9.25 (mmol/L), (TTKG) Transtubular Potassium Gradient 18 and (VBG) PH:7.38, Pco2:44 (mmHg) Po2:55 (mmHg) HCO3:25 (mEq/L). Patient has an increased renal potassium loss with normal VBG on separate days and normal Blood pressure that excludes diseases with associated acidemia or alkalemia. Our patient didn't want to go for any invasive diagnostic procedures and favored to wait for spontaneous recovery.

Conclusion

We followed up the potassium level of our patient for more than 5 months since he was diagnosed with COVID-19 to find out that he is still having hypokalemia, as well as, hypomagnesemia. Long term complications of COVID-19 infection such as hypokalemia and hypomagnesemia need to be observed and followed up closely to avoid life-threatening arrythmias and seizures. The attention of the scientific community to possible long term or permanent complications is needed to help find preventive measures and treatment for patients with complications.

Glomangiopericytoma of the inferior nasal turbinate: A case report

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Glomangiopericytomas, which arises in the nasal cavity and may extend into the paranasal sinuses, is categorized as a borderline low malignancy tumor by the WHO classification.

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Complete transnasal endoscopic excision is the optimal treatment.

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A regular postoperative follow-up is recommended for early finding of tumor recurrence.

Introduction

Glomangiopericytoma is defined as a sinonasal tumor with perivascular myoid phenotype, which was first described in 1942 by Stout and Murray as a soft tissue tumor with characteristic proliferation including branching vessels and small vessel perivascular hyalinization.

The tumor accounts for less than 0.5 % of all sinonasal neoplasms. The World Health Organization (WHO) classified this tumor as glomangiopericytoma in 2005.

Case report

A 47-year-women presented with two years history of permanent left nasal obstruction and frequent epistaxis. Rhinoscopy revealed a friable grayish pink polypoidal mass, fully occupying the left anterior naris. Computed tomography showed a lesion involving the left nasal cavity, with a soft tissue density (70 UH) measuring 50 × 16 mm, widely infiltrative.

Endoscopic surgery was performed to remove the mass, considering the size, limited expansion and the accessible location of the tumor. The immunohistochemistry examination showed positive staining b-catenin tumor cells which confirmed the diagnostic of glomangiopericytoma.

After a 2 years follow-up, the patient showed no signs of recurrence.

Conclusion

Glomangiopericytomas generally arises in the nasal cavity and may extend into the paranasal sinuses. It is categorized as a borderline low malignancy tumor by the WHO classification. Complete transnasal endoscopic excision is the optimal treatment.

Early total care in polytrauma patient with floating shoulder and occlusion of bilateral subclavian artery: A case report

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Early Total Care (ETC) in polytrauma patient.

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Patient with multitrauma with ISS Score 25.

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Early definitive fracture fixation recommended in stable, borderline patient, and unstable patient that respond well to resuscitation.

Introduction

Fracture in polytrauma patients have higher risk of morbidity and mortality compared to those found in monotrauma patients. The ideal approach of orthopaedic injuries is to perform definitive fixation of all fractures in one single procedure, an approach known as Early Total Care (ETC).

Presentation of case

A patient presented with history of being struck by heavy material forklift. He complained of pain in the shoulder and difficulty in breathing. The patient was diagnosed with polytrauma ISS Score 25, which consists of floating shoulder, closed fracture of multiple ribs, open hematopneumothorax, and thrombosis of subclavian artery. The following procedures were performed: debridement, ORIF plate and screw of right clavicle, ORIF lag screw of right glenoid scapula, thoracotomy segmental lobectomy, bypass of bilateral carotid artery to bilateral brachial artery.

Discussion

An early surgical treatment is paramount in the management of this patient, with the aim of restoring the joint and blood flow to the distal part of the hand, which will allow for early motion and more effective physiotherapy for the patient’srecovery.

Early definitive fracture fixation in ETC in recommended in for stable patients and those who falls under the category of borderline and unstable patients who responds well to resuscitation. ETC allows for early mobilization and therapies for the patient.

Conclusion

Early total care is an appropriate choice of treatment for polytrauma patients presenting with floating shoulder.

Expanding the scope of rhomboid flap: Large cutaneous defect reconstruction. Case report

Introduction

and importance: Large cutaneous defects may result from excision of skin malignancies. Typically, skin grafting is used to manage such defects, but the final result may be compromised by inadequate take and poor cosmesis. Accordingly, transposition flaps may be indicated.

Case Presentation and clinical discussion: A 93-year-old female presented with a painful, necrotic 12 cm × 12 cm Squamous Cell Cancer of left upper back. She underwent wide excision followed by a rhomboid transposition fasciocutaneous flap. The flap was easily designed, quickly executed, and did not require any special instruments. The overall result was a good cosmetic outcome with no complications.

Conclusion

Our case outlines successful use of rhomboid flap instead of a more complicated option to reconstruct a very large cutaneous defect. The flap healed with excellent contour, texture, thickness, and color match.

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A very large cutaneous defect was caused by excision of a Squamous Cell Cancer in an elderly female.

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A rhomboid fasciocutaneous flap was easily designed, quickly executed, and inset without any special instruments.

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The patient healed uneventfully with excellent contour, texture, thickness, and color match.

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The excision design, flap elevation, rotation, inset, and post-operative photographs are included to educate readers.

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The case has been presented based on SCARE guidelines.

Porto-mesenteric vein thrombosis after laparoscopic sleeve gastrectomy. A case report

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Porta-mesenteric vein thrombosis (PMVT) is a serious complication that maybe seen after sleeve gastrectomy.

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Abdominal pain is the most significant symptom of PMVT.

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Some patients may develop life-threatening intestinal ischemic symptoms.

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Early diagnosis and anticoagulant therapy are very important.

İntroduction and importance

Porta-mesenteric vein thrombosis (PMVT) is a rare but fatal complication in patients who are undergoing bariatric surgery. In this report, we present a rare case of a PMVT after laparoscopic sleeve gastrectomy (LSG).

Case presentation

A 52-year-old male patient with a body mass index of 42 kg/m² was admitted to our clinic for morbid obesity. Standart LSG was performed with 5 trocar technique. 15 days after LSG, the patient admitted to the emergency department with complaints of abdominal pain, nausea and vomiting. The patient was dehydrated. His C-reactive protein level was 138 mg/L. Abdominal computerized tomography with contrast was performed and showed thickening of a part of small bowel wall in 10 cm length. Also, major trombosis were detected in the superior mesenteric vein branches and portal vein. The patient was hospitalized and 2 × 10,000 IU/1.0 mL high dosage low moleculer weight heparin (LMWH) therapy was initiated. The patient’s clinical signs recovered rapidly following treatment.

Clinical discussion

İn LSG, if the gastroepiploic venous arcus, which runs along the greater curvatura, and has a direct connection to the portal circulation is damaged, a local thrombus may form and move towards the portal system over time. Dehydration is another significant predisposing factor for PMVT. Some patients may develop life-threatening intestinal ischemia. Abdominal tomography with contrast plays a major role in diagnosis.

Conclusion

PMVT should be considered as a serious complication after LSG in patients with abdominal pain. With early diagnosis and anticoagulant therapy, patients’s clinical symptoms may improve quicly.

Intestinal perforation secondary to intestinal Burkitt lymphoma

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We experienced a case of small intestinal perforation caused by intestinal Burkitt lymphoma.

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Pretreatment BL may present with bowel perforation.

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This is the first report of such a case.

Introduction and importance

Small intestinal perforation in patients with Burkitt lymphoma is extremely rare. We present the first report of such a case.

Case presentation

A 53-year-old woman was admitted with abdominal pain and vomiting. Abdominal examination revealed rigidity and tenderness in the upper abdomen.

Computed tomography scan showed thickening of the wall of the jejunum, intra-abdominal free gas, and ascites; the patient was diagnosed with small intestinal perforation, and underwent emergency surgery on the same day. Laparoscopic findings were a 50 mm jejunal perforation and perforation in the transverse mesocolon. A partial jejunal resection of the perforated area, partial transverse colectomy, temporary colostomy, and intra-abdominal drainage were performed. Histological examination showed diffuse infiltration of medium-sized atypical lymphocytes in the perforated area, exhibiting a “starry sky” appearance.

Immunostaining results showed that the atypical lymphocytes were CD20 and virtually 100% Ki-67 positive, and CD56, CD30, and EBER negative. The lesion was identified as Burkitt lymphoma (BL). The postoperative course was favorable. On postoperative day 18 the patient began chemotherapy through the hematology department. Currently, the patient is in remission.

Clinical discussion

The majority of the malignant lymphomas occurring in the digestive tract are identified in the stomach; over 90% are B-cell lymphomas and mucosa-associated lymphoid tissue lymphoma Nakamura et al. BL originating from the small intestine accounts for only about 9%.

Conclusion

The incidence of BL in the small intestine is low. Pretreatment BL can lead to bowel perforation. Prompt involvement of the hemato-oncologist after definitive diagnosis, and commencing chemotherapy as early as possible after surgery, are thought to improve prognosis.

Traumatic bilateral isolated palsy of Flexor Pollicis Longus: an uncommon case report

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Flexor Pollicis Longus (FPL) is responsible for the flexion of the distal phalanx of the thumb.

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The innervation of FPL is provided by an isolated motor branch of the anterior interosseus nerve (AIN).

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We report a bilateral isolated paralysis of FPL after a trauma. Instrumental exams did not suggest any diagnosis.

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Surgical bilateral exploration of FPL allowed to diagnose a post-traumatic neuroapraxia sustained by connective bands.

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The release allowed the complete restoration of FPL function.

Introduction and importance

Flexor Pollicis Longus (FPL) lies in the volar compartment of the forearm and is responsible for the flexion of the distal phalanx of the thumb. The innervation of FPL is provided by an isolated motor branch of the anterior interosseus nerve (AIN), a branch of the median nerve. AIN disfunction causes symptoms of exclusive motor involvement concerning the FPL muscle. Solitary paralysis of the FPL is very uncommon in clinical practice.

Presentation of the case

We report the case report of a bilateral isolated paralysis of Flexor Pollicis Longus (FPL) that occurred after a trauma. Two years after the injury, no organic lesions were found and instrumental exams did not suggest any diagnosis. Surgical exploration of FPL and its innervation allowed to diagnose a pure post-traumatic bilateral neuroapraxia sustained by the presence of post traumatic connective fibrous bands.

Discussion

Diagnostic and therapeutic bands release allowed the immediate functional recovery of the nerve function and the consequent restoration of FPL function. The surgical exploration of the suspected injured nerve was the resolutive procedure for diagnosis and treatment of the disease. During the surgical exploration, the cause of FPL palsy was identified and removed with a complete recovery of the neuromuscular unit function.

Conclusion

This case is very peculiar because of the clinical presentation with an important bilateral functional limitation of FPL. The release allowed the complete restoration of FPL function. No similar cases were described in literature.

Surgical management of medial and lateral elbow instability secondary to acute atypical complex elbow dislocation: Case report and literature review

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The patient presented with an atypical complex elbow dislocation with fracture.

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The patient underwent lateral collateral ligament repair.

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The patient also underwent medial collateral ligament reconstruction.

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Elbow stability improved and the patient experienced improved functionality.

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Care is needed to identify and manage the underlying injury in this type of case.

Introduction and importance

Elbow dislocation is common in adults, and complex elbow dislocations are generally associated with bone fractures. Anteromedial coronoid fracture, in association with lateral collateral ligament (LCL) disruption, often results from varus posteromedial forces. “Terrible triad” injuries are more likely to result from valgus posterolateral forces. However, our case presentation has combined medial and lateral elbow instability in addition to “terrible triad” injury of the elbow with no radial head injury.

Case presentation

The patient was a 38-year-old man with an atypical complex elbow dislocation. He was successfully treated by stabilizing the medial epicondyle and coronoid anterolateral facet fractures, in addition to LCL repair and medial collateral ligament (MCL) reconstruction. A radial head fracture was unnoted. The procedure yielded satisfactory functional outcome, with a stable and painless full elbow range of motion.

Clinical discussion

Multi-ligament injuries with coronoid fractures result in highly unstable elbow joints, forming a variant of the “terrible triad” injury. Surgical options vary according to the surgeon’s experience and equipment availability. In this case, direct LCL repair and MCL reconstruction were performed and were well tolerated. Elbow stability improved and the patient experienced improved functionality with minimal pain. However, it may be premature to report a definite outcome in this case because of short follow-up time postoperatively.

Conclusion

The injury described in this case has a unique presentation as a multi-ligamentous injury will make the elbow very unstable. Thus, careful clinical judgment, knowledge, and experience are needed to identify the underlying injury and for optimal management.

Favorable survival with combined treatment in a metastatic breast cancer patient undergoing hemodialysis: A case report

INTRODUCTION

Management of breast cancer patients undergoing hemodialysis (HD) is difficult because of a lack of evidence about drug selection, dose adjustment, and surgical procedures. We herein present a case of metastatic breast cancer in a patient undergoing HD.

PRESENTATION OF CASE

A 58-year-old Japanese woman with breast cancer undergoing HD underwent total mastectomy of the left breast and left axillary dissection. Histopathological examination revealed invasive ductal carcinoma, and the diagnosis was pT2N3cM0 Stage ⅢC. Immunostaining of the resected specimen indicated that the tumor was estrogen receptor-positive, progesterone receptor-negative, human epithelial growth factor receptor 2-positive, and the Ki-67 labeling index was 70%. A postoperative positron emission tomography/computed tomography (PET/CT) scan indicated fluorodeoxyglucose uptake in the supraclavicular nodes. She received adjuvant therapy of epirubicin and cyclophosphamide followed by docetaxel, trastuzumab (T-mab) and radiation therapy. However, she developed multiple liver metastases during adjuvant T-mab and hormone therapy. Therefore, her regimen was changed to trastuzumab emtansine (T-DM1) as first-line therapy, T-mab, pertuzumab (P-mab), and eribulin as second-line therapy, and T-mab, P-mab, and weekly paclitaxel as third-line therapy. Eventually, she was administered fourth-line treatment of T-mab, P-mab, and vinorelbine because of adverse events. She has survived more than 25 months after the initial detection of recurrence of breast cancer and maintained quality of life.

CONCLUSION

We report a case of breast cancer in a patient undergoing HD. It is very difficult to identify the appropriate drugs and dosages in patients undergoing HD to improve survival and quality of life.

Metaplastic squamous cell breast cancer: A case report and treatment strategy during covid-19 pandemic

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Squamous cell cancer is one of the rarest forms of breast cancer with an incidence of 0.1–0.4% of all breast malignancies.

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Clinical and imaging findings in squamous cell cancer can mimic those of a benign disease.

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Aggressive and rapidly-evolving tumour without specific clinical and radiological features.

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No well-defined guidelines for the treatment of this rare cancer form.

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Role of Covid-19 pandemic in the delay of correct oncological treatment.

Introduction

Squamous carcinoma is a very rare breast cancer resulting from a differentiated squamous metaplasia. Its diagnosis is late due to the absence of specific clinical and radiological features.

Presentation of case

The authors present the case of a 39-year-old patient with the clinical onset of an inflammatory cyst diagnosed with mammography and cytological examination. After segmentectomy, on histological examination was defined as: “squamous keratinizing aspect”. In light of this report she was subjected to quadrantectomy with lymphadenectomy. She did not undergo radiotherapy treatment, which was delayed due to the ongoing pandemic. After a few months developed a local recurrence and underwent a mastectomy with multidisciplinary treatment.

Discussion

Squamously-differentiated metaplastic carcinoma of the breast is one of the rarest forms of breast cancer. Its etiopathogenesis is still unclear but some authors suggest that it originates from a squamous metaplasia deriving from the epithelium of cysts. This is a very aggressive and fast-growing tumour especially in young women, in fact the patient had a recurrence after a few months. She came to our attention 6 months after the initial surgery with a relapse at a local-regional level for which she was subjected to radical treatment and with a metastatic spread for which she was given the first-line chemotherapy treatment.

Conclusion

There are no well-defined guidelines for the treatment of this rare form of cancer. The case illustrates how the rapid aggressiveness of the disease requires adequate and immediate multidisciplinary treatment from the very beginning.

X-linked hypophosphatemic osteomalacia with PHEX mutation presenting late in Pakistan

Abstract.introduction.and.importance

Autosomal dominant hypophosphatemic rickets is the most common form of rare rickets, commonly manifests in children but sometimes the condition remains undiagnosed due to lack of knowledge &/or awareness of treating physicians or surgeons.

Case presentation

We describe a case of 43 years old female with multiple fragility fractures since childhood, corrected surgically but never investigated. She had stunted growth, bowing deformities and loss of teeth.

Clinical discussion

A detailed history and examination along with metabolic and genetic work up mounted the diagnosis of X linked hypophosphatemic osteomalacia. The pathophysiology involves the mutation or the loss of the phosphate regulating gene on PHEX, that causes reduced mineralization of bones and teeth.

Conclusion

Diagnostic delay in this patient resulted in increased disabilities affecting her mobility and lif estyle.

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Rickets represents diseases of divergent causes, characterized by defect in matrix mineralization.

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Hypophosphatemic rickets is the most common form of autosomal dominant rickets.

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It involves the PHEX mutation.

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Awareness of these disorders among clinicians remains a diagnostic challenge because of their rarity and wide variety.

Giant bladder stone with squamous cell carcinoma of bladder: Case report and the literature review

INTRODUCTION AND IMPORTANCE

Concurrent bladder neoplasm and giant bladder stone are rare in contemporary urological practice. Squamous cell carcinoma (SCC) is rare histologic diagnosis of bladder cancer.

CASE PRESENTATION

A 45 y.o. male, with lower abdominal pain when urinating, that comes and goes in the last 35 years. He had gross hematuria a year ago. The patient comes from a rural region, which undiagnosed for years. Physical examination showed a suprapubic abdominal solid mass, sized 20 × 10 cm, without tenderness. On plain radiography, showed radiopaque lesion which fully occupies the bladder. The ultrasound showed bilateral hydronephrosis. The patient underwent vesicolithotomy, and a giant bladder stone (size of 14 × 9 cm) was found, with incidental finding of suspicious malignant mass. The patient refuses radical cystectomy. Due to mass characteristics that are manageable for complete excision and the need for histopathological studies, bladder preservative therapy was applied with complete tumor excision and biopsy. The mass pathological diagnosis is grade 2 squamous cell carcinoma with lamina muscularis invasion, staged pT3bN0M0. The patient underwent cisplatin-based chemotherapy, with regular evaluation. The possibility of future radical cystectomy remains open.

CLINICAL DISCUSSION

By diameter, the stones found in our patient is perhaps one of the largest that ever reported being associated with bladder SCC. The bladder stones causing chronic mucosal injury, lead to the development of SCC. In limited situation, bladder preservation therapy may be considered for muscle-invasive bladder cancer.

CONCLUSION

Despite its rarity, SCC along with the chronic bladder stone is possible, and needs more attention.

Wheezing of unexpected etiology: A case report of pea aspiration mimicking bronchus obstruction caused by a tumor

Introduction

Geriatric patients with foreign body aspiration (FBA) lack a detailed medical history. Meanwhile, FBA can mimic other diseases and present with wheezing. Here, we report on the difficulty of making a diagnosis of FBA in an elderly man with wheezing.

Case presentation

An 84-year-old man presented with wet cough. He had progressive lung cancer, for which only supportive care was provided. His physical examination revealed wheezing. We presumptively diagnosed acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) and administered inhaled procaterol and parenteral methylprednisolone, which did not mitigate his symptoms. Computed tomography revealed a round nodule, 1 cm in diameter, in his right intermediate bronchus. Central airway obstruction (CAO) caused by the tumor was initially suspected. However, bronchoscopy revealed a pea (Pisum sativum) lodged in his right bronchus, which was removed using forceps.

Discussion

The typical clinical presentations of FBA are sudden-onset cough and dyspnea. However, some geriatric patients do not have cough or lack the cognitive capacity to inform of an episode of FBA. FBA can mimic other entities including AE-COPD and CAO, as seen in our case. Clinicians should not terminate the diagnostic process until all available information explaining the patient's signs and symptoms is collected.

Conclusion

Despite the lack of apparent aspiration, FBA is an important differential diagnosis of new wheezing in the elderly. Physicians need to carefully evaluate “trivial” information or collect additional information when encountering airway symptoms in elderly patients to avoid missing an FBA diagnosis.

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Geriatric patients with foreign body aspiration (FBA) lack a detailed medical history.

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FBA can mimic other diseases and present with wheezing.

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Clinicians should not terminate the diagnostic process early to avoid missing FBA.

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Availability and anchoring biases could be involved during the process to diagnose FBA.

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We should seek more information from accompanying persons to diagnose FBA early.

Malignant rhabdoid tumours of the small intestine with multiple organ involvement: Case report

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Malignant rhabdoid tumours (MRTs) are aggressive disease with poor prognosis.

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Small intestine is the rare site of MRTs and curative resection is important.

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Effective systemic therapies are needed for MRTs with multiple organ involvement.

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Clinical trials are ongoing to develop new therapies for MRTs.

Introduction and importance

Malignant rhabdoid tumours (MRTs) were first described as an infrequent variant of Wilms’ tumour and have been reported in several organs. The small intestine is a rare site for MRTs.

Case presentation

A 70-year-old man presented with appetite loss and melena. Haemorrhagic small intestinal tumours, swollen mesenteric and paraaortic lymph nodes, a tumour in the left kidney, and multiple tumours in the lung were found. He underwent partial resection of two haemorrhagic small intestinal tumours classified as MRTs based on the results of a pathological examination. However, melena appeared again on postoperative day 6. We performed another operation and resected approximately 180 cm of the small intestine that contained multiple tumours. All lesions were classified as MRTs. Unfortunately, melena appeared again 4 days after the second operation. He did not want invasive therapy and died from massive melena 2 months after the initial surgery.

Clinical discussion

MRTs of the small intestine are uncommon and have an extremely poor prognosis. Although curative resection is an important treatment, cases of metastasis at diagnosis and postoperative early recurrence have been observed, as was the case for the patient described herein. In these cases, effective systemic therapy is necessary. Recently, tumour suppressor genes were shown to be involved in the occurrence of MRT, and new therapies for MRT have been studied.

Conclusion

We herein conclude effective systemic therapy is necessary for MRTs with multiple organ involvement. The development of new drugs for this disease is ongoing.

A single-stage computer-guided gap arthroplasty with simultaneous patient-specific total joint replacement with a novel flat fossa design: A case report

INTRODUCTION AND IMPORTANCE

The computer-guided approach for the patient-specific TMJ replacement is considered an ultimate reliable option in advanced cases. However, dislocation of the condylar head could happen with the concave fossa design. A flat design was described and used in this case.

CASE PRESENTATION

A 15 years old male patient with mandibular asymmetry and class IV recurrent ankylosis of the right TMJ received a patient-specific artificial joint with computer-guided gap arthroplasty and orthognathic corrective mandibular surgery for the left side. The fossa component was made entirely flat, and the patient was followed up over the next year.

CLINICAL DISCUSSION

Customized TMJ prosthetic solutions are reliable in advanced cases, especially when facial corrections are indicated; however, the commonly used concave design showed reported dislocations requiring some design modifications as proposed in the presented case.

CONCLUSION

The flat fossa design of the artificial TMJ secures the same results as the anatomical fossa design without the incidence of dislocation.

Gastro-colo-diaphragmatic fistula after sleeve gastrectomy

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Gastro-colo-diaphragmatic fistula (GCD) following sleeve gastrectomy is an extremely rare complication.

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The clinical presentation of chronic fistula following sleeve gastrectomy varies widely and depends on the type of fistula.

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Management requires a multidisciplinary approach and patient cooperation

Introduction

Postsleeve gastrectomy fistula is a serious complication, and its management remains quite challenging. The clinical presentation of chronic fistula after sleeve gastrectomy (SG) varies widely and depends on the type of fistula. Management requires a multidisciplinary approach and patient cooperation.

Case presentation

We present a case of a 41-year-old woman with a body mass index (BMI) of 46 kg/m² who initially underwent laparoscopic sleeve gastrectomy in our hospital. Later, she developed a gastro-colo-diaphragmatic fistula (GCD), which was successfully treated using an endolaparoscopic approach. Follow-up imaging and endoscopy showed complete healing of the fistula, as well as a marked clinical improvement of the patient.

Discussion

Gastro-colo-diaphragmatic fistula following sleeve gastrectomy is an extremely rare complication. This is the first case of a GCD fistula after sleeve gastrectomy that has been reported in the literature.

Conclusion

One staged endolaparoscopic management was successful approach in our case and can be considered for complex gastric fistula following sleeve gastrectomy.

Total gastric necrosis following acute pancreatitis in a patient with COVID -19: Case report and literature review

The Coronavirus Disease Pandemic - 2019 (COVID-19) has spread to more than 200 countries worldwide, affecting more than 2 million people and >120,000 deaths, Acute pancreatitis of infectious origin can be caused by different viruses but currently no study has concluded that COVID-19 is directly responsible for acute pancreatitis. We report the case of a COVID-19 patient admitted to the emergency room in a state of respiratory distress associated with stage E pancreatitis according to the classification of balthazar whose surgical exploration found total necrosis of the stomach. A total gastrectomy was performed with an esophagostomy and a wide drainage of the abdominal cavity, the postoperative sequelae were marked by the death of the patient at D6 postoperatively by cardiorespiratory arrest.

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The Coronavirus Disease Pandemic - 2019 (COVID-19) has spread to more than 200 countries worldwide, affecting more than 2 million people and >120,000 deaths.

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Acute pancreatitis of infectious origin can be caused by different viruses but currently no study has concluded that COVID-19 is directly responsible for acute pancreatitis.

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We report the case of a COVID-19 patient with stage E pancreatitis whose surgical exploration found total necrosis of the stomach.

Pancreaticoduodenectomy after transcatheter aortic valve implantation in an elderly patient with severe aortic stenosis and pancreas cancer: A case report

Introduction and importance

Not only pancreatic cancer but also aortic stenosis (AS) is increasing with the aging population. There is no optimal strategy for elderly patients with both pancreatic cancer and AS. We report a case of pancreatic head cancer with severe AS undergoing pancreaticoduodenectomy (PD) after transcatheter aortic valve implantation (TAVI).

Case presentation

An 88-year-old woman was referred to our hospital because of severe AS with symptoms of heart failure. Preoperative examination revealed resectable pancreatic head cancer, so TAVI was performed before PD to reduce the perioperative risk. The patient underwent PD 34 days after TAVI, with no significant postoperative complications, and was transferred to the other hospital for rehabilitation on postoperative day 45. No recurrence was observed at more than 7 months without adjuvant therapy.

Clinical discussion

Aortic valve replacement (AVR) is recommended before non-cardiac surgery in patients with symptomatic severe AS. Surgical aortic valve replacement (SAVR) is the standard treatment. However, owing to the highly invasive procedure and increased perioperative risk, SAVR is usually avoided in elderly patients with malignancy and severe AS. We demonstrated that TAVI followed by PD could be safely performed in high-risk elderly patients presenting with both severe AS and pancreatic head cancer. To our knowledge, this is the first case report of PD after TAVI in a patient with severe AS.

Conclusion

We demonstrated that TAVI followed by PD could be safely performed in high-risk elderly patients presenting with severe AS and co-existing malignancy.

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Severe aortic stenosis (AS) is a risk factor for non-cardiac surgery. In some cases, prior treatment of AS is recommended.

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Minimally invasive transcatheter aortic valve implantation (TAVI) may be a treatment option for the elderly cancer patients.

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Preceding TAVI may be a useful therapeutic strategy for elderly cancer patients with severe AS.

A rare case report of an ilio-psoas abscess due to entero-retroperitoneal fistula from gallstones post cholecystectomy

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Ilio-psoas abscess due to gallstone entero-retroperitoneal fistulation post-cholecystectomy has not been reported previously.

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De-novo stone formation in the CBD can occur post-cholecystectomy and can lead to complications.

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Surgeons should consider gallstones as a differential in small bowel fistulation.

Introduction and importance

This is a novel case of a 50-year-old female presenting with several months of left iliac fossa pain, on a background of a cholecystectomy 5 years prior. The aetiology of her pain was an ilio-psoas abscess secondary to an entero-retroperitoneal gallstone fistula, a condition not previously reported in the literature.

Case presentation

CT imaging revealed an abscess superior to the left psoas muscle, with a clear fistula to the small bowel and two calcified stones at the site of the fistula.

The patient was managed operatively, with the fistula disconnected and a 5 cm section of small bowel disconnected.

Clinical discussion

This is a novel case whereby a left sided iliopsoas abscess occurred due to entero-retroperitoneal fistulation of gallstones several years after the patient underwent laparoscopic cholecystectomy. Gallstone fistulation from within the small bowel does not appear to have previously been documented and the exact pathogenesis is unknown.

Conclusion

Gallstones should remain an important, albeit rare, differential diagnosis of small bowel fistulation and abscess formation following cholecystectomy.

"A hybrid approach for GISTs near the esophagogastric junction, a case report"

Introduction and importance

Gastrointestinal stromal tumors are the most frequent mesenchymal tumors of the gastrointestinal tract. Complete resection of GISTs is the only chance of cure for patients. When these tumors are located near the esophagogastric junction, the surgical risk can cause deformity or stenosis in the gastric inlet, leading to higher complications and diminishing their quality of life. In such cases, a more sophisticated and tailored approach should be used.

Case presentation

We present the case of a 42-year-old female; she presented to our office with a 3-year history of nausea, vomiting and abdominal distension. Two GISTs were located near the EGJ, and with a combined approach we achieved complete resection. On follow-ups, the patient is doing well.

Clinical Discussion, Conclusion

When diagnosis is confirmed, surgical resection must be the first choice for GISTs as complete surgical excision is the only permanent cure. The rise of endoscopic surgery has become a valuable tool and a critical element in surgery. Hybrid techniques that combine laparoscopic and endoscopic approaches can improve the patient's outcomes and provide better results.

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The rise of endoscopic surgery has become a valuable tool and a critical element in surgery.

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Early histologic diagnosis and surgical resection is the most reliable way to improve patients' quality of life.

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The surgical decision will be what define the future of the patient and, ultimately, his life.

Case report of multiple mesenteric mycotic aneurysms after perforated appendicitis

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Mesenteric mycotic aneurysms after perforated appendicitis are extremely rare.

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Optimal treatment options are debatable.

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Successful treatment can be achieved by embolization and long-term antibiotics.

Introduction and importance

Mycotic aneurysms are a severe and sometimes life-threatening complication of infections or sepsis. However, mycotic aneurysms of mesenteric arteries caused by a purulent peritonitis following perforated appendicitis are very rare and not previously reported. This case report contributes to the awareness and treatment of this rare complication.

Case presentation

We present a case of a middle aged patient with a purulent peritonitis after perforated appendicitis. Postoperatively, recovery was not as expected. One week after laparoscopic appendectomy, CRP increased and haemoglobin levels dropped. Abdominal CT imaging revealed several mesenteric mycotic aneurysms. Because of aneurysmatic rupture, coiling of several mesenteric arteries was performed, despite the risk of bowel ischemia. After long-term antibacterial and antifungal treatment, the patient recovered completely.

Clinical discussion

Formation of mycotic aneurysms in mesenteric arteries is very rare and optimal treatment options are debatable. Given the high mortality of conservative therapy with antibiotics alone, treatment of mycotic aneurysms by surgery or endovascular treatment is strongly advised. In our case, it was decided to treat the aneurysms by endovascular coil embolization and to observe whether bowel ischemia would occur, because aneurysms were present in multiple mesenteric arteries.

Conclusion

Mycotic aneurysms of several mesenteric arteries should be considered as a rare but potential complication of perforated appendicitis with purulent peritonitis. In case of rupture, successful treatment can be achieved by embolization followed by long-term antibiotics. A multidisciplinary approach including surgery, interventional radiology and microbiology is highly recommended and transfer to a tertiary referral centre should be considered.

Meniscal bearing dislocation following minimally invasive Oxford medial unicompartmental knee arthroplasty treated with simple open reduction: Case report

INTRODUCTION

Dislocation of polyethylene insert is one of the most common complications of mobile bearing-medial unicompartmental knee arthroplasty (MUKA). Bearing dislocation was diagnosed by radiograph examination in these cases upon trivial injury.

CASE PRESENTATION

We reported one case of meniscal bearing dislocation after an Oxford MUKA treated with a simple open reduction technique.

CLINICAL DISCUSSION

Simple open reduction surgery without change of the bearing and the use of knee brace for 6 months was effective in preventing re-dislocation.

CONCLUSION

Mobile bearing dislocation is one of the most common complications in mobile-bearing MUKA. Besides the prevention of technical errors, usage of UKA with a frequency of 10-15 per year is recommended to increase the surgeon's learning curve.

Primary pulmonary lymphoepithelioma-like carcinoma with positive expression of Epstein-Barr virus and PD-L1: A case report

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Pulmonary lymphoepithelioma-like carcinoma (LELC) is extremely rare in Japan.

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None of the studies regarding LELC in Japan described an association with PD-L1.

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This is the first case of LELC in Japan with both expression of EBER-ISH and PD-L1.

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An investigation of PD-L1 would be useful considering the PD-1/PD-L1 blockade.

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Thus, PD-L1 expression should be examined in patients with pulmonary LELC.

Introduction and importance

Pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare type of non-small cell lung cancer (NSCLC) that is classified as a subtype of unclassified carcinoma by the WHO. LELC is usually associated with Epstein-Barr virus (EBV) infection. LELC has often been observed in Southeast Asia; however, it is extremely rare in Japan.

Case presentation

A 60-year-old Japanese woman presented with an abnormal shadow in the left lung on chest radiography. Chest computed tomography showed a nodule located between the lingular and basal anteromedial segments. A blood test suggested an existing EBV infection, and LELC was suspected preoperatively in the transbronchial lung biopsy. She underwent a lingular and basal bi-segmentectomy. The EBV-encoded small ribonucleic acid in-situ hybridization (EBER-ISH) was positive, and she was diagnosed with LELC. Moreover, programmed death-ligand 1 (PD-L1) expression was moderately positive. No recurrence was observed for 30 months.

Clinical discussion

Although LELC has been reported as a low-grade malignancy with a good prognosis, the frequency of PD-L1 expression in LELC seems to be higher than that in other NSCLCs. Moreover, it has been reported that LELC patients with high PD-L1 expression are likely to have early recurrence/metastasis and poor prognosis.

Conclusion

An investigation of PD-L1 expression for LELC would be useful considering the benefit of PD-1/PD-L1 blockade in patients with pulmonary LELC with high PD-L1 expression. The present case is the first report of LELC with positive expression of EBER-ISH and PD-L1 in Japan.

Long-term survival after surgical resection of metachronous lung, brain and thyroid gland metastases from rectal cancer: A case report

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Brain and thyroid metastasis of rectal cancer are uncommon, and prognosis are poor.

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Lung, brain and thyroid metastasis of rectal cancer was resected metachronous.

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This case survived 19 years after the initial rectal surgery.

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Patients whose metastases were resected completely may get a prolonged survival.

Introduction and importance

Brain and thyroid metastasis from rectal cancer are uncommon, and the prognosis is poor. We report a patient with rectal cancer who developed metachronous lung, brain and thyroid metastases. Each metastatic lesion was curatively resected resulting in prolonged survival.

Case presentation

A 60-year-old male underwent rectal cancer resection, and the pathological diagnosis was tubular adenocarcinoma, pT2,pN1a,M0, pStageⅢa. Ten years after rectal resection, a solitary tumor in the left lung was detected. The tumor was resected thoracoscopically and the pathological diagnosis was metastatic tumor. Three years after the pulmonary resection, a solitary brain tumor was detected. The tumor was removed surgically, and the pathology was metastatic tumor. Two years after brain resection, a thyroid mass was detected. A partial thyroidectomy was performed and the pathology with immunohistochemical staining confirmed the thyroid lesion as a metastasis from the previous rectal cancer. Four years after thyroid resection (19 years after the initial rectal resection), he died from multiple lung and bone metastases.

Clinical discussion

Colorectal metastases to the brain and thyroid gland are uncommon and are usually found with other distant metastases. Overall survival has been reported to be extremely poor. In this patient, lung, brain, and thyroid metastases were solitary and metachronous, and each lesion was curatively resected. Surgical treatment might contribute to prolonged survival.

Conclusion

The treatment strategy of each patient should be individualized and depends on the timing of metastasis development. Selected patients with complete resection of metachronous metastases may have prolonged survival.

Resection of liver metastasis from submandibular gland carcinoma five years after the primary operation: A case

Introduction

Liver metastasis of submandibular gland carcinoma is not uncommon, yet its optimal management is still unclear. We report a case of resection of liver metastasis from submandibular gland carcinoma five years after the primary operation.

Case presentation

The patient was a 76-year-old male who had undergone resection of primary adenoid cystic carcinoma of the submandibular gland in 2012. On follow-up computed tomography (CT) five years after the initial operation, a tumor was found incidentally in hepatic segment 6. Magnetic resonance imaging (MRI) confirmed the lesion's presence. Based on imaging findings and medical history, the lesion was suspected to be a liver metastasis of the previous submandibular gland carcinoma. The patient underwent hepatic posterior sectionectomy. His postoperative course was uneventful except for minor bile leakage that subsided without surgical intervention, and he was discharged on postoperative day 25. Postoperative pathological examinations of the hepatic tumor showed exactly the same features seen in the primary submandibular gland carcinoma, and the diagnosis as metastasis from this carcinoma was confirmed.

Discussion

Liver resection may be a reasonable choice of treatment for liver metastasis of submandibular gland carcinoma. Further evidence from studies with larger patient populations must be accumulated to confirm this.

Conclusion

We report our experience with a case of liver metastasis from submandibular gland carcinoma, which was resected five years after the primary operation.

Minimally invasive surgery with adenocarcinoma of jejunum diagnosed pathologically before surgery: A case report

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Adenocarcinoma of jejunum is a very rare malignant tumor worldwide.

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Small intestine cancer is difficult to diagnose histologically before surgery, and whether it is diagnosed before surgery has an important influence on the surgical method.

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Multidisciplinary treatment was conducted to diagnose small intestine cancer and determine treatment options, which is a global trend.

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In this case, the preoperative balloon endoscopy was used to diagnose small intestine cancer histologically, as well as the location of the lesion, so that the operation could be performed by laparoscopy.

Introduction and importance

We report a rare case of a patient diagnosed with adenocarcinoma of the jejunum.

Presentation of case

The patient was a 58-year-old female patient who was tested for vomiting and dyspeptic symptoms at a local hospital and visited the hospital due to suspected small bowel obstruction. CT enteroscopy performed at our clinic revealed “progression of focal wall thickening in small bowel with proximal bowel dilatation”, and it was necessary to differentiate between malignant and infectious lesions. Balloon enteroscopy was planned for endoscopic observation up to the small bowel. The biopsy result was confirmed as adenocarcinoma with moderated differentiated. The patient underwent small bowel resection and anastomosis using standard laparoscopic surgery. Jejunum resection was performed by securing a safety margin of 10 cm or more, and sufficient LN dissection was also performed. The patient was discharged from the hospital without any specific complications, and as a result of pathology examination, it was confirmed as a stage 2 high risk group, and further treatment is in progress.

Clinical discussion

There are few reports of patients diagnosed with adenocarcinoma of the jejunum through symptoms of obstruction of the small intestine.

Conclusions

We report on a case of laparoscopic surgery for a rare jejunal cancer confirmed histologically before surgery.

Perforation of intestinal leiomyosarcoma: A case report

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Intestinal leiomyosarcoma is a rare tumor with a decreased incidence due to redefinition by WHO.

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Perforation is an atypical presentation of intestinal leiomyosarcoma.

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Invasion of the surrounding intestine weakened the intestinal wall resulting in perforation.

Introduction and Importance

The majority of gastrointestinal sarcoma is gastrointestinal stromal tumors and intestinal leiomyosarcoma is rare. Small intestinal mesenchymal tumors are often large at diagnosis, and they commonly present with bleeding or intussusception. We report a perforation associated with intestinal leiomyosarcoma.

Case Presentation

A 66-year-old man presented with severe epigastric pain. A physical examination showed tachycardia and a diffusely tender and rigid abdomen. Computed tomography showed a massive tumor and free air. A laparotomy was performed to treat lower digestive perforation. Massive tumor, which invaded surrounding intestine, was 20 cm in size at the ileum. The involved intestine was perforated. We confirmed that feeding artery was superior mesenteric artery and performed partial intestinal resection. His clinical course was uneventful and discharged 10 days postoperatively. The pathological findings showed spindle shaped and the tumor invaded the mucosa at the perforated site. Immunohistochemical spectrum resulted c-kit negative, S-100 negative, Desmin positive, alpha smooth muscle actin(αSMA) positive and Ki-67 30–40 %. The pathological findings were leiomyosarcoma.

Discussion

Gastrointestinal sarcoma is sometimes found by bleeding. In our patient, leiomyosarcoma invaded surrounding intestine, it made the intestine wall frail and caused perforation. The intestinal perforation which was involved by leiomyosarcoma has been rarely reported to the best of our knowledge since WHO refined leiomyosarcoma.

Conclusions

Although intestinal leiomyosarcoma is rare, we should know that it can involve surrounding intestines and make them perforated.

A case of midgut volvulus related to adult intestinal malrotation found with weight loss after streptococcus infection: A case report and literature review

INTRODUCTION AND IMPORTANCE

The incidence of intestinal malrotation is 1 in 6000 births, and 90% of cases occur within the first year of life. Adult cases are rare, with a reported incidence of 0.2%-0.5% of all cases. The significance of reporting this case is to recognize that some adult-onset cases require surgery even in the absence of intestinal necrosis.

CASE PRESENTATION

A 36-year-old man was infected with streptococcus and treated with antibiotics. He developed appetite loss and his weight decreased 12 kg in 4 months. His abdomen was flat and soft with no tenderness. A computed tomography scan showed that the horizontal duodenal leg was not anchored to the retroperitoneum. Rotation of the mesentery, which was wrapped around the superior mesenteric artery in a clockwise direction, was observed, suggesting midgut volvulus. We performed emergency surgery and Ladd's procedure.

CLINICAL DISCUSSION

A previous study reported that the most common symptom in the chronic course of intestinal malrotation was abdominal pain in 41.2% of cases, and weight loss was observed in only 2.6% of patients. The high degree of intestinal adhesion suggests that repeated torsion and release and the development of collateral vessels may have contributed to the asymptomatic course.

CONCLUSION

Adult-onset intestinal malrotation should be considered as a differential diagnosis in the presence of weight loss and gastrointestinal symptoms. The timing of surgery is still controversial. In chronic cases, severe adhesion might be expected and laparoscopic surgery should be considered carefully.

The deltopectoral flap in full-thickness cheek defect: A case report

Introduction

Defects caused after tumor resection should be closed with flaps that match the neighboring cheek's skin.

Presentation of case

the authors report a patient diagnosed with squamous cell carcinoma and its management. A 50-year-old man patient presented with a painless slow swelling in the left cheek, which had increased in size in the last four months, tobacco smoking, and alcohol intake for 15 years. Clinical examination revealed left cheek swelling without any lymph nodes at the palpation.

Discussion

Reconstruction of the full-thickness is a real challenge. The deltopectoral flap offers several advantages despite the increasing use of microvascular reconstruction; technically is a simple and reliable flap that is preferred for the reconstruction of large through-and-through defects after resection of oral carcinoma. Preoperative planning of flap and early recognition of issues can avoid postoperative complications.

Conclusion

This reconstruction technique was demonstrated in large, full-thickness defects involving the cheek.

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Reconstruction of through-and-through defects of the head and neck is a challenge.

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The deltopectoral flap is used despite the increasing use of microvascular reconstruction.

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Technically is a simple and reliable flap that is preferred for the reconstruction of large defects after resection of oral carcinoma.

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The main treatment of surgical management of head and neck tumors is to achieve a satisfactory functional and aesthetic results.

Peutz-Jeghers syndrome in a woman presenting as intussusception: A case report

INTRODUCTION

Peutz-Jeghers syndrome (PJS) is an uncommon autosomal dominant syndrome with a variable to high penetrance that leads to the development of polyps within the gastrointestinal mucosa. Here we report a case of an adult female suffering jejunoileal intussusception due to PJS.

PRESENTATION OF CASE

A 30-year-old woman came to an emergency department with a small bowel obstruction caused by intussusception. The patient underwent an emergency exploratory laparotomy. An intussusception at the level of 60 cm from the ligamentum treitz was revealed, and the intussusception small bowel segment was not viable; we decided to perform segmental jejunoileal resection with the Bishop-Koop procedure, and the specimen histopathology of the segmental jejunoileal resection showed a typical hamartomatous polyp features. Two month later, diagnostic endoscopy showed multiple polyps (between 5 and 15 mm) in the large bowel. The polyps were removed with endoscopic polypectomy and examined histopathologically, showing characteristics of PJS. Further detailed family history was obtained, and similar skin lesions were detected on our patient's child (since birth). Although endoscopy screening identified multiple polyps in the child's ileum and large bowel, he was not suffering from abdominal symptoms.

CONCLUSION

In patients with intussusception at a young age, PJS can be caused by the presence of a hamartoma polyp as a trigger for intussusception. If there are multiple polyps found in the gastrointestinal mucosa and other pathognomonic signs are found, such as hyperdense macular lesions on the lip and buccal mucosa, such cases should be confirmed as PJS.

Incarcerated hiatal hernia - A rare postoperative complication following gastrectomy for stomach cancer. A case report and literature review

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Complicated hiatal hernia following gastrectomy for carcinoma is a rare surgical entity.

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The early diagnosis is often challenging, therefore, a high index of suspicion and an appropriate imaging diagnosis are paramount.

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Crural exploration and repair during primary surgery are recommended to avoid future revisional surgery.

Introduction

Diaphragmatic complications following gastrostomies for gastric malignancies are extremely rare. The incidence of hiatal hernias after total gastrectomy for carcinoma is not well documented because of the poor prognosis associated with gastric cancer and the short life expectancy.

Presentation of case

This case report presents a 66-year-old male patient who developed an acute incarcerated hiatal hernia 8 month after total gastrectomy for gastric adenocarcinoma. The patient was found to have a herniated alimentary limb and dilated, incarcerated loops of the bowel through the 3.5-cm hiatal defect. The hernia was gently reduced. Posterior cruroplasty without mesh augmentation was performed with nonabsorbable sutures. The patient was discharged in good general condition. His history highlights an important and potentially morbid complication following gastrectomy.

Discussion

To our knowledge, only 5 cases have been reported in the literature. The incidence of symptomatic hiatal hernias following esophageal and gastric resection for carcinoma is 2.8%, and the median time between primary surgery and the diagnosis of hiatal hernias is 15 months.

Conclusion

During primary surgery, it is recommended, in the cases of pre-existing hiatal hernias or a crural dissection, to perform cruroplasty after adequate mobilization of the lower thoracic esophagus and a tension-free subdiaphragmatic anastomosis.

When eating makes you sick - Gastric stump obstruction caused by a phytobezoar. A case report and literature review

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Gastric outlet obstruction by a bezoar is a rare form of presentation.

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Impaired gastric function is the major the risk factor.

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Clinical presentation of bezoar-induced obstruction is similar to other types.

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CT-scan is the gold standard for diagnosis.

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Surgery in perforation/obstruction or other treatment failures.

Introduction and importance

Bezoars result from undigested material having an incidence of 0.4–1% (Gunner et al., 2012). Impaired gastrointestinal motility is one of the risk factors. The aim of this article is to highlight the importance of this commonly disregarded entity as well as the different treatment modalities available.

Case presentation

A 68-year-old female presented to our emergency department complaining of colicky lower left abdominal pain associated with vomiting and absence of bowel movements for the past 4 days. She had a previous history of a subtotal gastrectomy due to gastric cancer. The physical examination revealed a lower left quadrant palpable mass. Abdominopelvic CT scan showed distension of the gastric remnant with anastomotic obstruction caused by a bezoar. Attempted endoscopic dissolution of the bezoar was unsuccessful. The patient then underwent surgery enterotomy proximal to the obstruction with extraction of the mass.

Clinical discussion

Bezoars are responsible for 0.4%–4% of cases of mechanical gastrointestinal obstruction (Dikicier et al., 2015). Contrast-enhanced CT scan is the best diagnostic test with a sensitivity and specificity of 90% and 57%, respectively (Kim et al., 2003). Treatment options differ according to the type, size and location of the bezoar as well as clinical presentation. Conservative measures such as chemical dissolution and endoscopic fragmentation and extraction can be used with surgery being usually required for a bezoar-induced gastrointestinal obstruction.

Conclusion

The clinical findings of bezoar-induced ileus do not differ from the other different causes of mechanical intestinal obstruction. Hence, a high grade of suspicion and an early radiological exam are the keys for a prompt diagnosis and treatment.

Long-term follow-up of patients with rotationplasty

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Rotationplasty creates a neo-knee joint that acts similarly to the knee joint.

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Young patients’ limb-salvage procedures should insist on nearly full return to high activity daily life activities.

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Rotationplasty is considered a reasonable indication in patients with low-income status.

Introduction and importance

Rotationplasty considered a limb-salvage procedure and has a lot of advantages when comparing it with endoprostheses or above-knee amputation.

Case presentation

We report two cases of young patients with osteosarcoma with rotationplasty being performed for both of them.

Clinical discussion

Patients with rotationplasty have less restrictions in daily life activities due to pain comparing with patients with endoprostheses.

Conclusion

Our aim here is to confirm that rotationplasty is an applicable, successful and alternative procedure to endoprostheses or above-knee amputation, when doing it based on an accurate indication and patients regain their previous daily life activities and satisfaction.

Symptomatic pneumopericardium - A rare complication following retroperitoneal laparoscopic nephrectomy: A case report

INTRODUCTION AND IMPORTANCE

Pneumopericardium is collection of gas in pericardial space. Retrospective reviews have described pneumopericardium as a complication of laparoscopic surgery, however, without any symptoms. By this report, we present a case who developed acute cardiopulmonary symptoms after retroperitoneal laparoscopic radical nephrectomy because of pneumopericardium.

CASE PRESENTATION

A 40-year-old Vietnamese woman was admitted due to left flank pain. She was diagnosed with left dysfunctional hydronephrosis and right urolithiasis. Six hours post-operation of an elective retroperitoneal laparoscopic radical nephrectomy, she suddenly developed severe substernal chest pain and dyspnea. Evaluations for acute myocardial infarction and pulmonary embolism were immediately ordered with no abnormality. However, computed tomography scan of the chest showed pneumopericardium, pneumomediastinum, subcutaneous emphysema, gas collection in sub-peritoneal space and next to the aortic arch. She was then closely monitored and effectively managed by conservative treatments.

CLINICAL DISCUSSION

Pneumopericardium is a rare complication of laparoscopy and mainly detected by radiographical measures incidentally. Several case studies reported symptomatic pneumopericardium, as in our presenting case. Some factors might contribute to the mechanism of our case that include retroperitoneal approach, thoroughly dissection the renal helium area and long-lasting operation. Post-operative collection of carbon dioxide is well self-limited; therefore, conservative treatments are efficient for stable cases.

CONCLUSION

Pneumopericardium following laparoscopy is uncommon, and mostly subclinical. However, it can manifest as acute cardiopulmonary symptoms and signs that require carefully evaluation. The presence of gas in pericardial space is a negative prognosis factor itself; consequently, clinicians should be aware of when managing pneumopericardium subsequent to laparoscopic procedures.