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

Cavernous Sinus Thrombosis related to Orbital Cellulitis Serious Complication to Prevent: a case report and literature review

Introduction

The authors report a case which aims to underline the importance of multidisciplinary management and rapid diagnosis of orbital cellulitis, for an adequate treatment of ocular damages and related complications, to prevent serious and permanent sequelae and avoid a fatal prognosis.

Presentation of case

A 61-year-old female reported to the oral and maxillofacial surgery department after she was dragged around for two months. She presented with a right facial swelling and orbital apex syndrome including proptosis, ophthalmoplegia and ptosis.

Discussion

Complications of orbital cellulitis may be limited to the orbit, such as subperiosteal or orbital abscess, optic neuritis, blindness, or intracranial such as meningitis, sinus cavernous thrombosis, cerebral abscess and even death.

Conclusion

Maxillofacial surgeons must be aware of this complication in a multidisciplinary context to adopt adequate treatment as soon as possible.

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Orbital cellulitis is a rare ophthalmic disease due to pansinusitis with hard maxillofacial management.

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Cavernous sinus thrombosis is a rare but highly fatal complication of orbital cellulitis.

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Early and appropriate treatment can improve the bad prognosis of this condition and avoid visual sequelae.

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Maxillofacial surgeons must be aware of this complication in a multidisciplinary context to adopt adequate treatment as soon as possible.

Preoperative marking of a submillimeter metastatic pulmonary tumor using a mobile computed tomography scan with a navigation system: A case report

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A submillimeter metastatic lung tumor was resected successfully by intraoperative marking using a mobile CT with a navigation system.

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This method is safer and might be more accurate than the traditional hook wire marking without the necessity of percutaneous lung puncture.

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It also reduced a patient’s stress because the whole procedure could be done at a single stage under general anesthesia.

Introduction and importance

Preoperative localization of non-palpable lung nodules plays an important role in video assisted thoracic surgery (VATS). Although percutaneous computed tomography (CT)-guided hook wire marking has become widely accepted, it is accompanied by rare but fatal complications such as air embolisms. We herein report a case of a submillimeter pulmonary nodule successfully localized by a mobile CT scan with a navigation system.

Case presentation

A 40-year-old-man presented with the two right pulmonary nodules 4 years after a radical left nephrectomy for a renal clear cell carcinoma. One of the nodules was too small to palpate and preoperative marking was applied using a mobile CT scan with a navigation system. We successfully performed VATS wedge resection for both nodules and confirmed a pathological diagnosis of a metastasis from the renal cell carcinoma. The maximum pathological size of the smaller nodule was 500 μm.

Clinical discussion

Preoperative marking of the lower lobe lesion in the present case was essential for VATS. Our novel technique was helpful for the precise marking without any morbidity.

Conclusion

Preoperative marking using a mobile CT scan with a navigation system is safe and easily applicable. It might be a useful option for VATS of non-palpable lung nodules.

Lynch syndrome or hereditary non polyposis colorectal cancer (HNPCC) in a moroccan family: Case report

Introduction and importance

Colorectal cancer is a major global health problem. In 5% of cases, a genetic predisposition to cancer's syndrome is the etiology, such as Lynch syndrome. The population prevalence of Lynch syndrome has been estimated at 1/440. The objectives of this study are to show the interest of the oncogenetic consultation in the management of patients with suspicion of Lynch syndrome.

Case presentation

It is a 70-year-old patient with a family history of different neoplasms. The patient has also been followed for an adenocarcinoma of the colon. An oncogenetic consultation was indicated, which led to the diagnosis of Lynch syndrome, according to the Amsterdam II criteria. A study of the MisMatch Repair genes was requested, to allow a pre-symptomatic diagnosis of apparented subjects at risk, and thus to also allow monitoring and early diagnosis of neoplasms or prophylactic measures.

Discussion

Lynch syndrome is one of the most common cancer susceptibility syndromes. A constitutional deleterious mutation in one of the DNA MisMatch Repair genes, is responsible for nearly 70% of cases of this syndrome. The oncogenetic consultation and the identification of the genetics cause, makes it possible to set up specific monitoring and to offer a pre-symptomatic test to all major relatives of the index case.

Conclusion

This medical observation shows the benefit of the oncogenetic consultation, if a genetic predisposition to cancer's syndrome is suspected. The diagnostic of this predisposition and monitoring of the propositus and his exposed, like in Lynch syndrome will help in the early management of cancers, specially colorectal cancer and endometrial adenocarcinoma.

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Lynch syndrome in a moroccan family: A case report:

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It shows the interest of a oncogenetic consultation if we suspect a hereditary predisposition to cancers.

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And the necessity of the surveillance of the propositus and his exposed relatives, to make possible an early management of cancers.

Textiloma mimicking Crohn's disease in its features: A case report

Introduction and importance

Textiloma is a retained surgical item such as a sponge or gauze that is unintentionally left in the surgical field after the wound closure. Here, we present the first reported surgical gauze that penetrated the intestine, made a duodenal-ceca fistula and then stuck far away in the ileum. Mechanical obstruction didn't appear clinically or even in radiological investigations because of the fistula which provided the intestinal continuity.

Case presentation

We report a 34-year-old man with a previous abdominal interventions complained of cramping, frequent vomiting and presence of undigested food in stool. The frequency of the bowel movement increased recently. Endoscopies, radiological investigations and pathological findings figure out a duodenal-ceca fistula with nonspecific inflammatory tissues in the intestinal biopsy. When we performed the abdomen surgery, retained gauze in the ileum was taken out and the duodenal-ceca fistula was fixed.

Clinical discussion

Gauze or sponge that is forgotten in the surgical field called gossypiboma, textiloma, gauzoma or cottonoid. It could present with various complaints; as an acute or chronic problem, clear or ambiguous symptoms. It could reside in a space; extend across a gap, migrate through a tissue, or even make a fistula between lumina like in our case.

Conclusion

Textiloma could change pre-operative diagnosis, intra-operative techniques, postoperative follow-up plan and prognosis. This is the first report proves its ability to mimic inflammatory diseases that penetrate two different lumina and perform fistula. So it should be written in the list of any differential diagnosis when the patient has a previous procedure or surgery.

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Textiloma couldn't be always diagnosed preoperatively.

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It could give unrelated symptoms to its mass effect or contaminated problems.

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It could mimic Crohn's disease clinically, radiologically and even pathologically.

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It is a deferential diagnosis for every patient who has a previous procedure or surgery.

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Exploring the whole entire abdomen is necessary before performing the techniques.

A rare case of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery: A case report and literature review

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Blunt thoracic aortic injuries are life threatening and require urgent intervention.

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Rare presentation of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery off the aortic arch distal to the takeoff of the left subclavian artery.

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An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR.

Introduction

Blunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy.

Presentation of case

A 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent.

Discussion

BTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks.

Conclusion

Blunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality.

Gallstone ileus in a patient with amyotrophic lateral sclerosis: A case report

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Gallstone ileus is an uncommon complication of untreated cholelithiasis affecting an aged population.

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Amyotrophic lateral sclerosis has documented dysautonomia causing significant delays in colonic transit times and gastric emptying.

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Intestinal hypoperistalsis and adrenergic hyperfunctioning may be related to impaired gallbladder contractility resulting in sludge and stone accumulation.

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We present a unique case of gallstone ileus in a patient with amyotrophic lateral sclerosis.

Introduction and importance

Gallstone ileus is a rare disease that most commonly occurs in elderly females with a history of cholelithiasis. It has not been previously associated with Amyotrophic Lateral Sclerosis (ALS); a neurodegenerative disease that primarily affects the motor neurons at the spinal and bulbar levels. Autonomic malfunction, in particular, gastrointestinal dysfunction has been documented in ALS patients which may predispose this population to the development of gallstones and gut dysmotility.

Case presentation

In this paper, we report a case of gallstone ileus in a patient with diagnosed ALS. We performed an exploratory laparotomy, enterolithotomy, and an open cholecystectomy with takedown/closure of a cholecystoduodenal fistula. The patient had a relatively uncomplicated postoperative course and was discharged from the hospital on postoperative day nine.

Clinical discussion

Delays in gastric emptying and colonic transit times in ALS patients may pose a risk for the development of gallstones and the potential impaction of a gallstone ileus in patients who are left untreated. Multifactorial evaluation of this patient population is necessary when assessing a potential causal pattern of gallstone ileus in patients with significant comorbidities.

Conclusion

We present an unusual pathology without an established incidence, which has pertinent multidisciplinary implications. The suspicion of ALS as a potential cause for the development of a gallstone ileus is relevant and essential in the diagnostic workup for an elderly patient who develops a small bowel obstruction with multi-comorbidities.

Paraspinal plexiform schwannoma of unknown nerve origin: A case report

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Plexiform schwannomas are exceedingly rare in paediatric populations.

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This is a unique case located outside the spinal canal without a nerve of origin.

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Preoperative planning is imperative for complete resection and cosmesis.

Introduction and importance

Schwannomas are benign, slow-growing nerve sheath tumors of neoplastic Schwann cells. They are the most common peripheral nerve tumors in adults and are typically discovered incidentally due to their asymptomatic presentation. Despite the fact that most schwannomas are unassociated with a syndrome, their etiology is thought to be related to alterations or loss of the neurofibromatosis type two tumor suppressor gene.

Case presentation

We present the case of a fifteen-year-old female who presented with a recurrent lower back/upper buttocks 9 cm mass with imaging suspicious for schwannoma. Needle biopsy revealed an S100 positive cellular schwannoma with patchy Ki-67. During surgical dissection down to the sacrum, no nerve of origin was identified.

Clinical discussion

Schwannomas have no pathognomonic findings on MRI and may occur at any location that Schwann cells are present; therefore, confirming a diagnosis relies on histopathology. Plexiform schwannomas are defined by a “network-like” intraneural growth pattern and are exceedingly rare in paediatric populations. A location distinct from the spinal canal is also very rare as schwannomas typically originate from the head and neck region.

Conclusion

Paediatric plexiform schwannomas have been rarely reported. Surgical planning relies on multiple factors such as tumor size, tumor location, pathologic features and symptomatic burden. The distinctive features of this case including an unknown nerve origin and a location outside the spinal canal provide a unique opportunity to discuss the diagnosis and management of paraspinal schwannomas and the impact on operative planning when a nerve of origin is not identified.

Long-level intramedullary spinal cord astrocytoma complicated with spine scoliosis: Report of two cases

INTRODUCTION AND IMPORTANCE

Long-level intramedullary astrocytomas complicated with spine scoliosis are rare. Surgical treatment of such tumors becomes more complicated and challenging when spinal scoliosis is present. However, studies describing the treatment of long segmental intramedullary spinal cord astrocytomas complicated with severe spine scoliosis have been rarely reported.

CASE PRESENTATION

Two cases of long-level intramedullary astrocytomas complicated with severe spine scoliosis were surgically treated with one-stage operation of tumor resection and scoliosis correction in this report. Case 1: A 16-year-old boy presented to our hospital with a five-month progressive paresthesia, weakness of the left lower limb, and a long-time abnormal body appearance. MRI showed a T4-T12 intramedullary tumor combined with spinal scoliosis. Case 2: A 14-year-old boy presented at our service with a 6-year history of visible spine scoliosis and a 1-year progressive motor disability of bilateral lower limbs. Spine MRI indicated a long-level abnormal syringomyelia signal from C4 to L1 and there was irregular enhancement after intravenous contrast medium administration at C7-T2 and T9-T12 level.

DISCUSSION

We performed a laminectomy over the whole length of the tumor and corrected the scoliosis with trans-pedicle screws. The patients exhibited a long-time tumor free with largely neurological function preservation. One-stage operation did not generate severe short- or long-term complications. The correction of the scoliosis prevented the progression of the spinal deformity and facilitated the recovery of normal life.

CONCLUSION

This case report demonstrates that the one-stage resection of long-level intramedullary astrocytoma and correction of the complicated scoliosis might be a feasible option.

Juxtapapillary retinal capillary hemangioma: A clinical and histopathological case report

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Von Hippel-Lindau (VHL) disease is autosomal dominant, may cause benign or malignant tumors, and may affect the eye.

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Retinal capillary hemangioma (RCH) is a hallmark lesion in VHL disease and often presents early.

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We report a 15-month-old girl presenting with juxtapapillary RCH and a family history of VHL.

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If left untreated, juxtapapillary RCHs can lead to substantial visual deterioration secondary to complications.

Introduction and importance

Juxtapapillary retinal capillary hemangiomas (RCHs) are vascular hamartomas that occur adjacent to the optic disc. Juxtapapillary RCHs can be found as an isolated finding or in association with Von Hippel-Lindau (VHL) disease. VHL is a dominantly inherited disease that is characterized by multiple intracranial and retinal hemangioblastomas along with benign and malignant visceral tumors. RCH is a hallmark lesion in VHL and typically presents early in the disease.

Case presentation

We present the clinical and histopathological findings of a 15-month-old child with juxtapapillary RCH associated with exudative retinal detachment and a family history of VHL. The child presented initially at a late stage and lost to follow-up twice then came back with a blind painful eye secondary to neovascular glaucoma necessitating enucleation.

Discussion

Although juxtapapillary RCHs are benign, slowly growing tumors, they pose a serious threat to central vision secondary to posterior segment complications such as intraretinal and subretinal exudation, macular edema and exudative retinal detachment and anterior segment complications such neovascular glaucoma if left untreated.

Conclusion

Juxtapapillary RCHs are potentially blinding tumors if not treated in early stages given their close proximity to the optic nerve (ON) and macula.

Surgical treatment of osteochondroma on the first rib by double clavicle osteotomy and internal fixation with a reconstruction plate: A case report and literature review

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The solitary osteochondroma of the first rib is rare.

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There is no standard approach for removing the tumor of the first rib.

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The double clavicular osteotomy approach can provide wide surgical exposure.

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Excellent clinical outcomes are obtained from plate fixation of the clavicle following osteotomy.

Introduction

The accepted indication for surgical removal of osteochondroma is when a lesion becomes symptomatic. There have been no established standard surgical approaches to remove osteochondroma on the first rib and no report on management after that. This report aims to present a novel approach by double clavicle osteotomy followed with internal fixation.

Case presentation

A 17-year-old female presented with a gradually enlarged bony mass with tenderness at the supraclavicular area. Radiographic images revealed a bony mass attached to the first rib. The provisional diagnosis is osteochondroma. The tumor was approached by osteotomy at the proximal and distal shaft of the clavicle. After removing the entire tumor, the direct reduction and internal fixation of the clavicle were performed.

Discussion

Both, size of the mass and mobilization of the clavicle are factors in determining the surgical approach. Clavicular osteotomy, especially two sites, is considered when the lesion is extremely large. A possible complication after the clavicular osteotomy is nonunion or malunion. A proper technique of reduction and method of fixation contributes to reducing complications.

Conclusion

The double clavicle osteotomy is an effective route for removing a large tumor at the first rib. Plate fixation following clavicular osteotomy contributes to bone union and excellent functional outcomes postoperatively.

Endoluminal dilatation technique to remove stuck hemodialysis tunneled catheter: A case report from Indonesia

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The phenomenon of the ‘stuck’ catheter in the central vein, where significant traction or additional maneuvers are required to remove the catheter, is not frequently reported in spite of the vast usage of these catheters worldwide.

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The endoluminal balloon dilatation of the HD catheter not only separates the stuck HD catheter from the adherent vein by breaking the adhesions between them, but also expands the vein simultaneously, thus enabling easy removal of the HD catheter.

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Endoluminal dilatation technique is a minimally invasive percutaneous technique that appears safe and straightforward and can be performed in any interventional suite while allowing preservation of venous access.

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Consider endoluminal dilatation technique as a treatment option.

Background

Tunneled CVC is being increasingly used worldwide as a mean of vascular access for hemodialysis. Among these, one of the emerging complications is that of the “embedded” or stuck catheter. There have been registered cases of vasomotor collapse, non-ST-elevation myocardial infarction (NSTEMI), avulsion of the vena cava, damage to the tricuspid valve having fatal consequences, and breakage of the CVC (Lodi et al., 2016).

Case presentation

A 63-year-old female with mature AV fistula came to the clinic for removal of a tunnelled 15 fr double lumen dialysis catheter (Medical Components, Harleysville, Pensylvania) that had been inserted into the left internal jugular vein 15 months prior to this visit. In the OR, our surgical attempt to remove the catheter failed. The first few dilation procedures were performed using 0.035-inch guidewire and balloon catheters. The technique was subsequently modified as follows. In this case we use a 6 × 60 mm Scoreflex balloon. Endoluminal dilation was repeated along the length of the catheter up to the cuff. Once the catheter has been removed, pressure was applied using sterile gauze to aid hemostasis. The procedure was successful without any observed complication.

Conclusion

Endoluminal dilatation technique is considered as the easiest and safest technique to remove hemodialysis catheter. Our case is the first stuck hemodialysis catheter reported in Indonesia and probably the first case that happen and treat with endoluminal dilatation technique in our country.

Unusual presentation of a soft palate mass: A rare case report of solitary extramedullary plasmacytoma

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Plasmacytoma is a rare clonal neoplastic disorder of bone marrow that originates from plasma cells. It usually presents as a multiple myeloma. Less than 5% of patients present with either a single bone lesion as a solitary bone plasmacytoma or, even more rarely, as a soft tissue mass of monoclonal plasma cells representing a solitary extra medullary plasmacytoma (SEP).

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Diagnostic criteria of a SEP include a solitary lesion, histopathological confirmation, negative bone marrow examination or clonal plasma cells infiltration less than 10% of all nucleated cells, normal results on skeletal survey, negative urine test for Bence Jones protein, absence of anemia, hypercalcemia or renal impairment, absent or low serum or urinary level of monoclonal immunoglobulins.

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The primary treatment for most patients is radiotherapy, but surgery may also be required, and multidisciplinary decision between surgeon, hematologist and radiotherapist is crucial for planning optimum care.

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Our case report is unique in the clinical presentation and treatment option (chemotherapy) as the patient refused other treatment options.

Introduction

Plasmacytoma is a rare clonal neoplastic disorder of bone marrow that originates from plasma cells. It usually presents as a multiple myeloma (MM). Less than 5% of patients present with either a single bone lesion as a solitary bone plasmacytoma (SBP) or, even more rarely, as a soft tissue mass of monoclonal plasma cells representing a solitary extra medullary plasmacytoma (SEP).

Case presentation

We report a case of a 59-year-old man presenting with a mass of the soft palate evolving for a year. Physical examination showed an extension to the nasal cavity. Biopsy with immunohistochemical study demonstrated sheets of mononucleated plasmacytoid cells diffusely expressing CD138. The plasma cells showed monoclonal light chain Kappa. Further investigations did not show any other locations including bone and bone marrow. Thus, diagnosis of solitary extramedullary plasmacytoma of the soft palate was established. The patient was treated with chemotherapy with total remission on his one year follow-up.

Discussion

SEP may arise in any organ, either as a primary tumor or as part of a MM. Almost 90% of SEP arise in the head and neck, especially in the upper respiratory tract. Primary treatment for most patients is radiotherapy, but surgery may also be required, and multidisciplinary decision between surgeon, hematologist and radiotherapist is crucial for planning optimum care.

Conclusion

SEP is an extremely rare condition which requires diagnostic and therapeutic management in the same level of MM. Prognosis is better than the two other forms (MM and SBP).

Unforeseen encounter of acquired hemophilia A in a preoperative case of periampullary carcinoma: A case report

INTRODUCTION

Acquired hemophilia A (AHA) is a rare disorder characterized by development of antibodies against factor VIII, which can present as paraneoplastic syndrome in various malignancies like periampullary cancer, cancer of lung, prostate, gastrointestinal stromal tumour and non malignant cases like pregnancy, autoimmune disease and medication.

CASE PRESENTATION

We report a case of elderly man presented with paraneoplastic AHA in periampullary carcinoma in preoperative period which was diagnose by mixing study and inhibitor assay and managed with bypass agents like recombinant factor VII, FEIBA and immunosuppresion to eliminate inhibitor with help of steroid, cyclophosphamide and emicizumab. Patient underwent Whipple's pancreaticoduodenectomy after which coagulation study became normal in immediate postoperative period. Patient was discharged and followed up with chemotherapy.

CLINICAL DISCUSSION

Periampullary carcinoma presenting as AHA is rare and rarer in pre-operative settings. The usual mode of presentation is bleeding after biopsy and from minor surgical scars. The pathogenesis is yet to be delineated. It is managed by factor VIII administration and immunosuppressive therapy.

CONCLUSION

High index suspicion should be there to diagnose AHA as a paraneoplastic manifestation and elective surgery should be delayed till normalization of coagulation parameters.

A novel anatomic variation of the intrahepatic biliary tree in live liver donor surgery: A case report

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We presented a novel anatomic variation of intrahepatic biliary tree, which had never been reported.

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The computerized overlay visualization of MRCP and 3-D CT helped biliary anatomical understanding for operation planning.

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Precise preoperative evaluation helped safe living donor surgery and living donor liver transplantation.

Introduction

Anatomic variations of the biliary tree are common, making precise anatomic evaluation important before hepatobiliary surgery.

Presentation of case

A 52-year-old woman with no medical history was admitted to our hospital for a live-liver donation to her husband. During her evaluation, magnetic resonance cholangiopancreatography (MRCP) revealed a previously unknown anatomic variation in her biliary system. Segment 2 of the bile duct (B2) independently drained into the posterior branch and formed a common channel (B2+posterior) before joining the anterior branch. Then, bile duct segments 3 and 4 (B3+4) drained into this B2+posterior+anterior channel to form a common hepatic duct. The computerized overlay features shown by MRCP and three-dimensional computed tomography clarified this anatomic variation. A right lobe donor graft was then obtained successfully, with intraoperative cholangiography confirming that the donated graft had two bile duct orifices (i.e., posterior and anterior branches). We thus avoided surgical missteps that would have disallowed bile drainage of B2 and B3+4 into the common hepatic duct.

Discussion

Precise evaluation is mandatory for hepatobiliary surgical planning to rule out, or discover, challenging bile duct anatomy.

Conclusion

Preoperative computerized overlay visualization of MRCP and computed tomography allowed definition of a previously unknown biliary tree variation.

Arthroscopic Bankart revision using all suture anchor in recurrent anterior shoulder dislocation: A case report

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All suture anchor has the same biomechanical strength as conventional metallic anchor.

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Recurrent shoulder dislocation after arthroscopic Bankart repair is still a problem.

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The all suture anchor technique offers benefit of bone preservation and strong fixation.

Introduction

Arthroscopic Bankart revision after recurrent shoulder dislocation is still a matter of discussion. Several factors are contributing to this injury. Recently the development of all suture anchors has grown in popularity in arthroscopic stabilization. It was proven to preserve bone stock, smaller in size thus more anchors can be made.

Presentation of case

We presented a case of 27-year-old woman with recurrent anterior dislocation after seven years of arthroscopic Bankart repair. Seven years before, we performed Bankart repair using three 2.8 mm fiber-wire anchor (FASTak® (Arthrex, Karsfield Germany)). For the revision surgery we performed arthroscopic revision using four all suture anchor technique (Y-Knot® Flex All-Suture Anchor, 1.3 mm – One strand of #2 Hi-Fi® (Conmed, New York)).

Discussion

From preoperative and intraoperative assessment, we found no anchor failure and no massive bony lesion. To preserve the bone stock we insert four all suture anchors between the old anchor. One year post-operative follow up showed that patient could gain normal range of movement. No early or late complications were observed.

Conclusion

Compared to the conventional metallic anchor, all suture anchor has the same biomechanical strength. Moreover due to its relatively small size, it can reserve bone stock and more anchors can be made thus adding more stability to the shoulder.

Cholecyst-jejunostomy for palliative surgery

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Many cases of unresectable cancer that cause obstructive jaundice require treatment.

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Biliary reconstruction can be difficult to perform safely and quickly due to many factors.

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Cholecyst-jejunostomy may be completed within 10 min.

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Cholecyst-jejunostomy is an appropriate palliative surgery.

Introduction and importance

Many cases of unresectable cancer that cause obstructive jaundice require treatment. Depending on the patient's condition in these cases, surgery may be performed to treat jaundice. The main goal of palliative surgery is to improve the quality of life. Therefore, palliative surgery for obstructive jaundice must be performed safely and quickly.

Case presentation

This case presents a 45-year-old man with fever and back pain who was diagnosed with pancreatic head cancer and multiple liver metastases. Chemotherapy was initiated; however, during the course of treatment, the patient developed hemorrhage from pancreatic cancer that had invaded the duodenum caused hematemesis and melena. Therefore, the chemotherapy could not be continued. Because the patient also developed obstructive jaundice and cholangitis, a gastrojejunostomy and cholecyst-jejunostomy was performed. The surgery was successful; however, the cancer continued to progress, and patient died 31 days after surgery.

Clinical discussion

Biliary reconstruction can be difficult to perform safely and quickly due to many factors.

This study shows that cholecyst-jejunostomy is effective for patients with end-stage cancer. In the long term, cholecyst-jejunostomy is not suitable for biliary reconstruction due to the possibility of bile congestion and cholecystitis. However, this easy and quick procedure is well indicated for emergency patients with a short life expectancy.

Conclusion

As an easy and quick procedure for emergency patients with a short life expectancy, jejunal anastomosis of the gallbladder is an appropriate palliative surgery that is indicated for jaundice treatment.

Perforated mesenteric Meckel's diverticulum: Case report

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Meckel’s diverticulum has a variant in the mesenteric side.

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Mesenteric Meckel’s diverticula are often misdiagnosed until surgical intervention due to non-specific presentation.

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Complications are common presentation due to difficulty and delay in diagnosis.

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High clinical suspicion of Mesenteric Meckel’s diverticulum encouraged for acute abdomen.

Meckel’s diverticulum is a common congenital anomaly found in ∼2% of the population, its classic location aiding in its diagnostic criteria, is the anti-mesenteric side of the distal ileum. However, reported cases of Meckel’s diverticula found on the mesenteric side, are present but rare. Here we report a case of a perforated mesenteric Meckel’s diverticulum with synchronised anti-mesenteric Meckel’s diverticulum, in a 70-year-old male, initially misdiagnosed as left strangulated inguinal hernia. The purpose behind this paper is to raise clinical suspicion regarding this rare pathology, so that timely diagnosis and management could be carried out.

Use of Octreotide in association with talc poudrage for the management of a severe chylothorax: A case report

INTRODUCTION AND IMPORTANCE

Chylothorax is an uncommon form of pleural effusion characterized by the presence of chylomicrons, triglycerides and cholesterol in the physical and chemical examination of the pleural fluid. It may have poor prognosis if not properly treated. Currently, conservative measures are the first line of treatment for managing chylothorax. The aim of our study is to show and suggest the use of octreotide in association with talc poudrage as good option to manage post-operative a severe chylothorax.

CASE PRESENTATION

A 59-year-old male patient who underwent a replacement of the ascending aorta, aortic hemiarch and surgery of the aortic valve for aortic dissection showed a severe pleural effusion three months after surgery. Because the physical and chemical examination of the pleural fluid revealed high levels of triglycerides and cholesterol, a conservative treatment with pleural drainage, TPN and nihil per os was attempted, with the introduction of 0.3 mg/die of octreotide on day thirty-four. With the application of talc poudrage, the chylothorax completely resolved.

CLINICAL DISCUSSION

Octreotide has been shown to significantly decrease chylous effusion in many studies, but the dose and duration of therapy have not yet been defined. Our patient responded partially to octreotide after two days of treatment, with the drainage leak reduced to less than 100 mL/day.

CONCLUSION

After octreotide treatment associated with talc poudrage, the drainage leak was drastically reduced, suggesting that this could be a useful approach in the management of severe chylous leaks.

The use of interosseous dental wires and sutures for internal fixation in a patient with multiple comminuted middle facial fractures and facial nerve injury: A demonstrative case report

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We report on a case of multiple comminuted middle facial fractures.

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There was concurrent facial nerve injury.

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Fracture fixation was done with wires which is considered obsolete.

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Wire fixation was preferred to protect the facial nerve repair.

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The outcome was satisfactory.

Introduction

The use of plates and screws for facial fractures is considered the gold standard; providing accurate reduction and rigid fixation.

Case report

We report on a case with multiple comminuted middle facial fractures and concurrent facial nerve injury. The fractures were fixed with a combination of interosseous dental wires and polypropylene sutures with a satisfactory outcome.

Discussion

We aim to demonstrate two main advantages of wire/suture fixation in such cases when compared to plates and screws. Wire/suture fixation does not require periosteal dissection for fixation; and hence there is more preservation of the blood supply of the bony fragments. Furthermore, in the setting of concurrent facial nerve repair, the use of plates may risk re-injury of the repaired nerve during the late removal of the hardware. Interosseous wires/sutures do not require late removal and this is another advantage in these cases.

Conclusion

Interosseous dental wires and polypropylene sutures may be considered for fixation of multiple comminuted middle facial fractures and concurrent facial nerve injury.

Recurrent squamous cell carcinoma in a post cardiac transplant patient

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Patient having recurrent carcinomas following heart transplant due to possible immunosuppression.

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Early Cancer surveillance in transplant patients is necessary to detect and treat malignancies early.

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Unique in having two recurrences post-transplant.

Introduction and importance

Solid organ transplantation has evolved along with dramatic advancements in definitive treatment for irreversible and uncompensated organ failure. Transplanted organ survival has improved as a result of reduced allograft rejection. However, negative long-term outcomes which were largely due to the adverse effects of rapidly evolving immunosuppressive regimens are still evident. The emergence of malignancies following prolonged exposure to immunosuppression treatment has affected the quality of life in transplant recipients. They are approximately one hundred times more likely to develop squamous cell carcinoma (SCC) compared to the general population and the incidence of malignant melanomas, basal cell carcinomas, and Kaposi’s sarcomas are also on the rise. The incidence of de novo malignancies ranges from 9 to 21% and is commonly seen in the skin and the lymphoreticular system in these patients.

Case presentation

A 78-year-old male presented with a lump in the right axilla, which had grown in size over a 4-week period. Patient had received a cardiac transplant 9 years prior and was on a regimen of Tacrolimus and Mycophenolate Mofetil since then.

Clinical discussion

Following 4 years of immunosuppression therapy, the patient developed a non-healing ulcer on his right forearm and the biopsy confirmed SCC. The recent biopsy performed on the new axillary lump also confirmed SCC. Iatrogenic immune suppressive treatment is associated with the occurrence of de novo, non-melanoma skin cancers in the solid organ transplant recipients and this necessitates early and comprehensive cancer surveillance models to be included in the pre and post-transplant assessment.

Conclusion

Advances in immunology suggest that peripheral blood mononuclear cell sequencing and immune profiling to identify immune phenotypes associated with keratinocyte cancers allow us to recognize patients who are more susceptible for SCC following organ transplantation and immunosuppression.

A case report of an arthroscopic-assisted fixation of a small Hoffa fracture in a young patient

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Hoffa fracture should be suspected in any knee injury even with low energy mechanism.

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Careful reading of AP, lateral and oblique X-rays is the cornerstone in diagnosis.

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Arthroscopic-assisted fixation is a good choice even in small osteochondral fragments.

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Arthroscopic-assisted fixation is a good choice even in delayed presentation.

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Small fragments can be treated using only one screw with no doubt about stability or union.

Introduction

Hoffa fracture is a type of rare tangential supracondylar distal femoral fracture. The most common mechanism of this fracture injury is high energy trauma. In some cases, its poor visibility on X-rays makes its diagnosis difficult and needs more than routine X-rays. Treatment methods include conventional ORIF, or arthroscopy-assisted fixation as a more challenging method.

Case report

We present a case of a young female patient who sustained a low energy injury trauma to her left knee, which caused in a small minimally displaced lateral unicondylar Hoffa fracture.

Discussion

Although it needs more experience and special tools, arthroscopy-assisted fixation of Hoffa fracture provides a good method of treatment, and it has many advantages over open method.

Conclusion

Our aim here is to confirm that Hoffa fracture may occur even with low energy knee trauma, and that arthroscopy-assisted fixation is a successful, applicable and alternative method to ORIF for small and thin osteochondral fragments, and could provide good stability and union even when using only one screw for fixation.

Case report: Ballotable abdominal mass in a child - Definitely renal in origin?

Introduction and importance

The differential diagnosis of a paediatric abdominal mass can be extensive, as it potentially involves multiple organs including gastrointestinal, genitourinary, endocrine, and gynaecological systems. Hence, a systematic approach to history taking and physical examination is needed to clinch the diagnosis. Specifically, the approach for assessing, investigating, and managing a ballotable left hypochondrial mass in a child can be challenging.

Case presentation

We report a 10-year-old Dusun girl presenting with left hypochondrial pain and noted a left hypochondrial mass on examination. This report highlights the role of clinical imaging during the pre-operative and post-operative phases.

Clinical discussion

Ultrasound and CT imaging was useful in determining that the tumor originated from the tail of the pancreas. The presence of a definite capsule with internal solid-cystic components helped narrowed the differential diagnosis to solid pseudopapillary neoplasm (SPN) of the pancreas. MR liver was useful to rule out liver metastasis in this child.

Intervention and outcome

The patient was scheduled for laparotomy and tumour excision at a regional paediatric centre. Successful excision of the tumor en-mass was performed and the child's subsequent recovery was uneventful.

Conclusion

Clinical imaging plays a critical role in the diagnosis and management of paediatric solid organ tumours. Other than renal origin, suspicion of pancreatic tail origin should be considered by clinicians when encountering a ballotable left abdominal mass.

•

A mass arising from the pancreatic tail can present as a ballotable mass.

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Imaging findings for solid pseudopapillary neoplasm and differentials are presented.

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The role of imaging in the management of solid pseudopapillary neoplasm is discussed.

Chemoimmunotherapy-related enteritis resulting in a mechanical small bowel obstruction - A case report

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The causes of a mechanical small bowel obstruction are diverse, several of which can be managed non-operatively.

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One such example is when an obstruction occurs due to an enteritis in the setting of chemo- and immunotherapy.

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Treatment is initially supportive in the form fluid resuscitation, gut rest, antiemetics and nasogastric decompression.

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Corticosteroids and biological agents may be considered under some circumstances.

Introduction and importance

Mechanical small bowel obstruction (SBO) is amongst the commonest diagnoses encountered in surgical departments. Although the aetiology is frequently post-surgical adhesions, the condition can arise in a virgin abdomen and we now know several of these cases do not require acute operative management. Here we report one such case where a small bowel obstruction transpired due to enteritis in the setting of chemoimmunotherapy with no prior abdominal surgery.

Case presentation

A 62 year old male presented to our department with 2 days of vomiting and obstipation. This is on a background of metastatic non-small cell lung cancer for which he was due for his 4^th cycle of carboplatin, pemetrexed and pembrolizumab. Computed Tomography (CT) of the abdomen demonstrated a segment of thickened distal small bowel without any mass lesion, along with upstream dilatation. The findings were consistent with a mechanical SBO due to enteritis. Infective causes were excluded. The patient successfully recovered with non-operative intervention in the coming days.

Clinical discussion

Enteritis is an established adverse effect of various chemoimmunotherapy agents, though a case severe enough to produce a mechanical bowel obstruction is exceptionally rare. We demonstrate through this case that the condition may resolve through conservative measures.

Conclusion

The diagnosis of chemoimmunotherapy-related enteritis producing an SBO although uncommon, should be considered in the relevant population. A non-operative approach may be appropriate under some circumstances.

Ischemic stroke following operated head trauma in children: Discussion of a rare clinical case

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Strokes are rare in paediatric population.

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Posttraumatic strokes in children may be the result of several linked factors.

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Postoperative strokes may occur even several days after surgery thus the need for extended follow up.

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Based on trauma mechanism and consequences, children presenting stroke risk should be early identified.

Introduction

Traumatic brain injury (TBI) is the leading cause of morbidity and mortality in children. TBI in children are responsible for a range of clinical symptoms and signs that are comparable to those in adults, but present several differences in both physiopathology and management. Many postoperative complications may occur, ischemic stroke among others, which is generally related to an injury of an intracranial artery. Out of this case, it may be more difficult to find a suitable explanation to this complication.

Case presentation

We report the case of a child aged years old, who was collided by a car causing a polytrauma with head and chest injury. On body scan, she had a fracture of the sixth left rib, and a frontal cranio-cerebral wound. The patient was operated for debridement of the wound, and tight closure of the injured dura mater. Initial postoperative course was uneventful, but 5 days after first surgery patient presented an acute onset of a right hemiplegia followed by an alteration of her state of consciousness, and a left anisocoria. Follow up CT scan showed a stroke of the whole left carotid territory. The patient was re-operated through a left decompressive craniectomy. Following the second surgery, she showed an improvement of her level of consciousness and a normalization of the size of her pupils, but aphasia and a right hemiplegia persisted. 2 weeks after surgery, the patient had a progressive necrosis of the surgical scar, followed by an exposure of the underlying cerebral cortex. Despite of intensive local care, a plastic surgery to recover the wound and antibiotics, the patient presented a meningitis, followed by a septic shock and death.

Clinical discussion and conclusions

Ischemic stroke is probably the most harsh and unpredictable complication that may occur after TBI, mainly in children. Only rigorous surgical approach followed by stringent post-operative care may prevent such outcomes.

Sclerosing pneumocytoma in a 1-year-old girl presenting with massive hemoptysis: A case report

Introduction and importance

Sclerosing pneumocytoma (SP) is a rare benign neoplasm of the lung with peak age incidence in middle aged-women. Here we report, for the first time in the literature, a case of a 1-year-old girl with SP.

Case presentation

A 1-year-old girl was reported to emergency department for massive hemoptysis. After admission, the patient had a three-days episode of melena, with normal body temperature and generally stable condition.

Clinical discussion

Fiberoptic bronchoscopy was normal. MSCT was done along with angiography and Three-Dimensional Reconstruction which revealed a well-circumscribed round mass with well-defined borders located near the vessels in the upper lobe of left lung. Anatomic lingula resection was performed. Hilar node was also resected. The histopathological examination confirmed the presence of SP. Fourteen months postoperatively, the patient was in a good health with no clinical or radiological evidence of recurrence.

Conclusion

SP is a rare benign tumor which usually presents in middle aged-women asymptomatically or with nonspecific symptoms. We report this case to highlight that SP should be considered in cases of hemoptysis in young children.

An incidental finding of intraocular choristoma in an enucleated microphthalmic globe: A histopathologic case report

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Intraocular choristomas have been described in volving uveal tissue and optic nerve head.

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They are rare especially in association with microphthalmos.

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We report left intraocular choristoma in an infant with unilateral microphthalmia.

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Histopathologically it consisted of chondroid and adipose tissue.

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This association may necessitate future genetic testing for better understanding of the pathogenesis.

Introduction and importance

Choristomas are benign growth of normal tissue in abnormal location and in the ophthalmic practice, they are more commonly found in the epibulbar region. Intraocular choristoma has been reported in different ocular structures but it is very rare especially in association with microphthalmos.

Case presentation

We present a 13-month-old child with bilateral microphthalmia with the left side being more significantly smaller than the right that required enucleation for introducing a larger silicone implant. The histopathological examination revealed an intraocular choristoma consisting of chondroid and adipose tissue with surrounding fibrosis. Other areas in the globe were also underdeveloped and dysplastic including the optic nerve, which was replaced by dense wavy collagen fibers and fibrovascular tissue.

Discussion

Even though choristomas are benign, they may be extensive interfering with visual development especially the ones involving the epibulbar area.

Systemic disease can have choristomas as an ocular feature such as in Goldenhar-Gorlin syndrome. Choristomas inside the eye are rare and they commonly involve the uveal tissue and the optic nerve head mostly in the form of ectopic glandular tissue and choroidal osseous choristoma. Our case is unique in its intraocular retrolental location, composition of chondroid tissue and fat, in addition to the fact that it was found within a microphthalmic globe with other interesting histopathological findings.

Conclusion

We report a case of an incidental finding of intraocular choristoma with associated microphthalmia, genetic testing may be useful for establishing a genetic etiology in such cases even in the absence of dysmorphic features.

Wide-awake local anesthesia for clavicle fracture fixation: A case report

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Clavicular fracture was treated with plate osteosynthesis using the WALANT technique.

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Adequate pain control and minimal bleeding were observed during the surgery.

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WALANT technique can be used in cases with unsuitability of general anesthesia.

Introduction

The wide-awake local anesthesia no tourniquet (WALANT) technique has been used in many orthopedic surgeries. The benefits of this technique are the avoidance of the adverse effects of general anesthesia (GA) and the overall reduction of the cost of surgery. However, a literature search revealed no published report on performing the WALANT technique for clavicular fracture surgery.

Presentation of case

We report a case of mid-shaft clavicular fracture that was treated with plate osteosynthesis using the WALANT technique in a patient with uncontrolled atrial fibrillation. During the operation, the patient did not experience any pain, and the procedure could be performed easily due to minimal bleeding in the operative field. The operation was completed successfully without any complications, and the patient was discharged from the hospital the day after surgery. Follow-up radiographs after three months showed union of the clavicle at the fracture site, and the patient could use his arm normally.

Discussion

Clavicular fracture is routinely treated with plate osteosynthesis under general anesthesia. In some patients with high morbidity and other risk factors for whom GA is unsuitable, the WALANT technique can prove to be an effective alternative.

Conclusion

Clavicular fixation can be performed successfully and without any complication under WALANT technique.

Recurrence of thyroid carcinoma in cervical soft tissue following surgical implantation: Case report

INTRODUCTION

Thyroid cancer is the most common type of malignant endocrine cancer. Differentiated thyroid cancer, which includes papillary and follicular cancers, represents majority (90%) of all thyroid cancers and has a favorable prognosis. However, a minority of patients develops loco-regional recurrence.

CASE REPORT

We report here a rare case of a 63 years-old man who underwent total thyroidectomy in 2015 for multinodular goiter whose histopathological examination revealed a papillary thyroid carcinoma. He received 6 weeks later a 100 mCi of radioactive iodine therapy. In 2017, he was admitted for multiple cervical lymph nodes with high serum thyroglobulin level (234 ng/mL) which required a bilateral central and lateral neck dissection. He was readmitted in 2019 for multiple subcutaneous neck nodules with high serum thyroglobulin level (197 ng/mL). The histopathological examination of the excised nodules revealed a papillary thyroid carcinoma. The patient showed no sign of recurrence after 2 years follow-up.

CONCLUSION

Local soft tissue recurrence followed surgical implantation should be suspected when nodules are determined alongside the thyroid after previous thyroid surgery. Therapy for these soft tissue implants may be difficult; a comprehensive long-term postoperative evaluation should be completed to minimize the risk of recurrence in cervical soft tissue.

Central pancreatectomy for solid pseudopapillary neoplasm: A pancreatic-preserving procedure

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Pseudopapillary Neoplasm of the pancreas is a rare disorder with benign behavior.

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Preoperative diagnosis can change a treatment plan from a major to a simple operation.

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The treatment should aim for R0 resection; incomplete resection results in recurrence.

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Although recurrence is rare; it is considered a cause of poor outcomes.

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The overall 5-year survival is reported to be 97%.

Introduction and importance

Solid pseudopapillary neoplasm (SPN) is a rare pancreatic disorder that usually affects young women with no or nonspecific clinical manifestation. It accounts for approximately 1% of pancreatic neoplasms. The incidence of SPN is increasing, owing to improved imaging techniques and better recognition of this entity. Although most patients with SPNs have a favorable prognosis after radical resection, local recurrence or metastasis still occurs after surgery.

Case presentation

We present a 15-year-old female with a small solid pseudopapillary neoplasm in the Pancreas' proximal body. The patient presented with nonspecific symptoms and was diagnosed incidentally.

Clinical Discussion

The patient underwent a central pancreatectomy and was discharged on the fifth postoperative day without complications. Central pancreatectomy may prevent devastating complications of pancreaticoduodenectomy surgery.

Conclusion

As SPN is a rare entity of pancreatic tumors, the surgical options for management are still debated. The respect for surgery should account for the tumor site and size. Also, life expectancy and surgical complications for each choice should be considered. In localized disease, segmental resection may prevent devastating complications of radical resection.

A case of dyschromatosis symmetrica hereditaria with an associated eyelid hemangioma

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Dyschromatosis symmetrica hereditaria (DSH) is a rare pigmentary skin disorder.

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Our case is a 25-year-old female with DSH presenting with eyelid hemangioma.

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She had history of cutaneous lupus erythematosus (CLE) and nodular goiter.

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The association of the hemangioma, CLE, and hyperthyroidism with DSH is interesting.

Introduction and importance

Dyschromatosis symmetrica hereditaria (DSH) are rare autosomal dominant pigmentary genodermatosis characterized by reticular hyper- and hypopigmented skin macules on the dorsal aspect of the extremities and freckle-like spots on the face, sparing the palms and soles. Cutaneous hemangiomas were not reported in the literature with DSH. We describe for the first time to the best of our knowledge a case of DSH with histopathologically confirmed eyelid hemangioma.

Case presentation

A 25-year-old female was diagnosed with DSH in her childhood by a dermatologist then later developed cutaneous lupus erythematosus (CLE). Four years later she presented to our clinic with right lower eyelid painless mass. The histopathological examination showed inflamed epidermis overlying a mixed capillary and cavernous hemangioma. The patient had complete healing of the skin post-operatively with excellent cosmetic result.

Discussion

DSH is usually isolated, however, acral hypertrophy, psoriasis, dental anomalies, aortic valve sclerosis, dystonia and intracranial hemangiomas have been reported in association with the disease. The types of the hemangiomas reported were not specified with lack of tissue diagnosis. Our case is unique because of the late occurrence of this eyelid skin hemangioma, the concomitant CLE, the history of hyperthyroidism, and the positive family history of consanguinity.

Conclusion

The pathogenesis of DSH is not well understood, however the previously reported intracranial hemangiomas and the currently reported skin vascular lesion would raise the role of inheritance and variable expression of such an association especially with concomitant CLE. This may warrant further studies on the etiology of DSH.

Successful use of water-soluble contrast in patients with small bowel obstruction and virgin abdomen: A case report

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Trial of nonoperative management is standard of care for adhesive SBO.

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Prior surgery is the most common cause of adhesions.

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Management of SBO in patients without prior surgery is a challenge.

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This is a case of SBO in a virgin abdomen patient successfully managed nonoperatively.

Introduction and importance

Nonoperative management of adhesive SBO is well established but remains a challenge in patients without prior abdominal surgery. We aim to report a case of successful nonoperative management with the use of enteral hypertonic water-soluble contrast administration in a patient with virgin abdomen.

Case presentation

A healthy 24-year old man with no previous surgery presented to the emergency room with one day of abdominal pain. A CT abdomen and pelvis was consistent with SBO without clear anatomic etiology. The patient refused surgical intervention, so we performed a trial of nonoperative management. On hospital day 2, a repeat CT A/P with enterally administered water-soluble contrast showed resolution of SBO. The patient has had no symptoms since hospital discharge on 6 months follow up.

Clinical discussion

Small bowel obstruction is most commonly secondary to adhesions from prior surgeries.

Even in patients with virgin abdomen, adhesions are the cause of SBO in 53%–73%.

Recent studies in patients with virgin abdomen showed that 92.1% that underwent nonoperative management did not have a recurrence of SBO with mean follow up of 4.5 years. The use of water-soluble contrast in patients with virgin abdomen was reported to have 92–97% success rate.

A meta-analysis showed a pooled prevalence of 7.7% of malignant etiology of SBO in these patients, more common with previous SBO admission or history of malignancy.

Conclusion

Nonoperative management with the therapeutic use of hypertonic water-soluble contrast is a viable treatment option in select cases and avoids the morbidity of surgical exploration.

The endonasal endoscopic management of pediatric lateral frontal mucocele

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Frontal mucoceles in children are rare.

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A child with lateral frontal mucocele with no known etiology.

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This shows the usefulness of image-guided endoscopic sinus surgery.

Objectives

The aim of this report is to show the usefulness of endoscopic sinus surgery in management of lateral frontal mucocele in pediatric patient.

Case presentation

A 14 years old girl presented with right frontal bone depression and headache. CT and MRI showed lateral mucocele occupying the right frontal sinus. The patient was managed successfully by image-guided endoscopic sinus surgery and she was well after two years follow up.

Discussion & conclusion

Frontal mucoceles in children are rare. We report a rare case of a child with lateral frontal mucocele with no known etiology, treated successfully by image-guided endoscopic sinus surgery with no recurrence after two years follow-up. This case shows the usefulness of image-guided endoscopic sinus surgery in treatment of lateral frontal mucocele in children.

Rehabilitation of facial palsy by the lengthening temporalis myoplastie: A case report

Introduction

The lengthening temporalis myoplasty (LTM) is defined as a transfer of the entire temporal muscle from the coronoid process to the labial commissure reinserted into the orbicularis muscle.

Presentation of case

a 60-year-old man with grade III longstanding facial paralysis of the right hemi-face secondary to a right total parotidectomy. The surgery was performed for the rehabilitation of the right hemi-facial side by the lengthening temporalis myoplasty. The follow-up was favorable with improvement of the facial dynamics.

Discussion

Surgical management of the longstanding facial palsy is a real challenge. The lengthening temporalis myoplasty offers several advantages; technically is a simple. This technique was demonstrated in severe neglected facial palsy and is performed when there is a definitive complete, or almost complete, loss of the facial nerve and the trigeminal is preserved. Effective rehabilitation through training and physical therapy is necessary to optimize results.

Conclusion

Facial palsy should no longer be permanent, surgical techniques as lengthening temporalis myoplasty with early postoperative physiotherapy leads to good results. Preoperative planning and early recognition of issues can avoid postoperative complications.

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The value and contribution of temporal muscle lengthening myoplasty as a surgical technique in the long neglected facial palsy.

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Longstanding Facial palsy should no longer be permanent.

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The main treatment of surgical management of neglected facial plasy is to achieve a satisfactory functional and aesthetic results.

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Effective rehabilitation through training and physical therapy is necessary to optimize results.

Dormia basket impacted during ERCP, resolved by laparoscopic bile duct approach: Case report

INTRODUCTION

Endoscopic retrograde cholangiopancreatography (ERCP) is the method of choice for treating and removing common bile duct (CBD) stones with high success rates. Among the adverse effects, impaction of the Dormia basket when removing the stones is an unusual complication.

CASE PRESENTATION

Two cases of choledocholithiasis with endoscopic treatment by ERCP and Dormia basket impaction, resolved by a laparoscopic approach to the bile duct.

DISCUSSION

Laparoscopic common bile duct exploration (LCBDE) has been developed as a technique to treat choledocholithiasis and simultaneously vesicular lithiasis by laparoscopy. LCBDE can be by means of a transcystic approach or by choledochotomy. The success of the treatment depends on surgical experience and the availability of adequate equipment, with high effectiveness to eliminate CBD stones and a success rate greater than 95%, it is equally effective for the resolution of adverse events during ERCP.

CONCLUSION

LCBDE provides an alternative therapy where there is no other type of treatment for the resolution of complications of ERCP. It is a safe, effective and reliable technique with high success rates, which offers the benefits of a minimally invasive approach.

Recombinant activated factor VII administration in a patient with congenital lack of factor VII undergoing laparoscopic hysterectomy: A case report

INTRODUCTION AND IMPORTANCE

Case report of patient with congenital lack of factor VII, suffering from recurrent hematomas and massive menstrual bleedings resulting in severe anemia and multiple hospitalization.

CASE PRESENTATION

Patient was diagnosed with endometrial hyperplasia and not responding to hormonal treatment and substitution with recombinant factor VII was not effective to reduce the bleedings. This case describes successful laparoscopic technique of using bipolar coagulation and non-absorbable clips.

CLINICAL DISCUSSION

We describe premedication and post-surgical management - which we had to modify from this found in very scarce literature. Despite previous vaginal deliveries without any complications during the puerperium, 20 days after the surgery patient presented with intraperitoneal bleeding after stopping rFVIIa therapy. It was treated medically without the need for re-laparoscopy.

CONCLUSION

Laparoscopic surgery is possible in patients with lack and deficiency of FVIIa, but they need close post-operative surveillance and prolonged supplementation with recombinant FVIIa.

Endoscopic ultrasound-guided fine-needle aspiration of the left adrenal mass accessed via the gastrostomy tract: A case report with video

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Adrenal metastasis is uncommon in esophageal cancer.

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A biopsy of the adrenal mass is necessary for accurate cancer staging.

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Sampling could be endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA).

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In esophageal cancer, EUS-FNA becomes impractical due to esophageal obstruction.

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Gastrostomy could be a passage for EUS-FNA.

Introduction and importance

An adrenal metastasis is uncommon in esophageal cancer. Its diagnosis could be challenging if a percutaneous approach was inaccessible. Moreover, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), a useful adrenal sampling technique, is complicated by the luminal obstruction.

Case presentation

A patient with esophageal cancer accompanying by adrenal mass and established gastrostomy was described. The EUS-FNA of the adrenal lesion was successfully performed via the dilated gastrostomy tract. Adequate tissue for pathological examination was achieved, and the result indicated metastatic squamous cell carcinoma. Chemotherapy was started accordingly.

Clinical discussion

This report described an uncommon event of adrenal metastasis of esophageal primary. Even though it is possible to perform EUS via the gastrostomy tract, performing EUS from an unusual direction might add some difficulty to an endoscopist, considering that EUS involves image pattern recognition in identifying structures. Thus, this technique should be operated by experienced EUS endoscopists.

Conclusion

Gastrostomy can provide an enteral route for nutrition support in esophageal cancer patients. In addition, it could be an alternative EUS intervention portal when an esophageal stent is not accessible.

Retroperitoneal necrosectomy using lavage circuit as a new technique in the management of pancreatic infected walled off necrosis (WON): A case report

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Infected WON cases are representing as challenging.

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Step up approach is better than open necrosectomy in the treatment of infected WON.

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Retroperitoneal necrosectomy represents a 2nd step in the step up approach.

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Retroperitoneal necrosectomy using lavage circuit reduce the possible bleeding risk.

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Retroperitoneal necrosectomy using lavage circuit is a simple and easy modification of VARD.

Introduction

Walled off necrosis (WON) is clarified according to the revised Atlanta classification, 2013, as a late phase complication of acute necrotizing pancreatitis. Not all cases with WON need intervention but, if indicated both open approach and minimally invasive techniques were clarified. We are discussing here, a case presented to us with infected WON. We adopted the step up approach as the main line of treatment; the case was managed by percutaneous catheter drainage (PCD) followed by retroperitoneal necrosectomy using lavage circuit.

Case presentation

Diabetic male patient aged 58 year old gave to us with left hypochondrial pain accompanied with easy fatigability and poorly controlled DM. The patient had an attack of acute pancreatitis (AP) 2 months before admission. Abdominal CECT revealed infected WON. The case was managed successfully by retroperitoneal necrozectomy using lavage circuit after failure of PCD.

Discussion

A step up approach is followed for determining the optimal interventional strategy for patients presented with infected necrosis. We adopt retroperitoneal debridement using lavage circuit as a 2nd step in this approach. The concept of this technique is to facilitate the detachment of necrotic tissue using the force of saline while minimizing the risk of bleeding.

Conclusion

Infected WON cases are representing as challenging, we require to get rid of the necrotic material with infected fluid and reduce the hazard of complications. In this technique, we have the advantage of retroperitoneal necrosectomy where we can remove only the loose necrotic tissue by saline force and so, reduce the possible bleeding risk.

Two-point versus three-point fixation in the management of zygomaticomaxillary complex fractures: A comparative study

Introduction:

The zygoma plays an important role in the facial contour for both cosmetic and functional reasons; therefore, zygomatic bone injuries should be properly diagnosed and adequately treated. Comparison of various surgical approaches and their complications can only be done objectively using outcome measurements that require a protocol for management and long-term follow-up. The objectives of this study were to compare the efficacy of zygomatic bone after treatment with open reduction internal fixation (ORIF) using two-point fixation and ORIF using three-point fixation and compare the outcome of two procedures.

Materials and Methods:

Twenty patients were randomly divided equally into two groups. In Group A, ten patients were treated by ORIF using two-point fixation by miniplates and in Group B, ten patients were treated by ORIF using three-point fixation by miniplates. They were evaluated with their advantages and disadvantages and the difference between the two groups was observed.

Results:

We found that postoperative facial and neurological complications are minimum in two-point fixation group. Based on this study, open reduction and internal fixation using two-point fixation by miniplates is sufficient and the best available treatment of choice for the management of zygomaticomaxillary complex fractures.

Discussion:

Alignment of the fracture at three points and fixation at two stable points provide the most accurate and satisfactory postoperative results. Two-point interosseous fixation at the “buttress” fracture and the frontozygomatic (FZ) fracture is suitable for routine surgery. The results of these studies confirm with the present study that two-point fixation provided better stability in patients with clinical and radiological evidence of fracture in FZ and zygomaticomaxillary buttress area.

A case of multiple recurrent intussusceptions due to multiple lymphomatous polyposis associated with diffuse large B-cell lymphoma of gastrointestinal tract in a 15-year-old child: A rare case report

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Association of Multiple lymphomatous polyposis with Diffuse Large B-cell Lymphoma.

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Rare presentation of Multiple intussusceptions due to large Multiple Lymphomatous Polyposis.

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Primary gastrointestinal (GI) lymphoma clinical presentation, diagnosis and treatment.

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Review of literature on Multiple lymphomatous polyposis and Primary GI Lymphoma.

Introduction and Importance

Multiple lymphomatous polyposis (MLP) is a distinctive and rare entity of primary gastrointestinal (GI) lymphoma characterized by polypoid lymphomatous tissue in long segments of the gut and a strong tendency for spread throughout the GI tract. Although many cases of MLP presenting as intussusceptions in adults have been reported, we report a rare case of multiple recurrent intussusceptions due to MLP associated with high-grade Diffuse Large B-cell lymphoma (DLBCL) of the entire GI tract in a 15-year-old child.

Case presentation

A 15-year-old child previously operated for acute intestinal obstruction, presented with intermittent abdominal pain, nausea and vomiting. Imaging studies confirmed the diagnosis of multiple small bowel intussusceptions. Patient was treated by exploratory laparotomy and multiple resection anastomosis. Histopathology confirmed the diagnosis of MLP due to DLBCL. The patient received chemotherapy following surgery. So far, at 6 months of follow-up, Patient is doing well.

Clinical discussion

Malignant tumors of the small intestine are unusual, with non-specific clinical presentation. Although ultrasound (US), CT, FDG-PET/CT and endoscopic evaluation are essential modalities for the diagnosis of intestinal polyposis. Final diagnosis of MLP can only be confirmed after histopathological examination and immunohistochemistry studies. Surgical resection followed by appropriate chemotherapy is the treatment of choice.

Conclusions

MLP due to DLBCL has rarely been described in young patients under the age of 18 years. We should keep a high index of suspicion for malignant GI lymphoma in cases of intussusception, especially in older children.

Laparoscopic management of mesh migration into urinary bladder following laparoscopic totally extraperitoneal inguinal hernia repair-A case report

•

Mesh migration into bladder should be considered a differential in case of patients with recurrent UTI and history of laparoscopic hernioplasty.

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Computed tomography and cystoscopy will aid in the diagnosis of such cases and removal by TAPP approach is better than other approaches.

•

This case report will help the readers to get a knowledge on such an approach as it is easily reproducible.

•

Care should be taken to remove all the mesh as remnant mesh particles may act as a nidus for infection.

Introduction and importance

Mesh migration into urinary bladder is one of the rare complications following inguinal hernia repair (Laparoscopic/Open). On reviewing the literature, erosion of mesh following inguinal hernia repair has been into the urinary bladder in most of the cases, and the erosion may occur as early or late complication. It may occur as a result of improper suturing, inadequate fixation or foreign body reaction. The most common presentation is recurrent urinary tract infection and haematuria and may mimic bladder malignancy.

Case presentation

A 38-year male presented with recurrent UTI and mimicked to have bladder malignancy on CT scan. On Cystoscopy, mesh along with tackers is visualized within the bladder lumen. A diagnosis of Mesh migration into bladder following laparoscopic inguinal hernia repair was made. The Patient underwent Complete laparoscopic removal of mesh with partial cystectomy, per urethral and suprapubic catheter were placed. The patient made a good recovery without any post-operative complications. On follow-up, Patient underwent Fluoroscopy to look for urinary leakage, and suprapubic catheter removal was done. Patient is asymptomatic on follow-up.

Clinical discussion

Mesh migration into bladder is one the rare complications following laparoscopic hernia repair. Proper preoperative evaluation is necessary to determine whether mesh is free floating in the bladder lumen or adherent to bladder wall. This will help in deciding the surgical technique for route of extraction.

Conclusion

A case of mesh migration into the bladder can be easily managed by laparoscopic TAPP approach and it is better approach compared to other techniques.

When laparoscopy for fertility preservation prior to gonadotoxic treatment of an anterior mediastinal mass is a dilemma: A case report

INTRODUCTION

The management of anterior mediastinal masses is a challenge for anesthesiologists. Recommendations for their management in the context of diagnostic or curative surgery are well described. The added risk of laparoscopic surgery for fertility preservation has however never been discussed in the literature.

PRESENTATION OF CASE

We present the case of a 32-year-old female patient with a large malignant anterior mediastinal mass. She was referred for anesthesia evaluation before laparoscopic ovarian tissue harvesting as part of fertility preservation prior to gonadotoxic treatment. The patient presented dyspnea at rest. Chest computed tomography revealed a tracheal deviation and a partial obstruction of the left mainstem bronchus. Transthoracic echocardiography showed a pericardial effusion. Proceeding to high risk anesthesia for a non-curative surgery in a patient with a highly symptomatic mass was considered unacceptable and the procedure was postponed. The patient received a single cycle of neoadjuvant chemotherapy. Clinical and radiological improvement were shown after this single dose and laparoscopic surgery was performed under general anesthesia without complications.

CONCLUSION

In the context of an anterior mediastinal mass and fertility preservation a thorough benefit-risk analysis must be undertaken before non-curative laparoscopic surgery. In case of severe symptoms, surgery should be postponed until the patient's condition improves after the minimum necessary chemotherapy treatment. So far it is impossible to say whether the risk exceeds the expected benefit in this difficult situation. Further studies need to be conducted in this area.

Isolated comminuted trapezium fracture: A case report and literature review

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Isolated Trapezium fracture is difficult to be detected causing 1st carpometacarpal joint degeneration and limitation of thumb motion.

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In order not to miss trapezium fracture, a high index of suspicion is required.

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Persistent pain in the anatomical snuffbox or thenar eminence following a trauma should alert the physician to consider trapezium fracture.

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Open reduction and internal fixation even without graft seem to be a plausible choice for managing comminuted trapezium fracture.

Introduction and importance

Trapezium, as a carpal bone positioned at the distal row, is often associated with other wrist injuries such as distal radius fracture. Isolated trapezium fracture, especially in a comminuted form, rarely occurs. There are only six reports of isolated comminuted trapezium fractures in the literature to the best of our knowledge.

Case presentation

We present a case with an isolated comminuted trapezium fracture presenting pain in his thenar eminence and thumb motion limitation. He was treated by Open Reduction and Internal Fixation (ORIF) with the K wire pin.

Clinical discussion

We searched the published related studies and summarized the signs and symptoms of patients presented with trapezium fracture. The most common presentation of trapezial fracture include pain/tenderness at the base of the first metacarpal bone, pain/tenderness at the snuffbox area and 1st digit motion limitation. The treatment options described in the literature for isolated comminuted trapezium fracture are also presented. Open reduction and fixation with pin is the most common treatment mentioned in the literature. The priority is restoring the scaphotrapezial and trapeziometacarpal joint congruency to save the 1st digit range of motion.

Conclusion

Comminuted trapezial fracture may happen following either low energy (like our patient) or high energy trauma. This paper highlights the fact that even a comminuted trapezium fracture can be easily missed. Regardless of the trauma mechanism (high energy versus low energy trauma), a high index of suspicion and delicate work up would be necessary in order not to miss this type of fracture.

Spontaneous regression of lung metastases in hepatocellular carcinoma: A case report

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The prognosis of patients with advanced HCC remains poor even if appropriate treatments are administered.

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Spontaneous regression of lung metastases of hepatocellular is a rare condition.

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We discuss the mechanism for spontaneous regression of multiple pulmonary recurrences of hepatocellular carcinoma.

Introduction

Spontaneous regression of hepatocellular carcinoma (HCC) is a rare condition. However, although there have been multiple reports of spontaneous regression, the definitive pathogenic mechanism of this phenomenon is still unclear.

Case presentation

We encountered a case of a 78-year-old man who was undergoing dialysis for end-stage kidney disease with hepatitis C virus-associated chronic hepatitis presenting with HCC. The patient had previously undergone right lobectomy of the liver, but the cancer recurred with multiple lung metastases after 5 months. Approximately 13 months after the initial diagnosis of recurrence, the lung metastases decreased in size and eventually resolved without any anticancer therapy. The patient remains alive for over 41 months after recurrence.

Discussion

Based on our case and literature, Hypoxia with hypotension due to hemodialysis can reduce the blood and oxygen supply of the body, which may lead to the spontaneous regression of the metastatic tumors.

Conclusion

We herein reported a case of spontaneous regression of HCC undergoing dialysis.

Retroperitoneal ganglioneuroma causing chronic lower back and leg pain in an 80-year-old man: A case report

Introduction

and importance: Retroperitoneal ganglioneuromas that cause lower back and leg pain are extremely rare and are often misdiagnosed. Surgical resection has excellent prognosis in long-term survival.

Case presentation

We present an 80-year-old man with two-year worsening left lower back and leg pain. He was treated as presumed lumbar spine spondylosis with several courses of physical therapy together with medical treatment. An abdomen CT scan disclosed a tumour in the left retrorenal space. The tumour was resected and the histopathologic examination suggested a completely excised retroperitoneal ganglioneuroma. During one-year follow-up the patient is free of pain without any local recurrence.

Clinical discussion

Retroperitoneal ganglioneuromas are rare benign tumors that originate from neural crest-derived cells of the paravertebral sympathetic plexus and sometimes from the adrenal medulla. They are usually asymptomatic and discovered on routine clinical examination or on autopsy. Occasionally they may show symptoms due to local pressure effect or rarely they are hormonally active and present with adrenergic symptoms. Complete resection of the tumor is important in order establish the final diagnosis and alleviate symptoms from pressure effects.

Conclusion

This case highlights the need for great vigilance among physicians in order to consider any possible retroperitoneal pathology when indicated in the differential diagnosis of lower back and leg pain, before establishing other more common diagnosis, especially in the older population.

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Retroperitoneal ganglioneuromas that cause lower back and leg pain are extremely rare.

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They are composed by Schwann cells on nerve fibres and mature sympathetic ganglion cells.

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Complete resection of retroperitoneal ganglioneuromas has an excellent prognosis.

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High suspicion is required to rule out any retroperitoneal pathology in this clinical setting.

A case report of metastatic melanoma in the popliteal fossa

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Metastatic melanoma in the popliteal fossa is extremely rare with limited literature available.

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A case of popliteal fossa metastatis following primary diagnosis of right mid-calf malignant melanoma with inguinal metastasis.

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Surgical treatment involves a posterior approach to the popliteal fossa.

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High index of suspicion for early detection of metastasis to the popliteal fossa and inguinal region in distal lower extremity lesions.

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Popliteal lymph nodes could be a primary drainage site or interval nodes.

Introduction

Metastatic melanoma in the popliteal fossa is extremely rare with less than 5% of metastatic deposits from melanomas in the leg and foot draining into the popliteal region, while the majority drain to the inguinal region. If popliteal spread is clinically overlooked, it may lead to recurrence. Together with the accompanying literature review, this case report emphasises the need for thorough clinical and radiological assessment in the management of malignant melanomas of the lower extremity.

Presentation of case

A 66-year-old gentleman presented with metastatic melanoma to the right popliteal fossa three years after the diagnosis of a primary lesion in the right mid-calf with ipsilateral inguinal lymph node metastasis for which he underwent a right wide local excision and complete groin lymph node dissection.

Discussion

Studies show that a lesion anywhere below the knee can metastasize to the popliteal fossa. The groin can be the primary or secondary lymphatic drainage site in conjunction with the popliteal fossa. Concurrent popliteal and inguinal drainage may either reflect two separate lymphatic channels with popliteal nodes being the primary drainage site, or a single channel which drains to the popliteal basin as an interval node. Hence, popliteal lymph nodes should be carefully assessed in distal lower extremity lesions including melanomas. Modalities to delineate lymphatic flow and identify micrometastatic deposits should be used and when metastatic popliteal disease is identified, radical popliteal dissection is advised.

Conclusion

Proper clinical assessment, good surgical technique, a high index of suspicion, and active surveillance are all essential to ensure early detection of metastasis to the popliteal region.

First bilateral non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) co-occurring with bilateral papillary thyroid microcarcinoma. Case report and literature review

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Non-invasive follicular thyroid neoplasm with papillary-like features (NIFTP) is a benign lesion with no evidence of recurrence or metastasis.

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NIFTP is managed with partial or total thyroidectomy which is sufficient to achieve total cure.

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Co- coexistence of NIFTP and papillary microcarcinoma can be managed by resection and radioactive iodine ablation of the thyroid.

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The current case in probably the first reported bilateral NIFTP with bilateral papillary microcarcinoma.

Introduction

Non-invasive follicular thyroid neoplasm with papillary-like features (NIFTP) is a recently characterized lesion with very low malignant potential. This has allowed for less aggressive management of this tumor subtype. Papillary thyroid carcinoma (PTC) has malignant potential and requires different considerations in management.

Presentation of case

A 33-year-old woman presented to our Thyroid Surgery Clinic with a left neck swelling slowly enlarging over 4 years, and recent right-sided neck pain. Neck ultrasound and fine needle aspiration for cytology found bilateral thyroid nodules, labelled as ‘follicular lesion of undetermined significance’ (FLUS). Final pathology report after total thyroidectomy identified four distinct tumors: bilateral NIFTP lesions and bilateral papillary microcarcinomas.

Discussion

Management of NIFTP comprises partial or total thyroidectomy without further intervention. Management of PTC is the same but with the possible addition of radioactive ablation due to the increased malignant potential. This is the first report of bilateral NIFTP lesions and bilateral papillary microcarcinomas co-occurring together in the same patient, so management was challenging. The decision was made to give the patient low dose radioactive iodine ablation and continue monitoring. Ultrasound of the neck follow up 6 months later showed no residual thyroid tissue or local recurrence.

Conclusion

Although rare, NIFTP can co-occur with PTC. Bilateral NIFTP with bilateral PTC is extremely rare. Surgeons and pathologists need to be aware of this rare entity that can co-occur in both thyroid lobes. Total thyroidectomy is the definitive treatment. Post-surgery surveillance is important and follow up needs to be watchful for any recurrence or metastasis.

Case-report: A rare cause of intestinal obstruction in late pregnancy

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Caecal volvulus represents a rare and often life-threatening cause of intestinal obstruction, with associated high mortality rates.

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Diagnosis and early intervention remain a challenge, as patients may only present with vague nonspecific symptoms.

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More classical symptoms of volvulus eventually occur, usually secondary to obstruction or ischaemia.

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Early diagnosis and intervention are of paramount importance.

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We advise clinicians to remember this diagnosis, as a potential cause of abdominal pain and obstruction; especially in those with risk factors.

Introduction

Caecal volvulus represents a rare and often life-threatening cause of intestinal obstruction. Diagnosis and management of caecal volvulus remains a clinical challenge, since those presenting with symptoms can have vague nonspecific presentations. Symptoms eventually occur, usually secondary to obstruction or ischaemia. This case report will discuss the presentation, investigation and management options available.

Presentation

A 31-year-old multigravida, at 38 weeks and 6 days gestation; presented to hospital with a 2-day history of diffuse abdominal pain and distension. Initial examination was unremarkable aside from mild epigastric tenderness. Raised inflammatory markers and concerns for foetal health resulted in an emergency caesarean section. Symptoms however worsened and the patient underwent colonoscopy and computerised tomography (CT) of the abdomen and pelvis with contrast; showing caecal volvulus. The patient was taken to the operating theatres for an emergency right hemicolectomy with formation of end ileostomy. Intra-operatively, areas of necrosis were noted within the caecum suggestive of impending perforation. The patient recovered well post reversal of end ileostomy, with no complications to date.

Discussion

Caecal volvulus represents a rare, but potentially fatal cause of intestinal obstruction and ischaemia. High mortality rates are attributed to delayed diagnosis and treatment. Patients may initially present with vague symptoms, which rapidly progress with the development of ischaemia. Multiple management modalities exist. Central to prognosis is early diagnosis.

Conclusion

Early diagnosis and intervention are paramount. Imaging via abdominal x-rays and CT are of particular importance. Surgical management is widely reported as the mainstay of treatment. We advise clinicians to remember this rare diagnosis, as a potential cause of abdominal pain and intestinal obstruction; especially in those with predisposing risk factors.

Relapsed hip stiffness after recovery of range of motion in a hip treated for developmental dysplasia of the hip? Think again: A case report

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How to evaluate complications following DDH treatment.

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Muscular spasm can mislead physicians following treatment of DDH.

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Hip stiffness vs muscular spasm in DDH patients.

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Examination under anesthesia could be the answer for relapsed hip stiffness.

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The value of examination under anesthesia in DDH complications.

Introduction

Several complications have been reported following treatment of developmental dysplasia of the hip (DDH). Local muscular spasm is an extremely rare complication. This case serves to enlighten orthopedists about various and unique presentations of idiopathic local muscular spasm, natural history of such condition, and appropriate treatment.

Presentation of case

A two-year-old child presented with bilateral acetabular dysplasia for orthopedic evaluation and treated with bilateral simultaneous Dega osteotomy and postoperative cast for 12 weeks. Full range of motion (ROM) of both hips was regained three months after removal of the postoperative cast. Five months later, the child presented with apparent leg length discrepancy, and severe and painless global limitation of the right hip ROM, which initially was thought to be relapsed hip stiffness. Laboratory and radiological investigations were normal apart from pelvic obliquity on radiographs. Symptoms persisted for one month. Examination under anesthesia (EUA) was then performed and revealed full ROM of the involved hip. Physical therapy was started, and hip ROM fully recovered within 3 months without further intervention.

Discussion

Stiffness, which is one of the most reported complications following surgical treatment of DDH, is usually related to lengthy periods of immobilization and/or surgical treatment. Clinically, local muscular spasm of the hip can mimic stiffness. EUA is invaluable to differentiate the common postoperative stiffness from the rare local muscular spasm.

Conclusion

Idiopathic local muscular spasm of hip might present clinically as stiffness that pose a diagnostic dilemma to the treating physician. Close observation coupled with physical therapy is sufficient.

Pediatric bronchiectasis: An orphan disease ending in pneumonectomy: A case report

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Pediatric bronchiectasis causes early decline in lung function.

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Treatment of paediatric bronchiectasis should be multidisciplinary.

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Surgical resection should be the last option to treat bronchiectasis in children.

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Neglected paediatric bronchiectasis is fatal.

Introduction

Bronchiectasis is chronic infectious and inflammatory disease that results in irreversible thickening and dilatation of bronchi, and significant lung function decline in children. Prompt early diagnosis and multidisciplinary intervention is crucial to control recurrent exacerbation and preserve lung function.

Presentation of case

We present a case of pediatric bronchiectasis in a 10-year-old female who presented with a complaint of intermittent wet cough of 5 weeks’ duration associated with low grade intermittent fever, shortness of breath, easy fatigability and loss of appetite. Left pneumonectomy was done through left posterolateral thoracotomy and she was discharged home in good condition.

Discussion

Recurrent lower tract air way infections are the most common causes of pediatric bronchiectasis followed by primary immune deficiency, primary ciliary dyskinesia, foreign body aspiration and airway structural abnormalities. It is crucial to equip health care professionals with adequate knowledge about the disease as most pediatric patients may not have productive cough like adults leading to misdiagnosis or significant delay in diagnosis. High Resolution Computerized Tomography (HRCT) is the gold standard modality to diagnose and stratify severity of bronchiectasis.

Conclusion

Neglected pediatric bronchiectasis is associated with significant morbidity and mortality. So, it should be considered as differential diagnosis in children with recurrent respiratory symptoms as timely and prompt diagnosis is crucial for early intervention. Surgical resection is the last option of treatment for patients with bronchiectasis mainly reserved for those with recurrent infection despite adequate medical therapy.