Situs revisited: imaging of the heterotaxy syndrome

Polysplenia with situs inversus totalis, azygos continuation of the inferior vena cava, and duplication of the superior vena cava in a healthy adult: A case report

Polysplenia syndrome is an embryological disorder whereby the usual left-right asymmetry of thoracic and abdominal viscera fails to develop. It is a rare entity, estimated to occur at a frequency of 1 in 40,000, and is often associated with cardiac and biliary abnormalities. More than 75% of patients die before the age of 5 years, and even in the absence of cardiac anomalies, only 5%-10% of patients are expected to survive into adulthood without complications. Although polysplenia syndrome encompasses a wide range of anatomic abnormalities, there is no single pathognomonic feature. Hence, the prognosis of patients with polysplenia depends on their anatomy, thus necessitating radiology in their management. Here we present a case of a 56-year-old man with polysplenia syndrome and situs inversus totalis. This presentation is atypical because polysplenia is usually considered a form of situs ambiguus, and cases with situs inversus totalis are exceedingly rare. Also noted in our patient are variations in the great vessels, including aortic arch branches and the venae cavae which are features not typically associated with either polysplenia syndrome or situs inversus totalis. The patient is healthy and asymptomatic at baseline, with his diagnosis being made incidentally. Our case report is the first to describe this unique combination of cardiothoracic and cardiovascular anatomy. It also emphasizes the importance of radiologists in caring for patients with laterality defects. As these disorders are uncommon, more data on their anatomic variations may help provide better medical care to this patient population.

Mechanical thrombectomy for cerebrovascular occlusion in a patient with situs inversus

Situs inversus is a rare congenital abnormality characterized by mirror-image transposition of the major visceral organs and vessels. Few reports have discussed the use of mechanical thrombectomy in acute ischemic stroke with situs inversus. We present such a case, to raise awareness and deepen the knowledge on these cases. A 44-year-old man was admitted to our hospital with sudden-onset dysarthria and left-sided paresis. Computed tomography (CT) angiography revealed situs inversus and occlusion in the internal carotid artery. First, intravenous tissue plasminogen activator was administered, followed by immediate reperfusion with mechanical thrombectomy. We achieved thrombolysis in cerebral infarction grade 3. After the procedure, the patient fully recovered. Prompt diagnosis is crucial for rapid recanalization in patients with vascular anomalies such as situs inversus.

Locally invasive cholangiocarcinoma causing gastric outlet obstruction in heterotaxy syndrome: A case report and review of literature

Heterotaxy syndrome is a disease of embryo development resulting in abnormal distribution of thoracic and abdominal organs across the left-right axis. In this case, A 77-year-old gentleman was admitted with gastric outlet obstruction secondary to cholangiocarcinoma. This is on a background of heterotaxy syndrome, specifically situs ambiguus. The patient's anatomical variations included a right-sided stomach, midline liver, and asplenia. Due to variant anatomy and risk of aspiration; endoscopy was abandoned in favor of surgical bypass via a gastrojejunostomy. Although technically challenging, complex upper abdominal surgery in heterotaxy syndrome has been described in the literature. Variations in anatomy observed in heterotaxy syndrome may render patients ineligible for resection of cholangiocarcinoma and increase the risk of complications. Careful preoperative planning with imaging and meticulous intraoperative dissection is required.

CT Findings of Azygos Venous System: Congenital Variants and Acquired Structural Changes

The azygos venous system is a crucial conduit of the posterior thorax and potentially vital collateral pathway. However, it is often overlooked clinically and radiologically. This pictorial essay reviews the normal azygos venous anatomy and CT findings of congenital variations and structural changes associated with acquired pathologies.

Situs inversus totalis in an asymptomatic adolescent - importance of patient education: A case report

BACKGROUND

Situs inversus totalis (SIT) may be an incidental finding in asymptomatic children. Patients may not understand the implications of this condition and the importance of relaying the diagnosis to their healthcare providers.

CASE SUMMARY

We report an asymptomatic seventeen-year-old adolescent with previously-diagnosed SIT who presented for a routine well-child visit. During history taking, he denied any past medical conditions, including cardiovascular conditions. Only when physical exam revealed point of maximal impulse and heart sounds on the right side, did he convey that he had been diagnosed with SIT incidentally at age of 12 years. He was not aware of associated conditions or the potential implications of his diagnosis, nor did he realize it is pertinent medical history to be relayed to healthcare providers. Chest X-ray confirmed dextrocardia and abdominal X-ray showed right-sided stomach. Abdomen sonogram showed left-sided liver and right-sided spleen. Echocardiogram showed normal valvular structure and function. A comprehensive discussion was provided to address the patient's lack of understanding that SIT is a medical diagnosis with potential implications.

CONCLUSION

While SIT is rare and mostly asymptomatic, affected patients may not comprehend the importance of the diagnosis and its potential ramifications. Recognition of the patient's lack of awareness allows the healthcare provider to educate the patient and hopefully can prevent potential medical and surgical complications.

Successful leadless pacemaker implantation in a patient with dextroversion of the heart: A case report

BACKGROUND

Dextroversion is defined as the presence of dextrocardia with situs solitus, dextro-loop ventricles, and normally related great arteries. Dextrocardia can pose technical challenges when interventional treatments are required. However, the challenges posed by dextroversion can be amplified due to the disruption of typical anatomical relationships, the unpredictable positioning and boundaries of cardiac structures resulting from the shift, and the pathological processes influencing rotation.

CASE SUMMARY

A 73-year-old woman with cardiac dextroversion suffered from a recurrence of atrial fibrillation after her radiofrequency catheter ablation and Despite the cessation of antiarrhythmic medications, there were episodes of sinus pauses and symptomatic bradycardia, with heart rates dropping as low as 28 beats per minute.

CONCLUSION

Dextroversion makes the implantation of leadless pacemakers more challenging, and appropriate adjustments in fluoroscope angles may be crucial for intracardiac operations. Additionally, when advancing delivery systems, attention should be paid to rotational direction during valve-crossing procedures; changes in the perspective of posture angle between normal cardiac position and dextroversion can serve as references.

Imaging of inferior vena cava normal variants, anomalies and pathologies, Part 1: Congenital

The embryology of the inferior vena cava (IVC) is complex, involving the sequential appearance and regression of multiple segments that ultimately form the IVC. Any alteration in this process during embryogenesis can result in congenital anomalies of the IVC. This study aimed to recognise common as well as rare anomalies of the IVC and associated veins, and their clinical implications. The anomalies tend to have diverse appearances based on the timing and segments involved. The development of the IVC is intertwined with the development of other veins like the renal vein, azygos vein and portal vein, and these veins may also be anomalous. Additionally, IVC anomalies are associated with various other congenital anomalies including cardiac anomalies, the recognition of which may be important for patient care. The IVC tends to have multiple normal variants and anomalies because of a complex process involving multiple segments contributing to the adult IVC. Knowledge of these variants is crucial for preoperative planning of procedures.

Contribution

This study would help in understanding the embryogenesis of the IVC and correlation with the imaging appearances and the clinical implications of each of these common as well as rare types of congenital anomalies.

Left Bronchial Isomerism with Right-Sided Tracheal Bronchus: A Rare Case Report

The tracheal bronchus is a congenital bronchial branching anomaly defined as an aberrant bronchus arising in either the trachea or a main bronchus. Left bronchial isomerism is characterized by two bilobed lungs, bilateral long main bronchi, and both pulmonary arteries passing superiorly to their respective upper lobe bronchi. Left bronchial isomerism with a right-sided tracheal bronchus is a very rare combination of tracheobronchial anomalies. It has not been previously reported. We present multi-detector CT findings of a left bronchial isomerism with a right-sided tracheal bronchus of a 74 year old man.

An usual case of bilateral deep venous thrombosis with associated pulmonary embolus

Congenital absence of the inferior vena cava (IVC) triggers collateral vessel growth to drain the peripheries and abdominal organs. This causes venous stasis and increases the risk of deep vein thrombosis (DVT) and pulmonary embolism. Typically, patients with absent IVCs present before 30 years of age, with bilateral DVT symptoms triggered by intense exercise. The abnormality can remain undetected as computed tomography imaging is not usually performed. Due to the increased risk of clotting, these patients should be on life-long anticoagulation. Raising clinical awareness of this condition, to ensure appropriate investigations and treatment, is important.

OUP accepted manuscript

A 36-year-old female with a past medical history of primary ciliary dyskinesia and bilateral lung transplantation was noted to have a rare and confounding postsurgical anatomy acquired as a result of transplantation. Bronchoscopy and computed tomography showed isomeric main bronchi with a tri-lobed right lung, a bi-lobed left lung and dextrocardia. This rare phenomenon can be observed in lung transplant recipients with situs ambiguous morphology of their native lungs, who receive donor lungs with normal situs solitus morphology. To the best of our knowledge, ours is the first reported case of such a composite bronchopulmonary situs abnormality. Careful review of bronchial anatomy should be done with the help of CT imaging prior to undertaking any bronchial interventions in these subset of patients with bronchial isomerism and bilateral lung transplantation.

Isolated Dextrocardia with Situs Solitus - Dextroversion in a Ugandan Baby: A Case Report

Background

Dextrocardia is a rare congenital abnormality in the general population, with an estimated incidence of 1 in 12,000 live births. Isolated dextrocardia, the condition of right-sided heart with situs solitus is most commonly referred to as dextroversion.

Case Presentation

A 2-month-old Ugandan baby boy discovered to have isolated dextrocardia with situs solitus presented with fever, cough, and difficulty in breathing. Physical examination revealed moderate respiratory distress, bilateral basal fine crepitations, tachycardia with regular pulse, and heart sounds best heard on the right hemithorax, but no murmurs. Chest X-ray confirmed right-sided cardiac shadow with cardiac apex pointing to right. Echocardiography showed D-loop ventricular morphology with right cardiac axis and ventricular apex to right, plus tiny patent ductus arteriosus. Abdominal ultrasound showed normal situs solitus; however, the left kidney was noted in pelvic space.

Conclusion

Isolated dextrocardia with situs solitus (dextroversion) is a rare scenario. This case exhibits a learning point in the significance of routine medical examination of patients to identify anomalies and upon suspicion a thorough evaluation to prevent wrong diagnosis or poor prognosis due to delayed management.

Characterization of phenotypic spectrum of fetal heterotaxy syndrome by combining ultrasound and magnetic resonance imaging

OBJECTIVE

Heterotaxy or isomerism of the atrial appendages is a congenital disorder with variable presentation, associated with both cardiac and non-cardiac anomalies, which may have a serious impact on fetal outcome. The aim of this exploratory study was to assess the value of fetal magnetic resonance imaging (MRI), as a complementary tool to ultrasound, for describing the morphological spectrum encountered in heterotaxy.

METHODS

This retrospective study included 27 fetuses that underwent fetal MRI following prenatal suspicion of heterotaxy on ultrasound from 1998 to 2019 in a tertiary referral center. Heterotaxy was classified as left atrial isomerism (LAI) or right atrial isomerism (RAI) based on fetal echocardiography (FE) examination. In addition to routine prenatal ultrasound, fetal MRI was offered routinely to enhance the diagnosis of non-cardiac anomalies, which might have been missed on ultrasound. Prenatal findings on ultrasound, FE and MRI were reviewed systematically and compared with those of postnatal imaging and autopsy reports.

RESULTS

Twenty-seven fetuses with heterotaxy and cardiovascular pathology, of which 19 (70%) had LAI and eight (30%) had RAI, were included. Seven (7/19 (37%)) fetuses with LAI had normal intracardiac anatomy, whereas all fetuses with RAI had a cardiac malformation. All 27 fetuses had non-cardiac anomalies on fetal MRI, including situs and splenic anomalies. In 12/19 (63%) fetuses with LAI, a specific abnormal configuration of the liver was observed on MRI. In three fetuses, fetal MRI revealed signs of total anomalous pulmonary venous connection obstruction. An abnormal bronchial tree pattern was suspected on prenatal MRI in 6/19 (32%) fetuses with LAI and 3/8 (38%) fetuses with RAI.

CONCLUSIONS

Visualization on MRI of non-cardiac anomalies in fetuses with suspected heterotaxy is feasible and can assist the complex diagnosis of this condition, despite its limitations. This modality potentially enables differentiation of less severe cases from more complex ones, which may have a poorer prognosis. Fetal MRI can assist in prenatal counseling and planning postnatal management. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The pediatric stomach - congenital abnormalities

Diagnostic imaging of the pediatric stomach often provides a challenge for practicing radiologists. Radiologists should be aware of relatively unusual congenital pathology, especially when imaging very young children with gastrointestinal symptoms. We review congenital pathology of the pediatric stomach.

Polysplenia syndrome and sickle cell trait: extensive deep venous thrombosis from venous stasis and hypercoagulability

Deep venous thrombosis is a hitherto under-recognized complication occurring in patients with polysplenia syndrome, despite the high prevalence of venous anomalies such as interrupted inferior vena cava (IVC) with azygos/hemiazygos continuation. Here we report the first case of concurrent polysplenia (as evidenced by interrupted IVC with azygos/hemiazygos continuation, multiple left-sided spleens, bowel malrotation with inverted mesenteric veins, preduodenal portal vein, and pancreatic hypoplasia/partial agenesis of the dorsal pancreas) and sickle cell trait, complicated by extensive deep venous thrombosis refractory to medical and interventional radiologic management.

Heterotaxy syndrome with complex congenital heart disease, facial palsy, and asplenia: A rare newborn finding

Heterotaxy syndrome is associated with asplenia/polysplenia and complex congenital heart disease. Facial palsy in heterotaxy is very rare. The management is still challenging with a poor prognosis. Proper counseling to the family about the disease course, treatment modalities, and outcomes is essential.

Imaging findings in a case of situs inversus totalis

Situs inversus is an uncommon condition in which there is transposition of thoracic and abdominal structures. We report a case of situs inversus totalis detected incidentally in a 72-year-old female under investigation for haematuria. The imaging findings and role of imaging in this condition have been described in detail. This article emphasises the need for the clinicians to be aware of situs anomalies before planning surgical or radiological interventions in these patients.

Duodenal imaging on the spotlight: from A to Z

Abdominal computed tomography (CT) is frequently performed to evaluate gastrointestinal pathologic conditions. The majority of the gastrointestinal radiology literature has concentrated on the colon, stomach, and distal small bowel. The duodenum is often overlooked on imaging, namely on CT, but its anatomy (intra and retroperitoneal) and location in such close proximity to other viscera results in involvement by a multitude of primary and secondary processes, some of them exclusive to this bowel segment. While some conditions, like duplications, lipomas, and diverticula, are usually asymptomatic and are incidentalomas that have no pathologic significance, others are symptomatic and very relevant and should be recognized by every general radiologist: development conditions such as annular pancreas and gut malrotation; inflammatory processes such as ulcers and secondary involvement from pancreatitis; neoplastic conditions such as adenocarcinoma, lymphoma, or local extension from adjacent malignancies. They all can be reliably diagnosed with CT. In this article, we demonstrate the typical imaging features of various diseases involving the duodenum, such as developmental, traumatic, inflammatory, infectious, neoplastic, and postsurgical pathologic conditions in alphabetical order, focusing mainly on upper gastrointestinal series (UGIS) and CT but also some radiography, ultrasound, and magnetic resonance (MR) imaging.

Complicated acute appendicitis in a child with left atrial isomerism: a case report

Background

Heterotaxy syndrome is a rare clinical entity that is characterized by abnormal visceral organ arrangement in the chest and abdomen. Left atrial isomerism is a subcategory of heterotaxy syndrome characterized by the presence of multiple spleens with or without cardiac anomalies. Patients may remain asymptomatic their whole lives until they are diagnosed incidentally. Given that patients with left atrial isomerism might demonstrate atypical presentations of acute intrabdominal pathologies, it is important to keep a high index of suspicion when encountering such cases.

Case presentation

In this report, we present a case of a 9-year-old boy with a known history of left atrial isomersim who presented with left lower quadrant pain and positive McBurney, psoas, and obturator signs on the left side. A computed tomography scan of the abdomen confirmed the diagnosis of perforated acute appendicitis on the left, which prompted an emergent laparoscopic appendectomy.

Conclusion

Our case highlights the importance of keeping a high index of suspicion for a heterotaxy syndrome that is complicated by acute appendicitis in pediatric patients presenting with vague abdominal pain. Planning the location of trocar placement in patients with situs anomalies is of paramount importance to avoid technical difficulties in laparoscopic procedures.

Human Laterality Disorders: Pathogenesis, Clinical Manifestations, Diagnosis, and Management

Human laterality disorders comprise a group of diseases characterized by abnormal location (situs) and orientation of thoraco-abdominal organs and vessels across the left-right axis. Situs inversus totalis is mirror image reversal of thoraco-abdominal organs/great vessels. Situs ambiguus, better known as heterotaxy, is abnormal arrangement of thoraco-abdominal organs across the left-right axis excluding situs inversus totalis. Heterotaxy, also referred to as atrial or atrial appendage isomerism, is characterized by abnormal location of left-sided or right-sided organs with loss of asymmetry of normally paired asymmetric organs. It is associated with a variety of anomalies involving the heart, great vessels, lungs and intra-abdominal organs. Right and left atrial isomerism are associated with multiple complex congenital cardiac and vascular anomalies, many of which are lethal when untreated. Isomerism may also affect the lungs, spleen, liver, gall bladder, and intestines. Innovative surgical therapy of heterotaxy/isomerism has reduced early mortality and markedly improved long-term prognosis.

Heterotaxy Syndrome: Discordant Growth

Heterotaxy syndrome implies a discordance between placement of thoracic organs with respect to abdominal organs. A large number of these have associated congenital heart defects. This syndrome is unique as every patient is different and can have any permutation and combination of symptoms. In our case, the five-year-old male child presented with complaints of abdominal distension, fever, and bluish discoloration of limbs with even mild exertion. Radiological evaluation was diagnosed with a large atrial septal defect, cardiomegaly, partial pulmonary venous circulation, multiple small spleens on the right side of body, a large midline liver, malrotated bowel, inferiorly displaced kidneys, and two hemiazygos veins. The echocardiography and electrocardiogram too were consistent with atrial septal defect and right ventricular strain pattern. The reasons for this highly variable pattern are rooted in the genetically complicated process of lateralization with a strong link to the copy number variations. Due to the variable patterns, it is more efficient to report all the findings utilizing a step-by-step process of commenting on each and every individual organ, instead of classifying them under different categories based on atrial isomerism. This is important as any other way of classification predisposes to a certain bias.

Asymptomatic left isomerism with preduodenal portal vein: computed tomography appearance

Left isomerism (polysplenia), one of the two major variants of heterotaxia with right isomerism (asplenia), may be rarely diagnosed in adulthood. Most cases are nevertheless asymptomatic and incidentally detected during imaging or surgery performed for unrelated conditions. We hereby report a case of left isomerism fortuitously diagnosed in a 55-year-old man with unrelated tachy-cardiomyopathy. Thoraco-abdominal computed tomography revealed a typical preduodenal portal vein (PDPV) associated with a large series of other occult anatomic variations comprising: polysplenia, agenesis of both pancreatic body and tail, complete non-rotation of the bowel and finally azygous continuation of the inferior vena cava. Subtle but highly specific thoracic features of left isomerism were also found with a bilobed right lung and bilateral long hyparterial main bronchi. The features of adult left isomerism are remembered with special attention to the PDPV.

The multisystem nature of isomerism: left isomerism complicated by Abernethy malformation and portopulmonary hypertension

Isomerism, also referred to as "heterotaxy" is a complex set of anatomic and functional perturbations. One of the most obvious manifestations of isomerism is the disturbance of organ arrangement, such that the thoracic organs are no longer asymmetric on the left and right. We report the case of a 14-year-old female in whom exercise-induced dyspnea led to a late diagnosis of left isomerism complicated by Abernethy malformation and portopulmonary hypertension. A comprehensive evaluation revealed two anatomic left lungs and hyparterial bronchi, bilateral left atria, an interrupted inferior caval vein with azygos continuation, multiple spleens, sinus node dysfunction, hepatic hypertrophy with focal nodular hyperplasia, and absence of the portal vein. Pulmonary vasodilator therapy was initiated resulting in clinical improvement. This case exhibits unique features including a late diagnosis of isomerism with Abernethy malformation and portopulmonary hypertension. The patient's presentation, medical workup, and future treatment emphasise the importance of multidisciplinary care in children with complex multisystem disease. We review the multiple cardiac and extracardiac manifestations of isomerism.

Heterotaxy polysplenia syndrome in an adult female with complete endocardial cushion defect

Heterotaxy syndrome is a rare condition characterized by the abnormal arrangement of thoracoabdominal organs across the left-right axis of the body.

It is generally classified as right and left atrial isomerism or asplenia and polysplenia syndrome, even though there are overlaps and uncertainties. The diagnosis of isomerism is typically made by echocardiography. However, multidetector computed tomography and MRI can help in obtaining detailed data on the morphology of the heart, great vessels, the anatomy of the internal organs, and their mutual arrangement that make an accurate diagnosis of heterotaxy syndrome.

The authors present here the imaging findings of the heterotaxy polysplenia syndrome in a 21-year-old female with a complete endocardia cushion defect and a duplicated right renal vein.

Revisiting the Spleen—An Imaging Review of the Common and Uncommon Splenic Pathology

The spleen is the largest lymphatic organ and is responsible for both hematological and immunological functions. Several common etiologies such as trauma, developmental variants, infectious/inflammatory conditions, and benign and malignant lesions can occur in the spleen. The role of imaging modalities such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) in diagnosing these conditions continues to evolve. The main objective of this review article is to illustrate the role of imaging in identifying the common and uncommon pathology of the spleen.

Anatomical resection of lung cancer with isolated left bronchial isomerism: a case report with long-term follow-up

An isolated bronchial isomerism without accompanying malformations is known to be very rare and has little clinical problems. There are a few case reports demonstrating that the bronchial isomerism is incidentally found during lung cancer evaluations or surgeries, but none of them have reported the long-term outcomes after lung cancer surgeries. Thoracic surgeons should fully identify the anatomical details of the bronchial isomerism preoperatively to avoid unexpected resection of the wrong bronchi or pulmonary vessels. Herein, we report a rare case of an isolated left bronchial isomerism that was diagnosed preoperatively; the patient safely underwent anatomical pulmonary resection due to lung cancer in the right upper lobe and who has been followed up for >5 years.

The Spectrum of Cardiac Anomalies Associated with Heterotaxy: A Single-Center Study of a Large Series Based on Computed Tomography

The aim of the study was to identify and correlate the anatomical variants of cardiac structures among patients with heterotaxy. In this retrospective cross-sectional analysis of 13 years duration, 302 patients of congenital heart diseases associated with heterotaxy were studied. All these patients had undergone a meticulous clinical evaluation, echocardiography, and cardiac computed tomography. The mean age of the cohort was 38.4 months, with 180 males and 122 females. The cohort had 184 patients of right isomerism and 118 of left isomerism. More than half of the cohort had abnormal pulmonary veins. Over 75% of the cohort had low pulmonary blood flow. Abnormal relationship of great arteries was seen in nearly 69% of the cohort. Atrio-venticular canal defect was the commonest anatomical variant. Overall, 43% of the cohort had single ventricle physiology, predominantly associated with right isomerism. Heterotaxy forms a difficult anatomical subset to comprehend due to the plethora of possible abnormalities. However, unless the cardiac and visceral anatomy is delineated well, the surgical plan becomes suboptimal and often elusive, leaving tough choices for cardiac surgeon. It is essential to obtain all the possible anatomical information using additional imaging modalities to devise a basis for a comprehensive plan for medical and surgical management. A better understanding of the genetic and molecular factors in the etiology, coupled with the application of state-of-the-art imaging techniques, is likely to add to our knowledge of heterotaxy to bring about improved surgical outcomes and a better quality of life for patients suffering from this complex entity.

Unusual long survival in a case of heterotaxy and polysplenia

Heterotaxy syndrome with polysplenia is an extremely rare congenital disorder caused by a disruption in the embryonic development that results in an abnormal arrangement of the abdominal and thoracic organs. We present the case of a 59-year-old female patient with invasive ductal carcinoma of the right breast (luminal A type) and CT findings of heterotaxy syndrome with polysplenia. The most remarkable anomalies identified were a left inferior vena cava draining into the hemiazygos vein, absent inferior vena cava at the thoracic level, and hepatic veins directly draining into the right atrium. Moreover, an atrial septal defect was identified, explaining the pulmonary hypertension of unknown cause previously detected in the patient. The relevance of this case lies in the unusual anatomical abnormalities found and the large patient survival, having in to account the great rate of heterotaxy syndrome mortality in the first years of life.

Situs Ambiguous Anomaly during Laparoscopic Cholecystectomy in an Adult Female

Situs anomalies are rare structural defects affecting 0.01% of general population. They present with multisystem structural defects mostly involving cardiovascular, respiratory and GI systems. Situs abnormality with presence of multiple spleen is termed as left atrial isomerism with anatomical and structural differences to its countertype situs ambiguous with asplenia (right atrial isomerism). In this case report, we present an adult case of situs ambiguous anomaly which was diagnosed incidentally during laparoscopic cholecystectomy. The patient had enlarged left lobe of liver, multiple splenules on right side, malrotated small and large gut, interrupted inferior vena cava with azygos continuation, and bilateral bilobed lungs. It is concluded that variations in situs ambiguous cases differ and a single description is not possible. It is crucial to reveal these variations by using imaging modalities and being aware of them prior to surgery and invasive intervention to prevents the possible risks and complications.

99m-Technetium-Labeled Red Blood Cells' Single-Photon Emission Computed Tomography/Computed Tomography in Situs Ambiguous with Polysplenia

Situs ambiguous or heterotaxy syndrome is defined as the abnormal arrangement of organs and vessels within the body. Herein, we present an 8-year-old girl with growing right-sided suprarenal masses mimicking adrenal tumors. Technetium-99-m-radiolabeled red blood cells' planar images were inconclusive for the diagnosis of splenic tissue in the right side. Single-photon emission computed tomography/computed tomography imaging clearly identified right-sided functioning spleens and confirmed the diagnosis of situs ambiguous with polysplenia.

Polysplenia syndrome with situs ambiguous, common mesentery, and IVC interruption discovered incidentally in an adult

Polysplenia syndrome associates multiple spleens to other malformations, most frequently cardiac, vascular, visceral, and biliary malformations. Polysplenia has been described mainly in childhood owing to critical anatomic malformations related to cardiac defects or biliary atresia. We present a case of polysplenia syndrome found in a 58-year-old man. Only those with mild anatomical abnormalities reach adulthood without a diagnosis. Radiological examinations are helpful to the diagnosis by ascertaining the location and number of spleens, location of other organs in the chest and abdomen, and identification of other associated anomalies.

Robot-assisted Toupet fundoplication and associated cholecystectomy in symptomatic giant hiatal hernia with situs viscerum inversus-A case report and literature review

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All symptomatic paraesophageal hiatal hernias should be repaired, particularly those with acute obstructive symptoms or which have undergone volvulus.

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Laparoscopic hiatal hernia repair is as effective as open transabdominal repair, with a reduced rate of perioperative morbidity and with shorter hospital stays. It is the preferred approach for the majority of hiatal hernias.

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Robotic Assisted Giant-Paraesophageal Hernia repair remain technically challenging predominantly in the dissecation of the hernia sac from the posterior mediastinum.

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The robotic platform have the same benefits of the laparoscopic approach in terms of complication rate, total surgical time, and hospital length of stay and in particular case is superior.

Introduction

Giant hiatus hernia is defined as migration of >30% of the stomach with or without other intra-abdominal organs into the chest. Situs Viscerum Inversus is a rare congenital condition in which the major visceral organs are reversed from their normal arrangement; they are translated (completely or partially) on the opposite side of the body. Diagnosis is often incidental. We report a Robot-assisted Toupet fundoplication for a giant hiatal hernia with gastro oesophageal reflux disease and cholelithiasis, in a 63-years-old woman with situs viscerum inversus.

Presentation of case

A 63-year-old woman with Situs Viscerum Inversus was diagnosed with giant sliding hiatus hernia. We performed a Robot-assisted procedure of reduction of hiatal hernia in abdomen and Toupet fundoplication with Bio A mesh placement and gastropexy procedure associated to cholecystectomy. The operation time was of 190 min. The patient was discharged on third postoperative day after X-ray check and he tolerated a solid food.

Discussion

Minimally invasive surgery represents, nowadays, the standard approach for hiatal hernia and cholelithiasis.

Conclusion

In challenging cases as the giant hernias ad rare anomaly as situs viscerum inversus, the surgical treatment can be facilitated by the use of robotic technology.

Ductus arteriosus location in relation to aortic arch position, branching pattern, and viscero-atrial situs

AIM

To investigate ductus arteriosus (DA) location in relation to viscero-atrial situs and branching pattern of the right aortic arch (RAA).

MATERIALS AND METHODS

Computed tomography (CT) images of paediatric patients (May 2015 to July 2017, n=352) referred for evaluation of cardiovascular malformations were reviewed retrospectively. Patients with RAA were identified and images were analysed for documentation of the viscero-atrial situs, the branching pattern, DA location, and associated malformations.

RESULTS

The study included 64 RAA patients, 45 situs solitus, 11 situs ambiguous, and eight situs inversus. Mirror-image branching was observed in 34 situs solitus, 11 situs ambiguous, and seven situs inversus patients. Aberrant left subclavian artery (ALSCA) was present in 10 situs solitus and one situs inversus patient. One patient with situs solitus had isolated left subclavian artery. The location of the DA was identifiable in 32 patients (19 left and 13 right). In situs solitus with mirror-image branching, the DA was left in 10, right in four patients. In situs inversus and ambiguous with mirror-image branching, the DA was right in eight and left in two patients. In patients with ALSCA, the DA was left in seven and right in one patient. The location of the DA was identifiable in 85 patients with left aortic arch (left-sided in 84, right-sided in only one patient).

CONCLUSION

The location of DA in RAA varies according to viscero-atrial situs and branching pattern. In mirror-image branching, the DA is more commonly left-sided with situs solitus and more right-sided with abnormal viscero-atrial situs.

Heterotaxy syndrome with agenesis of dorsal pancreas and diabetes mellitus: case report and review of the literature

Heterotaxy syndrome (HS) is a rare congenital condition with multifactorial heritance, characterized by an abnormal arrangement of thoraco-abdominal organs and vessels. Patients present with multiple cardiac, gastrointestinal, hepatosplenic, pancreatic, renal, neurological and skeletal disorders without any pathognomonic alteration. Despite the described increased risk of diabetes mellitus (DM) in patients with altered pancreatic anatomy, just one case was reported in Korea regarding the association of HS and DM in a 13-year-old girl. Our report refers to a 40-year-old female Brazilian patient with a history of DM and HS with polysplenia and agenesis of dorsal pancreas without cardiac abnormalities. She presented a worsening glycemic control associated with weight gain and signs of insulin resistance. After a proper clinical management of insulin and oral medications, our patient developed an improvement in glycemic control. Although it is a rare disease, HS with polysplenia and pancreatic disorders can be associated with an increased risk of DM. This case highlights the importance of investigating DM in patients with HS, especially those with pancreatic anatomical disorders, for proper clinical management of this rare condition.

Complex congenital cardiac anomalies in the setting of right isomerism in a 31-month-old infant: a case report

Background

Congenital cardiac defects are not rare among neonates. Prompt assessment for life-threatening anomalies is essential for rapid management decisions and positive outcomes. Extracardiac anomalies can occur in congenital heart defects, and their presence increases morbidity and mortality in these neonates.

Case presentation

We report a case of a 31- month-old infant black girl in Tanzania who presented with an on-and-off history of difficulty in breathing, easy fatigability, facial and lower-limb swelling, recurrent respiratory tract infections, and failure to thrive.

Conclusions

Management of patients with heterotaxy syndrome is complex and largely depends on specific anatomy of both cardiac and noncardiac lesions. Cardiac and noncardiac management must be tailored to individual anatomy, including prophylaxis against encapsulated organisms for asplenic patients.

Thoracoscopic resection of mediastinal tumor in a patient with azygos continuation of the inferior vena cava

A 68-year-old man was referred to our hospital because of mediastinal tumor on chest computed tomography (CT). Contrast-enhanced CT showed azygos continuation of the inferior vena cava (IVC). The retro-hepatic IVC was absent superior to the renal veins. The IVC continued into the dilated azygos vein, which joined the superior vena cava. The hepatic vein drained directly into the right atrium. The mediastinal tumor was close to the dilated azygos vein. Video-assisted thoracoscopic resection of the mediastinal tumor was performed, using four ports and CO₂ insufflation. Histological examination of the resected specimen revealed a pericardial cyst without malignancy. After a favorable postoperative course, the patient was discharged 4 days after surgery. It is important to recognize this anomaly before thoracic surgery, because transection of the azygos vein can be fatal. Video-assisted thoracoscopic resection of mediastinal tumor close to the azygos vein using CO₂ insufflation avoids injury to the azygos vein.

Various congenital anomalies of the inferior vena cava: review of cross-sectional imaging findings and report of a new variant

The inferior vena cava (IVC) is an important structure receiving a large amount of venous return and is associated with various congenital disorders. Advances in diagnostic imaging and its increasing accessibility have led to an increase in the incidental detection of IVC anomalies. Congenital anomalies of the IVC are not uncommon and are occasionally critical to treatment planning. However, they are frequently overlooked in abdominal imaging. The IVC is composed of four segments (intrahepatic, suprarenal, renal, and infrarenal), and each segment arises from different embryonic structures in a complex process. Anomalies of the IVC can be classified according to the involved segment. Familiarity with the variety of IVC anomalies seen on imaging is vital for correctly diagnosing and managing patients in daily practice.