Laparoscopic treatment of intestinal obstruction due to a vitelline vascular remnant and simultaneous appendicitis: a case report

Infected urachal cyst in an adult patient

Urachal cyst is a clinical malformation caused by failure of the allantois to obliterate during embryological development. Because of its rare presentation in adults, urachal cysts are often incorrectly diagnosed. Delay in diagnosis can cause complications such as peritonitis, fistula, sepsis, or even malignant manifestation. We report the case of a 19-year-old adult male, who presented with clinical features mimicking appendicitis. Ultrasound and magnetic resonance imaging confirmed diagnosis of an infected urachal cyst, which was treated surgically.

Ectopic pancreatic adenocarcinoma in Meckel's diverticulum: a case report

BACKGROUND

Malignant neoplasms arising from Meckel's diverticulum are rare and an adenocarcinoma in Meckel's diverticulum originating from ectopic pancreatic tissue is even rarer. Herein, we report a patient with an ectopic pancreatic adenocarcinoma in Meckel's diverticulum who was successfully treated with surgery and chemotherapy.

CASE PRESENTATION

A woman in her sixties presented to another hospital with abdominal pain. Plain computed tomography suggested an abdominal tumor and she was referred to our hospital. Enhanced computed tomography revealed a 23-mm low-density tumor in the abdominal cavity. Surgery was performed with a tentative diagnosis of a mesenteric tumor, such as a gastrointestinal stromal tumor, schwannoma, or lymphoma. First, we inspected the peritoneal cavity with a laparoscope. This revealed numerous nodules in the small bowel mesentery, suggesting peritoneal dissemination. A 20-mm-diameter white tumor was found in the small intestine and diagnosed as a small intestinal cancer. The small intestine was partially resected laparoscopically through a small skin incision. The patient's postoperative course was uneventful, and she was discharged on postoperative day 9. Pathological examination revealed well-differentiated adenocarcinoma in the small intestine. The tumor had developed from a sac-like portion protruding toward the serosal side and had a glandular structure lined with flattened atypical cells. Neither pancreatic acinar cells nor islets of Langerhans were evident, suggesting a Heinrich type 3 ectopic pancreas. The final diagnosis was an adenocarcinoma originating from an ectopic pancreas in Meckel's diverticulum. After a smooth recovery, the patient commenced chemotherapy for pancreatic cancer.

CONCLUSIONS

We present a very rare case of ectopic pancreatic carcinoma in Meckel's diverticulum.

Laparoscopic management of intestinal obstruction in a young adult with a virgin abdomen: Unusual presentation of combined vitellointestinal duct remnants: A clinical case report

Key Clinical Message

In an 18-year-old, Meckel's diverticulum and a rare vitellointestinal fibrous band caused bowel obstruction. Clinicians should be vigilant for such anomalies, especially in young adults with virgin abdomens, as potential sources of intestinal obstruction.

Abstract

In this case report, we highlight the rarity of vitellointestinal or omphalomesenteric duct anomalies causing intestinal obstruction in the adult population. The patient, an 18-year-old male, presented to the emergency department with a two-day history of abdominal pain and vomiting. Physical examination revealed mild distension of his virgin abdomen with generalized tenderness. Abdominal X-ray displayed dilated small bowel loops, and a computed tomography scan indicated features consistent with closed-loop bowel obstruction. Diagnostic laparoscopy confirmed a vitellointestinal duct remnant as the cause of the small intestinal obstruction, involving a combined Meckel's diverticulum and vitellointestinal fibrous band. In early fetal development, the vitellointestinal duct communicates between the midgut and the yolk sac, expected to disappear during fetal growth. Failure to obliterate can lead to issues such as intestinal blockage, primarily observed in children, making occurrences in adults, as in this case, infrequent with only a few documented instances. Despite its uncommon occurrence in young adults, healthcare providers should consider the vitellointestinal duct anomalous remnant as a potential source of intestinal obstruction, particularly in individuals with a virgin abdomen. Early detection of intestinal obstruction is imperative for patient survival, facilitating prompt management and minimizing the risk of serious morbidities, ultimately contributing to a better patient outcome.

Vitelline vascular remnant causing intestinal obstruction in a patient with TARP syndrome

BACKGROUND

TARP syndrome, characterized by talipes equinovarus, atrial septal defect, Robin sequence, and persistent left superior vena cava, is an X-linked recessive condition caused by deleterious variants in RBM10. Vitelline vascular remnants (VVR) are a rare vitelline duct anomaly with approximately 26 cases previously reported. There are no previously reported cases of VVRs in patients with TARP syndrome.

CASE

We present a male neonate diagnosed with TARP syndrome via trio whole exome sequencing who had classic features of this syndrome, although his course was additionally complicated by feeding intolerance with multiple episodes of abdominal distension. Serial imaging and contrast studies of the upper GI tract and small bowel demonstrated small bowel obstruction of unclear etiology. Given the poor prognosis associated with this condition, life-sustaining measures were withdrawn, and he passed away at 38 days of age. On autopsy, a VVR was unexpectedly identified with proximal bowel dilation, explaining his feeding intolerance.

CONCLUSIONS

We highlight the importance of full post-mortem examination in understanding the complete spectrum of manifestations of genetic syndromes and provide a review of the literature.

Internal hernia beneath the left external iliac artery after robotic-assisted laparoscopic prostatectomy with extended pelvic lymph node dissection: a case report

BACKGROUND

Formation of an internal hernia beneath a skeletonized pelvic vessel after pelvic lymph node dissection is extremely rare. We report a case of an internal hernia formation beneath the left external iliac artery after a robotic-assisted laparoscopic prostatectomy with extended pelvic lymph node dissection.

CASE PRESENTATION

A 72-year-old man visited our hospital complaining of severe lower abdominal pain. On physical examinations, his abdomen was distended and tympanitic with rebound tenderness and muscular defense. Abdominal non-enhanced computed tomography showed a small bowel obstruction with marked ascites. A coronal non-enhanced computed tomography image revealed thickened loops of small bowel with surrounding mesenteric edema in the left lower quadrant. Enhanced computed tomography was not performed because we decided to perform urgent surgery with a diagnosis of strangulated small bowel obstruction based on physical examination and the computed tomography findings. The patient underwent urgent laparotomy at which time bloody ascites was seen in the peritoneal cavity. The ileum, which was approximately 60 cm proximal to the ileocecal junction, formed a closed loop beneath the left external iliac artery. The incarcerated ileum, 120 cm in length, appeared non-viable with a color change of the ileum to black. We therefore resected the strangulated ileum for a length of 120 cm and performed a functional end-to-end anastomosis. The orifice beneath the left external iliac artery was about 4 cm in diameter. We did not close the orifice because of the risk of injuring the left iliac artery. The postoperative course was uneventful, and the patient was discharged from our hospital 10 days after surgery. Presently, the patient is doing well 5 months after surgery without recurrent disease.

CONCLUSION

We report an extremely rare case of internal hernia formation beneath the left external iliac artery after a robotic-assisted laparoscopic prostatectomy with extended pelvic lymphadenectomy. Awareness of such complication and early surgical treatment are important when treating patients with this rare occurrence.