A case of lower digestive tract hemorrhage caused by appendicitis in China

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This article introduces a case of lower digestive tract hemorrhage caused by appendicitis in China. Patients have been successfully operated.

In this case, we report a case of lower digestive tract hemorrhage caused by appendicitis in China. An 46-year-old Chinese male was sent to China-Japan union Hospital of Jilin University with abdominal pain in 2015. The patient was diagnosed with anemia. In this report, the appendix of patient was excised by laparoscopic surgery. The patient's colonoscopy results showed patient could be seen a large number of dark red blood and fresh blood in the intestinal cavity. The patient's colon position found focal mucosal shedding, shallow ulcer formation. As last, the patient was successfully performed and reduced the patient's pain by laparoscopic surgery.

Isolated caudate lobectomy: Left-sided approach. Case reports

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The options of treatment for caudate tumors are presented.

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Treatment of caudate tumors by left-sided approach is proposal.

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Better results with left-sided approach are discussed.

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Selection of patients with tumors in caudate lobe for left-sided approach is important.

Introduction

The caudate lobe is a distinct liver lobe and surgical resection requires expertise and precise anatomic knowledge. Left-sided approach was described for resection of small tumors originated in the Spiegel lobe but now the procedure has been performed even for tumors more than five centimeters. The aim of this study is to present three cases of tumor of caudate lobe underwent isolated lobectomy by left-sided approach.

Presentation of case

Three patients with metastasis of colorectal cancer, carcinoma hepatocellular and metastasis of neuroendocrine tumor underwent resection. After modified Makuuchi incision, early control of short hepatic e short portal veins before hepatectomy was performed. The operative time was 200, 270 and 230 min respectively. No blood transfusion was used and no postoperative complications were observed. The length of stay was 7, 11 and 5 days respectively.

Discussion

Some approaches have been described to access and resect tumors of the caudate lobe, including the left-sided approach, right-sided approach, combined left- and right-sided approach and the anterior transhepatic approach. For liver resection in patients with malignant disease, parenchymal preservation is important in order to avoid postoperative liver failure or due to the risk of second hepatectomy. In these patients isolated caudate lobectomy is a safe option.

Conclusion

Isolated caudate lobectomy is a feasible procedure. Left-sided approach can be preformed even for tumors larger than 5 cm.

Primary and isolated thyroid Hodgkin's lymphoma: A case report

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Hodgkin’s lymphoma rarely involves the thyroid gland.

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We report a case of primary and isolated Hodgkin’s thyroid lymphoma.

Introduction

Hodgkin’s lymphoma rarely involves the thyroid gland. It is typically presented as a fast growing neck mass that is sometimes accompanied by respiratory compression symptoms.

Case report

We report one of the few (the seventeenth) case of primary and isolated Hodgkin’s thyroid lymphoma presented by a 65 years old man, consulting for a fast growing neck mass with Hodgkin’s symptoms. The patient had total thyroidectomy and short courses of chemotherapy, then total resolution of symptomatology.

Conclusion

Most thyroid Hodgkin’s lymphoma are presented by women, rarely man, isolated and primary. Since 1962, we only found sixteen cases described in the literature. Hodgkin’s lymphoma should be considered in the differential diagnosis of patients with a thyroid mass for rapid management.

Abdominal perineal resection or wilde local excision in primary anorectal malignant melanoma. Case report and review

INTRODUCTION

Primary anorectal malignant melanoma is a rare and aggressive tumor that carries a poor prognosis. Anorectal melanoma (ARM) is often misdiagnosed as hemorrhoids adenocarcinoma polips and rectal cancer. ARM spreads along sub-mucosal planes and is often to wide-spread for complete resection at time of diagnosis and almost all patients die because of metastases.

PRESENTATION OF THE CASE

A 77-year-old male patient presented a history of recurrent rectal bleeding and whose histopathological diagnosis was melanoma.

DISCUSSION

The treatment of choice remains controversial. Surgery with complete resection represents the typical treatment. However standard operative procedures related to the area of resection and lymph dissection have yet to be established. Abdominal perineal resection (APR) with or without bilateral inguinal lymphadenectomy or wide local excision (WLE) have been used to manage patients with ARM.

CONCLUSION

The higher serum levels of LDH and YKL-40 are suggestive for Anorectal Melanoma diagnosis. The decrease of these findings may be associated with good prognosis. The review of both APR and WLE options suggests no significant difference in survival among patients.

Rare mycotic aneurysms of internal jugular vein and innominate vein secondary to untreated parapharyngeal abscess: A case report

We report a 31 year old woman presented with three months history of large untreated parapharyngeal abscess and bleeding from the mouth. On evaluation chest CT scan identified the abscess extending down to the superior mediastinum and multiple small lung abscesses. Echocardiography showed tricuspid valve insufficiency. Patient was brought to the operating room (OR) and intra-operatively it was found that she had multiple large mycotic pseudoaneurysms of the internal jugular vein and right brachiocephalic veins. All these pseudoaneurysms were repaired with pericardial patches under cardiopulmonary bypass. Patient did well in the short postoperative follow up and was then referred to plastic surgery and ENT for further surgical interventions.

Bilateral vocal cord palsy after total thyroidectomy-A new treatment-Case reports

INTRODUCTION

Dyspnea due to bilateral vocal cord palsy after total thyroidectomy (BVCPATT) is a life-threatening complication; nevertheless, we try to avoid tracheotomy.

METHODS

Using normalized glottal area (NGA), we retrospectively studied 14 patients with BVCPATT. Nine patients without dyspnea were treated conservatively, while five with dyspnea received immediate bilevel positive air-way pressure (BiPAP) treatment. Both right and left recurrent nerves were grossly intact during surgery.

RESULTS

The mean NGA during inspiration of five patients with dyspnea was less than that of nine patients without (6.21±1.57 (mean±standard deviation) vs. 20.5±9.5; p=0.001). The mean age of patients with dyspnea was more than that of patients without (61.6±15.6 vs. 38±10.2; p=0.007). Five patients with dyspnea that occurred at 0-8days post operation recovered within 3-17days after BiPAP.

CONCLUSION

Dyspnea occurred in patients with BVCPATT who were relatively older. The mean NGA during inspiration in patients with dyspnea was less than that in patients without. BiPAP might be a new treatment for dyspnea.

Clinicopathological features of breast angiosarcoma: A 16-years single-institution experience

BACKGROUND

Breast Angiosarcoma is a rare type of malignancy arising from endothelial cells lining blood vessels, accounting for 1% of all soft tissue breast tumors. This retrospective study describes the clinical pathological features and clinical management and outcomes of a series of 5 patients with primary and secondary Angiosarcoma of the breast present to King Faisal Specialty Hospital and Research Center during the last 16 years.

METHODS

A retrospective review of our institution's pathology database was conducted and all patients who had a pathologically confirmed breast angiosarcoma were included in this study. The patient's data, including demographic characteristics, pathological features, clinical management history and clinical outcomes were collected.

RESULTS

Five patients were diagnosed with Breast Angiosarcoma (one secondary and four primary cases). The median age of patients with primary angiosarcoma was 22 years (range 13-25 years). All primary cases were presented late as post-excisional biopsy at local hospitals. Median tumor size was 6cm (range 4.0-17.0cm). All primary angiosarcoma patients had total mastectomy. Three-year disease-free survival (DFS) of patients with primary angiosarcoma was 25%. 5-year surviving rate of primary angiosarcoma was 50%. Recurrence was observed in three of the patients with primary Angiosarcoma and in the case of post irradiation Angiosarcoma.

CONCLUSIONS

Our study demonstrates that Breast Angiosarcoma exhibits high recurrence and mortality rates. Early detection, small tumor size, and clear surgical margins seem to be crucial factors for survival. Mastectomy with adequate tumor margin is recommended and close long-term follow-up is of utmost importance. Surgery for local recurrence may be potentially curative.

Anomalous V2 of the left pulmonary vein detected using three-dimensional computed tomography in a patient with lung cancer: A case report

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We report the rare anatomical variations of the pulmonary vein wherein the left V2 drained into the inferior pulmonary vein.

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The left V2 draining into the inferior pulmonary vein has not been yet reported, and this case is the first report.

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We identify this anomalous V2 before operation by 3D-CT and were able to perform the operation safely by VATS.

We report one of the rare anatomical variations of the pulmonary vein wherein the left V2 drained into the inferior pulmonary vein. A 63-year-old man was referred to our hospital because of an abnormal shadow in the left lower lung field that was noted on chest X-ray. Computed tomography (CT) revealed a tumor in the left lower lobe. A biopsied tumor specimen was diagnosed as an adenocarcinoma, and thus, left lower lobectomy was performed. Preoperative three-dimensional CT revealed that an anomalous V2 of the left lung drained from the superior segment into the inferior pulmonary vein. This variation type was confirmed during thoracoscopic left lower lobectomy. We were able to perform left lower lobectomy with the preservation of the anomalous V2. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. It is important to identify anatomical variations of the pulmonary vein and reliably preserve and process the affected area to prevent postoperative complications.

Two cases of late medial instability of the knee due to hip disease after total knee arthroplasty

INTRODUCTION

There are few specific reports of late medial instability after total knee arthroplasty (TKA). We described two cases of late medial instability of the knee due to hip disease with osteoarthritis or rheumatoid arthritis after TKA, which required revision TKA.

PRESENTATION OF CASES

An 82-year-old woman experienced right femoral neck fracture due to a fall that required conservative treatment at age 77 years and underwent left TKA at age 80 years. A 68-year-old woman underwent left TKA at age 54 years, right TKA at age 64 years, and left THA at age 67 years. Both cases required revision TKA with constrained knee prostheses due to the severe medial instability. Hip-knee-ankle (HKA) angle, range of motion (ROM), Knee Society score (KSS) and functional score (FS) were evaluated pre- and postoperatively. Their respective HKA angle improved from 134° and 155° preoperatively to 184° and 179° postoperatively. KSS improved from -4 and 53 points to 59 and 100 points, respectively. FS improved from -10 and 58 points to 25 and 90 points, respectively. In the 82-year-old woman, ROM did not improve from -10-90° to -20-90°. On the other hand, in the 68-year-old woman, ROM improved from 0-110° to 0-125°. The late medial instability in the current case report was partly due to a similar mechanism underlying the long leg arthropathy and coxitis knee caused by hip joint degeneration.

CONCLUSIONS

Constrained prostheses were applied for both patients, providing moderately good short-term results.

Pushing the boundaries in liver graft utilisation in transplantation: Case report of a donor with previous bile duct injury repair

INTRODUCTION

Liver transplantation is a recognised treatment for extensive bile duct injuries with secondary biliary cirrhosis or recurring sepsis. However, there have been no reports of successful liver transplantation from a donor who sustained a previous bile duct injury.

PRESENTATION OF CASE

Here we discuss the case of a liver transplant from a 51-year-old brain dead donor who had suffered a Strasberg E1 bile duct injury and had undergone a Roux-en-Y hepaticojejunostomy 24 years prior to donation. The liver was successfully recovered and transplanted into a 56-year-old male recipient with end stage liver disease consequent to alpha 1 antitrypsin deficiency. The graft continues to function well 36 months post-transplant, with normal liver function tests and imaging revealing a patent hepaticojejunostomy.

DISCUSSION

The potential associated vascular injuries should be identified during bench preparation whilst the management of biliary reconstruction at the time of transplant should follow the principles of biliary reconstruction in cases with biliary injuries, extending the hilar opening into the left duct.

CONCLUSION

This case highlights the successful utilisation of a post bile duct injury repair liver, employing an experienced procurement team and careful bench assessment and reconstruction.

Complete torsion of gallbladder following laparoscopic cholecystectomy: A case study

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Accurate preoperative diagnosis of gallbladder torsion is challenging because of the absence of clinical characteristics associated with it.

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Careful attention to symptoms during clinical presentation, including acute severe pain in the right quadrant and gallbladder deviation observed during radiological investigation, is required for accurate diagnosis of the condition.

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Upon confirmation of diagnosis, laparoscopic cholecystectomy would be the gold-standard treatment option rather than open cholecystectomy.

Introduction

Gallbladder torsion is mainly associated with a floating gallbladder. From an anatomical perspective, laparoscopic cholecystectomy is a more optimal treatment than open cholecystectomy.

Presentation of case

An 84-year-old woman visited the Onomichi General Hospital because of progressive pain in the right upper quadrant of her abdomen. Physical examination revealed a positive Murphy sign and peritoneal irritation. Laboratory data demonstrated that inflammatory marker levels were increased. Abdominal ultrasonography showed that blood flow in the cystic artery was reduced and the gallbladder was swollen. Abdominal contrast-enhanced computerized tomography indicated that the swollen gallbladder was modestly enhanced and the fundus was displaced under the midline and detached from the gallbladder bed. The cystic duct was twisted. Magnetic resonance cholangiopancreatography showed that the root of the cystic duct was unclear and the extrahepatic bile duct had V-shaped distortion. The gallbladder neck showed a tapering interruption with the common biliary duct. We made a preoperative diagnosis of gallbladder torsion. Accordingly, emergency laparoscopic cholecystectomy was performed. The intraoperative findings included a dark swollen gallbladder that was twisted in the counterclockwise direction. The patient was discharged without any postoperative complications on day 7.

Discussion

Combined acute onset of abdominal pain with characteristic radiological findings made it possible to precisely diagnose gallbladder torsion.

Conclusion

Laparoscopic cholecystectomy can be the gold standard treatment for gallbladder torsion after a preoperative diagnosis is made.

An isolated cuboid dislocation. A case report

INTRODUCTION

Isolated cuboid dislocations are rare injuries Jacobson (1990). It is clinically significant and important in surgical education, as it is an injury and a source of lateral foot pain that can be misdiagnosed at the time of initial presentation and may be difficult to identify clinically or with imaging Drummond and Hastings (1969).

PRESENTATION OF CASE

We present a case report in a 33year old rugby player, who was injured during a match after a tackle. The patient had ongoing concerns that he was not recovering following initial discharge, as he was unable to weight bear since his initial presentation to the Emergency Department (E.D.), and he had ongoing lateral foot pain.

DISCUSSION

Important clinical findings include lateral foot pain, a palpable gap at the cuboid level and difficulty weight-bearing. Closed reduction is usually difficult as it can be blocked mechanically by the extensor digitorum brevis muscle or peroneus longus tendon Dobbs et al. (1969). Initial X-Rays may be inconclusive with this presentation. CT scanning is indicated if suspicion for pathology is high. Open reduction and internal fixation with Kirschner wires are usually necessary for isolated cuboid dislocations.

CONCLUSION

Our take home message from this case report is that cuboid dislocations are rare injuries and are important to be aware of in reviewing X-rays in the E.D. Particularly in patients with inversion and plantar flexion type injuries to their foot and ankle joint, with an inability to weight bear and lateral midfoot pain following their injury.

A primary intraosseous cystic meningioma: Case report

INTRODUCTION

This is a very rare case of intraosseous cystic meningioma. There have been no reports of similar cases in the last 30 years.

PRESENTATION OF CASE

A 62-year-old man, suffering from a swelling of the lateral wall of the left orbit was admitted to our hospital. MRI and CT scan showed a large intradiploic lesion involving the lateral wall of the orbit and the greater wing of the sphenoid. The lesion was cystic with a mural nodule. We operated the patient and removed completely the mural nodule and the fibrous wall of cyst. Histological examination showed that the mural nodule was a benign meningothelial meningioma.

DISCUSSION

Primary intraosseous meningiomas represent a subtype of primary extradural meningiomas; they comprise about 2% of all meningiomas and are therefore rare entities. Cystic meningiomas are rare, their incidence compared to all other types of meningiomas is of 2-4%. The presence of a meningioma with both characteristics: cystic and intraosseous, like in our case, is an exceptional occurrence.

CONCLUSION

The surgical management of tumor was easy; its rarity means that the case is interesting.

Adductor canal compression syndrome in an 18-year-old female patient leading to acute critical limb ischemia: A case report

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Adductor canal compression syndrome is an unusual cause of limb ischemia.

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Adductor canal compression syndrome typically occurs in young, physically fit adults.

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Knowledge of rare disorders is crucial when treating young patients for limb ischemia.

Background

Adductor canal compression syndrome is a rare non-atherosclerotic cause of arterial occlusion and limb ischemia.

Presentation of case

The patient is an 18-year-old healthy female who presented to the emergency department with acute left lower extremity ischemia. Her symptoms began as sudden onset mild foot pain approximately two months ago. Over the 72 h prior to presentation, she developed severe pain, pallor, paralysis, loss of pedal pulses, paresthesia, and poikilothermia. Due to her advanced ischemia, she was taken immediately to the operating room for angiography and intervention. Initial angiography demonstrated distal superficial femoral and popliteal artery occlusions along with lack of tibial or pedal artery blood flow. She underwent percutaneous mechanical thrombectomy and initiation of catheter directed thrombolysis. After 48 h of catheter directed thrombolysis and repeat mechanical thrombectomy, computed tomography (CT) was performed and demonstrated external compression of the superficial femoral artery in the adductor canal and residual chronic thrombus. Echocardiography and CT of the thoracic aorta was also performed, and were negative, therefore excluding other potential sources of arterial embolism. She next underwent surgical exploration, division of an anomalous musculotendinous band compressing the left superficial femoral artery and thromboendarterectomy of the distal left superficial femoral artery. The patient recovered well without any post-operative complications and could return to her daily activities 3 weeks following surgery.

Conclusion

Knowledge of rare non-atherosclerotic vascular disorders, such as adductor canal compression syndrome, is paramount when treating patients who present with limb ischemia and lack traditional risk factors.

Colon cancer metastasis to the thyroid gland: A case report

INTRODUCTION

Thyroid metastases from colorectal cancer are uncommon and few cases are described in literature.

CASE PRESENTATION

A 64-year-old female patient presented with an asymptomatic right cervical nodule with a rapid growth six years after sigmoidectomy for cancer and two years after resection of colorectal lung metastases. Increased CA 19.9 was identified and a thoracoabdominal CT scan revealed the onset of new metastatic bilateral pulmonary lesions. Neck ultrasonography showed a suspicious nodule in the right thyroid lobe, and Fine-needle Aspiration Cytology (FNAC) of the nodule lead to the diagnosis of colorectal cancer metastasis. A right thyroid lobectomy with right central lymph node dissection was performed. The patient underwent chemotherapy with response, but this was posteriorly suspended due to haematological side effects, and the disease spread.

DISCUSSION

Thyroid metastases from colorectal cancer are rare, but, with the improvement of radiologic exams and the higher survival rate of these patients, more cases are being described. The majority of the cases present pulmonary and hepatic metastases and the prognosis is poor. The decision to operate and the type of operation depend on the extent of the metastatic disease and the patient's overall condition.

CONCLUSION

A low threshold of suspicion is crucial to make a timely diagnosis of thyroid metastases from colorectal cancer. Treatment is controversial, but, without surgery, the need may arise for tracheostomy.

A case report of an anterior tibial artery pseudo-aneurysm open surgical management: A rare complication post total knee arthroplasty

INTRODUCTION

Complications involving injury to neurological and vascular structures are infrequently reported after total knee arthroplasty (TKA). They are associated with significant morbidity and can be limb threatening.

PRESENTATION OF CASE

We present a patient with an anterior tibial artery (ATA) aneurysm post total knee arthroplasty. A 69-year-old female was referred for a swelling over her left antero-lateral aspect of her leg 4 years post TKA. Radiological investigations showed an ATA pseudo aneurysm. The aneurysm was repaired by open ligation.

DISCUSSION

ATA pseudo aneurysm is a rare condition post arthroplasty. Patients can complain about calf pain, digits discoloration, paresthesia and the presence of a pulsating or enlarging mass. Symptomatic aneurysms require surgical intervention.

CONCLUSION

ATA pseudo aneurysms are uncommon. They are usually identified shortly after the initial insult. A delayed manifestation of a post knee arthroplasty complication as illustrated in our case is likely the first reported case of its kind. Clinicians should maintain a high index of suspicion should there be persistent localised swelling post TKA. However, due to the rarity of this condition, a variety of interventions have been reported in the English medical literature with probably no compelling evidence that favors one modality over the others.

Laparoscopic management of a complicated case of Wilkie's syndrome: A case report

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Surgical intervention is the mainstay in complicated cases of SMA syndrome and in refractory cases to conservative management.

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Successful management of a complicated case of Wilkie’s Syndrome via duodenojeujenostomy is feasible using a laparoscopic approach.

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Advantages of laparoscopic approach over open surgery include rapid recovery time, reduced post-operative pain and shorter hospital stay.

Introduction

Superior mesenteric artery (SMA) syndrome also known as Wilkie’s syndrome is a rare condition caused by the entrapment of the third part of the duodenum between the aorta and the SMA. The incidence of Wilkie’s syndrome range between 0.013% and 0.3%. The normal angle between the aorta and SMA has been described to range between 38° and 65°, whereas in Wilkie’s syndrome this angle is reduced to less than 20° causing gastric outlet obstruction.

Case presentation

We report a case of a previously diagnosed 43 year-old male with SMA syndrome, whom had been conservatively managed for 5-years for recurrent admissions with symptoms of gastric outlet obstruction. During his last admission, CT abdomen demonstrated gastric pneumatosis and portal venous gas requiring urgent surgical intervention. Duodenojejunostomy was successfully performed using laparoscopic technique.

Discussion

SMA syndrome is thought to occur secondary to the rapid and excessive weight loss leading to the reduction of the mesenteric fat around the aorta and SMA, thereby reducing the normal angle between the two arteries. Conservative medical management is usually the first line of treatment in uncomplicated cases. Surgical management is usually reserved only after failed conservative management or complicated cases, at which time either an open or laparoscopic surgical approach is undertaking.

Conclusion

Surgical intervention is the mainstay in complicated cases of SMA syndrome and in refractory cases to conservative management. Advantages of laparoscopic approach over open surgery include rapid recovery time, reduced post-operative pain and shorter hospital stay.

An effective and safe surgical approach for a superior sulcus tumor: A case report

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Surgical approach for locally advanced superior sulcus tumor is difficult.

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We experienced a locally advanced superior sulcus tumor located from the anterior to posterior apex thoracic inlet.

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Our surgical approach was effective and safe for treating a SST located from the anterior to posterior apex of the thoracic inlet.

Introduction

Superior sulcus tumors, frequently referred to as Pancoast tumors, are a wide range of tumors invading a section of the apical chest wall called the thoracic inlet. For this reason, a surgical approach and complete resection may be difficult to accomplish. We experienced a locally advanced superior sulcus tumor (SST) located from the anterior to posterior apex thoracic inlet and performed complete resection after definitive chemoradiation.

Presentation of case

A 71-year-old Japanese male presented at our hospital due to left back pain and an abnormal chest computed tomography (CT) scan showing 80 × 70 × 60-mm tumor located in the left middle apex thoracic inlet. This tumor was located near the subclavian artery, and the subclavian lymph nodes were swollen. The tumor was found to be an adenocarcinoma (clinical-T3N3M0 stage IIIB). Therefore, we performed definitive chemoradiation therapy. Slight reduction in the tumor size was noted after the treatment, and the subclavian lymph nodes were not swollen. We next performed surgical resection for this SST. Regarding the surgical approaches, the anterior approach was a transmanubrial approach, and the posterior approach was a Paulson’s thoracotomy. In this manner, we were able to perform complete en-bloc resection of this tumor.

Discussion

This surgical approach was effective and safe for treating a SST located from the anterior to posterior apex of the thoracic inlet. The patient remains healthy and recurrence-free at 2.5 years after the operation.

Conclusion

Surgical approach for SST is difficult. Therefore, this approach is effective and safety.

Double cystic duct preoperatively diagnosed and successfully treated with laparoscopic cholecystectomy: A case report

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A single gallbladder with a double cystic duct is a very rare finding.

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MRCP showed strong suspicion of a single gallbladder with a double cystic duct and the definite diagnosis of a double cystic duct was made by ERC.

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Laparoscopic cholecystectomy could be successfully performed in combination with intraoperative cholangiography for double cystic duct.

Introduction

A single gallbladder with a double cystic duct is a very rare finding. In addition, few cases with this rare condition are preoperatively diagnosed. However, the preoperative confirmation or suspicion of this rare condition could facilitate safe laparoscopic cholecystectomy, which is a minimally invasive therapeutic modality for gallbladder disease. We herein present a case of gallstone disease in a patient with a double cystic duct who was preoperatively diagnosed and successfully treated with laparoscopic cholecystectomy.

Presentation of case

A 57-year-old woman was admitted to our hospital with epigastric pain. Gallstone disease in the gallbladder and common bile duct was diagnosed by ultrasonography and computed tomography. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiography (ERC) revealed that the aberrant cystic duct arose from the cystic duct and communicated with the intrahepatic bile duct of the posterior segmental branch. Laparoscopic cholecystectomy was successfully performed in combination with intraoperative cholangiography.

Discussion

If an anomaly of the biliary duct system is not identified during surgery, it may turn out to be a bile leak. The preoperative diagnosis of a double cystic duct allows laparoscopic cholecystectomy to be performed safely in combination with intraoperative cholangiography.

Conclusions

A single gallbladder with double cystic duct is a very rare anomaly. However, laparoscopic surgery can be facilitated by the use of preoperative and intraoperative images.

Use of a long distally fixed intramedullary stem to treat a periprosthetic femoral fracture following total hip arthroplasty using a thrust plate hip prosthesis: A case report

INTRODUCTION

The thrust plate hip prosthesis (TPP; Zimmer, Winterthur, Switzerland) is a hip prosthesis that is no longer in production. Few reports have focused on periprosthetic fractures following total hip arthroplasty (THA) with the use of a TPP.

PRESENTATION OF CASE

We report a 57-year-old woman with a periprosthetic femoral fracture 13 years after THA with the use of a TPP. A plain radiograph showed a displaced subtrochanteric fracture of the right femur just below the distal tip of the lateral plate without implant loosening. She underwent revision surgery with a long distally fixed intramedullary stem in conjunction with a plate and cable system. Three months after surgery, bone union was confirmed using radiography and the patient was clinically asymptomatic.

DISCUSSION

We encountered three major problems while planning surgical treatment, these being, discontinuation of the TPP system, loss of proximal femoral cancellous bone, and difficulties with the type of subtrochanteric fracture. After considering these problems, we planned revision surgery using a long distally fixed intramedullary stem in conjunction with a plate and cable system.

CONCLUSION

This case shows that sufficient implant preparation based on precise preoperative planning is necessary to obtain good clinical results for the surgical treatment of periprosthetic femoral fractures following THA with the use of a TPP.

Early anastomotic stricture occurring after colectomy that responded well to Transanal decompression and local steroid therapy: A case report

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Very few studies have reported anastomotic strictures occurring soon after colectomy. No established treatment is available.

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We describe our experience with a patient who had bowel obstruction due to an anastomotic stricture 12 days after colectomy.

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Steroid local therapy has been reported to be effective when combined with gastrointestinal endoscopic treatment. However, few studies have reported on anastomotic strictures of the colorectum.

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Transanal decompression therapy and local steroid therapy promptly improved symptoms in a patient with an anastomotic stricture of the colon.

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Transanal decompression therapy combined with local steroid therapy may improve anastomotic strictures occurring soon after colectomy.

Introduction

Anastomotic strictures occurring after colectomy are a most challenging postoperative complication for gastroenterological surgeons. Reports documenting anastomotic strictures developing in the early postoperative phase are scant, and no established treatment is available.

Presentation of case

A 78-year-old man who had undergone a laparoscopic left hemicolectomy for lower colon cancer presented on postoperative day 12 because of abdominal pain and no bowel movement. Endoluminal decompression was performed with a transanal decompression tube, and local steroid treatment was administered by concurrent intralesional steroid injection (ILe-SI) and intraluminal steroid instillation (ILu- SI). The anastomotic stricture promptly improved. The patient recovered uneventfully, with no recurrence of anastomotic stricture.

Discussion

A transanal decompression tube should be inserted and placed in a cautious manner within a short period of time. ILe-SI in the large intestine requires an understanding of potential adverse events and complications, as well as fully informed consent from the patient. ILu-SI has been reported to be an effective treatment for the management of strictures in various regions. To the best of our knowledge, however, this is the first report to document the treatment of an anastomotic stricture of the colorectum by ILu-SI.

Conclusion

Transanal decompression therapy combined with local steroid local treatment might promptly improve anastomotic strictures occurring after colectomy.

Emergency splenectomy for trauma in the setting of splenomegaly, axillary lymphadenopathy, and incidental B-cell chronic lymphocytic leukemia: A case report

INTRODUCTION

The spleen is the most commonly injured intra-abdominal solid organ following blunt trauma. B-cell chronic lymphocytic leukemia (CLL) is the most common leukocytic dyscrasia affecting adults in Western countries. Splenomegaly with axillary and retroperitoneal lymphadenopathy are common physical findings. This case investigates an emergency splenectomy in a community hospital involving a 45-year-old man with blunt abdominal trauma following an assault with incidental splenomegaly and axillary lymphadenopathy, with surgical pathology findings of B-cell CLL.

PRESENTATION OF CASE

A 45- year-old man without past medical or family history who was the victim of an assault presented to the emergency department 6h later with left upper quadrant pain and radiation to the left flank and a positive Kehr sign. An elevated absolute lymphocyte count above 7×109 and CT confirmation of a Grade V splenic laceration with splenomegaly, axillary lymphadenopathy, with hemodynamic compromise led to an exploratory laparotomy and emergency splenectomy regardless of the potential for malignancy.

DISCUSSION

Hemoperitoneum with blunt splenic injury (BSI) caused by abdominal trauma with hemodynamic instability should be treated with exploratory laparotomy and splenectomy even in the face of potential malignancy with splenomegaly and axillary lymphadenopathy. An appropriate oncologic work up and treatment can be provided after the emergency intervention.

CONCLUSION

An emergency splenectomy is an appropriate operative intervention for a grade V splenic laceration with hemoperitoneum, splenomegaly, and axillary lymphadenopathy regardless of the potential for a neoplastic process such as B-cell CLL. Post-splenectomy vaccinations and oncologic follow-up for systemic chemotherapy should be facilitated after recovery.

Rare case of incarcerated obturator hernia: Case report and review of literature

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Obturator hernia is a rare condition among abdominal hernias.

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Clinical diagnosis is challenging and it usually appears as an intestinal obstruction.

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Early diagnosis and surgical treatment reduce morbidity and mortality.

Introduction

Obturator hernia is a rare condition accounting for less than 1% of all intra abdominal hernias. Clinical diagnosis is considered a challenge for most surgeons. It usually appears as an intestinal obstruction. Confirmation of diagnosis is carried out by means of imaging or during surgery.

Case report

An 85-year-old female patient, with symptoms of intestinal obstruction of 24 h duration was admitted to the emergency room of Unimed Hospital – Belo Horizonte. Abdominal computed tomography (CT) demonstrated a herniation of the small bowel through the right obturator canal with an intestinal distension proximally. At laparotomy, the presence of a right obturator hernia with an ileal strangulation was confirmed. Segmental enterectomy with primary anastomosis and herniorrhaphy for the closure of the obturator foramen were performed.

Discussion

Obturator hernias typically affect women, elderly, emaciated and multiparous. Symptoms are non-specific and associated with an intestinal obstruction. Howship-Romberg sign, considered pathognomonic, is generally absent. Abdominal CT scan can aid in pre-operative diagnosis and the treatment is surgical.

Conclusion

Early diagnosis and surgical treatment are imperative in obturator hernias due to the high morbidity and mortality that occur in cases where the intervention is delayed.

Abdominal wall Hydatid cyst: A review a literature with a case report

INTRODUCTION

Hydatid cyst (HC) disease is a serious health problem in endemic areas. It is a parasitic infection that commonly involves liver and lungs while muscular HC is rare. HC of abdominal wall was reported only six times. We reported a 39-year-old male presented with HC of the right loin who was managed surgically with brief literature review.

CONCLUSION

HC should be put in the differential diagnosis of the abdominal wall masses. Its pre-operative diagnosis is important to prevent rupture with subsequent anaphylaxis and recurrence. Surgery is the main modality of treatment.

Dieulafoy's Lesion of the Anal Canal: A Rare Cause of Lower Gastrointestinal Bleeding

BACKGROUND Dieulafoy's lesion of the anal canal is an uncommon cause of lower gastrointestinal bleeding due to rupture of a submucosal artery. This could be an under-recognized cause of hemorrhagic shock in rare cases. CASE REPORT We present 2 cases admitted with bleeding per rectum and hemorrhagic shock, and both were diagnosed as Dieulafoy's lesion of the anal canal on sigmoidoscopy. One case was treated surgically and the second was managed endoscopically. CONCLUSIONS Dieulafoy's lesion of the anal canal can be a source of massive lower gastrointestinal bleeding. Initial anoscopy or sigmoidoscopy might miss such a lesion. Proper visualization helps not only the diagnosis, but also the provision of therapeutic intervention in the same setting.

A rare presentation: A case report of osseous metaplasia and mature bone formation in a follicular adenoma of the thyroid

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Osseous metaplasia and bone formation may be seen in a broad spectrum of diseases involving the thyroid gland especially in malignant neoplasms of the thyroid gland.

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However, this differentiation is not unique to malignant neoplasms. It may also be encountered in follicular adenomas of the thyroid.

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Awareness of thyroid nodules undergoing hemorrhagic, cystic, and fibrotic changes, as well as calcification and ossification is paramount in proper diagnosis and treatment of these pathologies.

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Particularly, patient’s history, associated risk factors and clinical presentation are the most important factors to consider in clinical differentiation of malignant and benign diagnoses.

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All ossifications in a thyroid nodule should be considered suspicious for malignancy until proven otherwise.

Introduction

Cases of multinodular goiter, thyroid hyperplasia, follicular adenoma, papillary thyroid carcinoma, and anaplastic thyroid carcinoma have been reported with histopathologic findings of osseous metaplasia (OM), bone marrow metaplasia (BMM), ectopic bone formation (EBF), ossification, and extramedullary hematopoiesis (EMH). To date no report of a follicular adenoma with OM and mature EBF in the absence of EMH has been reported in the English language.

Presentation of case

63-year-old woman with an incidental finding of thyroid nodule unable to be biopsied. One area was found to contain OM with mature EBF and without vascular invasion. The surrounding tissue was unremarkable, and no malignancy was found.

Discussion

Ectopic bone formation and osseous metaplasia in a thyroid nodule has an extensive differential diagnosis, from thyroid related pathologies to parathyroid causes, congenital syndromes, and hamartomas. A common theory amongst these is the role of basic fibroblast growth factor (bFGF) and bone morphogenetic protein-2 (BMP-2), signaling factors involved in cellular proliferation and growth.

Conclusion

This is the first case report of a follicular adenoma with OM and EBF in the absence of EMH. In this case, this adenoma was an incidental finding and the patient had no symptoms or accompanying laboratory abnormalities. Her benign presentation underscores the importance of awareness of the more common changes a thyroid nodule can undergo, such as hemorrhagic, cystic, and fibrotic changes, as well as the rarer changes of calcification with eventual ossification.

Wound management with negative pressure wound therapy in postoperative infection after open reconstruction of chronic Achilles tendon rupture

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NPWT can treat postoperative infection following chronic Achilles tendon repair.

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NPWT is also applicable in cases of tendon loss.

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NPWT has good functional outcome in postoperative infection for chronic Achilles tendon rupture.

Introduction

Deep infection after reconstruction of chronic Achilles tendon rupture is a major and intractable complication.

Case report

We report a case of late deep infection following a surgery for chronic Achilles tendon rupture, and its simple and successful treatment with negative pressure wound therapy (NPWT). Six months following the reconstruction of chronic Achilles tendon rupture, a deep infection developed and reconstructed part of the tendon ruptured again. After appropriate debridement.

Discussion

There is no definitive treatment strategy for postoperative infection following open Achilles tendon repair. NPWT was applied to the wound, to promote wound healing and healthy granulation. In our case, NPWT promoted the wound healing and the infected Achilles tendon with tendon loss formed a healthy bridge with granulation tissue spontaneously. The patient resumed her normal activities of daily living, without requiring tendon transfer surgery. NPWT seems to be a simple and successful candidate for this situation.

Conclusion

NPWT seems to be effective for the treatment of postoperative infection following Achilles tendon repair, even in cases of tendon loss.

Unusual primary breast cancer - malignant peripheral nerve sheath tumor: a case report and review of the literature

Background

Sarcomas are a rare type of breast malignancies and malignant peripheral nerve sheath tumors of the breast are even rarer. There are no specific clinical and radiological features for the diagnosis of this tumor and histological features are also reported to be nonspecific. Therefore, immunohistochemistry is required for its diagnosis. A definitive treatment protocol is unavailable because of its rarity.

Case presentation

We report a case of a sporadic form of breast malignant peripheral nerve sheath tumor found in a 16-year-old Asian Bangladeshi girl. She experienced local recurrence and she had multiple left breast lumps four times in a very short period after repeated surgeries. However, she was later managed successfully with chemotherapy and locoregional radiotherapy. A chemotherapy protocol with ifosfamide, vincristine, and actinomycin was used and radiotherapy was given with a total dose of 50 Gy given in 25 fractions of 2 Gy by a 6 MV photon linear accelerator followed by 10 Gy boost given in 5 fractions of 2 Gy by 9 MeV electron energy. With more than 3 years of periodic follow-up, she is still well without any locoregional and metastatic recurrence.

Conclusions

This report suggests proper immunohistochemical analysis whenever a breast sarcoma is found in order to find a rare histological variety. We believe that malignant peripheral nerve sheath tumor of the breast can be managed by total mastectomy followed by adjuvant chemotherapy and radiotherapy. Long-term meticulous follow-up is required to develop an optimum therapeutic strategy.

Case report of robotic dor fundoplication for scleroderma esophagus with aperistalsis on manometry

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Scleroderma commonly affects the esophagus.

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Tailored therapy is crucial for successful management of scleroderma esophagus.

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Robotic Dor Fundoplication is an effective option for patients with scleroderma esophagus.

Scleroderma is a systemic disease of collagen deposition resulting in fibrosis of small arteries and arterioles. It commonly affects the skin, lungs, and gastrointestinal tract. The most common site of GI tract involvement is the esophagus. We present the case report of a 44 year old female with scleroderma esophagus and severe reflux which was successfully treated with robotic dor fundoplication. Because of the wide variety of symptoms with which this problem can present, a tailored approach taking into consideration the patient’s symptomatology and findings during diagnostic work-up was implemented with good results. The patient exhibited complete resolution of symptoms at short term follow up. Robotic dor fundoplication is an effective option for patients with scleroderma esophagus and no evidence of hiatal hernia or esophageal shortening.

A case report of an unusual cause of postoperative leg pain after posterior lumbar fusion

We report the case of a 36-year old man who underwent elective posterior lumbar spinal fusion after presenting with bilateral leg pain with associated back pain. He had undergone a L5/S1 discectomy in 2001, which provided good symptomatic relief. On this admission, he underwent elective L4-S1 posterolateral fusion and bilateral L4/5 and L5/S1 decompression. Intra-operatively a pedicle screw had to be re-inserted after fluoroscopy confirmed a lateral breech. The patient had no major postoperative complications until the sixth day when the patient re-presented with acute leg pain and weakness. Following a local multidisciplinary meeting (MDT) an MRI showed a large haematoma at the right psoas muscle. CT angiogram confirmed a bleeding lumbar segmental vessel at the site of the previous misplaced screw and an emergency fluoroscopic guided embolisation of the vessel was performed. The patient recovered well post operatively and was discharged back to the community 12 days later. Haemorrhage, as in this case a psoas haematoma should be considered as one of the differentials in patients with recurrent post-operative radiculopathy following posterior lumbar spine fusion. This should be suspected particularly if there has been a misplacement of one or more screws as this can cause injury to blood vessels and be fatal for the patient.

Transient portal venous gas associated with reversible non-occlusive mesenteric ischemia: A case report

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Ultrasonography is a useful tool for portal venous gas identification in critically ill patients.

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Portal venous gas can be observed at the early phase of acute mesenteric ischemia.

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Transient portal venous gas with rapid disappearance is indicative of the resolution of the ischemia.

Objectives

To report the utility of abdominal ultrasonography (US) to identify the presence of portal venous gas (PVG) during non-occlusive mesenteric ischemia (NOMI), and to follow the disappearance of portal venous gas after resolution of the NOMI.

Data sources

This was a clinical observation of a patient, with images of abdominal computed tomography (CT), and a video of portal venous gas identified by ultrasonography.

Data synthesis

We describe the case of an adult patient admitted to our ICU for NOMI developing 48 h after cardiac surgery. Medical intensive care associated with jejunal resection and vacuum-assisted closure led to rapid recovery. Three weeks later, the patient presented acute pulmonary edema, and developed a new episode of NOMI that was suspected by identification of PVG on US, and then confirmed on abdominal CT. The patient rapidly improved after orotracheal intubation and treatment of pulmonary edema. A second US performed 9 h later showed disappearance of PVG. The laparotomy performed 10 h after the first US did not find evidence of small bowel or colon ischemia. The postoperative period was uneventful.

Conclusions

US is a useful tool for the detection of PVG in critically ill patients, prompting suspicion of AMI. PVG can be observed at the early phase of AMI, even before irreversible transmural gut ischemia; transient PVG that disappears rapidly (within several hours) may suggest resolution of the NOMI.

Mesenteric desmoid tumour presenting with recurrent abdominal abscess and duodenal fistula: A case report and review of literature

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Mesenteric desmoid is a rare benign tumor, usually asymptomatic, but can grow aggressively and cause complications.

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Recurrent intralesional abscess formation even after drainage and medical therapy should lead to the assumption of fistulization to the adjacent bowel.

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Treatment should be guided by a multidisciplinary team, and operation intervention should be performed by surgeons familiar with desmoid tumor biology.

Introduction

Desmoid tumors are locally destructive but histologically benign. Their management involves close observation and surgical, medical, or hormonal treatment.

Presentation of the case

A 36-year-old male was admitted for abdominal pain and fever. A CT scan showed fluid collections and air within a mesenteric mass. Diagnostic laparotomy was performed with drainage of the abscess and biopsy of the mass. The pathology suggested a desmoid tumor. His fever and abdominal pain persisted. An endoscopy was performed, which demonstrated a fistula track in the third part of the duodenum. After a multidisciplinary discussion, consensus was to pursue surgical intervention. The patient underwent an en bloc resection of the tumor including a portion of the wall of the third part of the duodenum. The final pathology confirmed a desmoid tumor with a fistula track to the duodenum. The patient had a re-laparotomy on POD2 for intra-abdominal bleeding but was discharged without further events on POD7. He had no evidence of recurrence on follow-up at 11 months.

Discussion

Desmoid tumors are rarely complicated by abscess formation or fistulization. The management of intra-abdominal desmoids in this setting is challenging, as patients are often symptomatic and unresponsive to medical management. Percutaneous drainage and antibiotics are often initiated as first-line treatment, followed by surgery or medical therapy after evaluation of resectability and tumor stage.

Conclusion

Rare complications can arise with intra-abdominal desmoid tumors. Principles of infection control should be applied in combination with optimization of oncologic outcome. A multidisciplinary approach helps to achieve both these objectives.

A rare case of male pseudohermaphroditism-persistent mullerian duct syndrome with transverse testicular ectopia - Case report and review of literature

INTRODUCTION

Persistent Mullerian duct syndrome (PMDS) is a rare type of male pseudohermaphroditism. Transverse testicular ectopia (TTE) is characterized by one testis moving to the opposite side and both testes traversing the same inguinal canal.

CASE PRESENTATION

An 11-month-old boy presented with bilateral cryptorchidism. The left testis was not palpable; the right testis was canalicular with a right inguinal hernia. Ultrasound showed both testes located in the right inguinal canal. Right inguinal exploration revealed two testes with intact spermatic cords. A primitive uterus with fallopian tubes was also identified on opening the processus vaginalis. After herniotomy, bilateral orchidopexy was carried out (left orchidopexy through a trans-septal approach). Karyotyping confirmed a male gender (46XY). One year after the operation, ultrasound showed both testes to be in good condition.

DISCUSSION

PMDS is caused by defects in the gene that encodes Antimullerian hormone(AMH). Treatment aims to correct cryptorchidism and ensure appropriate scrotal placement of the testes. Malignant transformation is as likely as the presence of abdominal testes in an otherwise normal man. Failing early surgical correction, gonadectomy must be offered to prevent malignancy. Division of the persistent mullerian duct structures is indicated only in patients where persistence interferes with orchidopexy.

CONCLUSION

TTE should be suspected in patients presenting with inguinal hernia on one side and cryptorchidism on the other side. Herniotomy and bilateral orchidopexy is optimal. Removal of mullerian structures may injure the artery to vas deferens and is hence not recommended. Follow-up for fertility assessment in the latter years should be counselled.

Mesothelial cyst in the liver round ligament: A case report and review of the literature

INTRODUCTION

Cysts of the liver round ligament are rare and they are benign in the majority of cases. Current literature has been reviewed on this subject.

PRESENTATION OF CASE

A 22-year-old woman with a history of epigastric pain was admitted at our institution. Computed tomography (CT) of the abdomen showed a 14-mm cystic lesion in the epigastrium. A large cyst of the liver round ligament was successfully removed during exploratory laparoscopy and histopathology revealed a benign mesothelial cyst.

DISCUSSION

Mesothelial cysts of the liver round ligament are rare entities and we found a total of 5 cases from the literature. Diameter varies from 5 to 14cm. Most patients were asymptomatic or may complain abdominal pain in the upper quadrants. Ultrasonography and CT scan are the most useful diagnostic tools, however differential diagnosis between various abdominal cystic lesions can be difficult. Treatment is usually surgical excision.

CONCLUSION

Mesothelial cysts of the liver round ligament are extremely rare but should be taken in consideration in the differential diagnosis of intra-abdominal cystic lesions. We stress the importance of exploratory laparoscopy that can allow both diagnosis and radical surgical excision.

Successful endoscopic treatment of gastric phytobezoar: A case report

INTRODUCTION

Gastric bezoars are a rare condition associated with situations of gastric dysmotility and prior gastric surgery, though sometimes they can present without any risk factor. We describe the first successful treatment in medical literature of a large gastric bezoar in the outpatient setting through endoscopic fragmentation.

CASE PRESENTATION

A 76-year-old man was referred to our outpatient endoscopy clinic because of dyspepsia and epigastric pain. Upper GI endoscopy with a standard endoscope revealed a 10-cm-diameter gastric phytobezoar with necrotic pressure ulcer of the angulus. We fragmentized the bezoar into smaller pieces, with complete dissolution and without any complication. The patient was then promptly discharged home with a medical therapy. Follow-up endoscopy at 6 months showed the total disappearance of any residual fibers.

DISCUSSION

Different types of bezoars are described in literature, of which phyto- and trychobezoars are the most frequent. They can be absolutely asymptomatic or can arise with epigastric pain, pressure ulcer bleeding, gastrointestinal perforation or small bowel obstruction. The treatment is debated though endoscopic removal or fragmentation with the help of Coca-Cola lavages has showed the best success rate. The main experiences in literature concern hospitalized patients or describe treatment techniques which require overnight stays. An effective and rapid treatment in the outpatient setting is described in our experience, without short- or long-term complications.

CONCLUSION

The endoscopic fragmentation of large gastric bezoars in the outpatient setting is safe with a good clinical course.

Ante situm liver resection with inferior vena cava replacement under hypothermic cardiopolmunary bypass for hepatoblastoma: Report of a case and review of the literature

INTRODUCTION

Hepatoblastoma with tumour thrombi extending into inferior-vena-cava and right atrium are often unresectable with an extremely poor prognosis. The surgical approach is technically challenging and might require major liver resection with vascular reconstruction and extracorporeal circulation. However, which is the best surgical technique is yet unclear.

PRESENTATION OF CASE

A 11-months-old boy was referred for a right hepatic lobe mass(90×78mm) suspicious of hepatoblastoma with tumoral thrombi extending into the inferior-vena-cava and the right atrium, bilateral lung lesions and serum alpha-fetoprotein level of 50.795IU/mL. After 8 months of chemotherapy (SIOPEL 2004-high-risk-Protocol), the lung lesions were no longer clearly visible and the hepatoblastoma size decreased to 61×64mm. Thus, ante situm liver resection was planned: after hepatic parenchymal transection, hypothermic cardiopulmonary bypass was started and en bloc resection of the extended-right hepatic lobe, the retro/suprahepatic cava and the tumoral trombi was performed with concomitant cold perfusion of the remnant liver. The inferior-vena-cava was replaced with an aortic graft from a blood-group compatible cadaveric donor. The post-operative course was uneventful and after 8 months of follow-up the child has normal liver function and an alpha-fetoprotein level and is free of disease recurrence with patent vascular graft.

CONCLUSIONS

We report for the first time a case of ante situ liver resection and inferior-vena-cava replacement associated with hypothermic cardiopulmonary bypass in a child with hepatoblastoma. Herein, we extensively review the literature for hepatoblastoma with thumoral thrombi and we describe the technical aspects of ante situm approach, which is a realistic option in otherwise unresectable hepatoblastoma.

Challenging abdominal incisional hernia repaired with platelet-rich plasma and bone marrow-derived mesenchymal stromal cells. A case report

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New treatment options for challenging procedures in hernia surgery are necessary.

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Possibility of improving prosthetic compatibility and reducing future recurrences.

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Tissue engineering offers new strategies to improve fascial healing.

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Case of a surgeon – challenging abdominal incisional hernia.

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Treatment provided was PRP and BM-MSCs on a biological mesh.

Introduction

The necessity to develop new treatment options for challenging procedures in hernia surgery is becoming even more evident and tissue engineering and biological technologies offer even newer strategies to improve fascial healing. The present case reports a patient-tailored surgical technique performed to repair a grade IV abdominal incisional hernia, with a combined use of platelet-rich plasma and bone marrow-derived mesenchymal stromal cells, implanted on a biological mesh.

Presentation of the case

A 71 year-old female patient complained of an abdominal incisional hernia, complicated by enterocutaneous fistula, four-months following laparostomy. Contrast enhanced computed tomography showed an incisional hernia defect of 15.5 × 20 cm, with a subcutaneous abscess and an intestinal loop adherent to the anterior abdominal wall, with a concomitant enterocutaneous fistula. Surgery involved abdominal wall standardized technique closure, with in addition platelet-rich plasma and bone marrow-derived mesenchymal stromal cells implanted on a biological mesh. Two years follow up showed no recurrences of incisional hernia.

Discussion

Coating surgical meshes with patient’s own cells may improve biocompatibility, by reducing inflammation and adhesion formation. Moreover, platelet-rich plasma is a good source of growth factors for wound healing, as well as a good medium for bone marrow multinucleate cells introduction into fascial repair.

Conclusion

This approach is likely to improve abdominal wall repair in high grade (IV) incisional hernia, with the real possibility of improving prosthetic compatibility and reducing future recurrences. The authors agree with the necessity of further studies and trials to assure the safety profile and superiority of this procedure.

Acute hemobilia from a pseudoaneurysm of the cystic artery arising from the left hepatic artery: Case report and literature review

INTRODUCTION

Hemobilia represents only 6% of all causes of upper gastrointestinal bleeding.

PRESENTATION OF CASE

We report a rare case of a bleeding pseudoaneurysm of the cystic artery, due to a re-activation of a chronic cholecystitis, which arose with a mixed symptomatology: jaundices and hematemesis.

DISCUSSION

The rarity of our patient is increased for some vascular anatomic variations detected by Computed Tomography that influenced the management of the disease. Our patient was treated by endovascular embolization of the pseudoaneurysm and subsequent cholecystectomy.

CONCLUSION

About pseudoaneurysm of the cystic artery only few cases have been already reported and to date there are no guidelines for its management. We describe both diagnostic features and therapeutic strategies in comparison to the most recent literature.

Primary squamous cell carcinoma of the thyroid: Case report and systematic review of the literature

BACKGROUND

Primary squamous cell cancer (PSCC) of thyroid is a rare malignancy with poor prognosis. It is mandatory to exclude secondary involvement of the thyroid by panendoscopy, CT-scan and immunohistochemical analysis. As treatment surgery, radiation and rarely chemotherapy is employed.

METHODS

A systematic review of the literature was conducted searching medline and embase database using the medical subject headings "primary squamous cell carcinoma of thyroid" and "primary squamous cell cancer of thyroid", for articles published until April 2016 (n=1733). Of interest were the used treatment modalities and survival outcomes.

RESULTS

A total of 35 publications reporting on 50 cases including ours were finally analyzed. A curative treatment approach was described in 24 patients (48%). Additional radiotherapy, chemotherapy or radiochemotherapy was applied in 17, 7 and 7 patients respectively. Median overall survival was 6 months [range 0-48] for 47 patients. Disease free survival was only achieved in 8 patients with disease limited to the thyroid gland, complete surgical resection and additional radiotherapy or radiochemotherapy [reported median 20 months; range 12-48].

CONCLUSION

Reported disease free survival of PSCC of the thyroid was only achieved in patients with complete surgical resection in combination with adjuvant radio- and/or chemotherapy. However long term survival has not been reported in the literature yet.

Neuropraxia following resection of a retroperitoneal liposarcoma

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Neuropraxia after resection of retroperitoneal masses can be a challenging postoperative problem.

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Intraoperative findings and postoperative suspicion have utmost importance in establishing differential diagnosis.

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Postoperative work up including neurological evaluation, MRI, and EMG help in diagnosing the condition.

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Aggressive postoperative physical therapy and steroids are very helpful in resolution of the condition.

Background

This is a unique case of neuropraxia of femoral nerve seen after resection of retroperitoneal liposarcoma which has not been reported before in the literature.

Introduction

Neuropraxia, a transient paralysis due to blockage of nerve conduction, commonly associated with athletes and orthopedic procedures, has not been previously reported as a complication following resection of retroperitoneal sarcoma.

Case

This is an 81-year-old female who, on CT for evaluation of her atherosclerosis, was found to have an incidental right-sided retroperitoneal mass extending from the right renal capsule inferiorly through the inguinal canal. At this point, the patient reported mild right sided abdominal pain and right lower back pain, but reported no neuromotor deficits of the right lower extremity. Given the symptoms of the patient as well as the size, location and the density of the lesion, surgical intervention was pursued. On exploration, the lipomatous lesion, suggestive of liposarcoma, was invading the right genitofemoral nerve and ilioinguinal nerve which were sacrificed to ensure a complete oncologic resection. Following complete removal of the mass, she developed right side femoral nerve neuropraxia, suffering complete loss of motor function in the femoral distribution. Pathology revealed the mass to be a low grade liposarcoma.

Discussion

The patient required only physical therapy and oral prednisone following surgery for treatment of the neuropraxia. She responded well and has regained significant neuromotor function of the affected limb. Cases presenting with post-resection neurological sequelae without any known intraoperative nerve injury may respond very well to conservative treatment. Hence, it is very important to collaborate with Neurology and Physical Therapy to achieve best possible outcome.

Aggressive gastrointestinal food allergy in neonates and its possible relationship to necrotizing enterocolitis

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Food allergy in neonates with secondary necrotizing enterocolitis is extremely rare.

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No typical risk factor for necrotizing enterocolitis due to food allergy was found.

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Methicillin-resistant Staphylococcus aureus in the stool may be a risk factor.

Introduction

The incidence of gastrointestinal food allergy (FA) in neonates is increasing. Despite this, cases of patients with gastrointestinal FA who develop necrotizing enterocolitis (NEC) requiring laparotomy are extremely rare.

Presentation of case

We describe two cases that presented with bloody stool with a probable diagnosis of FA as eosinophils were positive in the stool at onset. Both cases failed conservative treatment. Jejunostomy and ileostomy were performed in both cases due to secondary NEC with underlying acute FA. Post-surgery, raised peripheral blood eosinophil count, presence of cow’s milk-specific IgE antibody and positive allergen-specific lymphocyte stimulation test were found. Stoma closure were performed 3 and 1 months later in both cases. Postoperative recovery was uneventful.

Discussion

A few reports have not identified risk factors for NEC secondary to FA. Thrombocytopenia and rise in C-reactive protein (CRP) levels 2 days after the development of FA may be suggestive of FA with NEC. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in the fecal culture of both patients at the time of the onset of NEC. The toxic antigen produced by MRSA may cause activation of milk-protein-primed T cells and exacerbate FA.

Conclusion

The decrease of platelet levels and rise in CRP may indicate the development of secondary NEC in patients with FA. Additionally, MRSA detected in the fecal culture also may be a risk factor for NEC through the activation of cellular immunity reaction pathways.

Delayed diagnosis of esophageal foreign body: A case report

INTRODUCTION

Foreign body (FB) ingestion, a common and serious problem in children, can present with a wide variety of symptoms. This paper describes and discusses the case of an esophageal foreign body (EFB), in which the patient presented with primarily respiratory clinical signs causing delayed diagnosis.

PRESENTATION OF CASE

A six month old boy presented with three months history of harsh cough, stridor and pulmonary congestion. He was repeatedly treated with steroids and antibiotics. His symptoms worsened progressively. On examination, he was tachypneic with suprasternal recession, scattered crepitations, diffuse wheeze and a continuous stridor. Chest X-ray was normal. The flexible bronchoscopy showed a posterior external compression on the middle wall of the trachea. The CT scan was normal. The contrast X-ray study of the esophagus revealed an endoluminal filling defect. The esophagoscopy revealed narrowing at 12cm of dental arch, and a bourgeoning yellow mass easily bleeding on contact. Esophageal biopsies were obtained, and histology was inconclusive. A surgical exploration was planned, but the infant forced out a pistachio shell after a chest physiotherapy session.

DISCUSSION

Ingestion of FB by small children is a common problem. The majority of EFBs pass harmlessly through the gastrointestinal tract; however, some EFBs can cause significant morbidities. The diagnosis may be delayed leading to several complications especially if the ingestion of the FB is unwitnessed and when the clinician does not think of FB ingestion as part of the differential diagnosis of chronic respiratory signs.

CONCLUSION

This case highlights, the importance of recognizing, the rare and often forgotten respiratory symptoms of EFB body to avoid diagnostic delay especially in unwitnessed FB ingestion.

Study protocol of a phase IB/II clinical trial of metformin and chloroquine in patients with IDH1-mutated or IDH2-mutated solid tumours

INTRODUCTION

High-grade chondrosarcoma, high-grade glioma and intrahepatic cholangiocarcinoma are aggressive types of cancer with a dismal outcome. This is due to the lack of effective treatment options, emphasising the need for novel therapies. Mutations in the genes IDH1 and IDH2 (isocitrate dehydrogenase 1 and 2) occur in 60% of chondrosarcoma, 80% of WHO grade II-IV glioma and 20% of intrahepatic cholangiocarcinoma. IDH1/2-mutated cancer cells produce the oncometabolite D-2-hydroxyglutarate (D-2HG) and are metabolically vulnerable to treatment with the oral antidiabetic metformin and the oral antimalarial drug chloroquine.

METHODS AND ANALYSIS

We describe a dose-finding phase Ib/II clinical trial, in which patients with IDH1/2-mutated chondrosarcoma, glioma and intrahepatic cholangiocarcinoma are treated with a combination of metformin and chloroquine. Dose escalation is performed according to a 3+3 dose-escalation scheme. The primary objective is to determine the maximum tolerated dose to establish the recommended dose for a phase II clinical trial. Secondary objectives of the study include (1) determination of pharmacokinetics and toxic effects of the study therapy, for which metformin and chloroquine serum levels will be determined over time; (2) investigation of tumour responses to metformin plus chloroquine in IDH1/2-mutated cancers using CT/MRI scans; and (3) whether tumour responses can be measured by non-invasive D-2HG measurements (mass spectrometry and magnetic resonance spectroscopy) of tumour tissue, serum, urine, and/or bile or next-generation sequencing of circulating tumour DNA (liquid biopsies). This study may open a novel treatment avenue for IDH1/2-mutated high-grade chondrosarcoma, glioma and intrahepatic cholangiocarcinoma by repurposing the combination of two inexpensive drugs that are already approved for other indications.

ETHICS AND DISSEMINATION

This study has been approved by the medical-ethical review committee of the Academic Medical Center, Amsterdam, The Netherlands. The report will be submitted to a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

This article was registered at ClinicalTrials.gov identifier (NCT02496741): Pre-results.

Heterotopic mesenteric and abdominal wall ossification - Two case reports in one institution

INTRODUCTION

Heterotopic ossification occurs when bone develops in tissues which usually don't undergo ossification. Heterotopic mesenteric ossification, also known as intra-abdominal myositis ossificans, is a rare and benign form of ossification, usually related with previous abdominal surgery or trauma.

PRESENTATION OF CASES

We report two cases of heterotopic ossification both after multiple abdominal surgeries, with intraoperative findings of mesenteric and abdominal wall ossification. Histopathology revealed metaplastic bone deposition, without evidence of atypia or malignancy.

DISCUSSION

This rare entity shares clinical and pathological characteristics of myositis ossificans. It is important to consider the differential diagnosis with sarcomas. In the cases described, the patients were proposed for elective surgery and this pathology was as an incidental finding.

CONCLUSION

The simultaneous presence of mesenteric and abdominal wall ossification in both patients makes these cases even rarer.

Synchronous mucinous adenocarcinoma of the recto sigmoid revealed by and seeding an anal fistula. (A case report and review of the literature)

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The diagnosis of such conditions remains difficult when the colonic tumor is unknown and the chronic lesion of anal fistula seems to be a benign condition.

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The management of these cases remain controversial.

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The aim of this study highlights the importance of high suspicion with further investigation and the need of biopsy in all anal fistulas.

Introduction

There are few cases of synchronous rectal adenocarcinoma revealed by an anal fistula. The diagnosis of synchronous mucinous adenocarcinoma of the recto sigmoid and anal canal remains difficult. The chronic anal fistula can be mistaken as the common manifestation of a benign perianal abscess or fistula.

Case presentation

We present a rare case of a Greek Caucasian 79 year old male patient with anal fistula and a recurrent perianal abscess who subsequently was found to have developed synchronous rectosigmoid and perianal mucinous adenocarcinoma on biopsy. The histological exam revealed mucinous adenocarcinoma in two sites, representing two tumors, cells were immunopositive for cytokeratin 20 and negative in cytokeratin 7. The patient underwent “laparoscopic extralevator abdominoperineal excision ” with both lesions being resected. There is no recurrence after four years of follow up.

Conclusions

This case highlights the importance of high suspicion, further investigation and the need of biopsy in all anal fistulae.

Obstructive neonatal atrial myxoma

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In the foetus a tumour can be noted on a routine antenatal anomaly scan as an intracardiac mass.

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In postnatal life cardiac tumours may affect the integrity and function of the adjacent cardiac structures leading to severely compromised blood flow.

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Because of the potential life-threatening sequelae of cardiac myxoma, treatment consists of urgent surgical resection.

Introduction

Cardiac myxoma is a benign neoplasm representing the most common primary cardiac tumor in adults, however it is unusual in neonates. It is represented by an endocardial mass that occupies the cardiac chamber. Although the majority of myxomas are attached to the fossa ovalis of the interatrial septum, they also attach to the walls of the cardiac chambers and to valve leaflets surfaces. Approximately 75% of myxomas are found in the left atrium, 20% are located in the right atrium, and rarely in the ventricles.

Presentation of case

We describe a rare case of neonatal cardiac myxoma arising from interatrial septum, causing significant mechanical obstruction to blood flow through tricuspid valve, in an otherwise normal newborn. The patient underwent successful excision of the myxoma with an uneventful recovery [1].

Discussion

Cardiac tumors are rare in children, thus an understanding of the common types of benign and malignant paediatric cardiac tumors and their imaging features, is important because the epidemiology and tumor types differ from those encountered in adults.

Conclusion

Large neonatal myxoma is exceptionally rare and even more infrequent is the surgical excision in the first day of life.

Emergency incarcerated obturator hernia repair with biologic mesh in a male patient after ipsilateral hip disarticulation: A case report

INTRODUCTION

An obturator hernia is an uncommon form of abdominal hernia that is difficult to diagnose due to its non-distinct presentation. This case investigates an emergency treatment of an obturator hernia presenting in a patient with an ipsilateral hip disarticulation in a 266-bed community hospital.

PRESENTATION OF CASE

A 53-year old man with a history of a left hip disarticulation 3-weeks prior presented to the emergency department with fever, nausea, vomiting, and diarrhea for the past 5-days. An elevated WBC and presence of gas within the hip stump on CT led to an emergency operation to rule out necrotizing fasciitis within the stump. Opening of the stump incision revealed two herniated loops of small bowel corresponding to the left obturator foramen, revealing the diagnosis of an incarcerated obturator hernia. The bowel was reduced and secured within the hip stump and the defect was covered with Strattice biologic mesh.

DISCUSSION

Obturator hernias are rare and can involve vague symptoms, but it is essential to make an accurate diagnosis and repair the defect on an emergency basis. Obturator hernias may appear in the setting of a hip disarticulation, being caused by iatrogenic anatomic alteration, and can be treated in a community acute care hospital.

CONCLUSION

Being aware of the possibility of obturator foramen herniation and bowel incarceration as part of the differential diagnosis for patients with abdominal pain after a prior hip disarticulation can facilitate prompt diagnosis and reduce morbidity and mortality.

Extragastrointestinal stromal tumour of the lesser omentum: A case report and literature review

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EGISTs are very rare mesenchymal tumours which originate from cells outside the gastrointestinal tract and tend to have an aggressive biological behaviour.

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There have been only a few previous reports of EGISTs arising in the lesser omentum.

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Complete surgical resection is the most effective treatment associated with the use of imatinib in the presence of adverse prognostic factors.

Introduction

Extragastrointestinal stromal tumours (EGISTs) are very uncommon compared to their gastrointestinal counterparts. Most of them originate from the intestinal mesentery and the omentum.

Case report

A 70 year-old Caucasian woman presented with a bulky abdominal mass which on laparotomy was found to originate from the lesser omentum and was completely resected. Histological examination revealed spindle cells with severe pleomorphism and high mitotic activity. Immunohistochemically, the tumour cells showed strong positivity for c-kit (CD117), DOG-1 and human haematopoietic progenitor cell antigen (CD34). An exon 11 deleterious mutation was identified and thus regular dosing of 400 mg imatinib mesylate was initiated.

Discussion

There have been only a few previous reports of EGISTs arising in the lesser omentum. Although EGISTs seem to have morphological and immunohistochemical similarities with GISTs, their pathogenesis, incidence, genetic background and prognosis are not completely known because they are extremely rare. It is strongly believed that such tumours originate from cells, which have similar pathological characteristics and biological behaviour as the intestinal cells of Cajal. In most series of EGISTs, a female predominance, a greater size and a higher mitotic index than GISTs were observed.

Conclusion

EGISTs are very rare mesenchymal tumours which originate from cells outside the gastrointestinal tract and tend to have a more aggressive biological behaviour than their GI counterparts. Complete surgical resection is the most effective treatment associated with the use of imatinib in the presence of adverse prognostic factors. In any case a strict follow-up is necessary due to high recurrence rates.

Carcinosarcoma of the maxillary sinus: A rare case report

Introduction

Carcinosarcoma is a highly malignant tumor characterized by dual malignant histologic differentiation of epithelial and mesenchymal components. The tumor is extremely rare in the sinonasal tract, with only 13 cases reported since 1957 in the literature.

Presentation of case

We report a case of a 55-year-old man with right-sided face pain revealed a mass in the right maxillary sinus and nasal cavity. A large incisional biopsy from the nasal cavity concluded the diagnosis of carcinosarcoma. The patient was treated with chemoradiation, but no significant effect was obtained. The patient died 4 months after initial examination.

Discussion

In our case, the patient consulted late with a large tumor which darkens his prognosis. According to some authors, this histological type of tumors is known by local recurrences and its lethal metastases. Prognosis is related to location, tumor size, the invasion and stage of disease. Wide surgical excision is the treatment of choice. Radiotherapy can be discussed in inoperable cases.

Conclusion

This is an aggressive tumor, rapidly progressive with a poor prognosis. The management of this rare condition remains undetermined.

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Carcinosarcoma is a rare biphasic neoplasm and a variant of squamous cell carcinoma.

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Carcinosarcoma is an aggressive tumor, rapidly progressive with a poor prognosis.

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Occurrence in nasal cavity is very rare and only few cases have been reported.

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Management for this disease still remains undetermined.