Terminal ileostomy and on-table enteroscopy-A case report describing a novel approach for retrieval of foreign bodies in the difficult abdomen

•

Emergency abdominal surgery carries a high morbidity in the frozen abdomen.

•

Midline laparotomy can be avoided in the setting of severe adhesions if possible.

•

Foreign body retrieval can be performed in a hybrid technique.

•

Combined endoscopic and laparoscopic techniques can be used for retrieval.

Introduction

With any abdominal surgery in a difficult abdomen, the procedure is filled with potential hazards. In addition to a prolonged operative time, there is a risk of enterotomy or damage to blood vessels and ureters. An irradiated pelvis increases this risk and may cause additional morbidity such as delayed healing. An impacted foreign body can also be a challenging problem to deal with alone but when combined with a difficult abdomen can make the problem impossible.

Presentation of case

A 67 year-old male presented with a small bowel obstruction secondary to a foreign body impacted in the distal. The patient had a history of prostate cancer with radiation to the pelvis and thereafter developed perforated diverticulitis, requiring end colostomy. Later he underwent a colostomy take-down but developed wound infection and dehiscence resulting in an incisional hernia which was repaired. The patient failed conservative management and operative intervention was undertaken. Due to the extensive scarring of his midline abdomen, a right sided transverse incision was used. An enterotomy was made in the terminal ileum allowing the endoscope to advance to the foreign body to be retrieved with a snare. The foreign body was found to be a 3.5 cm piece of bone. Post-operative course was unremarkable.

Discussion

Foreign body ingestion is a rare cause of small bowel obstruction, and exploration and retrieval is recommended if the obstruction does not resolve or if the bowels perforate. The method of retrieval depends on the site of the foreign body. Fortunately, in the small bowel, the terminal ileum is the narrowest part and most likely the site of impaction. Operative retrieval is easier if there are no prior abdominal interventions. An irradiated pelvis or abdomen, multiple prior procedures and a frozen abdomen warrant an alternative approach. As it can be difficult or impossible to access the ileum using a colonoscope transanally, a limited right-sided transverse incision can be employed allowing immediate access to the cecum and terminal ileum through which endoscopic retrieval could be performed. A review of the literature to date did not yield any other descriptions of this approach for foreign body retrieval, however, an appendostomy and endoscopy to rule out malignancy in patients with right sided diverticulitis has been documented.

Conclusion

Consideration should be given to foreign body retrieval through an appendostomy or ileostomy if a midline laparotomy is considered too high risk in the setting of pelvic irradiation and multiple prior abdominal surgeries.

Giant epidermoid cyst in the breast: A common benign lesion at a rare site-A case report

INTRODUCTION

Epidermoid cyst is a common clinical entity and it can occur anywhere in the body. But its occurrence and huge size in the breast is very rare and more liable to develop complications, including malignant transformation.

PRESENTATION OF CASE

We present here an unusual case of a giant epidermoid cyst in the breast, which is about 7cm in greatest dimension. After proper preoperative diagnosis by clinical, imaging and histopathological findings, it was managed by total excision.

DISCUSSION

Imaging and fine needle aspiration cytology is essential for accurate preoperative diagnosis. However, it is often very difficult to differentiate it from other benign and malignant conditions of breast. Infection and malignant transformation are its potential complications. Total excision along with its capsule is the treatment of an epidermoid cyst.

CONCLUSION

Epidermoid cyst is an important differential diagnosis while managing benign breast disease.

Ileo-ileal intussusception of a sutured enterotomy site, 6days after laparotomy due to fetobezoar: A case report

INTRODUCTION

Postoperative small bowel obstruction due to intussusception is a rare entity but can lead to severe morbidity and even mortality. We present a case of this rare complication produced by an unusual cause.

CASE REPORT

A 22year old male, who is a fruitarian, presented to the E.R on day 6 after laparotomy due to obstructing fetobezors that were removed via gastrotomy and enterotomy. In his readmission, he had severe, diffuse abdominal pain, distended abdomen and diffuse peritonitis. Abdominal computed tomography (CT) showed a large amount of fluid in the abdomen, distended small bowel loops, a small amount of free air around the stomach and a suspected ileo-ileal intussusception. The patient underwent emergent laparotomy which revealed an ileo-ileal intussusception with the sutured enterotomy site from the previous operation as the lead point. In addition, a minor dehiscence of the gastrotomy site was identified. A reduction of the intussusception was performed with resection of the enterotomy site and side to side anastomosis. The gastrotomy site was debrided and re-sutured. Recovery was uneventful.

CONCLUSION

Postoperative intussusception, although rare, is potentially a dangerous complication, often not involving the site of the primary operation. To our knowledge this is the first report of an intussusception with a sutured enterotomy site as the lead point. Clinicians should be aware of this entity when assessing a patient with abdominal pain and distention after surgery with enterotomy or resection of bowel.

Magnetic resonance cholangiopancreatography uncovering massive gallbladder mucocele in a patient with ambiguous clinical and laboratory findings: A case report

•

MRCP can facilitate accurately the identification of acute biliary abnormalities in patients with atypical biliary symptoms.

•

MRCP is a complementary imaging modality where ultrasound is equivocal or inconclusive and computer tomography is contraindicated.

•

Timely assessment with MRCP can expedite clinical decisions to proceed with either surgical intervention or conservative management.

Introduction

Radiological imaging of the gallbladder is a fundamental aspect of assessing severity of acute cholecystitis in addition to guiding the optimal timing of surgical intervention. We present a case of acute severe cholecystitis with massive gallbladder mucocele initially presenting with equivocal and inconclusive clinical, laboratory, and ultrasound findings. Magnetic resonance cholangiopancreatography allowed accurate evaluation of cholelithiasis and demonstrated a massive gallbladder mucocele.

Case presentation

A 39-year-old Caucasian female presented with mild right upper quadrant pain coupled with intermittent epigastric discomfort after meals. Diagnostic abdominal ultrasound could not reliably detect cystic or common bile duct stones due to patient obesity and meteorism. Computed tomography was contraindicated due to severe contrast allergy. Magnetic resonance cholangiopancreatography allowed timely, accurate evaluation of cholelithiasis. This subsequently demonstrated a massive gallbladder mucocele requiring urgent laparoscopic cholecystectomy.

Conclusion

Magnetic resonance cholangiopancreatography should be considered as a complementary imaging modality to assess patients presenting with atypical biliary symptoms, particularly when ultrasound is equivocal or inconclusive, clinical and laboratory findings are non-specific, and computer tomography is contraindicated. Magnetic resonance cholangiopancreatography can also be considered in patients with acute cholecystitis not adherent to a specific severity grade.

A case of pancreatic schwannoma showing increased FDG uptake on PET/CT

•

Pancreatic schwannoma is rare and preoperative diagnosis is difficult due to the lack of specific symptoms, radiological characteristics and tumor markers.

•

Incidental detection of pancreatic schwannoma is predicted to increase due to the widespread use of CT and MRI. It is important to take into account this tumor in the differential diagnosis of pancreatic tumors.

•

We should be aware that FDG-PET/CT shows abnormal accumulation in a benign pancreatic schwannoma.

Introduction

Schwannomas are neoplasms originating from Schwann cells in nerve sheath, but pancreatic schwannomas are rare.

Presentation of case

A 59-year-old female incidentally pointed out a 2-cm-sized solid mass in the pancreas head by computed tomography (CT) which was performed for other reasons. Magnetic resonance imaging (MRI) showed a mass with hypointensity on T1-weighted images and a heterogenous hyperintensity on T2-weighted images. Magnetic resonance cholangiopancreatography (MRCP) showed no abnormal findings in the main pancreatic duct. The mass of the pancreas head showed a significantly increased uptake on fluorin-18 fluorodeoxyglucose positron emission tomography CT (FDG-PET/CT). Based on the radiological findings, a malignant potential tumor was preliminarily considered. Subtotal stomach-preserving pancreatoduodenectomy (SSSPD) was performed to make a definite diagnosis. The resected specimen showed a well-encapsulated circumscribed mass, measuring 2.0 cm, in the pancreas head. Histopathological examination revealed proliferation of spindle cells showing interlacing and palisading patterns in the tumor. The proliferating cells showed no atypia and few mitoses. Immunohistochemically, the spindle cells were positive for S-100 protein. The Ki67 labeling index was approximately 2%. Based on these findings, a diagnosis of benign schwannoma of the pancreas was made.

Conclusion

Although pancreatic schwannoma is a rare neoplasm, it is important to take into account this tumor in the differential diagnosis of pancreatic tumors. In addition, we should be aware that FDG-PET/CT shows abnormal accumulation in a benign pancreatic schwannoma.

Case report of diffusely metastatic rectal GIST

•

Rectal gastrointestinal tumors (GISTs) are rare mesenchymal tumors.

•

Rectal GISTs are extremely rare and account for approximately 2% of all GIST tumors.

•

Majority of GISTs have a benign course.

•

Treatment with imatinib mesylate should be arranged as soon as possible.

•

The most common cause of death after resection of a rectal GIST is distant metastasis.

This is a case report of an aggressive, diffusely disseminated Stage IV rectal gastrointestinal stromal tumor (GIST) in a 57-year-old male that presented for symptoms of malaise, constipation, and twenty pound weight loss in 2 months. Upon rectal examination, a hard 4 centimeter submucosal mass was found at the 9–12 o’clock position. Liver and lung metastases were visualized on computerized tomography (CT) of the chest, abdomen, and pelvis on metastatic work-up. He was deemed a poor surgical candidate due to diffuse metastatic disease and referred for palliative chemotherapy. The patient had suffered a perforation of his rectal wall two weeks after his initial presentation and passed away shortly thereafter. He never received palliative chemotherapy. We present a case report as a unique case of an extremely aggressive and quickly fatal GIST tumor.

Open and contaminated pediatric pelvic ring injury case report: Fixation without metal

•

Open pelvic fractures can present unique and difficult clinical problems.

•

The pelvic ring is a dynamic structure in normal physiologic conditions.

•

Suture and anchor fixation can be used as definitive fixation of the pelvic ring.

Introduction

Pelvic fractures are relatively uncommon in children, accounting for 0.3–7.5% of all pediatric injuries (Gänsslen et al., 2013; Ismail et al., 1996; Peltier, 1965; Galano et al., 2005; Spiguel et al., 2006). This case report describes a pediatric open pelvic injury caused by a crush mechanism between a car and guardrail.

Case

A 13 year old male presented with an open APC 3 pelvic injury after being pinned between a car and guardrail. His definitive treatment included bilateral SI screw placement, as well as a less invasive method for anterior pelvic ring disruption (Internal Brace suture anchor dynamic fixation).

Discussion/conclusion

A less invasive method for the anterior pelvic ring was used to avoid additional dissection due to extensive soft tissue loss, and to decrease hardware burden, which lessens the chance of complications such as infection. Suture fixation of the pubic symphysis provided stable fixation to allow healing in the current case of open pelvic fracture.

Incidental gastric accessory spleen during laparoscopic sleeve gastrectomy

•

Laparoscopic sleeve gastrectomy’s have now become the most common performed bariatric procedures as of 2014.

•

Although uncommon, the incidental finding of accessory spleens on the stomach may affect the process of the surgery.

•

The prompt and effective management of this finding is of importance for the prognosis of the patient.

•

Although this finding is mostly benign, it is crucial to resect and analyze via histopathology as for the safety of the patient.

Introduction

Bariatric surgery has shown to produce the most predictable and tangible results for weight loss, with laparoscopic sleeve gastrectomy’s being the most popular one of them. However, the occurrence of previously undiagnosed diseases can be encountered during bariatric operations. The work has been reported in line with the SCARE criteria.

Case presentation

This is the case of a 54 year old morbidly obese female, presenting to our hospital for a laparoscopic sleeve gastrectomy. During her procedure, it was discovered that she has an accessory spleen on the fundus of her stomach. The decision was made to resect it with the specimen of the stomach for histopathalogical examination.

Conclusion

Incidental findings during routine bariatric surgery are a common occurance, and therefore prompt and effective intra-op management is key to the prognosis of the patient. Accessory spleens, although uncommon, tend to be asymptomatic. However, if undiagnosed, could present with dangerous consequences.

Chest wall reconstruction following axillary breast augmentation and desmoid tumor resection using capsular flaps and a form-stable silicone implant: A case report, diagnosis and surgical technique

•

Desmoid tumors (DT) are a rare benign lesion, and chest desmoid tumors are much less frequent. A rare case of chest DT is presented and discussed.

•

Chest DT following breast augmentation is very rare and few cases have been described; all have been related to the inframammary approach and located in the implant capsule. The authors describe a chest DT following subfascial axillary breast augmentation and subsequent surgical management and chest wall reconstruction.

•

The case illustrates some aspects that may be useful for thoracic and plastic surgeons and may be used as guidance for surgical management.

Introduction

Chest desmoid tumors (CDT) are rare lesions characterized by fibroblastic proliferation from the connective tissue. Although CDT have been studied previously, no cases following subfascial transaxillary breast augmentation (TBA) have been described.

Presentation of case

The authors describe a case of CDT in a 28-year-old woman one year after TBA, which presented as a painful and progressive mass in the lower-inner right breast quadrant. MRI showed a soft-tissue tumor (6 × 3 × 4 cm) that affected the region of the right anterior costal margin, without signs of structural costal invasion. Patient was treated surgically, exposing the right costal-sternal region through an inframammary approach and resecting the CDT. The remaining capsular flap was mobilized into the defect and a form-stable silicone implant was utilized to cover the chest wall defect and achieve an adequate breast contour. The patient is currently in 5th year after chest reconstruction, with satisfactory results. Neither the tumor or the symptoms recurred.

Discussion

CDT is an uncommon evolution following TBA. Although it is a rare disease, thoracic and plastic surgeons must be alert to avoid misdiagnosis. Defect reconstruction is necessary, mobilizing the capsular flaps and replacing the implants in order to obtain a satisfactory outcome.

Conclusion

Knowledge of this rare post-operative evolution is crucial, and early surgical intervention is warranted in order to avoid more aggressive treatment. This case report provides general knowledge of CDT, and may be used as guidance for early diagnosis and treatment.

Minimally invasive appendectomy for resection of appendiceal mucocele: Case series and review of the literature

INTRODUCTION

Appendiceal mucoceles encompass neoplastic and non-neoplastic causes of a distended Appendix filled with mucus. Appendectomy is recommended when an appendiceal mucocele is identified, incidentally or otherwise, in the event it is secondary to a malignancy. For an intact mucocele, it is critically important to avoid rupturing the mucocele during resection, as rupture of a neoplastic mucocele can result in pseudomyxoma peritonei, or mucin deposits in the peritoneum, which is associated with long-term morbidity and mortality. For this reason, laparotomy is the traditionally recommended surgical approach for treatment.

PRESENTATION OF CASES

In our case series, we describe two patients, a 49-year-old woman and a 79-year-old man, with incidentally identified appendiceal mucoceles. These patients were successfully treated with minimally invasive approaches to appendectomy, one with a robotic approach and one with a hand-assisted laparoscopic approach. The mucoceles were removed without rupture, and both patients recovered well postoperatively without complication.

DISCUSSION

While laparotomy is the traditionally recommended surgical approach for resection of appendiceal mucoceles, certain minimally invasive techniques allow for safe removal of the mucoceles while minimizing the morbidity of laparotomy.

CONCLUSION

Minimally invasive approaches to appendenctomy, specifically the robotic-assisted approach and the hand-assisted laparoscopic approach, can be considered for safe resection of appendiceal mucoceles.

Eversion stripping of the esophagus with intraesophageal insufflation-A case report

•

The indications for stripping of the esophagus have decreased due to the widespread of endoscopic mucosal resection and thoracoscopic surgery.

•

Even if indications for this procedure have decreased, this is an important option in the armamentarium of the esophageal surgeon.

Introduction

Patients with esophageal cancer frequently cannot tolerate thoracotomy due to their overall debilitated condition. Moreover, some patients have severe adhesions in the thoracic cavity. Eversion stripping of the esophagus is an option for resection in these patients.

Presentation of case

A 64-year-old man was admitted to our institution with the chief complaint of epigastric pain. Endoscopic examination showed a protruding lesion 22 cm from the incisors, with a superficial and circumferential mucosal irregularity on the distal side of the lesion. Biopsy revealed squamous cell carcinoma. Clinical stage was T1b(sm)N0M0, cStage I. In addition to the poor pulmonary status of the patient, adhesions in the intrathoracic cavity were predicted. The decision was made to perform esophageal resection without a thoracotomy. In order to ensure complete invagination of the esophagus, the esophagus was insufflated prior to stripping. The stripping process was observed with a gastroscope. During the stripping, the esophagus did not bunch up, and stripping was smooth and with minimal resistance.

Discussion

The stripping resection of the esophagus is an important option for the esophageal surgeon. In this case report, we describe a new eversion stripping method of the esophagus. This easy and reliable stripping method incorporates intraesophageal insufflation.

Conclusion

The indications for blunt esophageal dissection without thoracotomy have been decreasing. On the other hand, our method seems to be useful in optimal case of stripping of esophagus.

Salvage photodynamic therapy accompanied by extended lymphadenectomy for advanced esophageal carcinoma: A case report

•

A case of esophageal cancer was treated with PDT after salvage Appleby operation.

•

Salvage lymphadenectomy is a safer procedure than salvage esophagectomy.

•

Salvage lymphadenectomy may be insufficient as a curative treatment.

•

PDT is a novel promising option for control primary carcinoma.

Introduction

Salvage surgery for locoregional failures after definitive chemoradiotherapy (dCRT) for esophageal cancer is widely practiced, but treatment options complementing it are also needed due to the high morbidity and mortality and low rate of curative resection.

Presentation of case

A 58-year-old man with a surgical history of right upper lobectomy for lung cancer was diagnosed as having esophageal squamous cell carcinoma. Computed tomography revealed swelling of the lesser curvature lymph node, and it had invaded the stomach, the body and tail of the pancreas and the left gastric artery, splenic artery and celiac artery. The patient underwent definitive-dose radiation with chemotherapy. Complete response was attained for the primary tumor, but the metastatic lymph node infiltrating the stomach, pancreas and major vessels remained. Therefore, the Appleby operation was proposed to the patient and subsequently performed aiming at curability. However, the primary tumor recurred 38 months after surgery, so the novel modality of photodynamic therapy using talaporfin sodium and a diode laser was performed, and a complete response was attained for this lesion. The patient is alive at 50 months after the salvage Appleby operation.

Discussion and conclusion

Salvage lymphadenectomy for esophageal cancer may be insufficient as a curative treatment because of regrowth of the primary lesion. However, photodynamic therapy may be applicable as a curative treatment option for recurrence of the primary lesion after salvage lymphadenectomy.

Preoperative left hepatic lobe devascularisation to minimize perioperative bleeding in a Jehovah's Witness undergoing left hepatectomy

•

Liver resection in a Jehovah’s Witness patient requires multimodal blood minimization strategies to improve patient centred outcomes.

•

Combination portal vein embolization and hepatic lobe revascularization for total vascular inflow occlusion can allow a bloodless resection.

•

Preoperative angio-embolization should be researched in a larger patient cohort to reduce blood loss and blood transfusion

Introduction

Major liver resection in a Jehovah’s Witness presents unique clinical challenges requiring multimodal blood minimization strategies to reduce perioperative complications. We report a case where complete left hepatic lobe devascularisation was undertaken to minimize bleeding in a Jehovah’s Witness undergoing left hepatectomy.

Presentation of case

A 65-year-old male Jehovah’s Witness presented for open left hepatectomy for a large left-sided hepatocellular carcinoma involving segment IV of the liver. Three weeks prior to surgery, the patient underwent left portal vein embolization. To isolate and devascularise the left lobe, the gastroduodenal artery and left hepatic artery were then occluded with coils. The bed of the left hepatic artery was then embolised to stasis with particles. Finally, the anastomosis back to the right hepatic artery was also occluded by coils. The patient underwent uneventful surgery with an estimated blood loss of 450 mls.

Discussion

Left hepatectomy in a Jehovah’s Witness patient is feasible but requires careful planning and a multidisciplinary approach. Major liver resection represents a well defined but complex haemostatic challenge from tissue and vascular injury, further complicated by hepatic dysfunction, and activation of inflammatory, haemostatic and fibrinolytic pathways. In addition to the haemoglobin optimization strategies utilized preoperatively, the use of interventional radiology techniques to further reduce perioperative bleeding should be considered in all complex cases.

Conclusion

Combination of portal vein embolization and hepatic lobe devascularisation to produce total vascular occlusion of inflow to the left lobe radiologically allowed a near bloodless surgical field during major liver resection in a Jehovah’s Witness patient.

Does additional reconstruction of the anterolateral ligament during a primary anterior cruciate ligament reconstruction affect tibial rotational laxity - A case series

Background

The current evidence suggests that rotational stability in not restored in patients with anterior cruciate ligament (ACL) ruptures, despite reconstructive surgery. The graded pivot-shift is a useful clinical test to delineate extent of ligamentous laxity within the knee. Given its lateralised position, we hypothesized that reconstruction of the anterolateral ligament (ALL) would provide restraint to excessive internal rotation, restoring rotational stability.

Methods

10 patients with MRI confirmed diagnosis of an isolated ACL rupture were included. Patients assigned a grade-3 pivot-shift underwent dual-ligament reconstruction for the ACL and ALL (Group 2), whilst patients with an absent pivot-shift, grade-1 or grade-2 underwent single ligament reconstruction for just the ACL (Group 1). Total range of rotation (TRR) was measured using a 3D-kinematic system at 30°,60°and 90° of knee flexion. Data was collected on the pathology-free contralateral normal knee (CNK), ACL-deficient knee (ADK) and the ACL-reconstructed knee (ARK).

Results

A statistically significant pre-operative difference in TRR between the CNK and ADK was noted between Group 1 and 2 (4.04° vs. 1.53°; p < 0.05). Postoperatively, both groups achieved a TRR that was either equivalent, or surpassed values that were observed on the CNKs. The absolute and percentage reduction in TRR at 30° of knee flexion was significantly higher in Group-2 compared to Group-1 (−8.15° vs. −2.96°; p < 0.001) and (28.04% vs. 13.31%; p < 0.001) respectively.

Conclusion

Our findings are based primarily in anaesthetized patients, with kinematic values at time-zero postoperatively. Patients presenting with significant rotational instability following a primary ACL injury and assessed to have a grade-3 pivot-shift may benefit from dual-ligament reconstruction. Further research is required to assess long-term patient-centered clinical outcomes.

•

To prevent excessive rotation in the knee, a structure needs to be present away from the centre axis; at the edge of a plane, resisting rotational motion.

•

The graded pivot-shift is a useful clinical test to help delineate extent of ligamentous laxity within the knee.

•

The higher the grade of the pivot-shift in the ACL deficient knee, the greater the TRR present.

•

The ALL plays a significant role in ACL deficient knees with a grade-3 pivot shift, restoring TRR at time-zero.

•

Further research is required assessing long-term patient-centered clinical outcomes.

The efficacy of steroids for postoperative persistent inflammatory reaction in a patient with barium peritonitis: A case report

•

Residual barium in intraperitoneal cavity causes persistent inflammatory reaction.

•

Steroids are effective for persistent inflammation caused by residual barium.

•

If infectious or other inflammation origins exist, steroids should be avoided.

Introduction

Barium peritonitis is a serious and life-threatening disease requiring intensive care. Residual barium in the intraperitoneal cavity can cause persistent inflammation, postoperatively.

Presentation of case

An 80-year-old woman was admitted to our hospital because of abdominal pain and vomiting after barium meal examination. Physical and radiographic examination showed sigmoid colon perforation. Barium sulfate extravasation was noted in the intraperitoneal cavity. We diagnosed the patient with barium peritonitis, and performed Hartmann’s procedure and thorough lavage of the intraperitoneal cavity with 20-L saline. Postoperative blood examination results were not readily improved because of the residual barium in the intraperitoneal and retroperitoneal cavities. We excluded the presence of any other inflammation origin, except that from residual barium. Methylprednisolone 500 mg/body/day was administered for 3 days and the dose was gradually decreased thereafter. The white blood cell count and serum C-reactive protein levels immediately improved to normal levels.

Discussion

Barium peritonitis is associated with high mortality. Residual barium in the intraperitoneal cavity can cause chemical peritonitis, leading to granuloma formation and ileus, postoperatively. Therefore, complete removal of barium in the abdominal cavity with aggressive drainage and large quantity of saline is necessary to prevent postoperative inflammatory reaction. The use of steroids improves the persistent inflammation caused by residual barium, unless any infectious origins are present, which can worsen with steroid-use.

Conclusion

Residual barium in the intraperitoneal cavity causes persistent inflammatory reaction in patients with barium peritonitis. The use of steroids is effective for postoperative persistent inflammation due to the residual barium.

Acute onset of paraganglioma of filum terminale: A case report and surgical treatment

•

A very rare case of paraganglioma of filum terminale is described.

•

Clinical and radiological features of spinal paraganglioma are listed.

•

Surgical management of paraganglioma of filum terminale is discussed.

Introduction

Paragangliomas of filum terminale are rare benign tumors, arising from the adrenal medulla or extra-adrenal paraganglia. These lesions usually present with chronic back pain and radiculopathy and only two cases of acute neurological deficit have been reported in literature.

Presentation of case

A case with an acute paraplegia and cauda equina syndrome due to an hemorrhagic paraganglioma of the filum terminale is described. Magnetic resonance imaging showed an intradural tumor extending from L1 to L2 compressing the cauda equina, with an intralesional and intradural bleed. An emergent laminectomy with total removal of the tumor was performed allowing a post-operative partial sensory recovery. Histopathological examination diagnosed paraganglioma.

Discussion

Paragangliomas are solid, slow growing tumors arising from specialized neural crest cells, mostly occurring in the head and neck and rarely in cauda equina or filum terminale. MRI is gold standard radiological for diagnosis and follow-up of these lesions. They have no pathognomonic radiological and clinical features and are frequently misdiagnosed as other spinal lesions. No significant correlation was observed between the duration of symptoms and tumor dimension. Acute presentation is unusual and emergent surgical treatment is fondamental. The outcome is very good after complete excision and radiotherapical treatment is recommended after an incomplete resection. Conclusion: Early radiological assessment and timely surgery are mandatory to avoid progressive neurological deficits in case of acute clinical manifestation of paraganglioma of filum terminale.

A case report of venous thrombosis after kidney transplantation - We can save the graft? Time is the success factor

•

Kidney graft vein thrombosis is a rare surgical complication.

•

The reports of graft rescue are scarce.

•

The diagnosis of vascular complications should be done as early as possible.

•

The fundamental to the success is the time of diagnosis to intervention.

Introduction

Venous thrombosis is a serious surgical complication that frequently results in loss of kidney graft.

Case presentation

We report the case of a female patient recipient of a decease kidney transplant that in the tenth postoperative presented with hematuria, graft pain and oliguria. Ultrasound examination was suggestive of venous thrombosis with abnormal doppler waveform pattern and reversal of diastolic flow. She underwent emergency surgical intervention after 2 h of diagnosis. The vein thrombus was removed by perfusing the renal graft artery with 1000 ml of Euro-Collins solution. The patient evolves with recovery of renal function after 1 week of the procedure

Discussion

Similar reports of graft rescue in the vein thrombosis are scarce and that the time of diagnosis to intervention is a determining factor.

Conclusion

Rapid diagnosis of exactly 2 h combined with the early re-operation may be successful in preserving renal graft in cases of venous thrombosis.

A rare case report of bilateral choanal atresia in an adult

•

Choanal atresia is a congenital malformation of the nasal cavity characterized by the complete obliteration of the posterior choanae.

•

Adult bilateral choanal atresia is a rare entity.

•

Endoscopic transnasal choanoplasty is the criterion standard treatment.

•

The exact role of the postoperative stent and use of mitomycin C is controversial.

Introduction

Adult choanal atresia is a rare congenital malformation of the nasal cavity characterized by the complete obliteration of the posterior choanae, only ninth cases are reported in the literature, we present in our observation the tenth case of adult bilateral choanal atresia.

Presentation of case

A 18-year-old man presented at our department with complaints of nasal obstruction, nasal discharge, snoring, anosmia, and mouth breathing since childhood. Endoscopic examination and paranasal sinus tomography revealed bilateral choanal atresia. An endoscopic choanoplasty was performed. Follow-up evaluation at postoperative 12th month showed that his symptoms improved significantly and, on endoscopic examination, both choanae remained patent.

Discussion and conclusion

Adult bilateral choanal atresia is a rare entity. The revelation in adulthood of congenital bilateral atresia remains exceptional. Nasal endoscopy and preoperative computed tomography scan help in planning surgery. Endoscopic transnasal choanoplasty is the criterion standard treatment. The exact role of the postoperative stent and use of mitomycin C is controversial.

Two giant peritoneal loose bodies were simultaneously found in one patient: A case report and review of the literature

•

The giant peritoneal body with a diameter >5 cm has rarely been described in the literature.

•

We report a case of two giant loose bodies(gPLB) which are simultaneously found in one patient.

•

Two gPLB lie respectively in the peritoneal cavity and in the pelvic cavity, measuring 10.4*8.3 cm and 7.6*6.0 cm, weight 182.5 g and 98.4 g.

Introduction

Peritoneal loose body(PLB) is usually small, therefore giant Peritoneal loose body(gPLB) with a diameter >5 cm has rarely been described in the literatures. We report a case of two gPLB simultaneously found in one patient.

Presentation of case

A healthy 79-year-old man palpated himself a solid mass with alternating localizations in his peritoneal cavity 6 months ago. It was not the complaint of frequency of urinatior until he saw the doctor a week ago. Surprisingly, two oval-shaped masses were simultaneously discovered by computed tomography (CT). One was in the peritoneal cavity, measuring 10.4*8.3 cm, weight 182.5 g, another was in the pelvic cavity, measuring 7.6*6.0 cm, weight 98.4 g. The case was confirmed by surgical operation.

Discussion

The gPLB is considered as uncommon. Two gPLB which were simultaneously discovered in one patient have never been reported in the literatures. The small PLB is usually asmptomatic, occasionally, the gPLB can cause symptoms with acute retention of urine or intestinal obstruction. It is crucial to diagnosis the peritoneal loose body.

Conclusion

Two gPLB that situated in one patient are rare findings. Clinically, if a solid mass alternating localizations cound be palpated in the Peritoneal cavity, CT or other imaging shows an oval-shaped mass with calcifications in the central region, PLB should be considered. Surgical removal is recommended for the patient with acute retention of urine or intestinal obstruction or unclear diagnosis.

Spontaneous temporomandibular joint herniation into the external auditory canal through a patent foramen of Huschke: A case report

Temporomandibular joint herniation (TMJ) can be caused by inflammation, trauma, tumor, or otologic procedures. However, spontaneous TMJ herniation can also occur as a result of a congenital bony defect in the external auditory canal (EAC), known as the patent foramen of Huschke (PFH), and occurs in 0.4% of the population. Herein, the authors present a case of spontaneous TMJ herniation through the PFH with clicking tinnitus. The patient underwent the surgical repair of bony defect in the EAC with placement of titanium mesh, and the symptom disappeared after surgery. They also review the relevant literature regarding this disease and discuss its embryologic development and clinical significance.

•

FH is an anatomical separator between the EAC and TMJ.

•

PHF develops through an imperfect serial ossification and fusion of the tympanic bone.

•

PHF can result in the TMJ herrniation due to persistent dehiscence of the bony wall of the EAC.

•

Awareness of TMJ herniation through PFH can be helpful for the diagnosis of a protruding EAC mass.

Perforation of the cecum resulting from a closed-loop obstruction in a patient with an adenocarcinoma of the sigmoid colon: a case report

INTRODUCTION

Bowel obstruction is one of the principal non-traumatic causes of general surgery emergencies, both in Brazil and worldwide. This condition can be classified according to the degree (complete or incomplete), clinical course (acute or chronic) or nature (mechanical, vascular or functional) of the obstruction.

CASE REPORT

ESS, a 62-year old Brazilian woman from Rio de Janeiro, was admitted to the emergency department complaining of constipation of two weeks' duration. She also reported fever and fecal vomiting in the preceding two days.A syndromic diagnosis of bowel obstruction was made, and the patient was referred for CT. The sigmoid colon, descending colon, transverse colon, ascending colon, the cecum and the terminal ileum were resected.

DISCUSSION

Colorectal cancer is one of the most common forms of cancer in the elderly, perforation of the cecum occurs in only around 3-8% of cases. 15 This can be explained by the fact that patients with colorectal cancer present with wasting syndrome before the bowel lumen becomes completely obstructed. In a literature review conducted for this study, only one publication was found in which rupture of the cecum was associated with colorectal cancer.

CONCLUSION

Although rupture of the cecum associated with colorectal cancer is a rare pathology, it constitutes a surgical emergency; therefore, all surgeons should be aware of the possibility.

Mandibular metastasis revealed papillary thyroid carcinoma: Rare case

•

Mandibular metastasis of thyroid cancer are rare and the initial metastases revealing papillary carcinoma are exceptional.

•

Few cases are reported in the literature.

•

Due to their rarities and relative lack of data on their management, there is no clearly defined processing algorithm.

Introduction

Papillary carcinoma is the most frequent differentiated malignant thyroid neoplasm, Metastasis occurs frequently in regional lymph nodes and mandibular metastasis are very rare and most are secondary to follicular carcinomas due to their blood diffusion, The mandibular metastasis of papillary carcinoma is exceptional.

Case report

We report a rare case of mandibular metastasis revealing papillary thyroid carcinoma in a 52-year-old patient, with a review of the literature on clinical features, radiological aspect, and treatment options.

Discussion conclusion

Mandibular metastasis of thyroid cancer are rare and the initial metastases revealing papillary carcinoma are exceptional, few cases are reported in the literature, and due to their rarities and relative lack of data on their management, There is no clearly defined processing algorithm.

Apocrine sweat gland adenocarcinoma: A rare case report and review

•

Apocrine Sweet Gland Adenocarcinoma is a very uncommon cancer that can cause structural deformities by metabolic disorder (paraneoplastic syndrome).

•

That’s the first case related on Brazil.

•

This case contributes to the best choice of the exams required for detection of this rare cancer (there is no consensus in the literature by the limited number of cases).

Introduction

Primary apocrine sweat gland carcinoma (PASGC) is an extremely rare neoplasia whose management and treatment are still evolving. The only curative therapy is wide local excision. Many patients have metastasis at the time of the diagnosis, mainly because this neoplasm has been misdiagnosed as some benign skin lesions.

Presentation of case

We herein report a case of a 72-year-old-man with PASGC affecting the axilla and regional lymph nodes that underwent surgical resection and lymphadenectomy at our Institution. This is the first case reported in Brazil.

Discussion

Our observation suggests just a MRI as necessary to study tumoral limits and lymph nodes and a full surgical excision with free margins is decisive for success.

Conclusion

Despite the PASGC be a rare cancer and require expensive tests, knowledge of this disease is critical to reduce costs in medical services without availability of investment.

A common cancer in an uncommon location: A case report of squamous cell carcinoma of the nipple

•

Squamous cell cancer of the nipple is rare but should be included in the differential diagnoses of pathologies of the nipple.

•

Patients with former history of skin cancer may present with skin cancers in unusual locations.

•

Thorough clinical and diagnostic evaluations are mandatory to rule out pathologiesand direct management decisions.

Introduction

Cutaneous squamous cell carcinoma (SCC) is common however SCC is rarely seen on the nipple, with only ten cases of SCC of the nipple in literature (American Cancer Society, 2015; Scotto et al., 1983; Pendse and O’Connor, 2015; Loveland-Jones et al., 2010; Brookes et al., 2005; Sofos et al., 2013; King and Kremer, 2012; Venkataseshan et al., 1994; Hosaka et al., 2011) [1–9].

Case

An 80 year old female presenting with a chief complaint of an abnormal lesion on the medial portion of her right nipple areola complex. A biopsy showed well-differentiated squamous cell carcinoma. She had an extensive history of prolonged sun exposure predisposing her to cutaneous SCC however none to the breast region. Her mammogram was negative for any invasive disease so a wide local excision was performed with no complications.

Discussion

Due to the rarity of SCC of the breast or nipple, a biopsy is necessary to rule out other more common types of malignancies on the nipple that present with a similar physical appearance. We then examined the many different risk factors for SCC and the different methods for treating SCC whether it is cutaneous or of the nipple or breast. We also discussed the treatment of Paget’s disease of the breast (PDB) as SCC of the nipple or breast can be mistaken for PDB.

Conclusion

The cases of SCC of the Nipple demonstrate the importance of recognizing changes of the skin even in locations not typically associated with SCC (American Cancer Society, 2015; Scotto et al., 1983; Pendse and O’Connor, 2015; Loveland-Jones et al., 2010; Brookes et al., 2005; Sofos et al., 2013; King and Kremer, 2012; Venkataseshan et al., 1994; Hosaka et al., 2011) [1–9]. We concluded with a future suggestion of investigating possible risk factors specific to SCC of the breast or nipple.

Small, spontaneously ruptured gastrointestinal stromal tumor in the small intestine causing hemoperitoneum: A case report

•

Hemoperitoneum is a rare and potentially life-threatening complication of GISTs.

•

Even small GISTs in the small intestine can rupture and cause hemoperitoneum.

•

Because of their high vascularity, ruptured GISTs can cause massive hemoperitoneum.

Introduction

Gastrointestinal stromal tumors (GISTs) are clinically asymptomatic until they reach a significant size; therefore, GISTs that are 2 cm or less are typically asymptomatic. Patients with symptomatic GISTs typically present with abdominal pain, gastrointestinal bleeding, or a palpable mass but rarely present with hemoperitoneum.

Presentation of case

A 72-year-old Japanese man presented to us with acute onset abdominal pain. Physical examination showed peritoneal irritation in the lower abdomen. Findings of abdominal computed tomography were suggestive of hemoperitoneum; therefore, urgent surgery was performed. Approximately 1500 ml of blood in the abdominal cavity was removed. A small, ruptured mass was found in the middle of the small intestine, and partial resection of the small intestine, including the mass, was performed. The resected tumor was 2 cm in size and exhibited an exophytic growth pattern. Immunohistochemical staining revealed that the tumor was positive for KIT and CD34; therefore, a final diagnosis of GIST was made. Treatment with imatinib at 400 mg per day was started from postoperative month 1. The patient is doing well without recurrence 5 months after surgery.

Discussion

Even small GISTs in the small intestine can spontaneously rupture and cause hemoperitoneum. Moreover, when a patient presents with sudden abdominal pain and hemoperitoneum without an evident mass on imaging, clinicians should be aware of the possibility of bleeding from a small GIST in the small intestine.

Conclusion

We present an extremely rare case of a patient with a small, spontaneously ruptured GIST in the small intestine, resulting in hemoperitoneum.

Bilateral peritonsillar abscess: A case report and pertinent literature review

INTRODUCTION

The peritonsillar space is defined as the area between the palatine tonsillar capsule medially and the superior pharyngeal constrictor muscle laterally. Unilateral peritonsillar abscess (PTA) is more common than the bilateral condition. To the best of our knowledge, only 13 cases of bilateral PTA have been reported worldwide; this is the first case reported from Saudi Arabia.

PRESENTATION OF CASE

We present a case involving a 16-year-old boy who presented to the emergency department with a5-day history of sore throat, dysphagia, trismus, drooling, and a muffled "hot-potato" voice, but with no symptoms of airway compromise. After several examinations, we diagnosed bilateral PTA. We performed an incision and drained the pus from both sides, which was positive for Streptococcus pyogenes. Postoperatively, the patient improved dramatically, and tonsillectomy was scheduled for 6 weeks later.

DISCUSSION

The difficulty in diagnosing bilateral PTA stems from the fact that it does not present with the usual clinical characteristics as unilateral PTA. These symptoms include asymmetry of the tonsils and palate, deviation of the uvula, and unilateral otalgia. As these cases carry the risk of impending airway compromise, we recommend airway management as the first step in treating such cases.

CONCLUSION

Based on our case and literature review, we recommend airway management as the first step, followed by further examinations, especially contrast-enhanced computed tomography, in cases of bilateral PTA. This condition lacks the hallmark of unilateral disease and may mimic many conditions, which will have different management approaches.

Post traumatic inferior vena cava thrombosis: A case report and review of literature

•

This serious post traumatic entity with high risk of pulmonary embolism is not well described and only few cases have been published.

•

Bleeding risk due to the frequent association of anticoagulation and trauma is the main difficulty encountered by health care providers.

•

Our manuscript tried to highlight diagnostic aspects, therapeutic options and outcome of post traumatic inferior vena cava thrombosis.

Introduction

Post traumatic inferior vena cava (IVC) thrombosis is a rare and not well described entity with nonspecific clinical presentation. It remains a therapeutic challenge in traumatic context because of haemorrhagic risk due to anticoagulation.

Presentation of case

We report a case of IVC thrombosis in an 18 year-old man who presented with liver injury following a traffic crash. The thrombosis was incidentally diagnosed on admission by computed tomography. The patient was managed conservatively without anticoagulation initially considering the increasing haemorrhagic risk. IVC filter placing was not possible because of the unusual localization of the thrombus. Unfractionated heparin was started on the third day after CT scan control showing stability of hepatic lesions with occurrence of a pulmonary embolism. The final outcome was good.

Discussion

The management of post traumatic IVC thrombosis is not well described. Medical approach consists in conservative management with anticoagulation which requires the absence of active bleeding lesions. Surgical treatment is commonly based on thrombectomy under extracorporeal circulation. Interventional vascular techniques have become an important alternative approach for the treatment of many vessel lesions. Their main advantages are the relative ease and speed with which they can be performed.

Conclusion

Post traumatic IVC thrombosis is a rare condition. Its management is not well defined. Early anticoagulation should be discussed on a case-by-case basis. Other alternatives such IVC filter or surgical thrombectomy may be used when the bleeding risk is increased. The most serious risk is pulmonary embolism. Outcome can be favorable even with non surgical approaches.

Capitellar fracture with bony avulsion of the lateral collateral ligament in a child: Case report

INTRODUCTION

Isolated capitellar fracture is a rare injury accounting for 1% of all elbow fractures Bryan and Morrey (1985) and Poynton et al. (1998). In children, a fall on an outstretched hand, before the fusion of the epiphysis, usually leads to lateral condyle physeal fractures. Very few cases of capitellar fractures in the paediatric population have been reported.

PRESENTATION OF CASE

Our patient, a 9-year-old girl presented with a capitellar fracture and lateral collateral ligament (LCL) avulsion of her left elbow. A type IV capitellar fracture, indicated by the double arc sign on the radiogram, was confirmed with 3-dimensional computed tomography. The patient underwent open reduction through a lateral approach and fixation with 2 Herbert's screws. The lateral collateral ligament (LCL) avulsion was repaired with 2 suture anchors. Early mobilization and rehabilitation were started soon after the surgery. Follow-up radiography showed union of the fracture with no signs of osteonecrosis.

DISCUSSION

Capitellum fracture in children is easily overlooked due to its rarity. And hereby, meticulous history, clinical examination and proper radiological views with high index of suspicion is crucial in order diagnose these injuries. Our patient had type IV capitellar fracture with lateral collateral ligament avulsion. Principles of management of these intra articular fractures include accurate reduction, stable fixation and early mobilization. We used an extensile lateral approach to expose, reduce and fix the fracture. LCL avulsion was fixed with 2 suture anchors.

CONCLUSION

Capitellum fractures are rare injuries in children. Careful evaluation and proper stable fixation are the cornerstones of good functional results.

A case of traumatic cardiopulmonary arrest with good neurological outcome predicted by amplitude-integrated electroencephalogram

INTRODUCTION

Traumatic cardiopulmonary arrest has a very high mortality, and survival of patients with this condition without neurological disability is rare.

PRESENTATION OF CASE

We herein report a case of traumatic cardiopulmonary arrest secondary to accidental amputation of the left lower leg that was successfully treated without any higher brain dysfunction. Although the long duration of cardiopulmonary arrest in this patient suggested hypoxic ischemic encephalopathy, amplitude-integrated electroencephalogram showed normal findings.

DISCUSSION

This system may help intensivists evaluate the neurological conditions of patients with suspected hypoxic ischemic encephalopathy in the early stage of the clinical course and may assist in guiding therapeutic interventions.

CONCLUSION

Our case supports the usefulness of neurological monitoring using amplitude-integrated electroencephalogram.

A rare case of subacute appendicitis, actinomycosis as the final pathology reports: A case report and literature review

•

Actinomycosis represents only the 0.02% of causes of acute apendicitis.

•

We present the first case of appendiceal actinomycosis reported in México.

•

As to our knowledge, this is the first case in the literature with appendiceal actinomycosis without been perforated.

Introduction

Acute appendicitis is the most common indication for an emergency abdominal surgery in the world, with a lifetime incidence of around 10%. Actinomycetes are the etiology of appendicitis in only 0.02%–0.06%, having as the final pathology report a chronic inflammatory response; less than 10% of the cases are diagnosed before surgery. Here, we present the case of a subacute appendicitis secondary to actinomycosis.

Case report

A 39-year-old male presented with a twelve-day evolution of intermittent abdominal pain in the right lower quadrant, treated at the beginning with ciprofloxacin and urinary analgesic. The day of the admission he referred intense abdominal pain with nausea. An open appendectomy was preformed, finding a tumor-like edematous appendix with a diameter of approximately 2.5 cm.

Discussion

Actinomyces are part of the typical flora of the oral cavity, gastrointestinal tract and vagina. The predominant form of human disease is A. Israelii, it requires an injury to the normal mucosa to penetrate and cause disease. Abdominal actinomycosis involves the appendix and caecum in 66% of the presentations, of these, perforated appendicitis is the stimulus in 75% of the cases. A combination of antibiotic therapy and operative treatment resolves actinomycosis in 90% of cases.

Conclusion

Abdominal actinomycosis is an uncommon disease been the common presentation a perforated appendicitis, here we present a less common presentation of it with a non-perforated appendix.

Spontaneous submental hematoma, a pseudo-Ludwig's phenomenon in 101-year-old patient: case report and literature review

•

Submental hematoma is a rare entity and physician should rule out other potential deferential diagnoses including angioedema, arteriovenous malformation (AVM), pseudoaneurysm, or cavernous hemangioma.

•

It can occur in any age group even as old as 101 year.

•

Always act proactive to secure the airway, preferably conservatively and electively early in presentation to avoid complications with acute/emergent interventions.

Objective

Submental hematoma or pseudo-Ludwig’s phenomenon, is a rare entity seen in anticoagulated patients and can precipitate upper airway obstruction. Our objective is to present a rare case of spontaneous submental hematoma due to poorly controlled hypertension in elderly patient and to perform a literature review.

Case report

101-year-old female presented to emergency room with sudden painful swelling in the floor of mouth and slurred speech. Not on anticoagulation and no history of trauma or known allergies. Physical examination and flexible laryngoscope revealed normal temperature and blood pressure of 190/100, submental/floor of mouth swelling that was tense to palpation, ecchymotic/hemorrhagic and extend to the tip of the tongue suggestive of recent submucosal bleeding and mild swelling at the base of tongue as well as small hemorrhagic vallecular cyst. CT scan ruled out AVM and pseudoaneurysm of lingual artery. She was diagnosed with spontaneous submental hematoma (SSH) probably due to the rupture of atherosclerotic vessels supplying the musculature related to the space due to uncontrolled sever hypertension. She was treated conservatively by electively securing the airway and the swelling resolved in 3 days. She got extubated and subsequently discharged home.

Methods

Systematic literature review was conducted and revealed only 5 cases since 2002 reported with this rare subgroup of spontaneous submental hematoma not related to anticoagulation. This case report has been reported in line with the SCARE criteria [1].

Results

4 cases were results of uncontrolled hypertension whereas one case was seen in cirrhotic liver patient. One patient was managed with surgical evacuation of the hematoma were in the others conservative management initiated but failed. Of those 4, 2 required an emergent airway procedure.

Conclusion

Spontaneous submental hematoma (SSH) is a clinical diagnosis and conservative management is successful in reducing the amount of swelling once the causative factors have been corrected/controlled. The main goal is to electively secure the airway and as in all emergent airway management the team must include members capable of a surgical airway.

Echinococcosis mimicking liver malignancy: A case report

INTRODUCTION

Human Alveolar Echinococcosis - Alveolar Hydatid disease (AE) is an omitted zoonotic infection presenting with focal liver lesions. Cause of AE is a larval stage of Echinococcus multilocularis tapeworms.

CASE PRESENTATION

In this report an extraordinary case of a 38 year-old female examined due to 2 liver tumors and 2 pulmonary nodules is described. The patient underwent pulmonary and liver surgery for suspected advanced cholangiocellular carcinoma and surprisingly AE was found.

DISCUSSION

Distinguishing intrahepatic AE from other focal liver lesion can be complicated and in many cases is diagnosed incorrectly as intrahepatic cholangiocarcinoma or other liver malignancy.

CONCLUSION

AE is a rare but potentially fatal parasitic infection primarily affecting liver, although it can metastasise to lung, brain and other organs. The diagnosis and treatment can be difficult and clinical misinterpretation as malignancy is not rare. The principal treatment of AE is surgery accompanied with chemotherapy.

Endometrial adenocarcinoma recurrence presenting with tibial metastasis: Report of a case

•

Endometrial adenocarcinoma recurrence in tibia after 2 years of total abdominal hysterectomy and bilateral salpingo-oophorectomy.

•

Endometrial adenocarcinoma metastasis to skeletal system is extremely rare and mostly have been reported to be in axial skeleton.

•

Fresh frozen femoral allograft was used after wide resection for the metastatic adenocancer area of the tibia and provided the bone union.

•

Wide resection and reconstruction with an allograft might be an option to increase survival and possible cure of the patient as seen in our case.

Introduction

Metastatic bone disease at extremities is mostly associated with lung, liver, prostat, thyriod or breast malignancies. There for surgeons generally tends to seek for a primary tumor originating from these organs. Herein a case of endometrial adenocarcinoma recurrence that presented with symptoms of tibial pain is described.

Presentation of case

59 year-old woman was admitted to our orthopaedic oncology unit with pain, swelling and tenderness at right cruris for two weeks without any trauma history. Her medical history revealed that she had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. During follow-ups no recurrence had been detected. Initial X-rays of the right tibia showed a lytic and expansile mass located at the shaft of the tibia suggesting metastasis. A wide resection of the lesion with clear margins was performed two weeks after first admittance. Resected area was replaced by fresh frozen femoral shaft allograft. At postoperative 17th month. X-rays obtained at last follow-up demostrated full healing and integration of allograft.

Discussion

Endometrial adenocarcinoma is a disease of postmenapousal women with 95% of the cases occurring after the age of 40 years. Patients with advanced or recurrent endometrial cancer often have distant metastases found within the lymph nodes, liver, and/or lung.

Conclusion

Recurrence of endometrial cancer as a solitary bone lesion is a rare situation. Wide resection and reconstruction with an allograft or an intercalar prosthesis might be an option to increase survival and possible cure of the patient.

A rare case report of vulvar necrotizing fasciitis in a healthy patient

•

NF should be considered regardless of atypical location and lack of associations.

•

Clinical findings are important indicators when diagnosing NF.

•

Immediate surgical intervention should be performed upon suspicion of NF.

Introduction

Necrotizing fasciitis (NF), a necrotizing infection of the soft tissue, is a medical emergency usually occurring in the lower extremities and abdominal regions and often difficult to diagnose promptly.

Presentation of case

This case report looks at one atypical presentation of NF with the unusual location of the vulva and no known associated comorbidities or risk factors.

Discussion

Diagnosing this patient was particularly difficult due to the inconsistent clinical, laboratory and imaging findings. The CT scans and WBC count were indicative of NF, but the LRINEC score was not high enough to make the diagnosis of NF. As a result, we relied on the hemodynamic instability and clinical findings of the physical exam to be strong indicators of NF, and acted on that indication.

Conclusion

Acting quickly on the hemodynamic findings and suspicion as opposed to waiting for a confirmed diagnosis resulted in a good prognosis since immediate surgical debridement is imperative to surviving this acute condition. Despite major advancements in the imaging modalities and the introduction of a laboratory score, our case suggests that the diagnosis still heavily relies on clinical findings, such as hemodynamic instability. Furthermore, our case suggests that NF should be included in the differential regardless of atypical location and lack of common clinical associations.

Charcot arthropathy of the knee after unsuccessful spinal stenosis surgery: A case report

•

We report here a case of a 62 years old patient with charcot arthropathy at her left knee developed one year after spinal stenosis surgery.

•

The patient’s knee joint was already beyond the fragmentation and coalescence stages at the moment of physical examination.

•

Unsuccessful spinal surgery affected polyneuropathy and migrated the level of the sensorineural loss proximally.

•

Elevated level of sensorineural loss resulted in Charcot knee joint in a short period of time.

Introduction

Charcot arthropathy was first described in 1868 by Jean Martin Charcot as a progressive and destructive joint disease. Diabetes, polyneuropathy, syphilis, syrengomyelia and chronic alcoholism are the main causes of the disease. In this study we present a Charcot arthropathy of the knee seen after unsuccessful spinal stenosis surgery.

Presentation of case

We report here a case of 62 years old patient with Charcot arthropathy at her left knee developed one year after spinal stenosis surgery. The patient’s knee joint was already beyond the fragmentation and coalescence stages at the moment of physical examination. Patient had already been treated for Charcot foot four years before spinal surgery. Because of an unsuccessful spinal surgery, proximal migration of the level of the sensorineural loss negatively affected the polyneuropathy and eventually resulted in Charcot knee joint in a short period of time.

Discussion

However, the etiology of the neuropathic arthropathy hasn’t been well described yet, it is usually seen at patients with diabetes mellitus as a long-term complication with or without polyneuropathy. In addition to the spinal canal pathologies, it is reported that Charcot arthropathy can be seen even after spinal anesthesia procedures.

Conclusion

In conclusion, spinal procedures should be applied with extra caution on the patients with polyneuropathy or any neuropathic arthropathy. It should be remembered that it is possible to encounter unexpected complications such as proximally migration of the level of sensorineural loss and progression of the actual disease after spinal procedures of these patients.

Management options in the treatment of femoral pseudoaneurysms secondary to intravenous drug abuse: A case series

•

Infected femoral pseudoaneurysms are a common presentation in intravenous drug users with little consensus as to their optimum management.

•

Excision and ligation of the femoral artery without revascularisation is the most common operative intervention.

•

With the identification and optimisation of suitable patients, revascularisation can be performed in the emergency setting.

•

Current endovascular approaches appear to be used only as a bridge to a future definitive revascularisation procedure.

•

Ligation of the common femoral artery without revascularisation is both safe and effective as most patients will avoid critical ischaemia.

Introduction

Infected femoral pseudoaneurysms are a common presentation in intravenous drug users with little consensus as to the optimum management of these patients. Whilst emergency revascularisation options are available, excision and ligation of the femoral artery remains the most common operative intervention but risks leaving the patient with critical ischaemia or intermittent claudication. This case series reviewed the outcomes of 4 patients who underwent excision-ligation without revascularisation of an infected femoral pseudoaneurysm at a district general hospital.

Presentation

Four patients (2 male, 2 female) with infected femoral pseudoaneurysms presented via the emergency room with diagnosis confirmed with contrast cross-sectional imaging. All patients underwent emergency excision and ligation of the pseudoaneurysm without revascularisation. One patient returned to theatre with critical ischaemia necessitating a hindquarter amputation. The remaining 3 patients were discharged without claudication symptoms.

Conclusion

With the identification of suitable patients and pre-operative optimisation, revascularisation can be performed in the emergency setting with an extra-anatomical bypass appearing to confer the best results. Currently endovascular approaches appear to be used only as a bridge to a future definitive revascularisation procedure, however, there are several case reports documenting successful outcomes when using a stent graft alongside a prolonged course of antibiotics. For the majority of patients, excision-ligation without revascularisation is both safe and effective as few are left with symptoms of limb ischaemia.

Giant true aneurysm of superficial femoral artery in patient with multiple atherosclerotic aneurysms: A case report

True atherosclerotic aneurysms of superficial femoral artery (SFA) are rare and often associated with other peripheral or aortic aneurysms. We report the case of a 84-year-old patient presenting a giant degenerative ruptured aneurysm of the superficial femoral artery. The patient underwent successful aneurysm resection and bypass grafting, with a satisfying long-term follow-up and patency of the graft. The patient was also operated one year before, for a ruptured aneurysm of the abdominal aorta. This case report is rare, because we described a case of patient with multiple atherosclerotic aneurysms, who present, for the second time, a life threating ruptured aneurysm. In this report, we see extreme and rapid evolution of SFA Aneurysm before being symptomatic. Degenerative aneurysms of the lower extremity most commonly involve the popliteal artery, while they are rarely detected in the femoral region (Leon et al., 2008). In this region, aneurysms most frequently involve the common femoral artery (CFA), whereas true aneurysms of the superficial femoral artery (SFA) represent only 15% to 25% of femoral arterial aneurysms [1-5]. Degenerative aneurysms of the SFA display peculiar characteristics (in terms of clinical onset, diagnostic timing, and clinical behavior) so that they differ from other peripheral aneurysms. Because the relative rarity of this location, our case report can be useful to participate to increase the number of reported cases, and define the therapeutic approach for this rare location.

Pericardial effusion as a rare complication of a perforated appendicitis

Introduction

Whilst pericardial effusion is a known complication of abdominal pathology, it is rarely reported following ruptured appendicitis and even more rarely requires drainage in that situation. This work has been reported in line with the SCARE criteria (Agha et al., 2016).

Presentation of case

We report a 14-year-old male who developed extensive right hepatorenal and right paracolic abscesses, bilateral pleural effusions and a large pericardial effusion following laparoscopic appendicectomy. Due to the size of the effusion, thoracoscopic pericardotomy was required.

Discussion

Pericardial effusion is a very rare complication of advanced appendicitis despite a demonstrable connection between the retroperitoneum and the mediastinum. Only two cases were reported in our literature search. There is no consensus as to whether percutaneous drainage or pericardiotomy is the treatment of choice.

Conclusion

The report is presented as a reminder of a rare complication of a common general surgical condition.

Giant hepatocellular carcinoma with bone metastasis in a young adult, emerged from pigmented adenoma with beta-Catenin activation: A case report

INTRODUCTION

Hepatocellular carcinomas (HCC) that are very large in size are a very rare finding in young adult. The malignant transformation of a pigmented hepatocellular adenoma (HCA) with beta-Catenin activation is a possible cause for appearance of HCC.

PRESENTATION OF CASE

We present the case of a 33-year-old male with a huge HCC with bone metastasis, emerged from pigmented HCA with beta-Catenin activation. As a two-stage surgical procedure, a left hepatectomy followed by a partial rib resection was performed.

DISCUSSION

Giant hepatocellular carcinomas mostly develop in non-cirrhotic livers and at time of diagnosis an extrahepatic spread occurs in up to 15%. In the present case, the progression from a benign HCA to malignant HCC was documented, as a unique finding. Surgical resection is the only curative treatment and was successfully performed in this case.

CONCLUSION

Hepatobiliary surgery with resection of metastases is the treatment with best long-term survival for patients with huge HCC. Molecular characterization as well as pigmentation analysis is useful tools for risk assessment of HCA.

Saving from unnecessary pancreaticoduodenectomy. Brunner's gland hamartoma: Case report on a rare duodenal lesion and exhaustive literature review

INTRODUCTION

Brunner's gland hamartoma (BGH) is an infrequently encountered, benign, polypoid proliferation of Brunner's glands. Usually these lesions are asymptomatic, just only occasionally presenting with duodenal obstruction or bleeding signs and mimicking a tumoral lesion.

CASE PRESENTATION

A 72-year-old male, referred for recurrent vomiting and epigastralgia, was investigated and all preoperative findings were suggestive of a tumour of the duodenum. During the scheduled pancreaticoduodenectomy a mass, resultant to a polyp, was palpatory felt inside the duodenum and then successfully and completely resected through a duodenotomy avoiding surgical overtreatment and connected postoperative morbidities. Histological analysis showed hyperplasia of Brunner's glands correspondent to a Brunner's gland hamartoma. BGH was undiagnosed before surgery, due to its particular sub-mucosal growth simulating an expanding process starting from the duodenum, and secondly due to unsuccessful biopsies performed during endoscopic procedure.

CONCLUSION

BGH is a rare lesion featuring, when symptomatic, obstructive or bleeding symptoms. Surgical treatment represents the gold standard approach in case of lesions that are technically impossible to remove endoscopically or in case of an undiagnosed lesion. Herein, we report a case of a patient presenting with a duodenal lesion mimicking, in all preoperative findings, a tumour of the duodenum. Duodenotomy and resection of the BGH provided a definitive cure avoiding surgical overtreatment. An intraoperative deep analysis of all surgical cases still remain crucial for a right therapeutic choice even in a new era for surgical technology. For similar intraoperative findings we recommend this technique.

Congenital unilateral diaphragmatic eventration in an adult: A rare case presentation

We present a rare case of 32year old female with congenital diaphragmatic eventeration female presenting in an adult. She had symptoms of intermittent dyspnea and occasional epigastric discomfort. Patient had no previous history of trauma. Physical examination showed bowel sound involving the left hemithorax. Imaging modalities confirmed the diagnosis of a congenital left diaphragmatic eventeration. Patient underwent plication of the diaphragm using the abdominal approach. Intra-operatively, the left diaphragm was attenuated. Plication was done with 1st layer of imbricating silk heavy sutures buttressed by a second layer of interrupted absorbable sutures. She post-operatively had atelectasis on the left lung. Incentive spirometry and deep breathing exercises were started with resolution of the atelectasis after 1 week post-operatively. Patient had an unremarkable post-operative stay with resolution of symptoms. There are reports that diaphragmatic eventration diagnosed even as late 70 years old, highlighting the dogma that this is an asymptomatic disorder does not need all the time surgical therapy. But we still recommend surgical therapy as soon as diagnosis is confirmed. In this patient, there was no recurrence of symptoms after a follow-up of 2 years. Whether surgery indeed improved lung functions in these vastly asymptomatic patients, these questions could be an active area of research in the long term outcomes of these patients.

Multi-sited hydatid cystic disease with muscular involvement in a young female: A case report from Syria

•

Musculoskeletal involvement with hydatid cystic disease accounts for less than 5% of all cases.

•

This low incidence is related to the filtering function of the liver and lungs.

•

Surgery is the optimal treatment of hydatid disease.

Introduction

Hydatidosis is a unique disease caused by a tapeworm called Echinococcus granulosus. Musculoskeletal involvement with hydatid cystic disease accounts for less than 5% of all cases. The main purpose of this study is to present a case of multi-sited hydatid cystic disease and how to manage it.

Presentation of case

Here we present a case of 14-year-old girl complained of a gradually enlarging mass on her left shoulder with a final diagnosis of triple-sited hydatid cystic disease including the right lung, the left trapezius muscle and the liver.

Discussion

The diagnosis was made by non invasive radiological procedures (CT scan and MRI). The management consisted of aspiration and reinjection of hypertonic solution to the lung cyst followed by complete surgical resection, enucleation of the muscular lesion and conservative management of the liver lesion. After Three months of follow up there was no recurrence at the sites of operation and the liver cyst reduced in size.

Conclusion

Multi-sited hydatid cysts could be treated through one stage surgery followed by chemotherapy with benzimidazoles.

A unique presentation of renal cell transformation into renal cell carcinoma in subcutaneous fatty tissue post twenty year old healing gun-shot wound: A case report

•

An RCC presenting as a result of malignant transformation of remnant renal cells.

•

At a site where twenty years ago the patient had sustained a gunshot wound.

•

He underwent several surgeries, including a nephrectomy for that gunshot trauma.

•

The case is unique in its time course, the preceding events, & no primary lesions.

•

Its unheard-of malignant transformation of seemingly non-functional cells.

Introduction

Renal cell carcinoma (RCC) is the most common malignancy in the genitourinary tract, and is among the 10 most common cancers in both males and females.

Presentation of case

We report a case of a 61-year-old male who presented with a cutaneous lesion on his left back side at a site where he had undergone several surgeries – including Left nephrectomy – twenty years ago for a gun-shot wound he sustained which penetrated his abdomen.

Discussion

At that time pathology reports turned out to be normal, specially left kidney pathology report which was negative for any malignancy. Twenty years later, patient presented with a clear fluctuating painless cutaneous mass of 1–2 cm on his left back side, which grew gradually over time. Histopathologically, the incisional biopsy showed trabecular & papillary clear cells with prominent vascularity and hemosiderin deposition in the stroma, consistent with a malignant Renal cell Carcinoma (RCC). Immunohistochemically, it stained positive for Vimentin, CD10, PAX-8. Labs revealed positive renal cell carcinoma antibody. CT scans, urine tests, and bone scans failed to reveal the site of the primary lesion. Furthermore, the patient reports minimal constitutional symptoms and is grossly well.

Conclusion

The authors have reported an interesting case of an RCC presenting in a healed gun-shot wound in a previously nephrectomized patient. To the best of authors’ knowledge, such a case hasn’t been reported in the literature before, with it being unique in its time course, preceding events, and absence of primary lesions.

Intestinal Obstruction Induced by Peach Stone in Stenosis of Sigmoid Colon by adenocarcinoma: A case report and literature review

Introduction

Intestinal obstruction is the second among the most frequent acute abdominal conditions of the non-traumatic surgical pathologies. It is Found in 20% of patients admitted to the emergency care services with acute abdominal pain. It often results in high morbidity and mortality.

Presentation of case

We report a case of a foreign body resulting in a colon obstruction, concomitant with the diagnosis of a sigmoid cancer in a 47-year-old female.

Discussion

There are only a few cases of Intestinal Obstruction Induced by Peach Stone in Stenosis of Sigmoid Colon by Adenocarcinoma reported in the world literature. Due to late diagnosis It has a high mortality rate. Vomiting and emesis, abdominal distention, dysphagia, colicky abdominal pain, failure to pass flatus and anorexia are clinical findings. The immediate treatment is importance for patient survival.

Conclusion

Intestinal obstructions and perforations are rare conditions caused by the ingestion of foreign bodies. These conditions must be taken into consideration especially owing to differing diagnoses and previous pathologies concomitant with the ingestion of objects such as those described in the foregoing adenocarcinoma case.

•

Intestinal obstructions are rare conditions caused by the ingestion of foreign bodies.

•

Intestinal obstruction is the second among the most frequent acute abdominal conditions.

•

There are only few cases of Intestinal Obstruction Induced by Peach Stone in Stenosis by Adenocarcinoma reported in the world literature.

•

Colonoscopy should be performed every 10 years from the age of 50.

Intraoperative dislocation of the trial bipolar cup into the pelvis during bipolar hip arthroplasty - A case report

INTRODUCTION

Bipolar hip arthroplasty is a good option for treating femoral neck fractures, although some contraindications have been indicated. We report a case of intraoperative dislocation of the trial bipolar cup into the pelvis during bipolar hip arthroplasty.

CASE PRESENTATION

A 74-year-old woman underwent bipolar hip arthroplasty for a femoral neck fracture (AO31-B2). She was placed in a lateral decubitus position, and a direct lateral approach was used. During intraoperative trial reduction, the trial bipolar cup became disengaged and dislocated into the anterior space of hip joint. Several attempts to retrieve it failed. The permanent femoral component was inserted, and the wound was closed. The patient was repositioned supine to allow an ilioinguinal approach, and the component was easily removed. She had an uneventful, good recovery.

DISCUSSION

Several cases of intraoperative dislocation of the femoral trial head during total hip arthroplasty have been reported, this is the first report of dislocation of a bipolar trial cup. A previous report described difficulty retrieving a trial cup.

CONCLUSION

We easily removed our trial cup using another approach. It is vital to plan systematically for this frustrating complication.

Epidermoid cyst of the spleen, a case report

•

Splenic tumors are not common, many can have minimal to no symptoms, and they can be found incidentally.

•

Splenic tumors can be primary or metastatic. They can be benign or malignant.

•

Splenic cysts can be infectious, traumatic or congenital.

•

Epidermoid splenic cysts may not always present in a classic fashion on imaging, making diagnosis challenging.

•

Many splenic masses and complex cysts would require surgical pathological diagnosis.

Introduction

Splenic tumors are rare and are either primary or secondary, benign or malignant. Most have none to minimal symptomatology and are found incidentally. Splenic cysts can be infectious, congenital, or traumatic. Epidermoid cysts and parasitic cysts are examples of primary cysts and usually have a classic presentation on imaging. Despite advanced imaging modalities and patient's clinical presentation, it can be difficult to diagnose an epidermoid cyst without histological examination. The purpose of this paper is to discuss typical findings of primary splenic cysts on imaging, but how they may differ in appearance.

Presentation of case

51 year old female who presented with vague abdominal discomfort and was found to have a large splenic mass with cystic components on imaging which did not demonstrate a typical primary splenic cyst appearance. Patient underwent an uneventful hand-assisted laparoscopic total splenectomy and had an uneventful recovery with histopathology revealing an epidermoid splenic cyst.

Conclusion

Primary splenic cysts are difficult to diagnose and differentiate with imaging alone. They have a variable presentation and can present like as a cystic mass. It is important to include them in the differential diagnosis of splenic masses since histopathology is the final determinant of the diagnosis.

Subtotal splenectomy preserving the inferior splenic pole for the treatment of Hodgkin's lymphoma

INTRODUCTION

Splenectomy is helpful in the management of selected patients with Hodgkin's lymphoma (HL), but in some cases this procedure is accompanied by a greater morbidity and mortality mainly due to sepsis. This is the first published case of subtotal splenectomy preserving the inferior splenic pole without the maintenance of the splenic vascular pedicle.

PRESENTATION OF CASE

A 53-year-old man with HL refractory to chemo and radiotherapy associated to a very large spleen was successfully treated with subtotal splenectomy, preserving the inferior splenic pole supplied only by the left gastroepiploic and inferior splenic pole vessels. After an eleven year uneventful postoperative follow-up, the dimensions and function of the spleen are still preserved, and the disease is under control with chemo- and radiotherapy.

CONCLUSION

Subtotal splenectomy is efficacious to preserve the splenic functions and to prevent adverse effects of a large spleen on the treatment of Hodgkin's lymphoma confined to superior pole and producing significant abdominal symptoms and hematological effects.