Trichobezoar presenting as a gastric outlet obstruction: A case report

INTRODUCTION

Rapunzel syndrome is a rare intestinal condition that starts with the ingestion of a trichobezoar. The condition is predominately found in females and can be associated with trichotillomania, or the compulsive urge to pull one's own hair out. There are less than 40 cases described in the literature with the prevention of recurrence aimed at psychological treatment.

PRESENTATION OF CASE

The patient is a 7 year-old girl with a history of trichotillomania with trichophagia as a young child who presented with abdominal pain, nausea, and vomiting, consistent with a gastric outlet obstruction. She had an exploratory laparotomy with gastrostomy performed revealing a 18cm by 18cm trichobezoar with extension into the small bowel.

DISCUSSION

Bezoars, an already rare entity, can occasionally lead to gastric and small bowel obstructions. Small collections of ingested hair build up in the intestinal tract causing significant symptoms. These obstructions can sometimes be treated through minimally invasive techniques but, in our case described, it is unlikely to have been treated any other way due to the substantial size of the trichobezoar.

CONCLUSION

Early consideration of Rapunzel syndrome is important in young females presenting with a gastric outlet obstruction.

A case of cholangiolocellular carcinoma featuring intratumoral hepatic artery penetration: A case report

INTRODUCTION

Cholangiolocellular carcinoma (CoCC) is thought to originate from hepatic stem cells. Its clinical characteristics, including radiological and prognostic factors, remain unclear.

PRESENTATION OF CASE

A 79-year-old woman with hypertension was admitted to our hospital after abnormal tumor marker levels were detected during an annual physical examination. Her laboratory data results were within normal range, and she was classified as Child-Pugh A. Enhanced computed tomography revealed a tumor located on the left side of the liver, with a maximum size of 60mm. The tumor showed heterogeneously enhancing edges in the arterial phase, while prolonged tumor enhancement was detected in the delayed phase. Tumor penetration by the left hepatic artery was evident, whereas the left portal vein was invaded by the tumor. The preoperative diagnosis was cholangiocellular carcinoma. Left hepatectomy and cholecystectomy were performed with no postoperative complications; the final diagnosis was CoCC. Multiple liver metastases appeared 6 months after surgery; the patient is now receiving systematic chemotherapy.

DISCUSSION

While portal vein penetration into CoCCs has been reported, the same is not true of the hepatic artery; therefore, this case illustrates a unique tumor growth pattern.

CONCLUSION

A unique growth pattern as well as a large primary tumor may contribute to earlier recurrence.

Ileocaecal and transverse colonic tuberculosis mimicking colonic malignancy - A case report

INTRODUCTION

Gastrointestinal tuberculosis is common in the developing world especially in the lower socioeconomic groups. In elderly, it may mimic malignancy.

CASE PRESENTATION

A 46-year-old female presented with a 6 month history of diffuse pain in abdomen with low grade fever and loss of weight and appetite. Clinically, differential of malignancy of the large bowel was considered. The computerized tomography(CT) scan of the abdomen revealed a diffuse concentric long segmental thickening of terminal ileum, ileo ceacal junction, ascending colon and narrowing of the transverse colonic end of the splenic flexure suggesting an infective etiology. Colonoscopy showed an ulcero-nodular lesion at the splenic flexure raising the possibility of colonic cancer and thickening of ascending colon and caecum. Colonoscopic biopsy from both sites, on histopathology, showed a moderate mixed inflammation and occasional lymphoid collection and crypt abscesses in the lamina propria giving a differential of tuberculosis or Crohn's disease. Biopsy smear showed occasional acid fast bacilli(AFBs) and the gene Xpert detected mycobacterium tuberculosis(MTB). The patient was started on anti Koch's therapy(AKT).

DISCUSSION

In this case the differential diagnosis was malignancy of the colon, inflammatory bowel disease and tuberculosis as all these conditions may have similar clinical profile and radiological findings. Tuberculosis of bowel was considered as the most probable diagnosis due to the CT findings. But the colonoscopy suggested malignant etiology.

CONCLUSION

Possibility of tuberculosis should be kept in mind while dealing with synchronous lesions in large intestine.

A case report of wound site seeding following cholecystectomy for dysplastic gallbladder

Wound site metastasis following cholecystectomy is an uncommon but well recognised complication following laparoscopic surgery for unsuspected gallbladder carcinoma. We describe a case of implantation of dysplastic cells with subsequent malignant transformation at the incision site 3 years post-cholecystectomy for an inflamed gallbladder. Histopathological examination of this tumour confirmed adenocarcinoma of pancreatobiliary origin, possibly secondary to gallbladder cells implantation and subsequent carcinomatous change. Unlike previously reported cases, the present case has two unique features: Firstly, the histology of the resected gallbladder at the initial operation was that of a low-grade dysplasia and not carcinoma; and secondly, there was a long interval between initial surgery and subsequent development of the wound site tumour. This case highlights that careful handling of the specimen tissue intraoperatively is paramount as cells implanted in the wound site can survive and undergo malignant transformation. All new masses occurring along the surgical wound site should be followed up and investigated to exclude implanted tumours.

An unexpected diagnosis of primary omental endometrial stromal sarcoma in a patient with acute right abdominal pain: A case report and review of literature

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Only case in literature without history of endometriosis, on Hormone replacement therapy.

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Only the second case with isolated omental lesion.

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Extrauterine Endometrial Stromal Sarcoma (EESS) is an extremely rare mesenchymal tumour.

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This condition can simulate chronic or acute abdominal pathologies.

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The tumour can occur without preceding endometriosis, and in upper abdominal location.

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Biopsy showing typical immunohistochemistry markers is the best way to achieve diagnosis.

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Hormone replacement therapy may be an independent risk factor for EESS occurrence.

Introduction

Extrauterine Endometrial Stromal Sarcoma (EESS) is an extremely rare mesenchymal tumour that simulates other pathologies, and therefore poses a diagnostic challenge. This report outlines a case of EESS arising from the greater omentum mimicking a colonic tumour, with review of literature.

Presentation of case

A 47-year-old woman, with history of hysterectomy for menorrhagia and hormone replacement therapy (HRT), presented with right sided abdominal pain and localized peritonism. On exploratory laparoscopy an omental tumour, suspected to arise from the transverse colon was identified and biopsied. The histological features suggested an EESS. Colonoscopy ruled out colonic lesion. A laparoscopic tumour resection and bilateral salpingo-oophorectomy (BSO) was performed. Immunohistochemistry confirmed the diagnosis. No additional lesions or associated endometriosis were found. Resection was followed by adjuvant medroxyprogesterone-acetate therapy.

Discussion

We reviewed 20 cases of EESS originating from extragenital abdominopelvic organs reported since 1990. Acute presentation is rare, as well as upper abdominal occurrence. Isolated omental involvement was previously reported in only one case. Endometriosis is a risk factor for development of EESS and history and/or histological evidence for endometriosis is usually present. HRT is another acknowledged risk factor, mostly on the background of endometriosis. To our knowledge, this is the only report of EESS occurring in a woman on HRT treatment without background of endometriosis.

Conclusion

EESS can occur without endometriosis and HRT may be an aetiological factor. The condition can mimic a chronic or acute abdominal pathology and laparoscopic core biopsy is the best way to achieve a diagnosis and formulate management.

Unusual combination of femoral head dislocation associated acetabular fracture with multipart femoral fractures: Case report

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Traumatic hip dislocation associated with multipart femural fractures is a rare and severe injury and it usually occurs following a high energy trauma, associated acetabulum fracture are even more rare.

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High energy traumas of the hip joint potentially cause devastating consequences including avascular necrosis (AVN) and subsequent early secondary osteoarthritis of the hip.

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In managing an unstable polytraumatized patient the surgeons must be more careful and propose a staged treatment strategy.

Introduction

Traumatic hip dislocation associated with femur intertrocanteric fracture is a rare and severe injury and it frequently occurs following a high energy trauma, Associated acetabular fractures with this injury are even more rare and potentially cause devastating consequences including avascular necrosis of the femoral head and subsequent early secondary osteoarthritis of the hip joint.

Presentation of case

In this case report, we present a 20 year old polytraumatized patient with traumatic hip dislocation associated with ipsilateral acetabulum fracture and simultaneous fractures of the ipsilateral femur.

Discussion

Traumatic hip dislocation associated with femur intertrochanteric fracture is a rare and severe injury and it frequently occurs following a high energy trauma. In polytraumatized patients, musculoskeletal injuries are the most common lesions requiring surgical intervention frequently presenting challenging scenarios in terms of functional outcome and quality of life. Osteonecrosis of the femoral head is a serious and unpredictable complication that may occur after displaced femoral neck fracture and traumatic hip dislocation due to the disturbed blood supply of the femoral head.

Conclusion

A staged treatment strategy may be useful managing an unstable polytraumatized patient or a patient who requires prolonged transfer to receive definitive care.

The first case report of failed single-anastomosis-duodeno-ileal bypass converted to One anastomosis gastric bypass/Mini-gastric bypass

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Revisional bariatric surgery will rise in the future.

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The established single-anastomosis-duodeno-ileal bypass with sleeve gastrectomy (SADI-S) as the restrictive part of the procedure. Due to preserved pylorus, SG has the disadvantage of a high-pressure system with de-novo or worsening of existing gastroesophageal reflux disease in the long-term.

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One anastomosis gastric bypass/Mini-gastric bypass (OAGB/MGB) reduces the high-pressure system of SG in a low-pressure system of OAGB/MGB.

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OAGB/MGB might be a simple method to rescue failed SADI-S patients.

Introduction

The established single-anastomosis-duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is based on a sleeve gastrectomy (SG) as the restrictive part of the procedure. Due to preserved pylorus, SG has the disadvantage of a high-pressure system with de novo or worsening of existing gastroesophageal reflux disease (GERD).

Case presentation

A female patient presented herself due to protracted GERD and weight regain after multiple bariatric surgeries. At an initial weight of 158 kg (BMI 62.5 kg/m²) the patient underwent adjustable gastric banding in 2009. After band removal in slippage, the patient underwent SG at a weight of 135 kg in 2012. Nine months after SG, SADI-S was performed as a malabsorptive second step procedure. After 32 months the patient suffered from severe GERD under proton pump inhibitor therapy. Actual weight was 107.9 kg (BMI 42.7 kg/m²). Upper endoscopy showed a hiatal hernia and esophagitis B and dorsal hiatoplasty was performed. After 6 months in still existing severe GERD and weight regain indication for laparoscopic conversion to One anastomosis gastric bypass/Mini-gastric bypass (OAGB/MGB) was given, aiming to reduce the high-pressure system of SG in a low-pressure system of OAGB/MGB. One year after revisional surgery reflux was reported to be only occasionally. Further weight loss was seen (91 kg, BMI 36 kg/m², EWL 67.7%).

Conclusion

SG as the restrictive part of SADI-S may lead to GERD and consequently to pathologic eating of “soft” calories, that defeats the operation and results in weight regain. OAGB/MGB might be a simple method to rescue such failed SADI-S patients.

Evolution of diagnostic approaches in betalactam hypersensitivity

INTRODUCTION

Betalactams are the most widely used drugs against infections and the primary cause of antibiotic hypersensitivity reactions. Reaction patterns for different betalactams have been changing in accordance with consumption trends, and vary among countries. As a consequence, in vivo and in vitro tests have had to change with to keep up with new tendencies. Areas covered: This review is focused on advances in betalactam hypersensitivity diagnosis. Changes in in vivo methods have been limited to the inclusion of new haptens. In contrast, major progress has been achieved for in vitro tests since the 1960s, from the first description of immunoassays, the basophil activation test and the lymphocyte transformation test, to the more sophisticated assays developed in last years. Expert commentary: Issues with diagnosis are related to test sensitivity. In vivo tests show higher sensitivity, however they can be risky, especially in severe and life-threatening reactions. Therefore, we believe that in vitro tests should be the preferred method. Current efforts are under way to enhance their sensitivity. Only multidisciplinary approaches involving immunology, proteomics, nanotechnology and chemistry can help us to fully understand conjugate structures and mechanisms involved in hypersensitivity reactions to betalactams, and consequently lead to advances in in vitro methods.

Skin-nipple-sparing mastectomy: The first approach in primary myxoid chondrosarcoma of the breast

The primary mammary chondrosarcoma corresponds to less than 0,5% of the mammary malignancies. For the period ranging from 1967 to 2014, only 18 cases were reported in the literature. A 41year old woman found a hard nodule on her external right superior quadrant/axillary prolongation through breast self-examination. The vacuum-assisted core biopsy (VACB) revealed "high grade extra-skeletal myxoid chondrosarcoma". A skin-nipple-sparing mastectomy with the insertion of a mammary expander was performed. A protocol of adjuvant radiotherapy was also indicated. Until 2013, the gold standard was the radical mastectomy. By 2014, there were two cases of conservative approach to quadrantectomy. To our knowledge, this represents the first case in the literature in which a skin-nipple-sparing mastectomy has been performed on a primitive mesenchymal neoplasm of the breast. Such an oncoplastic approach was performed considering the young age of the woman, to assure the surgical radicality and a better quality of life to the patient.

Subacute thyroiditis causing thyrotoxic crisis; a case report with literature review

INTRODUCTION

Subacute thyroiditis is a self-limited, inflammatory viral thyroid disease which presents with neck pain, usually accompanied by systemic symptoms. On the other hand, thyroid storm is a clinical condition of severe sudden hyperthyroidism accompanied by physiologic de-compensation. We presented a 29-year-old male with features of subacute thyroiditis and thyroid storm who is the third reported case managed by steroid, beta-blocker and analgesics.

CONCLUSION

subacute thyroiditis may present with thyrotoxic crisis which respond dramatically to corticosteroid therapy.

Long-term observation of a large keratocystic odontogenic tumour of the mandible treated by a single enucleation procedure: A case report and literature review

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Keratocystic odontogenic tumours (KCOTs) are rare, benign lesions of the jaw.

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We present a 49-year-old woman with a rare, large KCOT of the mandible.

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We describe a treatment method involving enucleation with Carnoy’s solution plus inserting a titanium plate.

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Although the patient showed recurrence once, she has not shown recurrence since 2010.

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Our approach was effective for the treatment of a large KCOT with tooth preservation.

Introduction

Keratocystic odontogenic tumours (KCOTs) are benign lesions of the jaw that are characterised by expansive growth and high rates of recurrence. Herein, we present a novel minimally invasive method for the surgical treatment of KCOTs.

Case presentation

We present a 49-year-old woman with a rare, large KCOT of the mandible extending from tooth 37 to tooth 47. A single enucleation procedure was selected as the surgical technique combined with a titanium plate. Teeth interfering with the cystic lumen were preserved. The bone surrounding the cyst was partially removed and rinsed with Carnoy’s solution. Recurrence was observed 1 year later between teeth 43 and 45, and was treated by single enucleation with Carnoy’s solution. After the second operation, the teeth interfering with the KCOT still elicited a positive response to dental pulp testing. No further signs of recurrence were observed after a total observation period of 7 years.

Discussion

Various surgical interventions have been described for KCOTs. However, a general guideline for a specific surgical intervention has not yet been established owing to the heterogeneity of these tumours.

Conclusion

Immediate enucleation in combination with a titanium plate offers an effective surgical approach for the treatment of large KCOTs of the mandible without the need for radical tooth removal or resection of the afflicted side.

Temporary total hip arthroplasty-like spacer for treating an infected periprosthetic femoral fracture using a long stem: A case report

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Total hip arthroplasty-like spacer using a long stem facilitated the eradication of infection.

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Total hip arthroplasty-like spacer allowed a good range of motion without pain.

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Our method is simple and effective for treating an infected periprosthetic femoral fracture.

Introduction

Infected periprosthetic femoral fractures are among the most complex and significant complications of total hip arthroplasty (THA). We report the novel use of a temporary THA-like spacer for treating an infected periprosthetic femoral fracture after revision surgery using a long stem.

Case presentation

We present a 72-year-old woman sustained a left infected periprosthetic femoral fracture after revi - streptococci in the culture sample. On suspicion of a periprosthetic joint infection, we planned a two-stage procedure. We used a temporary THA-like spacer comprising the removed femoral long stem, which was autoclaved and then reimplanted, and applied a new polyethylene acetabular liner. Both components were cemented in place with antibioticloaded bone cement, without applying strong pressure. Pain control waseasily achieved postoperatively because the fracture had been stabilized early. The THA-like spacer was stable, and allowed a good range of motion without pain. She was allowed to move with a wheelchair and was walk with partial weight bearing without pain. Seven week after the initial THAlike spacer placement, we performed a revision THA after successful control of infection. At the 1-year follow-up, the patient remained free of infection.

Conclusions

Temporary antibiotic-loaded cement-coated THA-like spacer using a long stem facilitated the eradication of infection, fracture stabilization, and enables partial weight bearing without pain.

A case report of invasive candidiasis and fungal osteomyelitis mimicking oropharyngeal carcinoma recurrence in an immunocompetent patient following transoral robotic surgery

INTRODUCTION

Transoral robotic surgery(TORS) for the excision of oropharyngeal tumour is increasingly considered for its lower rates of postoperative complications and better functional outcomes. However, we report a case of invasive candidiasis in an immunocompetent patient with previous radiation therapy years ago who underwent TORS recently.

CASE PRESENTATION

A 55year old Chinese female with previous radiation therapy for nasopharyngeal carcinoma diagnosed in 1986 underwent wide excision of a newly diagnosed oropharyngeal carcinoma with TORS. From 4 to 8 weeks post-op, an enlarging exophytic lesion at the surgical excision site was noted. Initial biopsy did not show malignancy or fungal organisms. A repeat biopsy under anaesthesia was done as CT imaging showed suspicion of either infective or tumour recurrence. The patient was treated with long term antifungals as final culture results showed invasive candidiasis. The surgical site showed no further lesions 6 months post-op.

DISCUSSION

Previous radiation therapy to the oropharyngeal area predisposes a patient to colonization of fungal organisms. Despite TORS showing lower rates of infection, patients who have had previous radiotherapy may be more susceptible to infections as the dissection involves down to the pre-vertebral fascia. Hence, it is appropriate for such patients to have microbiological and fungal cultures performed for a lesion such as this and be treated according to the results of the culture.

CONCLUSION

This case serves as a reminder of the risk of invasive candidiasis requiring early investigation and treatment in an immunocompetent patient with prior history of both radiation therapy and recent TORS.

Three-dimensional laparoscopy for living-donor nephrectomy with vaginal extraction: The first case

Introduction

Two-dimensional laparoscopy for living donor nephrectomy is the current standard of care. We report the first case of three-dimensional laparoscopy for living-donor nephrectomy with vaginal extraction.

Presentation of case

The procedure was performed in a 66-year-old woman donating his left kidney to her son with the HD S 3D column (Karl Storz, Tuttlingen, Germany). Preoperative computed tomography showed one left renal artery. The warm ischemic time was 2 min 20 s and the operative time was 200 min. There was no loss of blood and no intraoperative or postoperative complications.

Discussion

This report demonstrates the feasibility of using 3D laparoscopy which allows for a more in-depth vision, greater overall definition of planes, better accuracy of dissection and reduced operative times, for nephrectomy with vaginal extraction for kidney donation.

Conclusion

Three-dimensional laparoscopy for living-donor nephrectomy with vaginal extraction is feasible and could become a new standard.

Eosinophilic funiculitis initially diagnosed as irreducible inguinal hernia: A case report

BACKGROUND

Most groin masses are first suspected to be groin hernias. More than 80% of bulging groin lesions are reportedly diagnosed as hernias by ultrasonography. Establishment of the correct diagnosis of hernia among all differential diagnoses is not easy. We herein describe a very rare case of groin eosinophilic funiculitis that presented as an irreducible groin hernia.

CASE PRESENTATION

A 59-year-old man presented to our hospital with suspicion of a right groin hernia. He had a 1-week history of a painful right groin tumor. The tumor was about 4 cm without skin redness or warmth, irreducible even in the supine position, and associated with mild tenderness. Enhanced computed tomography showed that the mass seemed to be connected to the intra-abdominal structures. With time, the patient's pain did not increase, the inflammatory response did not worsen, and no ischemic signs were observed by enhanced computed tomography. Therefore, we diagnosed the tumor as an irreducible but not incarcerated hernia and performed elective surgery. Intraoperative examination revealed no hernia sac, and a 4-×3-cm tumor was observed around the spermatic cord. A malignant tumor was not completely ruled out. High orchiectomy was performed after consultation with the urologists. Pathological examination of the tumor showed no malignant features, and the final diagnosis was eosinophilic funiculitis with massive inflammatory changes and eosinophil invasion.

CONCLUSION

Eosinophilic funiculitis is very rare; only three cases have been reported to date. We should always consider unusual causes of groin masses during a surgical approach to hernia-like lesions.

A case report of bloody pancreatitis

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Haemobilia is a rare complication of laparoscopic cholecystectomy.

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Pancreatitis is not usually caused be an obstructing thrombus.

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Advances in surgical practise predisposes to haemobilia occurring as a complication.

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Surgeons must be aware of spectrum of complications related to modern techniques.

Introduction

Haemobilia is an uncommon entity even though its frequency has increased with hepato-biliary instrumentation and procedures. It can be associated with obstructive jaundice and pancreatitis (Green et al., 2001) [1]. Haemobilia following cholecystectomy has frequently been reported in association with hepatic artery pseudo-aneurysm (Curet et al., 1981; Ribeiro et al., 1998) [2,3]. The authors wish to report a case of haemobilia due to a porto-biliary fistula presenting as acute pancreatitis.

Presentation of case

A 34-year-old female admitted as an urgency with upper abdominal pain for 3 weeks. She had, in the preceding days, been admitted to another hospital with acute pancreatitis. She reported an episode of rectal bleeding during that admission and possessed an abdominal ultrasound scan (USS) and magnetic resonance cholangiopancreatography (MRCP) which suggested the presence of a biliary tract neoplasm. The patient was also found to be jaundiced and the diagnosis of a porto-biliary fistula was made at operation.

Conclusion

The diagnosis in this case was found to be a portal vein-biliary tract fistula occurring post cholecystectomy. An awareness of the spectrum of complications related to modern surgical techniques may aid timely diagnosis and the achievement of favourable outcomes.

Emergency room thoracotomy for acute traumatic cardiac tamponade caused by a blunt cardiac injury: A case report

INTRODUCTION

Traumatic blunt cardiac injuries have a high mortality rate, and prompt diagnosis and treatment can be lifesaving in cardiac tamponade.

PRESENTATION OF CASE

A 62-year-old man was transferred to the emergency department after a motor vehicle accident. He was hemodynamically unstable. A focused assessment with sonography in trauma (FAST) showed pericardial fluid with right ventricular collapse consistent with cardiac tamponade in the subxiphoid view. He collapsed despite a subxiphoid pericardiotomy. Owing to the ongoing hemodynamic instability, we performed a left anterolateral thoracotomy. Direct incision of the pericardium showed blood and clots within the pericardial space, indicating hemopericardium. The heart stroke and hemodynamic status recovered on removing the clot.

DISCUSSION

Although the physical findings of cardiac tamponade are not always apparent in life-threatening acute cardiac tamponade after blunt trauma, FAST is a reliable tool for diagnosing and following cardiac tamponade. A median sternotomy is a standard approach for evaluating cardiac injury in hemodynamically stable patients with or without cardiopulmonary bypass. However, a left anterior thoracotomy was the fastest, simplest life-saving procedure considering the need for open-chest cardiac massage given our patient's life-threatening condition.

CONCLUSION

A prompt diagnosis using FAST and treatment can be lifesaving in traumatic acute cardiac tamponade. A pericardiotomy via a thoracotomy is mandatory for lifesaving cardiac decompression in acute traumatic cardiac tamponade in cases of ineffective drainage due to clot formation within the pericardial space.

Successful endovascular coil embolization in an elder and asymptomatic case of anomalous systemic arterial supply to the normal basal segment

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An anomalous systemic arterial supply to the normal basal segment without sequestration is a rare congenital vascular malformation.

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We experienced a case of successful endovascular embolization of in an elderly and asymptomatic patient with an anomalous systemic arterial supply to the normal basal segment.

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Coil embolization is a very useful treatment method for elderly patients with an anomalous systemic arterial supply to the normal basal segment.

Introduction

An anomalous systemic arterial supply to the normal basal segment without sequestration is a rare congenital vascular malformation. The discovery age is relatively young, and the most common clinical symptom is hemoptysis due to pulmonary hypertension or heart failure. We herein describe a case of endovascular embolization of in an elderly and asymptomatic patient with an anomalous systemic arterial supply to the normal basal segment.

Presentaition of case

An 80-year-old male was referred to our hospital due to an abnormal chest shadow. The patient was diagnosed with an anomalous systemic arterial supply to normal basal segment. We performed coil embolization via the catheterization.

Discussion

The application of coil embolization via catheterization results in a low risk of infection and small burden on the body compared with surgery. There are few report of the coil embolization for an anomalous systemic arterial supply to the normal basal segment. Hence, it is necessary to accumulate additional cases.

Conclusion

The outcome of thie case indicates that coil embolization is a very useful treatment method for elderly patients with an anomalous systemic arterial supply to the normal basal segment.

Leydig cell tumor in grey zone: A case report

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Leydig cell tumor is a testicular tumor with a low incidence accounting for 1–3% of testicular neoplasms.

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Only about 10% of them show malignant behavior in the form of metastatic disease.

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When diagnosed and treated early, long-term favorable outcomes are seen even with its potential metastatic behavior.

Introduction

Leydig cell tumor constitutes only about 1–3% of testicular neoplasms. There is apparently increased incidence in the last few years; one possible explanation for this phenomenon is the widespread use of ultrasound technology and the subsequent increased early detection of smaller lesions that have not been found in historical series.

Case presentation

We report a case of Leydig cell tumor of testis in a patient presenting with painless long standing slowly growing left scrotal mass who found to have intrapulmonary nodule and multiple enlarged retroperitoneal lymph nodes on staging work up. The mass was managed by radical orchiectomy. Pathological diagnosis was Leydig cell tumor.

Discussion

Orchiectomy is the accepted mode of treatment but follow-up every 3–6 months with physical examination, hormone assays, scrotal and abdominal ultrasonography, chest radiography, and CT scans is essential in such a case with a potential for malignant behavior.

Conclusion

Inguinal orchiectomy is the therapeutic decision of choice and long-term follow-up is necessary to exclude recurrence or metastasis. Cases which fall in the grey zone like ours need to be followed up carefully for metastasis instead of rushing into an early retroperitoneal lymph node dissection, with its potential risks and complications.

A case report of distal radioulnar joint dislocation fixed by using mini-plate-button

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Pathological factors may cause significant distal radioulnar joint (DRUJ) dislocation, which is a rare clinical entity in the orthopaedic literature, and treatments are not uniform.

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At surgery, the stabilization of DRUJ was constructed by using mini-plate-button after removal of intraoperative debridement of the tumor.

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Reduction of DRUJ dislocation was facilitated by mini-plate-button and absorbable suture.

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The treatment avoid the intra-articular or extra-articular ligament construction and the damage of adjacent tissue and bone.

Introduction

Pathological factors may cause significant distal radioulnar joint (DRUJ) dislocation, which is a rare clinical entity in orthopedic literature, and corresponding treatments are not uniform.

Presentation of case

We describe the case of a DRUJ dislocation caused by giant cell tumour of tendon sheath (GCTTS) in wrist. At surgery, the stabilization of DRUJ was constructed by using mini-plate-button after removal of intraoperative removal of the tumor. Postoperative plain films showed good position, and no obvious dislocation was found.

Discussion

Reduction of DRUJ dislocation was facilitated by mini-plate-button and absorbable suture. The treatment avoided intro-articular or extra-articular ligament construction and damage of adjacent tissue and bone.

Conclusion

For DRUJ dislocation caused by GCTTS leading to severe tendon and ligament damage, the operative treatment of mini-plate-button may be effective.

Laparoscopic approach to colo-renal fistula with renal preservation and omentoplasty: A case report

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Percutaneous ablation is being increasingly used to treat renal masses.

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A colo-renal fistula can result as a potential complication.

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Initial treatment should focus on conservative management involving antibiotics and ureteral stent placement.

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If failed, fistula can be resected laparoscopically safely without the need for nephrectomy.

Colorenal fistula as a result of percutaneous cryoablation has not been extensively reported. We report a gentleman who presented with urosepsis after percutaneous biopsy of a renal mass complicated by colorenal fistula. After failed attempts at conservative management, he underwent laparoscopic resection of his fistula with renal salvage and omentoplasty highlighting that nephrectomy is not always indicated.

Spontaneous perforation of common bile duct in a young female: An intra-operative surprise

INTRODUCTION

Spontaneous CBD perforation is one of the rare causes of acute abdomen in infants and extremely rare in adults. It is rarely suspected and correctly diagnosed preoperatively.

PRESENTATION OF CASE

A 17year old female presented to Emergency Department with sudden onset of pain and distention of abdomen, associated with vomiting and non-passage of flatus and stool for 3days and features of generalized peritonitis. On exploration, a perforation of size 0.5cm in diameter was present on the antero-lateral surface of supraduodenal part of common bile duct (CBD) below the junction of cystic duct and common hepatic duct. Cholecystectomy done and the CBD repaired over a T-tube.

DISCUSSION

Spontaneous perforation of bile duct should ideally manage with T-tube drainage of the CBD along with cholecystectomy. In case with distal obstruction of the CBD, a biliary enteric bypass should be done.

CONCLUSION

Due to the paucity of cases, the index of suspicion for this diagnosis is low. But bilious peritoneal tap, features of generalized peritonitis and absence of free gas under diaphragm in abdominal x-ray may be considered as clues for suspicion. Accordingly, Surgery remains the mainstay of treatment.

Acute appendicitis presenting as an abdominal wall abscess: A case report

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Amyand’s hernia is uncommon in females.

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The initial presentation as an abdominal wall abscess is very rare in the contemporary literature.

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An index of suspicious, early diagnosing and surgical intervention lead to favorable recovery.

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The management should follow general guidelines of appendectomy, hernia repair and dealing with the associated pathology if present.

Introduction

Amyand hernia (AH) is a rare type of hernia characterized by the presence of appendix vermiformis in the inguinal hernial sac. It is rarely reported in women.

Presentation of case

We presented a case of a 60- year old woman who was admitted initially with an abdominal wall abscess and found to have perforated appendix in the right inguinal hernia. The patient underwent standard open appendectomy and the post-operative course was uneventful.

Discussion

The initial presentation of our case as an abdominal wall abscess is rare in the contemporary literature.

Conclusions

A high index of suspicious, early diagnosis and timely surgical intervention are the keys to have favorable outcome in amyand hernia. The management should follow general guidelines of appendectomy, hernia repair and dealing with the associated pathology if present.

Gastropleural fistula after single anastomosis gastric bypass. A case report and review of the literature

INTRODUCTION

Pulmonary complications after bariatric surgeries are rare but usually serious. They often occur early after surgery but the presentation might be delayed for several months. Gastropleural fistula after bariatric surgery is extremely rare and has been reported in a very small number of patients post sleeve gastrectomy and gastric bypass.

CASE PRESENTATION

A 37-year-old lady presented with left sided pleural effusion and empyema 2 years post single anastomosis gastric bypass surgery. She was found to have a large gastropleural fistula and was managed by surgical repair of the fistula with conversion to gastric bypass and decortication of the affected pleura. That resulted in significant clinical improvement and resolution of the empyema.

CONCLUSION

Gastropleural fistula is a very rare complication of bariatric surgeries and should be considered in patients who present with chronic or recurrent pulmonary infections.

A case report on esophageal tuberculosis - A rare entity

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Esophageal Tuberculosis accounts for only 2.8% of all cases of Gastrointestinal Tuberculosis.

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Upper gastrointestinal endoscopy revealed an ulcerative growth in the distal esophagus.

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Dysphagia is the commonest presenting feature of esophageal tuberculosis.

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Histopathology and TB-PCR are the key to confirm the diagnosis.

This is a case report of a rare form of tuberculosis in a patient presenting with dysphagia. Patient was subjected to upper gastrointestinal endoscopy, which revealed an ulcerative growth in the distal esophagus. Histopathology revealed esophageal tuberculosis. Patient was managed conservatively with Anti-Tuberculosis Treatment (ATT). Follow up endoscopy after two months revealed resolution of the growth and patient was symptomatically better. In spite of the rare nature of the disease, it can be managed effectively with ATT to avoid complications (fistula, stricture, and esophageal perforation), which might warrant surgery.

A case of multiple synchronous quadruple cancers of the stomach, sigmoid colon, rectum, and pancreas

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The increased screening results in more pick up multiple primary tumors and that they are being reported more.

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Diagnosis and treatment of multiple primary tumors is usually difficult.

•

A cancer board can be useful for this process.

Introduction

Multiple primary neoplasms are relatively rare, but their incidence has increased because of aging and improvements in diagnostic imaging.

Presentation of case

A 67-year-old man presented with epigastric pain. On upper gastrointestinal endoscopy, an ulcer was seen at the gastric angle, and biopsy showed moderately differentiated adenocarcinoma (AC). Colonoscopy demonstrated a 15-mm lesion in the sigmoid colon and a submucosal lesion in the lower rectum. The biopsy showed well differentiated AC and neuroendocrine tumor (NET). In addition, abdominal CT and MRI showed a 14-mm nodular lesion in the pancreatic body suggesting pancreatic duct cancer. Based on the above findings, four synchronous cancers, including the pancreas, stomach, sigmoid colon and rectum, were diagnosed, and surgery was performed. A midline incision was made in the upper abdomen, and a distal gastrectomy, pancreatic body and tail resection, and sigmoidectomy were performed. Trans-anal tumor resection was performed for the rectal lesion. Histopathology showed invasive pancreatic duct cancer, moderately differentiated AC of the stomach, moderately differentiated AC of the sigmoid colon, and NET G1 of the rectum. The patient had no postoperative complications, 4 years 3 months after resection, and he was disease-free from all of the cancers.

Discussion

The strategy of perioperative diagnosis and treatment for multiple primary tumors is usually difficult. This process was performed by consulting a cancer board, which could be useful as a practice guideline.

Conclusion

This patient in whom four tumors were completely resected at the same time and who has had a good clinical course was reported.

Successful primary repair of late diagnosed spontaneous esophageal rupture: A case report

•

Diagnosis of spontaneous rupture of the esophagus is often delayed.

•

Significant contamination of the mediastinum and pleural space is not uncommon.

•

Debridement and drainage of the mediastinum and pleural space are necessary to control sepsis.

•

Debridement of necrotic tissue is necessary.

•

Primary repair in layers of the esophagus is possible in majority of the cases regardless of the time lapsed from rupture.

Introduction

Spontaneous esophageal rupture is rare, roughly 300 cases reported annually. Diagnosis is often delayed or missed. Overall mortality is about 20%. This feared high mortality rate has led to the misconception that primary esophageal repair should be avoided in late diagnosed patients. We report a successful primary repair of spontaneous esophageal rupture which was delayed for more than two weeks.

Methods

A 53 year-old male presented to our medical service after falsely having been treated for pneumonia at an outside hospital. He was subsequently diagnosed with spontaneous esophageal rupture and treated with over the scope clips followed by stenting. Persistent leak into mediastinum made surgical exploration necessary. At exploration a primary repair could be performed successfully.

Results

Unsuccessful endoscopic management of esophageal perforation that was delayed for two weeks underwent primary surgical repair without complications.

Conclusion

Primary closure of late diagnosed spontaneous esophageal rupture can be successful, even when it is complicated by a prolonged delay in treatment and failed endoscopic procedures. We conclude that primary surgical repair should be attempted in patients with spontaneous esophageal rupture if tissues are viable.

Dyspnea and dysphagia associated to hypopharyngeal fibrolipoma: A case report

Fibrolipomas are benign lesions conformed by fat and connective tissue, classified as histologic variants of lipomas. They are rarely located in the head and neck and represent less than 0.6% of the benign tumors of the larynx and hypopharynx. Their clinical presentation depends on its location and size. We present the case of a 51-year-old male patient who reported progressive dyspnea, dysphagia and obstructive sleep symptoms with a duration of 3 months, without apparent cause. A pharyngolaryngeal fiberoptic endoscopy showed a smooth, rounded mass in the posterior wall of the hypopharynx, partially obstructing the laryngeal vestibule, creating a valve effect. Complete trans-cervical resection of the lesion was performed after the airway was secured by means of a tracheotomy. The final histopathology report was fibrolipoma. He is currently asymptomatic and without evidence of relapse one year after the procedure.

Case report of an intracaval leiomyomatosis 10 months after complete hysterectomy

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Intravenous leiomyomatosis within the vena cava can spread rapidly as far proximally as intracardially.

•

Intravenous leiomyomatosis can be removed bluntly through cavotomy.

•

Sternotomy can be avoided, reducing the surgery to a laparotomy.

Introduction

Intravenous leiomyomatosis (IVL) is a rare smooth muscle tumor, usually found in women with tumors of the reproductive organs, such as uterus myomatosous. Surgically, this case belies the call for sternotomy and two-stage surgery in caval IVL extending to the right atrium: we suggest one-stage median laparotomy as a minimal procedure with maximal benefit.

Presentation of case

We present the case of a 60-year-old postmenopausal woman with suspected intravenous leiomyomatosis of the right internal iliac vein. The patient had undergone hysterectomy and bilateral adnexectomy for uterus myomatosous in September 2015, where an IVL limited to the veins of the uterus and the right adnex had been diagnosed. No further medical treatment had been implemented. IVL of the inferior vena cava was diagnosed when a CT scan of the abdomen was performed due to an infected abdominal seroma in June 2016. Although histologically benign, we found this case of IVL to be clinically aggressive because of its expansion to the heart. This may lead to thromboembolic complications (e.g. pulmonary embolism) or signs of right sided cardiac failure. The patient was asymptomatic, but because of the extension of the intracaval thrombus to the heart, we decided to operate and performed thrombectomy via a median laparotomy. The patient left the hospital shortly after on newly started oral anticoagulation.

Discussion

For caval IVL without intracardiac attachment, the extraction via laparotomy without sternotomy is the treatment of choice. It calls for an interdisciplinary approach and careful surgical planning.

Conclusion

There is no inherent need for sternotomy in IVL extending to the right atrium. A one-year follow-up with sonographic control is advised. Medium term oral anticoagulation should be considered.

This work has been reported in line with the SCARE criteria Agha et al. (2016). The SCARE Statement: Consensus-based surgical case report guidelines. Agha RA, Fowler AJ, Saeta A, Barai I, Rajmohan S, Orgill DP; SCARE Group. Int J Surg. 2016 Oct;34:180-186 [1].

Incidental posterior mediastinal paraganglioma: The safe approach to management, case report

INTRODUCTION

Paragangliomas are neuroendocrine tumors arising from chromaffin cells located in sympathetic paraganglia. Mediastinal paragangliomas are extremely rare and can be classified as functional or non-functional according to their ability for secreting catecholamines. Patients can be asymptomatic and the diagnosis is usually incidental. Complete surgical resection remains the standard of care for paragangliomas.

PRESENTATION OF CASE

We present a 44-year-old woman with a functional mediastinal paraganglioma incidentally found during the perioperative imaging workup for a diagnosed breast carcinoma. Chest radiograph and computed tomography (CT) showed a well-defined lesion in the posterior mediastinum suspicious for an esophageal malignancy. Endoscopic and CT-guided biopsies were performed confirming the diagnosis of a neuroendocrine tumor. Laboratory studies showed elevated catecholamines and chromogranin A levels, consistent with a paraganglioma. Appropriate pre-operative management was done and successful surgical resection without catecholamine related complications was achieved.

DISCUSSION

The workup and treatment of incidentally discovered adrenal and extra-adrenal lesions are controversial. Because of the absence of symptoms and the wider differential diagnosis of extra-adrenal lesions, an attempt for biopsying and surgically remove these lesions prior to biochemical testing is not an uncommon scenario, although this could be potentially harmful. Surgeons should have an index of suspicion for catecholamine-secreting tumors and hormonal levels should be assessed prior to biopsy or surgical resection.

CONCLUSION

Surgeons should consider paragangliomas as a differential diagnosis for extra-adrenal lesions. Biochemical testing with catecholamines and chromogranin A levels should be performed prior to biopsy or surgical removal in order to avoid catastrophic complications.

Successful treatment of nonocclusive mesenteric ischemia after aortic valve replacement with continuous arterial alprostadil infusion: A case report

INTRODUCTION

Nonocclusive mesenteric ischemia (NOMI) after surgery has an extremely poor prognosis with a mortality rate of 30-100%. We report a patient with NOMI following aortic valve replacement who failed to improve despite continuous intra-arterial infusion of papaverine, but was successfully treated with alprostadil (prostaglandin E1 [PGE1]) infusion.

PRESENTATION OF CASE

The patient is a 77-year-old man who underwent aortic valve replacement. Due to elevated serum lactate levels five hours after intensive care unit admission, superior mesenteric arteriography was performed, establishing the diagnosis of NOMI. Although continuous intra-arterial infusion of papaverine was begun, lactate levels remained elevated. Repeat angiography and laparotomy revealed extensive ischemic changes of the intestine. The vasodilator was changed to PGE1, which improved arterial spasm. The patient ultimately needed an ileocecal resection, but the extent of the resection was limited with concomitant PGE1 administration.

DISCUSSION

In the present patient, although NOMI was unresponsive to appropriate treatment including intra-arterial infusion of papaverine, continuous intra-arterial infusion of PGE1 salvaged most of the intestine.

CONCLUSIONS

In a patient with recurrent NOMI despite appropriate treatment including intra-arterial infusion of papaverine, continuous intra-arterial infusion of PGE1 may limit the extent of intestinal resection needed. Continuous intra-arterial infusion of PGE1 may be a useful treatment for patients with refractory NOMI.

Hassab's operation for Joubert syndrome with congenital hepatic fibrosis: A case report

INTRODUCTION

Joubert syndrome is characterized by psychomotor developmental delay, hypotonia, oculomotor abnormalities, occasional retinal dystrophy and cystic kidneys, and frequent and often, striking breathing abnormalities, especially in the neonatal period, with panting tachypnea followed by apnea. We report a case of Joubert syndrome with hepatic fibrosis, portal hypertension, and pancytopenia treated by Hassab's operation.

PRESENTATION OF CASE

Our patient was a 27-year-old woman with a history of tachypnea, muscle hypotonia, and psychomotor retardation shortly after birth and a diagnosis of Joubert syndrome at 2 years of age. At 19 years of age, she was diagnosed with progressive pancytopenia. At 27 years of age, she visited her local doctor for sudden-onset hematemesis. Endoscopy revealed esophageal varices exhibiting the red color sign and no evidence of recent bleeding. Splenomegaly and development of portal collateral circulation were observed on computed tomography scans. The patient was referred to our hospital, where she was diagnosed with Joubert syndrome and hepatic fibrosis, portal hypertension, and hypersplenism. After performing Hassab's operation, the pancytopenia improved, but anticoagulant therapy was required for splenic vein thrombosis. The patient was discharged on postoperative day 25. Two years following surgery, the gastroesophageal varices were controlled, and no progression of the splenic vein thrombosis or hepatic failure was evident.

CONCLUSION

This is the first case report of Hassab's operation for congenital hepatic fibrosis in a patient with Joubert syndrome, a rare congenital condition. We achieved a favorable clinical outcome.

Endovascular repair of a ruptured thoracic aortic dissection with a right sided aortic arch: A case report

BACKGROUND

Emergency treatment of complex aortic pathology is challenging in the setting of a right-sided aortic arch. We report the successful treatment of a ruptured thoracic aortic aneurysm (TAA) in the setting of a Stanford type B aortic dissection (TBAD) and right-sided aortic arch.

PRESENTATION OF CASE

The patient is a 66-year-old male with chronic kidney disease (CKD) admitted with right sided chest pain and hypotension. Computed tomography angiography (CTA) revealed a 5cm ruptured TAA in the setting of a TBAD and right-sided aortic arch. The TBAD began just distal to the right common carotid artery and involved the origin of the left subclavian artery (SCA). Using a totally percutaneous approach, a conformable Gore^® TAG^® thoracic endoprosthesis was placed in proximal descending thoracic aorta covering the left SCA. Aside from progression of his pre-existing CKD, the patient had an uneventful recovery. CTA one-month post-procedure revealed a type IB endoleak with degeneration of the distal descending thoracic aorta. To exclude the endoleak, the repair was extended distally using a Medtronic Valiant^® thoracic stent graft. The left subclavian artery was subsequently coil embolized to treat an additional retrograde endoleak. The patient has done well with no further evidence of endoleak or aneurysm expansion.

CONCLUSION

Right-sided aortic arch presents challenges in the emergency setting. CTA and post-processing reconstructions are very helpful. While the endoleaks prompted additional interventions, the end result was excellent. This case displays the importance of careful attention to detail and follow-up in these complicated patients.

Minilaparotomy without general anesthesia for the treatment of sigmoid volvulus in high-risk patients: A case series of 4 patients

•

Sigmoid colectomy under local anesthesia, with or without intravenous conscious sedation, is feasible.

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A minimally invasive technique that spares general anesthesia to high risk patients.

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Development of new surgical techniques will be important in an aging population.

Background

Sigmoid volvulus (SV) is a common cause of large bowel obstruction worldwide. Presenting symptoms can be nonspecific and varied amongst the elderly population, making medical and surgical management challenging. This population is at markedly increase risk of complications and mortality with surgery under general anesthesia. In this case series, we describe 4 cases of sigmoid volvulus in octogenarians.

Goals

To demonstrate that sigmoid colectomy under local anesthesia, with or without intravenous conscious sedation, is feasible and can be done safely and with a low rate of converting to a general anesthetic.

Results

Four patients, mean age 90 years, were admitted a total of 4 times for acute sigmoid volvulus. All patients had serious comorbidities and were classified as ASA III. There was no relevant past surgical history. All patients were severely physically deconditioned but alert and able to interact meaningfully with their families and caregivers. Three patients suffered recurrent volvulus following endoscopic decompression and one patient underwent immediate surgery due to abdominal tenderness.

Conclusion

Our experience demonstrates that minilaparotomy for sigmoid volvulus is effective and safe. The techniques and can extend the applicability of definitive surgical intervention to this high-risk population of patients. In our series postoperative outcomes were excellent, however, additional studies are needed to determine if this technique results in improved 30-day and long-term mortality and morbidity in high-risk patients and to determine the utility of extending the technique to all patients with sigmoid volvulus.

Segmental arterial mediolysis with 5 splenic artery aneurysms. A rare finding of a rare disease: Case report and literature review

•

The article represents SAM in SAA which is a rare finding in a rare disease and due to the paucity of sample of cases there is no standardization in the management.

•

SAM should be suspected when multiple aneurysms are found in the same anatomic site.

•

Angiography is important to detect adjacent involvement. CT angiography of brain should be done to rule out distal vascular disease.

•

Endovascular option is the first choice but sometimes it is not feasible, in this case was excluded due to anatomical and configuration reasons.

Introduction

Splenic artery aneurysms (SAA) are uncommon findings. They are usually single and isolated; however they can be multiple; hence vasculopathy and segmental artery mediolysis may be considered.

Presentation of case

In our manuscript we present a case of a 54 year old multiparous lady who was discovered incidentally to have a diseased splenic artery containing five SSAs. The largest aneurysm was close to the takeoff of the vessel and the smallest was distal embedded in the splenic hilum. Endovascular option was technically not feasible. Therefore the patient underwent a complete splenic artery resection with splenectomy and the histopathologic examination was suggestive of segmental arterial mediolysis (SAM).

Discussion and conclusion

Multiple SAAs remains a rare finding of a rare disease. Complications can be crucial and high index of suspicion is important. Segmental arterial mediolysis can be considered in patients with several aneurysms on one anatomic site; Angiography is the gold standard diagnostic and therapeutic method. Complete splenic artery resection with splenectomy is the best treatment option for solitary vessel involvement.

Large bronchogenic cyst of stomach: A case report

INTRODUCTION

Bronchogenic cysts are congenital cysts arising as an abnormal budding from primitive tracheobronchial tree. They are lined by pseudostratified columnar or cuboidal ciliated epithelium and contain smooth muscle fibers, submucosal bronchial glands and/or cartilage. They are most frequently located in the mediastinum or the lung parenchyma. Intramural occurrence of bronchogenic cyst in the gastric wall is very rare.

PRESENTATION OF CASE

We present a case of 65-year-old lady with a 7×8cm lesion in the gastric cardia suspicious of gastrointestinal stromal tumor. Because of the large size, total gastrectomy with Roux-en-Y esophagojejunal anastomosis was performed. The postoperative course was uneventful. Histopathological examination revealed a sub-mucosal cyst lined by PCCE with presence of smooth muscle fibers and focal mucous glands. Final diagnosis of bronchogenic cyst was made. On the last follow up at one year, she was symptom free.

DISCUSSION

On extensive Medline/Pubmed search, only 38 cases of gastric bronchogenic cysts were found to be reported till date. They are typically located in the posterior gastric wall close to the gastric cardia. On radiological imaging, they appear as well defined intramural cystic lesion without any characteristic features. Surgical resection is considered in symptomatic cases or in case of diagnostic dilemma.

CONCLUSION

Gastric bronchogenic cysts often mimic gastrointestinal stromal tumor on preoperative imaging. They should be included in the differential diagnosis while dealing with an intramural gastric lesion close to the cardia or gastroesophageal junction.

Concomitant unilateral post-traumatic leg and foot compartment syndrome in a 5 years-old child - Case report

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Concomitant leg and foot compartment syndrome in a child.

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5 years old male child with leg trauma and significant swelling.

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Examination finding and radiological evaluation.

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Surgical treatment and fracture fixation.

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Intra-operative finding.

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Post-operative fasciotomy wound care.

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Secondary closure and follow up.

Background

Compartment syndrome is one of the most serious orthopedic emergencies [4]. It is usually anticipated and looked at in every single orthopedic case. Early recognition and management of those cases are quite important in order to avoid the devastating consequences of such condition.

Case summary

This is a case report of a 5 years old child with concomitant unilateral leg and foot compartment syndrome after a roll over trauma. The patient was presented with significant leg and foot swelling, severe pain and absent distal pulses. He was rushed to operative theatre where compartments decompression and fracture fixation were performed. Vac dressing and secondary closure followed the primary treatment. Post-operatively, the patient improved in a good way with no heeling complications or functional deficits.

Conclusion

Compartment syndrome in children is a serious complication that can occur after trauma, high index of suspicion is crucial to start early management and to avoid complications. This injury can occur in un-fractured limb and in more than one site at the same time.

An Appendiceal Carcinoid Tumor within an Amyand's Hernia Mimicking an Incarcerated Inguinal Hernia

Introduction. We report the case of an appendiceal carcinoid tumor within an Amyand's hernia, presenting as an incarcerated right inguinal hernia. Presentation of Case. A 52-year-old male presented in the emergency department due to a persistent right inguinal pain. Clinical examination revealed a tender right groin mass. Laboratory tests revealed leukocytosis and an increased serum CRP. Under the diagnosis of an incarcerated right inguinal hernia, an emergency operation was taken. Intraoperatively, an inflamed appendix and a part of the cecum were found in the hernia sac. The operation was completed with an appendectomy and a modified Bassini hernia repair. Histological examination revealed a carcinoid tumor, resulting in the performance of a right hemicolectomy. Discussion. Amyand's hernia is estimated to account for 0.4% to 0.6% of all inguinal hernias. Coexistence of an Amyand's hernia and a neoplasia is quite rare. Carcinoids are the most frequent tumors found in the appendix, with the size of the primary tumor to be considered the most important prognostic factor and the basis upon which the operative plan is decided. Conclusion. A malignancy of the appendix should always be in the differential diagnosis of a right inguinal mass, in order to provide optimum surgical treatment.

A rare case of congenital bronchoesophageal fistula in an adult

INTRODUCTION

When congenital bronchoesophageal fistulas exist without atresia of the esophagus, the diagnosis can be delayed, although symptoms may occur early following fistula development. Therefore, while they are usually found in infants, they can be extremely rarely found in adults. We herein report a rare case of bronchoesophageal fistula without atresia in an adult.

CASE

An 69-year-old male presented to the outpatient clinic with a decades-long history of cough with expectoration immediately after taking food, especially liquids. Computed tomograph, esophagoscopy, and esophagography revealed the fistulous communication between the mid-esophagus and right lower lobe bronchus, with consolidation in the right lower lobe. We performed right lower lobectomy with the closure and excision of the fistula. The histopathology of the fistula revealed the mucosa to be lined by stratified squamous epithelium. There was no evidence of inflammation, granuloma, or carcinoma.

CONCLUSION

In conclusion, despite the benign nature of this malformation, if left untreated, it can cause long-term debilitating respiratory symptoms associated with the fistula. Therefore, the diagnosis should be considered in the evaluation of recurrent lung infection.

Metaplastic breast carcinoma with osseous differentiation: A rare case report

INTRODUCTION

Metaplastic breast carcinoma (MBC) is a rare type of breast cancer. Osseous differentiation is a very rare subtype. Reporting this kind of case is important because its clinical course and line of management are poorly mentioned in the literatures. We present a very rare case of MBC with osseous differentiation. A 48-year-old female presented with painless hard mass of the left breast. Examination and investigations showed MBC with osseous differentiation. She was managed by operation with adjuvant chemotherapy.

CONCLUSION

MBC with osseous differentiation is a very rare type of breast carcinoma presenting with hard mass and managed by mastectomy, axillary lymph node sampling and adjuvant chemotherapy.

From tooth extraction to Gorham-Stout disease: A case report

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Gorham-Stout disease (GSD) is a very rare idiopathic bone disorder characterised by spontaneous and progressive osteolysis, associated with angiomatous proliferation and soft tissue swelling without new bone formation.

•

The clinical presentation of GSD includes pain, functional impairment, and swelling, although a few asymptomatic cases have been reported, similar to our case.

•

We present this rare case of GSD with several localisations to emphasise that any procedure appearing to be simple can go catastrophically wrong and can result in the discovery of something that is unexpected and extremely rare.

•

We wish to emphasise the extreme rarity of the case, focusing on the large difference between the preoperative panoramic radiograph and whole-body CT and MRI images obtained on the day after the first surgical procedure.

Introduction

Gorham-Stout disease (GSD), or vanishing bone disease, is a very rare condition of unknown aetiology. It is characterised by progressive osteolysis and angiomatosis.

Case presentation

We report the discovery of this very rare disease following a trivial deciduous tooth extraction in a 14-year-old female. We focus initially on the difference between the preoperative orthopantomography and the whole-body computed tomography and magnetic resonance images obtained post-haemorrhage, and then on the improvement of strategies for the correct diagnosis and treatment of this disease.

Discussion

Bone loss and the proliferation of vascular structures can occur in a single bone or spread to soft tissue and adjacent bone; areas commonly affected by GSD include the ribs, spine, pelvis, skull, clavicle, and the maxillofacial area. The clinical presentation of GSD includes pain, functional impairment, and swelling, although a few asymptomatic cases have been reported, similar to our case.

Conclusion

We report a very rare case of this multicentric disease in an asymptomatic child who presented for dental extraction, almost died, and was then diagnosed with and treated for GSD.

Laparoscopic resection of sigmoid colon cancer with intestinal malrotation: A case report

•

Intestinal malrotation accompanied by colon cancer is extremely rare.

•

Laparoscopic resection of a sigmoid colon cancer with intestinal malrotation was performed without difficulty using the usual trocar placement.

•

Attention should be paid to a variation in vascular anatomy.

Introduction

Intestinal malrotation is a congenital abnormality which occurs due to a failure of the normal 270° rotation of the midgut. The non-rotation type is usually asymptomatic and discovered incidentally on imaging studies. Intestinal malrotation accompanied by colon cancer is extremely rare.

Presentation of case

A 53-year-old male presented with postprandial abdominal discomfort. Colonoscopy showed a 14 mm polyp in the sigmoid colon and endoscopic polypectomy was performed. Pathological evaluation revealed an adenocarcinoma invading the submucosa more than 1000 μm with positive vertical and horizontal margins. A contrast enhanced computed tomography scan showed an anatomic variant of the ileocolic and inferior mesenteric arteries originating from a common channel branching from the abdominal aorta. Laparoscopic sigmoid colon resection was performed. The patient did well post operatively.

Discussion

The usual trocar placement for laparoscopic left side colectomy was used, and we found no difficulties intraoperatively. To secure safe ligation, the divisions of the common channel branching from the abdominal aorta were exposed as in a usual D3 dissection, and the inferior mesenteric artery was ligated after confirmation of the bifurcation of the ileocolic and inferior mesenteric artery.

Conclusion

To the best of our knowledge, this is the first report of laparoscopic resection of a sigmoid colon cancer with intestinal malrotation. It was performed without difficulty using the usual trocar placement, with appropriate attention to the variant in vascular anatomy.

Congenital absence of vas deferens and ectopic kidney

INTRODUCTION

Congenital absence of the vas deferens (CUAVD) is a rare clinical entity, usually discovered accidently during surgical procedures of the urogenital zone, CUAVD has the prevalence of 0.5-1.0% in male population and it is associated with various forms of congenital genitourinary malformations like renal agenesis. we present a case of a 21 years old, male, managed in our private hospital for varicoceles and discovered to have CUAVD and ectopic kidney.

PRESENTATION OF CASE

A 21 years old male, with no significant medical or surgical history presented to our out-patient clinic complaining of scrotal heaviness and pain. upon physical examination he was discovered to have a bilateral varicocele and was scheduled for a bilateral varicocelectomy, during the procedure he was discovered with left side CUAVD.

DISCUSSION

Congenital unilateral absence of the vas deference is a very rare clinical entity in the male population it has an incidence of 0.5-1.0%. it is usually discovered during evaluation for infertility or surgical procedures of the urogenital zone. Unilateral congenital absence of the vas deference is more associated with renal agenesis (73.3%), compared to the bilateral form (11.8%)_. CAVD is responsible of 1-2% of male infertility.

CONCLUSION

Congenital absence of the vas deference is a unique clinical entity due to its great association with a large variety of urogenital abnormalities, we present this case to stress the importance of including scrotal examination in the routine physical exam to reduce the late diagnosis of such abnormality and it associated comorbidities.

A single thyroid nodule revealing early metastases from clear cell renal carcinoma: case report and review of literature

INTRODUCTION

We report the case of an incidental solitary renal cancer cell (RCC) thyroid metastatic nodule treated by thyroidectomy.

PRESENTATION OF CASE

A 53 year male presented with a solitary, asymptomatic thyroid nodule. He was treated with left nephrectomy 1 year before for a RCC. Radiological standard follow-up was negative for secondary lesions but ultrasound (US) 12 months after surgery revealed a 1.5cm solid nodule in the right lobe of the gland. Fine needle aspiration biopsy (FNAB) was inadequate and the patient was submitted to total thyroidectomy. Histology showed the presence of solitary metastasis from RCC. At 2 years follow-up, no evidence of recurrence has been found.

DISCUSSION

Solitary RCC metastasis to the thyroid usually occurs late from nephrectomy and have no specific US pattern. When FNAB provides an uncertain cytological results, the patient received thyroidectomy for primary thyroid tumors and diagnosis of metastases from RCC was incidentally made.

CONCLUSION

Thyroid nodules in a patient with history of malignancy can pose a diagnostic challenge. The presence of a solitary thyroid nodule in a patient with history of RCC should be carefully suspected for metastasis. We suggest to extend at neck the thorax and abdomen CT scan routinely recommended during the follow-up in high-risk cases. Thyroidectomy may result in prolonged survival in selected cases of isolated thyroid metastasis from RCC.

A case of abdominal enteric cyst in China

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This article introduces A case of abdominal enteric cyst in china. Patients have been successfully operated.

To investigate a case of abdominal enteric cyst in China. The patient was admitted to the china-Japan Friendship Hospital of Jilin University, which was due to intermittent pain in the left side for the last 4 months. In this surgery, CT was used to diagnose the basic condition of the patient. Surgery was used for Treatment of patients with diseases. As soon as patients have been successfully operated by laparoscopic surgery.

Superior mesenteric artery syndrome: A diagnosis to be kept in mind (Case report and literature review)

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Superior mesenteric artery syndrome is rare cause of duodenal obstruction.

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Superior mesenteric artery syndrome is caused by narrowing of aortomesenteric angle.

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High index of suspicion is needed for diagnosis.

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Most common cause is significant weight loss.

•

Simple Contrast enhanced CT scan can help in reaching diagnosis.

Introduction

Superior mesenteric artery (SMA) syndrome or what is called Wiklie’s syndrome is one of the rare causes of small bowel obstruction. Its exact incidence is not known. It is due to decrease in Aortomesenteric angle.

Case presentation

A thirty-Four-year old male patient presented to our accident and emergency (department) with 3 days history of epigastric pain, which was not radiating anywhere. It had no aggravating or relieving factors. Patient complained of repeated attack of vomiting as well. Contrast enhanced Computed tomography (CT) showed duodenal obstruction caused by superior mesenteric artery compression on 3rd part of duodenum.

Discussion

Superior mesenteric artery syndrome (SMA) is one of the rare causes of small bowel obstruction. Incidence of superior mesenteric artery syndrome reported in literature is ranging from 0.1 to 0.3%. The most common cause is significant weight loss which leads to loss of retroperitoneal fat. Treatment usually is conservative but surgical intervention should be considered if that failed.

Conclusion

Superior mesenteric artery syndrome is a rare cause of intestinal obstruction but should be kept in mind. Persistent vomiting after history of weight loss should raise the suspicion of this diagnosis. Upper GI endoscopy may be necessary to exclude mechanical causes of duodenal obstruction. Contrast enhanced CT scan is useful in the diagnosis of superior mesenteric artery syndrome and can provide diagnostic information.

Intramuscular hemangioma causing periosteal reaction and cortical hypertrophy misdiagnosed as osteoid osteoma

•

We report a case of intramuscular hemangioma mimicking osteoid osteoma.

•

Magnetic resonance image (MRI) is the most precise diagnostic tool for the identification of soft-tissue mass adjacent to the bone.

•

Precise preoperative diagnosis is essential to avoid excessive surgery.

Introduction

Intramuscular hemangioma in the periosteal region is rare. Although comprising less than 1% of all hemangiomas, they represent the most common type of intramuscular tumors. When located adjacent to bone, a periosteal reaction can occur. The deep localization of the hemangioma poses the diagnosis difficult. Only 8% to 19% of cases were diagnosed before surgery according to the literature review.

Presentation of case

We present a case of forty-one-year-old female diagnosed with intramuscular hemangioma, mimicking osteoid osteoma, adjacent to the periosteal region of tibia diaphysis treated by surgical excision.

Discussion

When intramuscular hemangioma occurs nearby a bone structure, it can cause cortical, medullary and periosteal bone changes that are frequently misdiagnosed by plain radiography. Due to their infrequency, deep location, and atypical presentation, these lesions are seldom diagnosed at presentation. The hemangioma of the periosteal region can be locally destructive due to compression exerted on neighboring structures. It does not regress spontaneously, and surgical excision is frequently needed.

Conclusion

Intramuscular hemangioma of periosteal region occurs most commonly adjacent to long bones of the lower limb. They can cause hypertrophic periosteal reactions mimicking a periosteal or parosteal tumor. Although osteoid osteoma was considered in the differential diagnosis, MRI with enhancement should be performed to exclude intramuscular hemangioma. This may avoid unnecessary aggressive en-bloc tumor excisions resulting in bone weakness and prolonged rehabilitation.

This case report has been written in line with the SCARE criteria (Agha et al., 2016 [1]).

Trochanteric hip fracture during cardioversion therapy. A case report

•

The propofol sedation should be complemented with skeletal muscle relaxants in the cardioversion therapy to avoid hip fracture in select patients with osteoporosis.

•

Hip fracture in osteoporotic bones should be considered after muscle violent contraction that causes hip pain and functional impotence.

Introduction

Trochanteric hip fractures in elderly patients with osteoporosis are commonly caused by low energy trauma. The cardioversion therapy is an extremely rare cause of this type of fracture.

Presentation of case

We report the case of a woman with hip fracture after cardioversion.

Discussion

We discuss the production mechanism of this injury and the importance of the care of the osteoporotic bone under these therapies.

Conclusion

The propofol sedation should be complemented with skeletal muscle relaxants in the cardioversion therapy to avoid hip fracture in select patients with osteoporosis.

Acute large bowel pseudo-obstruction due to atrophic visceral myopathy: A case report

PURPOSE

Atrophic visceral myopathy is a pathological diagnosis characterized by atrophy of the smooth muscle layers of the viscera with intact ganglia. Rarely, it can present acutely as an intestinal pseudo-obstruction. We describe a rare case report and explore how this diagnosis can be distinguished from other forms of intestinal obstruction.

CASE DESCRIPTION

A 60-year-old male with a past medical history of hypothyroidism presented to the emergency department with a two-day history of worsening abdominal distention and pain associated with nausea and vomiting. Upon evaluation patient was found to have tachycardia, with abdominal distention and localized tenderness with peritonitis. Computed tomography demonstrated large bowel obstruction, likely caused by sigmoid volvulus. The patient underwent emergent laparotomy. Intra-operatively, the entire colon was found to be extremely dilated and redundant. With a working diagnosis of recurrent sigmoid volvulus causing intermittent large bowel obstruction, a sigmoid colectomy and primary anastomosis was performed. Pathology revealed atrophic visceral myopathy, with an extremely thin colonic wall and atrophic circumferential and longitudinal muscularis propria without inflammation or fibrosis. The ganglion cells and myenteric plexus were unaffected. Post-operatively, the patient developed prolonged ileus requiring nasogastric decompression and parenteral nutrition. The ileus resolved with pro-kinetic agents, and patient was discharged home on post-operative day fifteen.

CONCLUSIONS

Atrophic visceral neuropathy is a rare cause of intestinal pseudo-obstruction. While often presenting with chronic obstruction in younger populations, we present a rare late-onset acute presentation that may have been secondary to underlying hypothyroidism.

Resection and reconstruction following recurrent malignant phyllodes-Case report and review of literature

INTRODUCTION

Phyllodes tumors are uncommon biphasic fibroepithelial neoplasms of the breast of varying malignant potential occurring in middle aged women. They exhibit diverse biological behavior. Margin free excision is the mainstay of treatment.

CASE PRESENTATION

A 27 year-old lady was referred with a painless ulceroproliferative right breast lesion which had rapidly progressed over six months. Three years back, she had been diagnosed with a borderline phyllodes tumor and underwent a wide local excision followed by a right mastectomy for recurrence. The resection margins were positive hence she underwent postoperative radiation. We performed a radical resection of the chest wall and reconstruction using a composite mesh (inner PTFE and outer vypro), pedicled latissimus dorsi flap and a split skin graft for the recurrent malignant tumor. She recovered uneventfully thereafter.

DISCUSSION

Malignant phyllodes tumor is uncommon and treatment principles are from case reports and retrospective studies. Aggressive resection of the lesion and reconstruction of the chest wall with bone cement and two meshes-a composite mesh (inner layer -polytetrafluroethylene and outer layer of polypropylene) and a Vypro mesh is a possibility. This case highlights the challenges encountered in managing these patients and presents a radical solution.

CONCLUSION

Treatment of phyllodes tumor necessitates adequate excision of the tumor and adjacent tissues to ensure tumor free margins. Pathological evolution from intermediate to malignant histology may be exhibited. A full-thickness chest wall resection and reconstruction although radical is a feasible option as these tumors rarely respond to other modalities of cancer management.