Mucocele complicating stapled hemorrhoidopexy

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Mucocele is a variant of rectal pocket.

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Mucocele is a rare complication after stapled procedure.

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Mucocele has problems of differential diagnosis with paraectal lesion, especially abscess.

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It is usually treated with transanal approach.

Introduction

Stapled hemorrhoidopexy is a safe and effective treatment for circumferential hemorrhoidal prolapse. The overall rate of complications ranges from 12,7% to 36,4% and the surgeon should be aware about their early identification and adequate treatment.

Presentation of case

Female patient, 57 years was treated with stapled hemorrhoidopexy. Two years after surgery she reported to our center the occurrence of perineal discomfort, anal spasm and tenesmus. The anal exploration showed a bulge of the right lateral wall of the rectum at the level of stapled line without any related pain. 3D 360° transanal ultrasound showed a pararectal fluid collection. A surgical operation was performed and a great amount of mucus was drained. After one year the patient is completely asymptomatic with normal defecation.

Discussion

Mucocele is a rare complication which usually occurs after months from the operation and it is considered a variant of rectal pocket and it is usually completely separated from the rectal lumen at the level of stapled line. The differential diagnosis between mucocele and pararectal lesions, especially abscess may be often difficult. Surgery is the treatment of choice with a transanal approach that is generally preferred to the trans-perineal.

Conclusion

Mucocele is a rare complication of stapled hemorrhoidopexy that may remain asymptomatic for a long period. In case of perineal discomfort after stapled procedure the physical examination combined with 3D 360° transanal ultrasound is necessary to reach the diagnosis. The knowledge of the possible rare complications is at the base of a correct treatment.

Life threatening presentation of thoracic duct injury post thyroid surgery; a case report

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Injury to thoracic duct, and the formation of chyle leak, is a rare complication and carries significant metabolic and immunological consequences.

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Thoracic duct injury during thyroid surgery is an uncommon event with an incidence rate of 0.5–1.8%.

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High output chyle leak in a confined space was life threatening.

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Surgeons must be familiar with thoracic duct anatomy.

Background

Injury to thoracic duct is a rare potential complication of time-honored conventional thyroidectomy. Nevertheless, it can be a cause of significant morbidity, and sometimes life-threatening.

Patient findings

A 78-year-old female patient with a previous surgical history of thyroid lobectomy for nodular disease presented with primary hyperparathyroidism, and a nodule in the remaining thyroid lobe. The patient underwent completion thyroidectomy and parathyroidectomy. Less than 24 h post operatively, the patient developed progressive shortness of breath and neck swelling requiring immediate intubation and re-exploration. A large amount of chyle was drained and an injured thoracic duct was identified and ligated.

Summary

In experienced hands thyroid surgery is safe. Nevertheless, factors such as the type of pathology and its extent, the level of surgery, and re-operative surgery increase the risk of postoperative complications. Immediate surgical exploration is necessary when patients present with neck swelling and respiratory distress. In our case, a high output chyle leak in a confined space was life threatening.

Conclusion

Timely re-exploration following thyroid surgery and thorough knowledge of the anatomy of neck structures is crucial in sparing patients potential morbidity and/or mortality.

Haemorrhagic gastritis following Gastrografin administration for adhesive small bowel obstruction: A case report of a rare outcome

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First reported case of haemorrhagic gastritis post Gastrografin for adhesive SBO.

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Gastrografin is proven to be effective and generally safe in adhesive SBO.

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Caution may be warranted when considering Gastrografin in patients at risk of gastropathy.

Introduction

Adhesive small bowel obstruction (ASBO) is common after abdominal surgery. Water soluble contrast agents (WSCA) such as Gastrografin have been demonstrated to be safe and effective in predicting resolution of ASBO with conservative management while decreasing the time to resolution, decreasing the need for surgery and reducing overall length of stay. Few adverse effects have been reported. To the authors knowledge this is the first report of haemorrhagic gastritis following administration of Gastrografin for ASBO.

Presentation of case

We present a case of haemorrhagic gastritis following Gastrografin administration in a 69-year-old male with adhesive small bowel obstruction who was managed conservatively with a good outcome. The report complies with the criteria outlined in the SCARE statement (Product Information Gastrografin [Product information], 2013).

Discussion

The characteristics, mechanism of action, safety profile and efficacy of Gastrografin in ASBO are discussed along with the possible mechanisms underlying the haemorrhagic gastritis.

Conclusion

This patient at high risk of gastropathy experienced haemorrhagic gastritis following administration of Gastrografin for adhesive small bowel obstruction. WSCA such as Gastrografin are usually safe and effective in ASBO however caution may be warranted in patients at high risk of gastropathy.

A rare case of a strangulated Littre's hernia with Meckel's diverticulum duplication. Case report and literature review

INTRODUCTION

The Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract present in approximately 1-4% of the population; the MD duplication is exceedingly rare with only a few reports of it. Here we present the firs case of a strangulated Littre's hernia with MD duplication.

PRESENTATION OF CASE

A 30-year-old male presented to the emergency room with clinical signs of small bowel obstruction, at physical examination, a right incarcerated inguinal hernia with erythema was found. We did a laparotomy, and two MD were found, one in the sac with ischemia, and the other 90cm from the Bahuińs valve. A diverticulectomy of the ischemic diverticulum was done, and the other MD was left in place; the inguinal region was repaired with a Lichtenstein technique.

DISCUSSION

The complications of the MD are 3-4 times more frequent in men, been an intestinal obstruction, hemorrhage, diverticulitis, ulceration, and perforation. A Littrés hernia is when the MD is found in the sac; this is seen in the inguinal region in 50% of the cases. The management of a Littre's hernia is the resection of the MD; it could be done by an intestinal resection or by a diverticulectomy accordingly to the Park criteria.

CONCLUSION

As to our knowledge, this is the first case of an incarcerated Littre's hernia with duplication of a Meckel's diverticulum.

Giant leiomyosarcoma of the rectum with lymph node metastasis: A case report and review of the literature

INTRODUCTION

Leiomyosarcoma of the gastrointestinal tract is very rare, with a reported frequency of less than 0.1% of all malignancies of the colorectum. It is important to diagnose leiomyosarcoma definitively by immunohistochemical profiling of smooth muscle actin, desmin, and CD34. True leiomyosarcoma of the colorectum diagnosed by immunnohistochemical profiling is extremely rare that only 13 reports have been published in reviews of resected gastrointestinal mesenchymal tumors after 1998. In addition, lymph node involvement is rare in patients with leiomyosarcoma. Herein we report an aggressive case of LMS in a rectosigmoid lesion with lymph node metastasis.

CASE PRESENTATION

A 76-year-old woman visited our hospital complaining of intermittent anal bleeding that had lasted 5 months. Image studies aiming at examining the cause of her anal bleeding revealed a tumor located between the right ovary, uterus, and the rectosigmoid. Histopathology of biopsied materials from the colonoscopy suggested a malignant tumor of mesenchymal origin. Surgical resection was performed with curative intent. The tumor was diagnosed as leiomyosarcoma by pathological examination. Moreover, one of the 31 regional lymph nodes retrieved was metastasized by leiomyosarcoma. Eight months later, follow-up CT scans revealed multiple recurrent lesions in the liver and peritoneum. Despite systematic chemotherapy, she deceased 12 months after the surgery.

CONCLUSION

It is crucial to diagnose leioyosarcoma precisely based on immunohistochemistry, and thereby distinguish it from GIST. Although lymph node metastasis is rare, lymphadenectomy appears to be important for high-risk LMSs to perform R0 resection. Further investigation on leiomyosarcoma cases so far is required to establish standard treatment strategies.

Thoracoscopic enucleation in the left decubitus position for leiomyoma of the upper thoracic esophagus: Utility of preoperative diagnosis applying endoscopic ultrasound-guided fine needle aspiration

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We report a case of esophageal leiomyoma enucleated by thoracoscopic procedures.

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Preoperative EUS-FNA is useful to decide the operative procedure.

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Preoperative EUS-FNA does not adversely influence subsequent enucleation.

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Precise preoperative diagnosis is necessary to avoid excessive surgery.

Introduction

We report a relatively rare case of esophageal leiomyoma in the upper thoracic esophagus enucleated by thoracoscopic procedures. The usefulness of preoperative diagnosis and an adequate surgical approach are described along with a review of the relevant literature.

Presentaion of case

A submucosal tumor 45 mm in diameter was detected in the upper thoracic esophagus of a 69-year-old man. The tumor was preoperatively diagnosed from histopathological biopsy under endoscopic ultrasound-guided fine needle aspiration. Thoracoscopic enucleation was therefore preoperatively scheduled under the left decubitus position in consideration of the low risk of malignant disease. Histopathological diagnosis of the resected specimen was benign leiomyoma and patient outcomes were good.

Discussion

The need for preoperative biopsy of esophageal submucosal tumor is a controversial issue. However, preoperative biopsy provided the benefits to decide the operative procedure or confirm adequate resection, and our experience suggested that preoperative biopsy did not adversely influence subsequent enucleation.

Conclusion

Precise preoperative diagnosis is necessary to avoid excessive surgery when managing esophageal submucosal tumor.

Modified Masquelet technique using allogeneic umbilical cord-derived mesenchymal stem cells for infected non-union femoral shaft fracture with a 12 cm bone defect: A case report

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A case of infected non-union fracture with critical-sized bone defect.

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Modified Masquelet technique was used to overcome the defect.

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The addition of allogenic UC-MSCs, BMP-2 and hydroxyapatite encourages healing.

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This technique may serve as an effective way to overcome large defects.

Introduction

Non-union due to large bone loss often causes significant long-term morbidity. We incorporate the use of allogeneic umbilical cord-derived mesenchymal stem cells (UC-MSCs) as part of the diamond concept of regenerative medicine in a case of infected non-union fracture.

Presentation of case

We reported a 54-year-old female patient presenting with pain on the right thigh. She was previously diagnosed with a closed fracture of the right femoral shaft and underwent four surgeries before finally being referred to Dr. Cipto Mangunkusumo General Hospital with infected non-union of the right femoral shaft. The patient was treated with a combination of UC-MSCs, bone morphogenetic protein-2 (BMP-2), Hydroxyapatite (HA), and mechanical stabilization using Masquelet Technique. The combination of allogeneic MSCs, BMP2, HA, and Masquelet Technique was successful in creating new bone with no apparent side effects.

Discussion

Bone loss might be caused by external factors (true defects), or structural loss of the existing bone. The combination of allogeneic UC-MSCs, BMP-2, HA and an induced membrane technique pioneered by Masquelet allowed for faster regeneration process and more optimal bone healing. This paper aims to assess and compare the result of such procedures with the previous four surgeries done to the patient, which did not yield satisfactory results.

Conclusion

The application of allogeneic UC-MSC, BMP-2, HA and Masquelet technique as proposed in the diamond concept is a viable method in treating critical-sized bone defect and provides an effective way to overcome non-union caused by large defect.

Gallstone-related abdominal cystic mass presenting 6 years after laparoscopic cholecystectomy: A case report

INTRODUCTION

Although gallbladder perforation and gallstones spillage are common complications during laparoscopic cholecystectomy (LC), clinically significant complications resulting from stones left in the peritoneum are extremely uncommon. We report a rare case of spilled gallstones complication with a late and uncharacteristic presentation.

PRESENTATION OF THE CASE

A 44-year-old Caucasian female presented with a complaint of a mass in the right upper quadrant associated with a cramping pain for the last 6 months. Her past surgical history included a laparoscopic cholecystectomy performed six years ago. Abdominal computed tomography demonstrated an intra-abdominal cystic mass. On open exploration, a cystic mass adhered to the abdominal wall was excised containing two gallstones. The patient tolerated the procedure well and had uneventful postoperative recovery.

DISCUSSION

Although unretrieved gallstones are considered harmless, serious complications can occur early or late. The most frequent complication is the formation of abscesses in different locations.

CONCLUSION

The diagnosis of gallstone abscess after years of LC is usually a diagnostic challenge. Obtaining a comprehensive past surgical history still plays an important role in the assessment of patients presenting with unusual findings.

A rare case of acute osteomyelitis due to Panton-Valentine leukocidin-positive community-acquired methicillin-resistant Staphylococcus aureus in a young healthy adult

INTRODUCTION

Most community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections affect skin or soft tissues, while invasive and life-threatening illnesses including osteomyelitis are less common. CA-MRSA infections occur especially in the pediatric age group, while the occurrence of CA-MRSA osteomyelitis in adults is uncommonly reported.

PRESENTATION OF CASES

A rare case of acute osteomyelitis of the femur caused by Panton-Valentine leukocidin (PVL)-positive CA-MRSA in a 37-year-old man in good health is presented. A pure bone biopsy revealed extensive inflammation, suggestive of acute osteomyelitis, with no evidence of neoplasm, and PVL-positive MRSA was isolated from the culture. Antibiotic treatment, with 6 weeks of intravenous vancomycin and 4 weeks of clindamycin, followed by 2 weeks of oral linezolid, was given, and 2 years after treatment completion, there has been no relapse of infection.

CONCLUSION

This case strongly suggests that we need to be aware of CA-MRSA osteomyelitis, which requires a high level of suspicion, prompt diagnosis, and appropriate antibiotic treatment.

Epidural lipomatosis with cauda equina syndrome in chronic alcoholic patient: A case report

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Case of epidural lipomatosis with cauda equina syndrome in chronic alcoholic patient is provided.

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Posterior decompression was applied and neurologic deficit was significantly recovered.

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MRI is the best imaging tool of choice. Short T1 inversion recovery (STIR) sequence may be useful for confirmation of diagnosis as lipid is hypointense in this sequence.

Introduction

Epidural lipomatosis of the lumbar spine is a rare condition, which is described as the accumulation of fat in the extradural territory.

Presentation of case

We report the case of a 60-year-old, non-obese, and chronic alcoholic man who was transferred to our spine department with cauda equina syndrome (CES) for 4 months. On magnetic resonance imaging (MRI), spinal epidural lipomatosis (SEL) was confirmed in the multilevel lumbar lesion. A decompression surgery was performed and the patient recovered significantly.

Discussion

The patient was not obese, had no abnormal liver laboratory test results, and no history of steroid injection or administration. The clinical signs at onset suggested bilateral lower cauda equina dysfunction, indicating a more diffuse involvement, consistent with lumbosacral epidural lipomatosis.

Conclusion

This case report is the first description of SEL in a non-obese, chronic alcoholic patient who was neither receiving steroids nor had any kind of endocrinopathy.

A case report of thoracic endometriosis - A rare cause of haemothorax

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The diagnosis of thoracic endometriosis is complicated, because it has no specific symptoms and signs, and often delayed. TES should be suspected in a reproductive age woman with exacerbating symptoms during the menstruation.

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TES treatment should be started with medicine. If medical therapy fails, surgical treatment should be performed.

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Our case report shows that TES may be the cause of dangerous situation when an urgent operation must be performed. It is the first case of TES that has required urgent surgical treatment in our hospital in past fifteen years. Not all clinicians know that TES sometimes might complicate to pneumothorax or massive bleeding, which might cost a patient’s life. We suggest performing VATS as soon as possible for reproductive age woman with unknown aetiology of pneumothorax or haemothorax to find out the lesions in pleural cavity and start appropriate treatment on time.

Introduction

The presence of endometrial tissue in airways, pleura and lung parenchyma is called thoracic endometriosis syndrome (TES). It is a rare pathology, and typically consists of catamenial pneumothorax, haemothorax, haemoptysis, and pulmonary nodules. We report a case of a 36-year-old woman with thoracic endometriosis causing catamenial haemothorax.

Conclusions

The diagnosis of thoracic endometriosis is complicated and often delayed. TES should be suspected in a reproductive age woman with exacerbating symptoms during the menstruation.

Treatment may be medical and surgical.

Three-Port, Two Located on the Pfannenstiel Line, Laparoscopic Cholecystectomy Comparison with Traditional Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is seen as a gateway to minimally invasive surgery. We defined a new three-port technique with different port sites and compared the postoperative results with traditional four-port LC procedure in a case-match study. Between June 2012 and May 2013, 104 consecutive patients underwent three-port LC by same experienced surgeon. In the same center, 2963 consecutive patients underwent four-port LC, and of these 2963 patients, a matched group of 104 patients was selected. Data included patient age, gender, body mass index, American Society of Anesthesiologists score, history of abdominal operations, intraoperative data about operating time and conversion to open surgery, and postoperative data about length of hospital stay and postoperative complications were recorded prospectively. We concluded that our new three-port technique with different port sites is as feasible and safe as traditional four-port technique.

Sclerosing Encapsulated Peritonitis: A devastating and infrequent disease complicating kidney transplantation, case report and literature review

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Sclerosing encapsulating peritonitis is a rare and dangerous complication.

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Kidney transplanted patients with peritoneal dyalisis history are in risk of SEP.

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Adhesiolisis is the ideal surgical management for Sclerosing encapsulating peritonitis.

Introduction

Sclerosing Encapsulating Peritonitis (SEP) is a rare condition with an incidence of up to 3% and a mortality of up to 51% among peritoneal dialysis (PD) patients (Brown et al., Korte et al. and Kawanishi et al.). In the last ten years, the incidence of SEP in kidney transplant recipients has increased (Nakamoto, de Sousa et al. and Korte et al.).

Presentation of case

A 31-year old male with a 15 years history of PD and later kidney retransplantation was admitted to the emergency service after experiencing several weeks of diffuse abdominal pain which had escalated to include vomiting and diarrhea during the 24 h previous to admission.

The patient underwent an exploratory laparotomy where severe peritoneal thickening was found, in addition to signs of chronic inflammation and blocked intestinal loops. Histopathologic findings were suggestive of sclerosing peritonitis. After two months of treatment in hospital, the patient presented an obstructed intestine, with a rigid and thickened peritoneum compromising all the intestinal loops.

Discussion

Despite being rare, SEP, represents a significant complication due to its high mortality and recurrence. It is insidious in its early stages and culminates in an intestinal obstruction (Fieren). Risk factors for its development in kidney transplant recipients include a history of prolonged treatment with PD and the use of calcineurin inhibitors as an immunosuppressive treatment (Korte et al.).

Conclusion

Given the increase in the incidence of SEP in kidney transplant recipients, the clinician should be alert to the presence of this complication. A greater number of multi-centre studies are required to identify the risk factors for SEP that are inherent in renal transplant recipients.

Diagnosis of autoimmune pancreatitis with cholesterol granuloma mimicking intraductal papillary-mucinous carcinoma: A case report

INTRODUCTION

Pancreatic cysts are often observed incidentally on abdominal computed tomography (CT). For cysts involving intracystic nodules, malignant neoplasms such as intraductal papillary-mucinous carcinoma (IPMC) should be suspected. In contrast, cholesterol granuloma (CG) rarely occurs in the pancreas, and CG-associated autoimmune pancreatitis (AIP) has not yet been reported. To our knowledge, this is the first reported case of AIP with CG mimicking IPMC.

PRESENTATION OF CASE

A 56-year-old woman underwent abdominal CT for preoperative breast cancer screening. Asymptomatic polycystic lesions were detected in the pancreatic tail (maximum diameter, 5cm). Magnetic resonance cholangiopancreatography and endoscopic ultrasonography revealed main pancreatic duct obstruction and a lesion with intracystic nodules (maximum diameter, 10mm). Serum levels of pancreatic cancer tumor markers and IgG4 were within normal ranges. Because IPMC was suspected, distal pancreatectomy and splenectomy with regional lymphadenectomy were performed after surgery for breast cancer. Pathological examination of the specimen revealed no epithelial neoplasm; however, cholesterol crystals with foreign body giant cells were observed. Moreover, IgG4-positive plasma cells, diffuse lymphocyte infiltration, storiform fibrosis, and obliterative phlebitis were identified in the non-cystic pancreatic parenchyma. The final diagnosis was AIP with CG.

DISCUSSION

CG in the pancreas is rare and its pathogenesis remains unclear. The findings of the present case suggest that chronic inflammation due to AIP may cause local bleeding, and that a reaction to the leaked blood cells causes CG.

CONCLUSIONS

Although preoperative diagnosis may be difficult, AIP with CG should be considered as a differential diagnosis in pancreatic cysts involving nodular lesions.

Abdominal adhesions: A practical review of an often overlooked entity

Formation of intra-abdominal adhesions is a common consequence of abdomino-pelvic surgery, radiation therapy, and inflammatory processes. In a small but clinically significant proportion of patients, adhesive disease may develop, wherein adhesions lead to a variety of chronic symptoms such as abdominal distension, pain, nausea, and abnormal bowel movement pattern which can be daily, intermittent, or episodic. Due to the chronic and troublesome nature of these symptoms, adhesive disease may be life-altering in many patients, particularly when not recognized and appropriately addressed, as is the case not infrequently. In addition, there is a paucity of literature regarding the evaluation and management of patients with suspected abdominal adhesive disease. Therefore, in this concise review, we provide a clinically practical synopsis of the etiopathogenesis, symptoms, differential diagnosis, evaluation, and treatment of abdominal adhesive disease.

Solid pseudopapillary neoplasm-Case report of a rare pancreatic tumor

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Solid pseudopapillary neoplasm is a rare pancreatic tumor.

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Most patients are female and within the second or third decade of life.

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The radiologic features are crucial for an accurate diagnosis.

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Tumor size has not been shown to be a predictor of resectability.

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Surgical resection is the treatment of choice with an excellent long-term prognosis.

Introduction

Solid pseudopapillary neoplasm (SPN) is a rare pancreatic tumor. Most patients are female within the second or third decade of life with only a small minority concerning children. Frequently described as low malignant potential tumors, surgical resection remains the main treatment.

Presentation of case

The authors present a case of a SPN diagnosed in a 17-year-old Caucasian girl with vomiting and abdominal pain localized to the right upper quadrant. CT scans and MRI scans showed the presence of a well-defined tumor arising from the pancreatic head with 14 cm of greater diameter. Pylorus-preserving pancreatoduodenectomy was performed and histopathology confirmed a SPN with complete resection and no evidence of malignancy.

Discussion

SPN are usually found incidentally hence the importance of an accurate radiologic diagnosis. Symptoms may be present such as abdominal pain or vomiting due to compression, namely in large tumors. A surgical approach is usually indicated aiming complete resection, with tumor size not predicting resectability.

Conclusion

Solid pseudopapillary tumors of the pancreas are extremely rare and usually have an excellent long-term prognosis after surgical resection.

Longest gallbladder: A case report

INTRODUCTION

A gallbladder mucocele is the distention of the gallbladder by an inappropriate accumulation of mucus. Decreased bile flow, decreased gallbladder motility, and altered absorption of water from the gallbladder lumen are predisposing factors to biliary sludge. However, it is more likely to be a small part of a complex disease process involving inflammation of the gallbladder wall and changes to the lining of the gallbladder changing the consistency of its secretions. We would like to present a case of mucocele gallbladder operated successfully by laparoscopic cholecystectomy.

CASE REPORT

Herein, we present a case of 46year old female presenting with symptoms of pain in right hypochondrium with ultrasonographic diagnosis of cholelithiasis undergone successful laparoscopic cholecystectomy with Intraoperative findings of: 1. The length of the gallbladder was measured to be 30cm. 2. A large stone was impacted at the neck of gallbladder, which was leading to mucocele formation.

CONCLUSION

Mucocele of gallbladder present an important hurdle in successful laparoscopic cholecystectomy. A habit of calm and slow dissection with precautions should be developed. Clearance of the calot's triangle with limited use of electro cautery should be done before proceeding towards ligation or clip application to various structures.

Image-guided system endoscopic drainage of orbital abscess caused by methicillin-resistant Staphylococcus aureus in an infant

INTRODUCTION

The management of orbital abscesses in neonates and infants is very challenging. Surgical drainage of the abscess is aimed at removing the pus and preventing blindness. We describe a case of orbital abscess in an infant that was caused by methicillin-resistant Staphylococcus aureus and that was successfully drained with image-guided endoscopic surgery.

PRESENTATION OF CASE

A 39-day-old infant presented with progressive right maxillary swelling complicated by methicillin-resistant Staphylococcus aureus orbital abscess. Tooth bud abscess was the most likely primary cause and a combination of intravenous antibiotics was initially prescribed. The collection of intra-orbital pus was removed using image-guided system-aided endoscopic surgical drainage.

DISCUSSION

Prompt diagnosis and management are very crucial. Endoscopic drainage of these abscesses in children has been described. Image-guided drainage of the orbital abscess is a newer technique that has been reported in a teenager and in adult patients. This is the first reported case of endoscopic orbital drainage surgery in an infant. The procedure was performed successfully. This approach provides for better identification of the anatomical structures in a very young patient. Injuries to the medial rectus, globe and optic nerve can be avoided with this technique.

CONCLUSION

Aggressive management of orbital abscesses in infants is mandatory. Image-guided endoscopic orbital drainage offers precise visualization and a safer technique in a relatively smaller orbit.

Ovarian serous cystadenoma with ectopic adrenal tissue in a 65-year-old patient: A case report

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A very rare case of ectopic adrenal tissue (EAT) with ovarian serous cystadenoma is presented.

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EATs usually disappear by age, however it can remain until old stages of life.

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Surgically removal of all suspicious lesions is strongly recommended.

Introduction

Ectopic adrenal tissue is a very rare entity in adult females, especially in the ovary, and is generally diagnosed incidentally during surgery. Although it can present at various sites during childhood, it becomes atrophic by adulthood due to normally functioning adrenal glands. Patients are predominantly asymptomatic; however, in some cases endocrine symptoms such as hypertension and fasciotruncal obesity due to hormonal activity can be seen or neoplastic transformation can appear.

Presentation of case

A 65-year-old patient with progressive pelvic pain and postmenopausal vaginal bleeding was evaluated by transvaginal ultrasound, which revealed bilateral adnexal masses measuring 5 cm in size and a normal uterus with an increased endometrial thickness of 7 mm. Initially the endometrial sampling result was reported as benign. The patient underwent abdominal hysterectomy and bilateral salpingo-oophorectomy and the pathological diagnosis was again benign, with serous ovarian cystadenoma being found in both ovaries. The pathologist also reported incidental ectopic adrenal tissue on the wall of the left ovarian cystadenoma.

Discussion

Ectopic adrenal tissue is infrequent in female genital organs especially at older ages. Only a few cases of ovarian ectopic adrenal tissue have been reported. To the best of our knowledge the present case is the fourth report in the English literature, and is of additional importance given the patient’s age.

Conclusion

Ectopic adrenal tissues are generally asymptomatic and revealed incidentally during surgery; however some cases have demonstrated the risk of neoplastic transformation. Therefore, surgeons must be aware of this rare entity that bears the risk of malignancy, and should surgically remove all suspicious lesions.

Successfully-treated asymptomatic celiac artery aneurysm: A case report

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Although rare, celiac artery aneurysm may carry a definite risk for rupture and other complications.

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Because of its rarity, no strong consensus concerning indications for intervention of asymptomatic celiac artery aneurysm exists in the literature.

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Clinicians awareness regarding this rare entity and efforts to discover before rupturing are imperative.

Background

Celiac artery aneurysm is a rare vascular lesion. It is frequently discovered after rupture, which leads to death in most cases. We present a case of an asymptomatic celiac artery aneurysm discovered in a 72-year-old female during an evaluation for high grade fever and general fatigue.

Case presentation

The patient visited our department with complaints of fever and general fatigue. The patient’s medical history included type 2 diabetes mellitus with poor control and hypertension. Blood culture and urine culture that were submitted at arrival presented E. Coli. Then, she was diagnosed with bacteremia by urinary tract infection. Transesophageal echocardiography revealed no vegetation at her valves. Computed tomography was performed for investigating her urological abnormalities, revealing a 28 × 30 mm aneurysm at the trunk of the celiac artery. Blood and urine cultures submitted at arrival were positive for E. coli. Surgical repair performed after the improvement of her urinary tract infection revealed a non-infective aneurysm; thus, aneurysm closure and prosthetic grafting were conducted.

Conclusion

Clinician awareness regarding this rare entity and discovery efforts to discover the splanchnic aneurysm before rupturing are imperative.

Glycogen Rich Clear Cell Carcinoma (GRCC) of the breast may not have a poor prognosis

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Glycogen Rich Clear Cell Carcinoma (GRCC) is the commonest cause of clear cell morphology in breast malignancies.

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No specific radiologic characteristics associated with GRCC carcinoma.

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Axillary lymph node involvement is the most important prognostic factor.

Introduction

Glycogen Rich Clear Cell Carcinoma (GRCC) is a rare variant of breast carcinomas and believed to be linked with a poor prognosis.

Case summary

We are presenting a 60-year-old Saudi lady with a 2 cm GRCC carcinoma associated with clear cell ductal carcinoma in situ (DCIS) and no axillary lymph node involvement. The tumor was Estrogen and Progesterone receptors (ER & PR) positive and HER 2-neu negative. She underwent mastectomy with sentinel lymph node biopsy followed by hormonal therapy. She is alive and free of disease for 35 months.

Conclusion

The prognosis of GRCC may not be different from other types of invasive breast cancer.

Single-incision laparoscopic ileocecal resection using an organ retractor

INTRODUCTION

Single-incision laparoscopic surgery has been reported to be a safe and feasible technique for colorectal cancer. However, the technique needs skill due to the limitations of the device. An organ retractor is a new grasp device that has the potential to overcome these limitations.

PRESENTATION OF CASE

A 63-year-old woman with a tumor palpated in the right lower quadrant of the abdomen presented to hospital. Colonoscopy showed a type 2 mass with nearly complete stenosis, and a biopsy specimen showed well-differentiated adenocarcinoma. Single-incision laparoscopic surgery ileocecal resection was performed using an organ retractor. A 3-cm incision was placed in the umbilicus, and three conventional ports were inserted. An organ retractor was used for hepatocolic ligament resection, resection of the ileocolic vessels, and resection of the insertion of the mesentery proper. For each resection, the trailer line's tension was adjusted to provide a good operative view. The patient's postoperative course was good, and she was discharged 7days after surgery.

DISCUSSION

An organ retractor was effective for single-incision laparoscopic surgery technique not only to maintain a good operative view, but also to change trailer line tension, which enabled safe dissection.

CONCLUSION

An organ retractor could facilitate single-incision laparoscopic surgery.

Lessons learnt from a case of extracorporeal shockwave lithotripsy for a residual gallbladder stone

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ECSWL failed to treat a residual gallbladder stone after failed cholecystectomy.

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Even if a stone is fractured, it may not be expelled by a diseased gallbladder.

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ECSWL should be followed by endoscopic retrieval to complete treatment.

Introduction

Extracorporeal shockwave lithotripsy (ECSWL) for gallstones is rarely used due to high recurrence rates, but has been reported to be effective in some circumstances.

Presentation of case

We describe a case of a failed attempt at laparoscopic cholecystectomy due to gallbladder contraction and complete obliteration of Calot’s triangle. Cholecystotomy was performed to remove all visible stones, and completed by a subtotal cholecystectomy and closure of the gallbladder remnant. The patient remained symptomatic due to a residual stone in the Hartmann’s pouch. ECSWL was attempted to fragment the stone; however, follow-up imaging showed persistence of the calculus.

Discussion

Literature review shows that ECSWL for multiple gallbladder stones has a low success rate. Even if a stone is successfully fragmented, a diseased gallbladder remnant seems incapable of expelling the fragments. Without completion endoscopic clearance, therefore, the treatment is considered incomplete.

Conclusion

Our case suggests that ECSWL is ineffective in management of residual gallbladder stones after failed cholecystectomy.

Successful treatment of proton pump inhibitor induced sporadic fundic gland polyps with an argon plasma coagulator in a patient with polycythaemia vera

INTRODUCTION

Proton pump inhibitor (PPI) use is associated with the development of fundic gland polyps (FGPs); discontinuing PPIs is associated with regression of FGPs. Here, we report a rare case of non-respondent FGPs after discontinuation of PPI that were successfully treated using an argon plasma coagulator (APC).

PRESENTATION OF CASE

We present the case of a 68-year-old woman with a history of polycytheamia vera. She also had gastroesophageal reflux disease (GERD) and had been taking 10 mg of omeprazole daily for the past three years. Esophagogastroduedenoscopy (GF) revealed over 100 pedunculated polyps in the gastric body and fundus. Histological examination of the specimens showed dilated oxyntic glands with flattened parietal and mucous cells. Based on these findings and the clinical history, a diagnosis of FGPs was made. Omeprazole use was then discontinued. Repeat GF performed 6 months and 1 year later showed a significant increase in the number and size of the polyps. APC treatment was performed every 6 months for 3 years. Further GF showed a significant decrease in the number and size of the FGPs 4 years after discontinuing PPI.

DISCUSSION

We conclude that PPI use is a strong risk factor for the development of FGPs and discontinuing PPI is associated with regression of FGPs, but not in patients with polycythaemia vera. However, the mechanism involved in the interaction between FGP and polycytheamia vera remains unknown.

CONCLUSION

Non-respondent FGPs after discontinuation of PPI use may be successfully treated using APC.

A case of single-incision laparoscopic surgery for a bleeding Meckel's diverticulum diagnosed pre-operatively by double-balloon endoscopy

INTRODUCTION

　Meckel's diverticulum (MD) is a congenital true diverticulum that is residual yolk duct tissue, and some cases with complications require surgery. It has been reported that laparoscopic surgery is effective for patients with an MD.

PRESENTATION OF CASE

A 79-year-old man with melena visited our hospital. Upper gastrointestinal series and colonoscopy showed no bleeding lesion. Double-balloon endoscopy was then performed to examine the small intestine. The examination showed a large diverticulum 80cm proximal to the ileocecal valve and a circular ulcer. MD resection was performed using single-incision laparoscopic surgery (SILS) technique through a 3-cm zig-zag incision in the umbilicus. Three ports were inserted for the scope and forceps devices. The MD was located 80cm proximal to the ileocecal valve. There were no other intestinal lesions. From the wound, the lesion could be easily moved outside the body. The MD including the ulcer lesion was then resected. The patient's postoperative course was good, and he rarely felt wound pain. He started dietary intake three days after surgery and was discharged from hospital eight days after surgery.

DISCUSSION

SILS technique has attracted attention in the field of laparoscopic surgery. Using a single port with multiple working channels, SILS can reduce the number of incisions and the rates of incisional hernia port site-related complications, as well as improve cosmesis.

CONCLUSION

A definite diagnosis of an MD was made by double-balloon endoscopy preoperatively. The SILS approach was effective for cosmesis, postoperative pain, and a shortened hospital stay.

Neglected dorsolateral dislocation of the first metatarsophalangeal joint: A case report

INTRODUCTION

Although the first metatarsophalangeal (MTP) joint is frequently injured, Complete dislocation of the first MTP joint represents a relatively rare traumatic injury.

PRESENTATION OF CASE

A 46-year-old gentleman presented with a traumatic first MTP joint dislocation resulting from an automobile accident. Due to coronavirus outbreak in the hospital at that time, patient was referred to another hospital. Six months later, reduction was achieved surgically and fixation of the MTP with K-wires was done.

DISCUSSION

Only few case reports have described the injury, and the ideal treatment along with the long-term result of the injury has yet to be further studied because reports are rare in this regard.

CONCLUSION

Functional range of motion may result even after 6 months of delayed treatment with ORIF and osteopenia may result.

An impressive choledochal cyst and its surgical resection

INTRODUCTION

Choledochal cysts are rare congenital dilations of the biliary tree that can present with non-specific symptoms such as abdominal pain, jaundice, cholelithiasis and pancreatitis. Although most commonly identified in children, they can be found in the adult population. However, because of the non-specific symptoms, this diagnosis may be difficult to make in the adult. A physician therefore must keep this diagnosis within their differential, as it may arise in an unexpected patient population who may present with a convoluted work up.

CASE PRESENTATION

In this report, we present the case of a 50-year-old African American woman with recurrent cholelithiasis, cholangitis and eventually obstructive jaundice despite undergoing a laparoscopic cholecystectomy six years prior. Her only work up at that point was a right upper quadrant ultrasound revealing gallbladder sludge, which led to her cholecystectomy. It was the persistence of her symptoms-abdominal pain, cholangitis and obstructive jaundice-previously attributed to chronic cholecystitis and choledocholithiasis that warranted further work up. After multiple physician visits, she was referred to our academic center after an ERCP was performed and she was found to have a dilation of her common bile duct consistent with a choledochal cyst. Furthermore, the ERCP identified multiple bile duct stones within the cyst. This was not identified on her original ultrasound or prior ERCPs. The patient underwent a complete cyst excision with Roux-en-Y hepaticojejunostomy and did well post-operatively.

DISCUSSION

This report illustrates how choledochal cysts can be an elusive diagnosis, but may present with repeated infections, recurrent biliary stones, and biliary obstruction despite a cholecystectomy. Had she an MRCP prior to her cholecystectomy, she would likely have avoided multiple surgeries, and years of persistent symptoms. Choledochal cysts are associated with an increased risk of biliary malignancy and therefore cyst excision is the standard of care.

CONCLUSION

Although rare, physicians need to keep this diagnosis in mind, and be aware of the clinical and imaging findings consistent with a choledochal cyst in order to facilitate appropriate work up, referral and treatment.

Severe fatal protein malnutrition and liver failure in a morbidly obese patient after mini-gastric bypass surgery: Case report

INTRODUCTION

Mini-gastric bypass (MGB) is a bariatric surgical technique popular in many centers due to shorter duration, easier technique, and excellent weight loss results. However, it may be associated with postoperative malnutrition. This case describes the clinical course and unfortunate outcome of a morbidly obese patient who underwent MGB and developed malnutrition in the first postoperative year.

PRESENTATION OF CASE

A 37 year-old female patient with a BMI of 44kg/m2 successfully underwent MGB surgery in June 2015 and was discharged uneventfully. She presented with lower extremity edema and generalized weakness 8 months later, with a blood albumin level of 3.1g/dL, compared to a normal preoperative value. She was admitted and received a high-protein diet, and her clinical condition improved. Three months after her discharge, she was readmitted with the same complaints, as well as pancytopenia. She was also hypocupremic. After unsuccessful intensive supportive measures, she finally underwent revisional gastrogastrostomy. However, she developed signs and symptoms of profound liver failure postoperatively (albumin 1.8g/dL; total bilirubin 7.5mg/dL; prothrombin time 34s) and pancytopenia persisted. All resuscitative measures were unsuccessful and she expired in July 2016.

DISCUSSION

Multiple factors can contribute to postoperative malnutrition and liver dysfunction after MGB, including the presence of baseline liver disease, inadequate diet supplementation, leaving a too-short common small intestinal channel, and ethnic variations in small bowel length. These factors should also be considered when deciding to perform corrective surgery.

CONCLUSION

Careful, individualized treatment and follow-up plans may help to prevent such catastrophic consequences.

Emergency valve surgery for infective endocarditis complicated by acute intracranial hemorrhage: A case report

INTRODUCTION

Optimal timing of surgical treatment for infective endocarditis (IE) complicated by intracranial hemorrhage remains controversial.

PRESENTATION OF CASE

A 43-year-old man with IE received appropriate antibiotic therapy but had recurrence of cerebral infarction and intracranial hemorrhage (ICH). Emergency valve surgery was performed 2days after ICH onset because of heart failure and recurrence of cerebral complications. Postoperatively, he showed no neurologic symptoms; neuroimaging showed no enlargement of ICH.

DISCUSSION

Postoperative risk of neurologic deterioration may be relatively lower than previously thought in patients with IE who undergo surgery within 1 month after ICH onset.

CONCLUSIONS

Emergency surgery in patients with ICH is justified in cases of multiple indications for such small ICH. Further evaluation regarding the risk of subsequent hemorrhage in patients with ICH who require emergency valve surgery is warranted.

Reconstructive considerations following a necrotic spider bite on the face: A case report

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Necrotic spider bites in the facial region can result in extensive soft tissue defects.

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Healing by secondary intention is slow in necrotic spider bite lesions on the face.

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19-year-old female with suspected recluse spider bite on her face while sleeping.

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Single-stage reconstruction with a trimmed FTSG resulted in high patient satisfaction.

Introduction

Spider bites as the cause of necrotic skin and soft tissue lesions occur very rarely in Central and Northern Europe. Recluse spiders, distributed almost worldwide, are one of two genera of spiders with confirmed capability of causing necrotic lesions. In the facial region, the resulting defects represent a potential reconstructive challenge, especially in younger patients.

Methods

This case report has been reported in line with the SCARE criteria.

Presentation of case

We describe a case of a 19-year-old female with a suspected bite from a recluse spider sustained during a recreational trip to Guatemala. She was bitten on the right upper aspect of the nose, and within a week developed a large necrotic lesion extending to the medial canthus. Following her return to Denmark the defect was reconstructed with a trimmed full-thickness skin graft. An initially planned second-stage reconstructive procedure was cancelled, as the patient was satisfied with the primary result.

Discussion

Most aspects of the extended reconstructive ladder were evaluated before selecting the optimal reconstruction for this patient. In younger patients, reconstructive surgery requires special considerations, primarily due to age-related limitations combined with generally high expectations to the aesthetic outcome.

Conclusion

In the few reported cases of necrotic spider bites in the facial region, active reconstructive measures have resulted in the best outcomes. Tissue expansion of local or regional skin may have a potential role, but in certain patients, simple reconstructive solutions will provide an aesthetically satisfactory result without requiring extensive or multi-stage surgeries, as demonstrated in this case.

Pulmonary metastatic angiosarcoma from scalp with fatal complication: A case report

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AS of the scalp is rapidly progressive, the potential of metastatic lesions should be considered, and a preoperative chest CT may be recommended.

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AS with Pulmonary metastasis had repeated hemoptysis pneumothorax.

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Tissue confirmation following management of complications and chemotherapy with paclitaxel resulted in good prognosis

•

Cytology of pleural effusion maybe first considered for differential diagnosis due to lesser invasive procedure.

Introduction

Angiosarcoma is a rare malignant neoplasm with poor prognosis. Angiosarcoma of the scalp is frequently recurs locally, and metastasizes early despite various treatments. The common sites of metastatic are lung, liver, and lymph nodes. Pulmonary metastasis with hemoptysis and pneumothorax is rare but threatening.

Presentation of case

A 77-year-old male had recurrent angiosarcoma of the scalp even with post operation radiotherapy. At the same time, recurrent pneumothorax was noted, thus he underwent wedge resection of the right upper lobe of the lung plus pleural biopsy. The final pathologic report of cystic lesions showed metastatic Angiosarcoma. He received intravenous paclitaxel and the lung lesions dramatically diminished subsequently.

Discussion

Pulmonary metastasis from soft tissue sarcoma had fatal complications and poor prognosis. Metastases of AS to the lung have a well-described morphology on CT scan, but appear to be hypometabolic on PET scan and are easily misinterpreted as benign cysts.

Conclusion

Angiosarcoma is a rare but highly vascular invasive endothelial tumor that generally metastasizes to the lung. It could cause repeated hemoptysis pneumothorax and pleural effusion. Preoperative chest CT may be recommended routinely. Aggressive treatment resulted in not only symptoms control but also good prognosis.

De Garengeot hernia with perforated appendicitis and a groin subcutaneous abscess: A case report

•

De Garengeot hernia with a groin subcutaneous abscess is rare.

•

Appendectomy and herniorrhaphy via the same incision may be more effective.

•

Clinicians should consider de Garengeot hernia in patients with a groin hernia.

Introduction

De Garengeot hernia is rare. Although previous reports have suggested various surgical options according to patient condition, comorbidities, surgeon preference, and clinical findings during surgery, a treatment strategy has not been established.

Presentation of case

An 81-year-old woman presented with an irreducible tender mass that was subsequently diagnosed as an incarcerated femoral hernia with a subcutaneous abscess in the right groin. Intraoperative findings revealed a necrotic and perforated appendix strangulated by the femoral ring for which an appendectomy and herniorrhaphy was performed concurrently through the hernia sac. The subcutaneous abscess cavity was washed thoroughly and a drainage tube was placed within it. The patient recovered uneventfully.

Discussion

We suggest that the approach through the inguinal incision in both appendectomy and herniorrhaphy with drainage may be useful in avoiding intra-abdominal contamination in cases of de Garengeot hernia with subcutaneous abscess.

Conclusion

Here, we described a case of de Garengeot hernia with a subcutaneous abscess in the groin. Clinicians should consider de Garengeot hernia in patients with a groin hernia, make an early diagnosis, and promptly provide surgical treatment to reduce the risk of complications.

Paracaecal hernia: a case report on the evolving role of laparoscopy

A paracaecal hernia, a type of pericaecal hernias, is a rare cause of small intestinal obstruction. Failure of early recognition and reduction of this type of internal hernia may lead to strangulation of the herniated intestine. There has been a number of case reports in the literature about the different types of pericaecal hernias, however the anatomy of these hernias is still poorly understood and the management is still evolving. We are presenting a 75year old woman, who presented clinically and radiologically with distal small intestinal obstruction. Her past medical history was unremarkable and she had no prior abdominal surgery. After resuscitation, she was taken to the operating theatre for a diagnostic laparoscope, which showed a herniated loop of ileum through a congenital defect in the parietocaecal fold. Reduction of that loop and closure of the peritoneal defect were achieved laparoscopically. Following the procedure, the patient recovered very quickly and she was discharged home within 48h of her initial admission. Patients with pericaecal hernias tend to present with symptoms of distal small intestinal obstruction. The presence of localised peritonism in the right iliac fossa usually indicate strangulation and that should prompt an urgent surgical intervention. In summary, based on our case, excellent results were achieved from early laparoscopic intervention. Therefore, we recommend early laparoscopy for patients presenting with small intestinal obstruction with no history of abdominal surgery.

Prevotella intermedia infection causing acute and complicated aortitis-A case report

INTRODUCTION

Aortitis is a general term that refers to all conditions involving an inflammation of the aortic wall. This case report describes the surgical approach of a patient with infectious and symptomatic aortitis caused by the rare vector Prevotella intermedia.

PRESENTATION OF CASE

A 44-year old male patient was admitted with fever and general discomfort after a period of sore throat in a non-teaching hospital. After two weeks he developed acute abdominal and back pain accompanied by sweating and elevated infection parameters. Computed tomography angiography revealed atherosclerotic changes of the infrarenal aorta with a locally contained rupture of the aorta alongside peri-aortal signs of inflammation (and aortitis aspects). An urgent aortic reconstruction was performed according to Nevelsteen. The blood cultures turned out positive for Prevotella intermedia. Postoperatively the patient received antibiotics for six weeks. The patient recovered uneventful from this infection and surgical procedure.

DISCUSSION

A complicated and acute aortitis is a rare but potentially life-threatening disease. The aetiology can be ordered into two main groups; inflammatory and infectious. Diagnosis is based upon symptoms, biochemical values, microbiological results and imaging modalities. Treatment depends on aetiology and should be discussed in an experienced multidisciplinary setting. Infectious aortitis should be treated with antibiotics for at least six weeks with close monitoring of the patient's clinic and biochemical values, even after surgery.

CONCLUSION

Prevotella intermedia is a rare causative agent for aortitis. Acute aortitis is a challenging clinical entity which should be managed in an equipped medical center by an experienced multidisciplinary team.

Foreign body in the bladder: A case report

Foreign bodies are occasionally reported in the bladder. In most cases, the foreign body is removed via the transurethral approach. A 57-year-old male patient was referred to our hospital to undergo the retrieval of a foreign body from his bladder. However, the foreign body had become severely calcified and could not be removed transurethrally. Thus, an open bladder wall incision was necessary to remove it. We herein report a case of a foreign body in the bladder that had become calcified and which was successfully removed using a higher bladder incision approach. A careful preoperative examination should be performed to detect the characteristics of the foreign body and avoid the risk of bladder wall perforation.

Laparoscopic partial splenectomy for congenital splenic cyst in a pediatric patient: Case report and review of literature

Non-parasitic splenic cysts (NPSC) are a rare condition that makes difficult to know their true incidence and represent 10% of all benign splenic cysts, they can be either congenital with the presence of epithelial lining that originate from invagination of the capsular mesothelial lining or post-traumatic with absence of epithelial lining. We present our management of a splenic congenital cyst in a pediatric patient. A 10-year-old female patient presented to the clinic complaining with a 3-week abdominal pain at the left upper quadrant. An ultrasound showed an enlarged spleen with a thinned walled cystic image on the lower pole of 5cm. An abdominal CT confirmed the presence of a splenic cyst at the lower pole of the spleen of 5cm in diameter. Three-port laparoscopic partial splenectomy was done isolating and dividing the lower splenic artery and vein and the lower pole of the spleen with a vessel sealing device. Management of a non-parasitic splenic cyst is controversial: cystectomy, fenestration, percutaneous drainage and sclerotherapy have been previously described, most of them aiming to preserve spleen function and avoiding overwhelming post-splenectomy infection. Partial splenectomy seems the most effective one in terms of preserving spleen function and avoiding recurrence.

Appendiceal diverticulitis, a rare relevant pathology: Presentation of a case report and review of the literature

INTRODUCTION

Appendiceal diverticulitis is a rare pathology that mimics acute appendicitis. Appendiceal diverticula are classified into congenital and acquired with difference in incidence and pathogenesis. Appendiceal diverticulitis is often overlooked because of mildness of symptomatology with increasing risk of complications, such as perforation. Appendiceal diverticula are often associated to higher risk of neoplasm especially carcinoid tumors and mucinous adenomas.

PRESENTATION OF CASE

A 40-year-old caucasic male presented into Emergency Room with right lower quadrant pain associated with vomit, abdominal tenderness, fever and moderate leukocytosis (11.93×10; neutrophils 78.5%). Acute appendicitis was suspected and a surgical approach was chosen with a McBurney access. The removed specimen (Figs. 1 and 2) was 11cm long with multiple hyperaemic and oedematous diverticular protrusions. The postoperative course was regular. Discharging was on 4th postoperative day in optimal clinical conditions. The histological examination (Fig. 3) showed acute inflammation of appendiceal pseudodiverticula with acute peridiverticulitis and abscess.

DISCUSSION

Currently, appendiceal diverticulitis is often overlooked with high risk of complications, above all perforation. Attention should be kept during the surgical procedure and the patholological examination in order to identify any associated neoplasm.

CONCLUSION

Appendiceal diverticulitis should be considered in adult male patients with right lower quadrant pain or tenderness. Accurate appendectomy should be performed in order to permit an appropriate pathological examination and possible associate neoplasm should always be searched through. Prophylactic appendectomy should be performed in case of incidental finding of appendiceal diverticula in asymptomatic patients in order to avoid the high perforation risk.

Rare presentation of Wegener's granulomatosis in the pituitary gland: Case report and literature review

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Pituitary involvement is a rare recognized complication of Wegener’s granulomatosis.

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Central diabetes insipidus and varying hypopituitarism is a common presentation.

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Radiological abnormalities occur in greater than 90% of cases.

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Surgery is indicated to confirm diagnosis or when compressive symptoms develop.

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Long-term prognosis of patients with pituitary WG is unknown.

Introduction

Wegener’s granulomatosis (WG) is a systemic vasculitis that can affect a variety of organs including ear, nose and throat, lungs and kidneys. However WG is unusual in the pituitary and rare in the central nervous system.

Presentation of case

A 56-year-old male with likely WG presented with polyuria and polydipsia despite six months of conservative medical management. MRI scanning revealed an enlarging heterogeneously enhancing pituitary gland. Following endoscopic transsphenoidal pituitary biopsy and debulking, final tissue pathology was diagnostic for WG in the pituitary gland.

Discussion

Diagnosis remains difficult but most patients present with central diabetes insipidus (CDI) as well as varying degrees of hypopituitarism on a background of disease activity in other organs. Clinical judgment needs to balance the need for invasive surgical tissue diagnosis with increasing immunosuppressive therapy.

Conclusion

It is important to consider this rare complication of WG to ensure timely diagnosis and management.

Carotid free-floating thrombus causing stroke in a young woman with lupus anticoagulant: A case report and review of the literature

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Free floating thrombosis (FFT) is a rare disease of carotid arteries.

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Patients of FFT-ICA are mostly old men with atherosclerotic underlying disorder.

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This case; FFT in a young girl with high levels of lupus anticoagulant is unique.

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Surgical treatment resulted in complete resolution of symptoms without recurrence.

Introduction

In young adults Stroke is a challenging condition and various tests are needed to diagnose and manage its underlying problems. Free floating thrombosis of internal carotid artery (FFT-ICA) is one of the rare problems among carotid artery diseases which can lead to stroke in adults. Owing to limited cases of FFT-ICA there is not a worldwide accepted consensus on management of FFT-ICA, but some recurrences after medical management have been reported in the literature.

Presentation of case

A-25-year old woman was referred to hospital with sudden onset aphasia and right sided hemiparesis. Carotid duplex ultrasonography showed an iso-echogenic thrombus ranged about 5 × 10 mm partially attached to arterial wall of the right internal carotid artery. It was floating in accordance with the heartbeat. Anticoagulation therapy was initiated and subsequently she underwent an urgent operation. To explore the etiology of her problem, various lab tests were carried out; the results showed markedly elevated levels of lupus anticoagulant. She was discharged from hospital after an uneventful recovery showing gradual improvement of symptoms in follow-up visits.

Discussion

FFT-ICA is one of the scarce disorders of carotid artery. Less than 150 cases have been reported in the literature indicating its common occurrence in old men. Hence the etiology of this case (FFT in a young patient with high levels of lupus anticoagulant antibody) may be the first of its type.

Conclusion

In this case we chose surgical treatment resulting in complete resolution of symptoms and non-recurrence within 6 month follow-up.

A very rare case report of long-term survival: A patient operated on in 1994 of glioblastoma multiforme and currently in perfect health

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Glioblastoma is the most common and most aggressive type of brain tumors. Prognosis is poor: death occurs within 12–18 months from diagnosis.

•

There is however a small percentage of Patients affected by glioblastoma who survive 3 years or longer.

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There are some exceptional cases when people have survived decades after surgical removal of a glioblastoma without any recurrence.

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We report a case of a 44 year-old man operated for a glioblastoma. 22 years after surgery the patient has no recurrence of the tumor.

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Long-survival depends on young age, complete surgical excision, good Karnofsky index score, radiotherapy and molecular make-up of glioma.

Introduction

Glioblastoma multiforme is the most aggressive type of primary brain tumors, but there is a small percentage of patients who have a long-term survival and some exceptional cases who survive decades after surgical removal of tumor.

Presentation of case

In 1994, a 44 year-old man, suffering from intense headache and loss of strength of the left arm, was operated for a glioblastoma multiforme in the posterior part of the right frontal lobe. After the operation the patient underwent whole-brain radiotherapy and chemotherapy. 22 years after surgery the patient has no recurrence of the tumor.

Discussion

A very small percentage of glioblastoma cases showed >3 years survival. There have been exceptional cases of long-survival spanning 10 years or more, without tumor recurrence, so as to deem those affected ‘cured’. The long-survival for glioblastoma multiforme is linked to young age, to aggressive and complete surgical excision, a good Karnofsky index score before surgery, the application of radiotherapy after surgery and to the molecular make-up of a specific glioma.

Conclusion

The fact that there are extremely rare cases of long-term survival and even zero recurrence of the glioblastoma should serve as a stimulus to continue the research effort and not give up the fight against this tumor on a day-to-day basis.

Inguinal lymph node presenting as the delayed site of metastasis in early stage endometrial carcinoma: Case report

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Inguinal lymph nodes metastasis are rare in endometrial carcinoma.

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Proper preoperative assessment is important.

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CT-PET imaging is important tool in obese patients.

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Treatment is surgery and adjuvant chemo-radiotherapy.

Introduction

Inguinal lymph nodes are the frequent sites of metastasis for malignant lymphoma, squamous cell carcinoma of anal canal, vulva and penis, malignant melanoma and squamous cell carcinoma of skin over lower extremities or trunk. Anatomically, endometrial carcinoma is less likely to spread to the superficial or deep inguinal lymph nodes, thus metastatic involvement of these lymph nodes can easily be overlooked.

Case presentation

Here-in we report a case of a 65-year old Saudi morbid obese female, who presented with left inguinal lymphadenopathy as initial delayed site of metastasis almost 19 months after the initial treatment for FIGO IA endometrial carcinoma. Patient underwent left inguinal lymph node dissection. Histopathology confirmed metastatic endometrial adenocarcinoma, positive for cytokeratin (CK-7), estrogen receptor (ER) and progesterone receptors (PR), negative for CK-20 and CDX2. Following the post-surgery recovery, she was given extended field radiation therapy to para-aortic, pelvis and bilateral inguinal lymph nodes with concurrent cisplatin chemotherapy followed by high dose rate brachytherapy.

Conclusion

Inguinal lymph nodes as delayed site of metastasis in early endometrial carcinoma is extremely rare entity. Incorporation of FDG-PET during the preoperative screening of inguinal nodes may be helpful. The impact of lymph node dissection and adjuvant radiation therapy on survival needs to be established.

Trocar-site evisceration of the vermiform appendix following laparoscopic sigmoid colectomy: A case report

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Trocar-site evisceration of the vermiform appendix following laparoscopic surgery is a rare complication.

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A regular intraoperative appearance of the vermiform appendix does not reliably rule out the presence of a diseased appendix.

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Incidental appendectomy should be considered in all patients undergoing colorectal surgery.

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The restrictive use of prophylactic drains after colorectal procedures is recommended.

Introduction

There is an ongoing debate whether prophylactic drainage or incidental appendectomy should be performed in patients undergoing colorectal surgery. On the other hand, it has been shown that the placement of drains through former trocar sites as well as the use of large (≥10 mm) trocars, incomplete fascial closure or closed laparoscopy technique all predispose for the occurrence of trocar site hernias.

Presentation of case

We report the case of a 59-year-old male patient who underwent laparoscopic sigmoid colectomy with primary anastomosis for recurrent sigmoid diverticulitis. Preoperative diagnostics revealed no abnormalities other than multiple diverticula in the sigmoid colon. The subsequent surgery was conducted without any complications. Due to inconspicuous intraoperative appearance of the vermiform appendix, no incidental appendectomy was performed. On the 4th postoperative day, the Easy Flow drain − which had been placed prophylactically through the 12 mm trocar site in the right lower abdomen − was removed. Four hours after drain removal, trocar-site evisceration of the vermiform appendix occurred, requiring emergency surgery.

Discussion and conclusion

The present case is yet another argument for restricting the use of prophylactic drains in colorectal surgery as well as closing port sites of ≥10 mm diameter. Furthermore, incidental appendectomy may be considered since it is able to prevent this type of complication and can be performed with minimal cost and morbidity.

Idiopathic neonatal pneumoperitoneum, a case report

INTRODUCTION

There have been non-surgical conditions secondary to neonatal pneumoperitoneum (e.g., mechanical ventilation, pulmonary diseases and pneumatosis cystoides intestinalis) that neonates were able to overcome without the need for abdominal exploration. Idiopathic pneumoperitoneum, although similar to perforation of the alimentary tract and the previously mentioned non-surgical conditions, is a rare and benign condition that does not yet have a definite cause. The criteria by which a surgeon decides on which abdomen to open and which one to observe, is ill-defined. Thus, increasing the awareness of neonatologists and surgeons about this condition will help decrease complications due to unnecessary procedures.

PRESENTATION OF THE CASE

We report a case of a neonate with a massive pneumoperitoneum who obtained a surgical intervention with negative finding. We had noted that the bag of the abdominal drain was expanded with gas every 2days, we replace the bag by new one every 2days for 10days postoperative. Nonetheless, the cause of pneumoperitoneum remains unclear.

DISCUSSION

There are five main nonsurgical causes of free air in the peritoneal cavity. These are categorized as follow: pseudopneumoperitoneum, thoracic, abdominal, gynecological and idiopathic. This is a condition in which imaging shows free air in the peritoneal cavity that can either be managed with observation and supportive care alone or results in a negative laparotomy.

CONCLUSION

This case demonstrated that laparotomy is not a true routine in neonates with idiopathic pneumoperitoneum if a timely diagnosis is established. Future research is still necessary to understand the source of the free gas in the abdomen, as well as the underlying causes of delayed postoperative gas underdiaphragm and postoperative abdominal drain bag gas expansion.

Long term follow up of mucous membrane grafting for cicatricial ectropion in Ichthyosis: A case report

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In this case report we highlight briefly the unique entities of Icthyosis, the commonest ophthalmological manifestation and the reported modalities of surgical therapy, which includes Mucous Membrane Graft (MMG).

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Up to our knowledge this is the first reported long term follow up of MMG offered for Ichthyosis-related cicatricial ectropion.

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Thus we believe that this case has a value in using MMG as the standard therapy for a generalized condition, which is not peculiar only to ophthalmologists.

Introduction

Ichthyosis is a group of keratinizing diseases characterized by scaly and dry skin. One of the ocular complications associated with ichthyosis is cicatricial ectropion which often results in exposure keratopathy and eventually corneal scarring.

Presentation of case

In this report we are presenting a 21-year-old female who is known to have ichthyosis-related bilateral lower lid cicatricial ectropion, which was managed with Mucous Membrane Grafting (MMG) six years ago.

Discussion

Despite the serious complications of ichthyosis-related eyelid malposition such as cicatricial ectropion, until present no single way has been standardized to treat the ectropion in these patients. MMG has been previously described, but up to our knowledge this is the first reported long term follow up of MMG offered for ichthyosis-related cicatricial ectropion.

Conclusion

We strongly recommend MMG as a promising surgical treatment option offered for ichthyosis patients with cicatricial ectropion providing good outcome and acceptable cosmetic results.

Bilateral asymmetrical hip dislocation with one side obturator intra-pelvic dislocation. Case report

•

Hip dislocation is considered an orthopedic emergency and should be reduced as soon as possible to decrease rate of complications.

•

Bilateral hip dislocation is very rare and usually results from high energy trauma mostly motor vehicle collisions.

•

Asymmetrical bilateral simultaneous hip dislocation with one hip dislocated intra-pelvic through the obturator foramen is rare.

•

Complex dislocation might better be reduced in the theatre.

Introduction

Hip dislocations usually occur as a result of motor vehicle accidents and require high energy trauma. Bilateral hip dislocations are rare compared to unilateral ones. Most reported cases are asymmetrical simultaneous bilateral anterior and posterior dislocations.

Case presentation

This case report describes a 32years female passenger who was involved in road traffic accident and had bilateral asymmetrical hip dislocations with one side posterior and the other side obturator intra-pelvic dislocation. Concentric reduction was achieved by closed reduction of both sides under general anesthesia but the patient required skeletal traction applied to the unstable side for three weeks.

Discussion

Hip dislocation is considered an orthopedic emergency and should be reduced as soon as possible to decrease rate of complications. Since hip dislocation usually occurs with high energy trauma so looking for associated injuries is of paramount importance and assessing such patients should be done according to advanced trauma life support.

Conclusion

Obturator intra-pelvic hip dislocation is challenging case and can be treated by closed reduction.

A massive haemorrhage developing during deciduous tooth extraction in a young child: A case report

INTRODUCTION

Major haemorrhage developing during oral or maxillofacial surgery is uncommon, but potentially life-threatening. Dental extractions in childhood are common, but blood loss is unusual.

CASE PRESENTATION

Here, we report a rare case of a complication developing during a trivial deciduous tooth extraction. We focus on the great difference between the preoperative orthopantomography and the maxillo-facial computed tomography obtained post-haemorrhage.

DISCUSSION

The surgical procedures most commonly associated with acute haemorrhage are orthognathic, oncological, and temporomandibular joint procedures. When acute haemorrhage develops, the surgeon must remain calm, temporarily arrest the bleeding, and ultimately definitively control it. Although ligation of the offending artery, vein, or vascular malformation is clearly the treatment of choice, identifying the offending vessel and gaining adequate access thereto are often difficult.

CONCLUSION

We emphasise that what we encountered could happen in routine daily practice.

VAC therapy with long term continuous saline infusion for secondary septic peritonitis: A new strategy for the reduction of perioperative risks?

BACKGROUND

The management of a septic peritonitis open abdomen is a serious problem for clinicians. Open surgery is associated with several complications such as bleeding and perforation of the bowel.

CASE PRESENTATION

The authors report a case of a 59-years-old female who underwent a sigmoid resection with an latero-terminal (L-T) anastomosis for the perforation of a diverticulum. After a few days the patients developed a new widespread peritonitis. At the emergency re-laparotomy, surgeons found dehiscence of the posterior wall of the anastomosis with fecal contamination. At admission in ICU (Intensive Care Unit) the patient had open abdomen with dehiscence of cutaneous and subcutaneous layers.

CONCLUSION

Conservative therapy with antibiotic therapy and use of the Vacuum-Assisted Closure® (VAC) Therapy with a long term continuous saline infusion led to the resolution of the septic shock and to the wound healing.

Ileal strangulation by a secondary perineal hernia after laparoscopic abdominoperineal rectal resection: A case report

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Secondary perineal hernia can develop after abdominoperineal resection of the rectum.

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An incarcerated secondary perineal hernia caused strangulated bowel obstruction.

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Wound-healing-delaying factors are the risk factors for perineal hernia development.

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The pelvic floor and peritoneum should be repaired via laparoscopic rectum surgery.

Introduciton

We report a recent case of strangulated bowel obstruction due to an incarcerated secondary perineal hernia that developed after laparoscopic rectal resection.

Presentation of case

A 75-year-old man undergoing treatment for alcoholic cirrhosis underwent laparoscopic abdominoperineal resection of the rectum (APR) for lower rectal cancer after preoperative chemoradiotherapy. Lung metastases were diagnosed 2 months postoperatively. Ten days after chemotherapy initiation, the patient was hospitalized on an emergency basis due to hepatic encephalopathy. Ten days thereafter, we observed perineal skin protrusion. Moreover, the skin disintegrated spontaneously, resulting in ascetic fluid outflow. Pain and fever developed, with inflammatory reactions. Contrast-enhanced computed tomography showed strangulated small bowel obstruction due to perineal hernia. We performed an emergency surgery, during which we found small intestine wall incarcerated in the pelvic dead space, with thickening and edema; no necrosis or perforation was observed. We performed internal fixation by introducing an ileus tube into the ileocecum and fixing its balloon at the cecal terminus.

Discussion

Secondary perineal hernia is rare and can develop after APR. Its prevalence is likely to increase in future because of the increasing ubiquity of laparoscopic APR, in which no repair of peritoneal stretching to the pelvic floor is performed. However, only two case of secondary perineal hernia causing strangulated bowel obstruction has been reported in the literature. The follow-up evaluation of our procedures and future accumulation of cases will be important in raising awareness of this clinical entity.

Conclusion

We suggest that the pelvic floor and the peritoneum should be repaired.

Esophageal adenocarcinoma five years after laparoscopic sleeve gastrectomy. A case report

INTRODUCTION

Laparoscopic sleeve gastrectomy has become the most popular bariatric procedure worldwide. However, postoperative gastroesophageal reflux disease appearance is a matter of concern. Only two cases of esophageal adenocarcinoma after gastric sleeve have been described, none of them with preoperative endoscopic evaluation.

PRESENTATION OF CASE

We report a case of a 48-year-old male with morbid obesity and normal preoperative endoscopy and esophagram who underwent a laparoscopic sleeve gastrectomy and developed an esophageal adenocarcinoma five years later.

DISCUSSION

Despite promising results in terms of weight loss and resolution of comorbidities, the onset or worsening of gastroesophageal reflux and its related complications, such as Barrett's esophagus or esophageal adenocarcinoma, is a matter of concern and need further study.

CONCLUSION

We present a case of an esophageal adenocarcinoma five years after a laparoscopic sleeve gastrectomy for morbid obesity. There is need to better determine the relationship between sleeve gastrectomy and gastroesophageal reflux disease in order to prevent its related complications, such as esophageal adenocarcinoma.