Retroperitoneal unicentric Castleman's disease: A case report

INTRODUCTION

Castleman's disease (CD) is an angio-follicular lymph node hyperplasia presenting as a localized or a systemic disease masquerading malignancy. The most common sites of CD are mediastinum, neck, axilla and pelvis. Unicentric CD in the peripancreatic region is very rare.

PRESENTATION OF CASE

We report a case of the 34-year-old lady presenting with epigastric pain for 3 months. Abdominal imaging revealed a retroperitoneal mass arising from the pancreas suspected to be neuroendocrine tumor. Tumor markers were not elevated. Complete surgical excision was performed and patient had uneventful recovery. Pathologic findings demonstrated localized hyaline-vascular type of Castleman's disease.

DISCUSSION

CD is a very rare cause for development of retroperitoneal mass. It is more frequent in young adults without predilection of sex. It can occur anywhere along the lymphoid chain. Abdominal and retroperitoneal locations usually present with symptoms due to the mass effect on adjacent organs. CD appears as a homogeneously hypoechoic mass on ultrasound and non-specific enhancing homogeneous mass with micro calcifications on computed tomography. Histologically, the hyaline vascular type demonstrates a follicular and inter-follicular capillary proliferation with peri-vascular hyalinization, with expansion of the mantle zones by a mixed inflammatory infiltrate of numerous small lymphocytes and plasma cells. The standard therapy of localized form is en bloc surgical excision as performed in our case.

CONCLUSION

Unicentric CD in the peripancreatic region is difficult to differentiate from pancreatic neoplasm preoperatively. However, preoperative biopsy in cases of high clinical suspicion can help in avoiding extensive surgery for this benign disease.

Ligation of huge spontaneous porto-systemic collaterals to avoid portal inflow steal in adult living donor liver transplantation: A case-report

INTRODUCTION

In adult living donor liver transplantation (LDLT), maintenance of adequate portal inflow is essential for the graft regeneration. Portal inflow steal (PFS) may occur due to presence of huge spontaneous porto-systemic collaterals. A surgical procedure to increase the portal inflow is rarely necessary in adult LDLT.

PRESENTATION

A 52 years male patient with end-stage liver disease due to chronic hepatitis C virus infection. Preoperative portography showed marked attenuated portal vein and its two main branches, patent tortuous splenic vein, multiple splenic hilar collaterals, and large lieno-renal collateral. He received a right hemi-liver graft from his nephew. Exploration revealed markedly cirrhotic liver, moderate splenomegaly with multiple collaterals and large lieno-renal collateral. Upon dissection of the hepato-duodenal ligament, a well-developed portal vein could be identified with a small mural thrombus. The recipient portal vein stump was anastomosed, in end to end fashion, to the graft portal vein. Doppler US showed reduced portal vein flow, so ligation of the huge lieno-renal collateral that allows steal of the portal inflow. After ligation of the lieno-renal collateral, improvement of the portal vein flow was observed in Doppler US.

DISCUSSION

There is no accepted algorithm for managing spontaneous lieno-renal shunts before, during, or after liver transplantation, and evidence for efficacy of treatments remains limited. We report a case of surgical interruption of spontaneous huge porto-systemic collateral to prevent PFS during adult LDLT.

CONCLUSION

Complete interruption of large collateral vessels might be needed as a part of adult LDLT procedure to avoid devastating postoperative PFS.

Numb chin syndrome as a sign of mandibular metastasis: A case report

INTRODUCTION

Metastasis to the oral cavity can be located in both the soft and bony tissues and comprise only 1% of all oral malignancies; however, it is clinically significant because it indicates widespread metastatic disease and an unfavorable prognosis. A numb chin is an important presentation of oral metastasis, but other dental and systemic pathology may be involved.

PRESENTATION OF CASE

We present the case of a 54-year-old woman who presented with numb chin syndrome 8 years after a diagnosis of primary breast carcinoma. The former was caused by mandibular ramal metastasis of the tumor, which also spread to the spinal canal, ribs, pelvic bones, sacrum, and proximal femur. Because of widespread metastasis, palliative treatment was administered.

DISCUSSION

Despite its low incidence, oral metastasis should be considered as a diagnostic option when patients present with numb chin syndrome. Bony metastasis may produce symptoms late, in contrast to soft tissue metastasis. Pain is the first presenting symptom in most cases, but paresthesia, hypoesthesia and anesthesia in the facial region are possible symptoms too. Most oral bony metastasis are located in the mandible, especially in the molar region. Despite treatment, the average survival after diagnosis of mandibular metastasis is 6-7 months.

CONCLUSION

In most cases with oral metastasis, palliative treatment is indicated. Early detection of oral lesions could improve treatment outcome and survival. A full diagnostic work-up is therefore of great importance.

An intestinal carcinoid causing transient jejunal intussusception in an adult-A case report

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Transient jejunal intussusception is a rare cause of intestinal obstruction in adults.

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There are eight recorded cases in the English literature and this is the first known case of a malignancy.

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The usual presentation is in the 6th and 7th decades of life but the patient here is in her thirties.

Introduction

Transient jejunal intussusception in an adult is a rare clinical finding as reported in the English literature. The diagnosis is usually a matter of exclusion given the extremely rare nature of this medical condition.

Presentation of the case

A young female presented to our hospital with abdominal pain and distention of six months duration. The episodes were intermittent in nature and resolved with conservative management. The aetiology remained obscure until a computerized tomography(CT) scan diagnosed a small bowel intussusceptionIntraoperatively a small bowel tumour was identified and resected. Pathology confirmed an intestinal carcinoid of the small bowel with no evidence of metastatic disease.

Discussion

Transient jejunal intussusception is a rare finding with only eight reported cases in the English literature. All previously reported cases have been ascribed to benign aetiologies and to our knowledge this is the first case of a malignancy causing transient jejunal intussusception. The management is usually conservative unless an actual cause for the intussusception can be ascertained. The diagnosis is usually one of exclusion and CT scan remains the gold standard in eliciting a diagnosis.

Conclusion

Transient jejunal intussuception in adults is an extremely rare pathological condition and the diagnosis is usually entertained as a matter of exclusion.

Pulmonary emboli cardiac arrest with CPR complication: Liver laceration and massive abdominal bleed, a case report

INTRODUCTION

Massive pulmonary emboli may cause right ventricular failure and backward stasis with parenchymal organ swelling thus increasing the risk for laceration, e.g. if CPR is needed.

PRESENTATION OF CASE

A 28-year-old Colombian female with no medical history but taking contraceptive pills and having had a recent longer flight was admitted to Danderyds hospital Emergency Department because of respiratory failure. She developed cardiac arrest in the emergence department following the emergent diagnosis of pulmonary emboli. Cardio-pulmonary resuscitation was initiated, initially with manual and subsequent mechanical compressions with a so called LUCAS device. Patients did not respond properly to the CPR and showed signs of hypovolemia. Emergent ultrasound raised suspicion of abdominal bleed. Emergent laparotomy confirmed liver laceration and massive haemorrhage.

CONCLUSION

Pulmonary emboli with subsequent right ventricular failure may cause backwards stasis, and parenchymal organ e.g. liver enlargement. The risk for laceration injuries and internal bleed must be acknowledged when applying external forces as in case of cardiac arrest and need for resuscitation. Frequent and vigilant control of positioning of manual as well as mechanical compressions is of importance.

Adult primary cervical extra-osseous Ewing’s sarcoma: A case report and short literature review

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EES primarily located in the spine is extremely rare.

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Treatment of adult EES is a challenge due to a lack of established guidelines.

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A more conservative treatment modality is needed for old patients with EES.

Introduction

Primary spinal epidural extraskeletal Ewing’s sarcoma (EES) is extremely rare, with a peak incidence in the second decade of life. EES in old people is challenging to treat due to the lack of specific guidelines. In this paper, I present a unique case of adult primary cervical epidural EES with a 13-month follow-up. A short literature review of the therapeutic approaches and prognosis is also presented.

Presentation of case

I present a case of a 49-year old male patient who presented with right upper limb pain, numbness, hand grip weakness, and hyperreflexia of 3 months duration. Enhanced cervical magnetic resonance imaging showed a homogenously enhancing epidural and paravertebral soft tissue mass extending from the C6 to the T2 that appeared hypointense on T1 and hyperintense on T2. The patient underwent biopsy that confirmed EES via histopathology. Treatment with chemotherapy and radiotherapy resulted in tumor resolution and symptom relief.

Discussion

EES is a type of PNET. Surgical removal is generally the treatment of choice, followed by adjunctive chemotherapy and radiotherapy. In old patients with large tumors, a more conservative approach with biopsy, adjuvant chemotherapy and radiotherapy is recommended.

Conclusions

Adult primary cervical epidural EES is a neurosurgical challenge due to the extension to the surrounding vital structures making the tumor not amenable for total resection as in the present case. In the absence of specific therapeutic guidelines, our case highlights the need to individualize the treatment modality according to age, tumor extension, and feasibility of total tumor resection.

A case report of small bowel perforation secondary to cytomegalovirus related immune reconstitution inflammatory syndrome in an AIDS patient

Non-traumatic small bowel perforation is rare in adults but carries a high morbidity and mortality. The diagnosis is made on clinical suspicion, and the most common causes in developing countries are infectious diseases, being cytomegalovirus infection in immunocompromised patients the main etiology. We describe a patient with a recently diagnosed advanced stage HIV infection and an intestinal perforation associated with cytomegalovirus immune reconstitution inflammatory syndrome after highly active antiretroviral therapy initiation.

Comment on: “A case report of a complete degloving injury of the penile skin”

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Genitalia are a key element for male self-esteem, contributing towards mental and physical balance and influencing their social life.

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Scrotal dartos-fascio-mio-cutaneous flap for shaft coverage offers a large amount of tissue with low donor site morbidity, avoiding unsightly scars in more visible parts of the body.

Introduction

We recently published an article in the International Journal of Surgical Case Reports titled: “Scrotal dartos-fascio-myo-cutaneous flap for penis elongation after catastrophic iatrogenic skin shaft sub-amputation: A case of recovery using an extremely adaptable flap”.

Presentation of case

We propose a comment on a recent article titled “A case report of a complete degloving injury of the penile skin” by Helena Aineskog and Frederik Huss that we read with great interest.

Discussion

Genitalia are linked to self-esteem and male sexual identity, especially among young men, who sometimes require a surgical procedure to acquire more confidence. Various techniques are available for pe-nile skin covering, such as skin grafts or cutaneous flaps. The skin of the scrotum seems to be the most suitable tissue to be used to reconstruct the skin covering of the shaft as it is the most similar.

Conclusion

Scrotal flap is a single stage procedure that is easy and safe to perform.

Extended thymectomy, left pneumonectomy, pericardiectomy and partial pleurectomy for a large thymoma, using only a median sternotomy

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Extended resection of a large thymoma

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Median sternotomy.

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Thymectomy, left pneumonectomy, pericardiectomy and partial pleurectomy.

We present a case of a large thymoma with invasion to the hilum of the lung and pleural dissemination. A 58-year-old woman was diagnosed with a type B2 thymoma, with suspected pericardium, pulmonary artery and left lung invasion and pleural metastasis (Masaoka-Koga stage IVb). A radical resection was planned after systemic chemotherapy. Through a median sternotomy, we resected the tumour, and after confirmation of pericardium and left lung invasion, we also performed resection of the pericardium, of the lung and of the pleural metastasis. The median sternotomy allowed a safe dissection of pulmonary vessels and main bronchus.

A chip off the old block—A case report of gallstone ileus in which identification of a facetted stone was essential in preventing re-laparotomy

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Interesting case discussing a comparatively rare but serious presentation.

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Important operative learning point to avoid return to theatre and associated morbidity/mortality.

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Excellent intra-operative images to highlight learning points.

Gallstone ileus is a rare presentation, accounting for 0.1% of cases of mechanical small bowel obstruction. Patients are often elderly with significant comorbidity. Treatment is based upon laparotomy and enterolithotomy. We present the case of a 75 year old lady admitted as an emergency with a 4 day history of small bowel obstruction. She was found on CT scan to have an impacted gallstone in the distal ileum. At operation, her impacted stone was removed through a proximal enterostomy. The stone however was found to have a squared off edge, raising the suspicion of a second fragment within the proximal small bowel lumen. Failure to retrieve this could have led to re-obstruction requiring a return to theatre and repeat laparotomy in an elderly patient with the associated morbidity.

Report of two cases of large cell neuroendocrine carcinoma of duodenal ampulla with contrasting outcomes following pancreaticoduodenectomy according to the use of adjuvant chemotherapy

INTRODUCTION

Large-cell neuroendocrine carcinoma (LCNEC) in the duodenal ampulla of Vater is a rare malignant tumor, with frequent postoperative recurrence and poor prognosis even following complete resection. Effective adjuvant chemotherapy is expected to offer longer survival.

PRESENTATION OF CASE

We present two patients with LCNEC accompanied by components of tubular adenocarcinoma/adenoma in the duodenal ampulla of Vater who underwent pancreaticoduodenectomy (PD), resulting in longer survival of 1 patient. The first patient was an 81-year-old man in whom a 14-mm protruding solid tumor of the ampulla was observed. Pylorus-preserving PD (PPPD) was performed for the diagnosis of adenocarcinoma of the ampulla, and the final histological diagnosis of the resected specimen was LCNEC with an adenoma component. The patient showed a liver metastasis 4 months after surgery and died of carcinoma after 11 months. The second patient was a 72-year-old man with a 24-mm ulcerative solid tumor of the ampulla. PPPD was also performed in this patient, and the final histological diagnosis was LCNEC with mixed adenocarcinoma component (21%). Adjuvant chemotherapy of cisplatin and etoposide was administered, and the patient survived without tumor relapse for 24 months after surgery.

CONCLUSION

In the surgical treatment of LCNEC of the ampulla showing malignant behaviour, an accurate preoperative diagnosis and effective adjuvant chemotherapy after curative resection are necessary for longer survival.

Postoperative disseminated intravascular coagulation in a pregnant patient with Blue Rubber Bleb Nevus Syndrome presenting with acute intestinal obstruction: Case report and literature review

BACKGROUND

Blue Rubber Bleb Nevus Syndrome (BRBNS) is a rare condition which usually manifests as multiple hemangioma-like skin and gastrointestinal lesions. The latter often present with chronic bleeding. There is no consensus regarding the optimal management of such patients. Although rare, complications such as intestinal intussusception might occur, demanding surgical treatment. Postoperative complications such as coagulation disorders can increase morbidity and should be timely addressed. This is the first report of a life-threatening postoperative disseminated intravascular coagulation in such patients. The main objectives of this case report are to present diagnostic and treatment features of this condition and, more importantly, address the optimal management of postoperative disseminated intravascular coagulation.

CASE PRESENTATION

Twenty-five year-old female pregnant patient presents to the emergency department with colicky pain and oligohydramnios. After C-section, persistent symptoms and further investigation led to the diagnosis of intestinal intussusception. After surgical management she showed clinical and laboratory signs of disseminated intravascular coagulation (DIVC), which was corrected with transfusional therapy and intraperitoneal clot evacuation. After optimal management, she was discharged home. Sirolimus was initiated further improving her condition.

CONCLUSION

This rare presentation of acute intestinal intussusception in a patient with Blue Rubber Bleb Nevus Syndrome was further complicated with postoperative coagulation disorder. Prompt surgical evaluation is essential especially when complications are suspected. Operative treatment might be necessary in the emergent setting. Close monitoring of infectious and coagulation parameters is essential in the postoperative period, and aggressive treatment should be timely initiated when disseminated intravascular coagulation is suspected.

Conservative management of an unusual bilioduodenal fistula post laparoscopic Duodeno-Ileal Switch (SADI-S) case report

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A bilioduodenal fistula may rarely occur after duodenal switch. This case report is original and interesting showing a successful conservative management of this rare complication.

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A review of the literature on different types of Internal Biliodigestive Fistulae and their appropriate management are reported and briefly discussed.

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We highlight the differential diagnosis and optional treatment in such a rare complication, and how we succeeded in its conservative management.

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An accurate diagnosis and a team work between gastroenterologists and surgeons may be salvatory in this type of complication.

Introduction

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is an advanced operation for morbid obesity. To our knowledge, no internal Biliodigestive Fistula has yet been reported as specific complication in the field of metabolic and bariatric Biliopancreatic diversion.

Case presentation

In this case report, we detail the case of a 57-year-old man who underwent a Single Anastomosis Duodeno-Ileal Switch (SADI-S) bariatric procedure for morbid obesity.

Upon admission 3 weeks after the SADI-S procedure acute sepsis caused by a delayed choledoco-duodenal Fistula was diagnosed.

A conservative management of this rare complication was successful.

Discussion

We highlight the differential diagnosis and optional treatment in such a rare complication, and how we succeeded in its conservative management, without any need for endoscopic nor surgical intervention.

A review of the literature on different types of Internal Biliodigestive Fistulae and their appropriate management are reported and briefly discussed.

Conclusion

The aim of this case report is to highlight the existence of such a rare complication, and its successful multidisciplinary conservative medical management.

Synchronous hepatic metastasis and metachronous Krukenberg tumor from advanced colon cancer. A case report with an unexpected disease-free survival

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The prognosis of a colon cancer with hepatic and ovarian metastasis is very poor.

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A colon cancer patient with hepatic and ovarian metastases can heal.

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In the literature we have never found a similar case.

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An appropriate surgical approach, a tailored chemotherapy and an intensive follow-up are essential.

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The degree to which HIPEC may have had an impact is still unknown.

Background

In the international literature we have never found a long survival in patients treated for a colon cancer with synchronous hepatic metastases and for a metachronous Krukenberg tumor.

Presentation of case

A 46-year old woman for an advanced colon cancer with a synchronous hepatic metastases was subjected to a left hemicolectomy and a resection of liver segment V (R0 resection; T4N2bM1; stage IVa according AJCC 2010). After one year a CT of the abdomen revealed an expansive formation of the left ovary. The patient was subjected to a bilateral ovariectomy, hysterectomy and hiperthermic intraperitoneal chemotherapy (HIPEC). The patient, after several cycles of adjuvant chemotherapy, is disease-free 13 years after surgery.

Discussion

To our knowledge, in the literature there do not appear to be cases of such disease-free survival. The survival of patient despite the prognostic indexes is discussed. The authors discus the importance of an adequate surgical treatment especially for liver metastases simultaneously treated to colon cancer. The authors also focus on chemotherapy (FOLFOX and then FOLFIRI) performed in a pre-biological era. Furthermore, the degree to which the HIPEC may have had an impact is still unknown, although it seems to be the gold standard for the treatment of the microscopic peritoneal neoplastic remnant.

Conclusion

The authors emphasize that the long term survival in colon cancer with hepatic and ovarian metastases is possible as long as it has an adequate surgical approach, a tailored chemotherapy and an intensive follow-up. Most likely new prognostic markers will have to be identified.

Multidisciplinary management of a patient with van der Woude syndrome: A case report

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We described the orthodontic treatment of a girl diagnosed with VWS.

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Multidisciplinary techniques resulted in satisfactory outcomes.

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Genetic testing determined a known putative splice site mutation.

Introduction

Van der Woude syndrome (VWS) is the most frequent form of syndromic cleft lip and palate (SCLP) accounting for 2% of all patients with CLP.

Case presentation

We describe the orthodontic treatment of a girl diagnosed with VWS referred by her family dentist for her cosmetic concerns.

Discussion

Comprehensive orthodontic treatment, secondary bone graft, distraction osteogenesis (for a deficient maxilla), secondary palatoplasty and excision of lower lip pits, as well as orthodontic and prosthetic procedures may provide a satisfactory outcome. Genetic testing showed a known putative splice site mutation (c.174 + 1 G/A) as the prime cause of VWS in our patient and her family.

Conclusion

SCLP has significant effects on facial aesthetics and the psychosocial status. Parents should be assessed and counseled appropriately. This condition is treatable in the absence of life threatening systemic anomalies. An interdisciplinary team approach is advocated.

Infarcted mesothelial cyst: A case report

INTRODUCTION

Mesenteric and omental mesothelial cysts are rare, accounting for only 1 in 100,000 hospital admissions for abdominal pain (Tan Jane et al., 2009) [1]. They are often discovered only on CT imaging, which is frequently non-definitive in identifying an exact tissue source owing to overlapping radiographic features with other masses (Stoupis et al., 1994) [2]. The symptoms manifested by such masses are also nonspecific, favoring consideration of more frequently encountered problems in the scope of general surgery over cystic masses in the differential diagnosis. Definitive diagnosis of a mesothelial cyst in this case was made on histopathologic examination of a surgically resected specimen. This case is reported in line with SCARE criteria (Dragoslav et al., 2007) [6].

PRESENTATION OF CASE

A 41 year-old male patient presented to an academic teaching hospital with several days of abdominal pain with nausea and vomiting. Initial workup was unremarkable, save for abdominal CT revealing a central mesenteric focus of inflammation. Neuroendocrine tumor was excluded by normal serum octreotide, 5-HIAA, and chromogranin A. A 4×2cm mass was identified and resected on laparoscopy. Histopathologic diagnosis of the specimen was infarcted mesothelial cyst. The patient reported resolution of symptoms and remains well on most recent follow-up.

DISCUSSION

The rapid diagnosis of intra-abdominal cystic masses is obscured by their rarity, nonspecific symptomatology, and radiographic features that overlap among such masses (Stoupis et al., 1994) [2]. The etiology of symptoms is likely owed to local mass effect exerted by the cyst on surrounding tissues. Continued resolution of symptoms on resection of such a cyst supports this conclusion.

CONCLUSION

imaging following an overall unremarkable physical and laboratory workup for this patient's abdominal pain directed our further workup and management efforts towards surgical excision of an intra-abdominal cystic mass. Histopathologic examination of the cyst was ultimately diagnostic of an infarcted mesothelial cyst.

Forgotten CBD stent (102 months) with stone-stent complex: A case report

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Choledocholithiasis can be treated by endoscopic extraction with or without stenting or by surgery.

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Stents cam form nidus for development of stones in CBD,may lead to cholangitis.

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Patients should be informed about ill effects of stent in-situ and advised to review for stent removal after 6 weeks.

Introduction

Choledocholithiasis is presence of stone in Common bile duct (CBD) which can be treated by endoscopy or surgery [1]. Retained foreign bodies like stents forms a nidus for stone formation resulting in pain, fever, jaundice.

Case presentation

60 years female patient admitted in surgery ward with features of cholangitis with computed tomography showing cholangitic abscess with dilated common bile duct and sludge around stent in situ. Stone was found at proximal end of stent during surgery.

Discussion

Stents may remain without complications or may migrate, and rarely form nidus for stone formation. If kept for long time they lead to bacterial proliferation, biofilm formation and precipitation of calcium bilirubinate presenting as fever, pain, jaundice. Stent-stone complex can be treated endoscopically and surgically [6,7]. As stent can cause stone formation, infection and other complications, timely removal of stent should advised.

Conclusion

III-effects of stent in-situ should be explained, record should be maintained [8] and patient should be advised regular follow up and stent removal after 6 weeks.

Adrenal failure due to bilateral adrenal metastasis of rectal cancer: A case report

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Bilateral adrenal metastases can be lead to adrenal insufficiency.

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A rapid ACTH test is useful to diagnose adrenal insufficiency.

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Adrenal crisis may be fatal if not promptly recognized and treated.

Introduction

It is rare for a patient to present with adrenal insufficiency secondary to bilateral adrenal metastases from a malignant colorectal tumor.

Case presentation

An 82-year-old Japanese man presented to our hospital with high fever and malaise. He was receiving oral chemotherapy for the treatment of rectal cancer with multiple metastases. Computed tomography showed new bilateral adrenal gland metastases. A rapid adrenocorticotropic hormone (ACTH) test showed adrenal insufficiency. Treatment with hydrocortisone provided immediate symptom improvement.

Discussion

Adrenal insufficiency secondary to bilateral adrenal metastases from rectal cancer is rare. A rapid ACTH test is useful to diagnose adrenal insufficiency.

Conclusion

The incidence of adrenal insufficiency may be underestimated in patients with multiple metastasis. Appropriate therapy with adrenal corticosteroid hormone supplementation may lead to a significant improvement in the patient’s symptoms and quality of life.

An association between transmesenteric internal hernia and abdominal cocoon syndrome: A case report

Introduction

Transmesenteric internal hernia is defined as the herniation of the small intestine from a mesenteric defect in the abdominal cavity, and abdominal cocoon syndrome is the partial or entire encapsulation of the small bowel like the shape of an accordion, by a fibrocollagenous membrane.

Presentation of case

A 32-year old male patient applied with complaints of abdominal pain, nausea, and vomiting bile. Signs visualized in the abdominal computer tomography were as follows: gatto formation of the small intestinal loops and suspected of an internal hernia.In the operation, a membrane was detected encapsulating the entire intestine resembling a tube, making the intestines to appear like an accordion and an opening was present in the small intestinal mesentery. The intestine was separated from the defect, and placed in its normal anatomical position. The defect in the mesentery was closed and the encapsulating membrane was removed from small intestine. Intestinal resection was not required.

Discussion

Internal hernias comprise less than 1% of all intestinal obstructions, and are formed by the herniation of the intestine and mesentery into the opening of the visceral peritoneum or into the recessus. Abdominal cocoon syndrome is a disorder characterized by the partial or total encapsulation of the small intestine by a thick and fibrotic membrane. Preoperative diagnosis is very difficult and is generally diagnosed during laparotomy exploration.

Conclusion

The association of internal herniation and abdominal cocoon syndrome is an extremely rare cause of mechanical intestinal obstruction. If not promptly diagnosed and treated, can lead to serious complications.

Severe hypoalbuminemia and steatohepatitis leading to death in a young vegetarian female, 8 months after mini gastric bypass: A case report

BACKGROUND

Hypoalbuminemia is an important complication after Mini Gastric Bypass (MGB) and is more frequent in vegetarians, diabetic nephropathy, and alcoholic and liver disease patients. The patients must be followed in regular intervals and serum albumin must be checked in every visit after MGB. Hypoalbuminemia must be prevented by good protein regimes.

CASE SUMMARY

A 29 years old female was admitted 8 month after Laparoscopic Mini Gastric Bypass with malaise, dyspnea, icter, nausea, vomiting, diarrhea and edema of extremities from 2 weeks before admission. She had become vegetarian autonomously and had not participated in routine postop follow up, and also discontinued her high protein regimen. In para clinictest results, she had severe hypoalbuminemia, anemia, elevated liver enzymes and direct bilirubinemia, metabolic acidosis in Arterial Blood Gas (ABG), and in Core Needle Biopsy (CNB) marked Steatohepatitis was shown. Unfortunately, the patient did not respond to medical care and died.

CONCLUSION

Regular follow up after Mini Gastric Bypass is very important for many reasons such as early diagnosis and treatment of hypoalbuminemia.

Conservative approach to Hepatic Portal Venous Gas: A case report

INTRODUCTION

Hepatic Portal Venous Gas (HPVG), a rare condition in which gas accumulates in the portal venous circulation, is often associated with a significant underlying pathology, such as Crohn's disease, ulcerative colitis, diverticulitis, pancreatitis, sepsis, intra-abdominal abscess, endoscopic procedures, mesenteric ischemia, abdominal trauma.

PRESENTATION OF CASE

Here we report a case of HPVG in an 82-year-old patient who underwent a left colectomy for stenosing tumor of the descending colon. The patient was treated conservatively, and his symptoms resolved. Follow-up computed tomography (CT) scan showed complete resolution of HPVG.

DISCUSSION

The mechanism underlying the passage of the gas from the intestine into the mesenteric, then portal, venous system is not fully understood. Historically, this condition has been related to acute intestinal ischemia, as a consequence of a bacterial translocation through a wall defect.

CONCLUSION

This case underscores the role of conservative management, highlighting how the severity of the prognosis of HPVG should be related to the underlying pathology, and not influenced by the presence of HPVG itself.

Total hip arthroplasty for femoral neck fracture with pyoderma gangrenosum patient: A case report

INTRODUCTION

Pyoderma gangrenosum is a rare inflammatory aseptic, ulcerative neutrophilic dermatosis which manifest as skin recurrent, painful ulcers.

PRESENTATION OF CASE

A 65-year-old man with pyoderma gangrenosum underwent left total hip arthroplasty because of femoral neck fractures. Glucocorticoid, antibiotic, anticoagulant drug, etc. were given in perioperative period. Complication of pyoderma gangrenosum was prevented successfully in perioperative period.

DISCUSSION

No consensus has been reached about whether to use glucocorticoid, as well as the dosage and administration, in perioperative periods for pyoderma gangrenosum patients as prophylactic means of wound complication.

CONCLUSION

We herein report a case of pyoderma gangrenosum patient underwent total hip arthroplasty, meanwhile raise the issue of management in perioperative period for pyoderma gangrenosum patient, especially explore series of standardized therapies for this disease during arthroplasty.

A case report of unusual pneumomediastinum after endoscopic sinus surgery

INTRODUCTION

Endoscopic sinus surgery is a minimally invasive procedure used to restore normal sinus ventilation and mucociliary function. It is a routine otolaryngology procedure with a success rate of about 90% for symptomatic improvement in patients with refractory chronic rhinosinusitis. Because of the proximity of the paranasal sinuses to the brain and the orbit, it cannot be performed without a potential risk of complications. In our case, without early clinical suspicion, proper diagnosis and management, this unusual occurrence of pneumomediastinum after endoscopic sinus surgery may have led to major complications or even death.

PRESENTATION OF CASE

We report a case of unusual mediastinal emphysema in a 53-year-old man after removal of the nasal pack on the day after endoscopic sinus surgery.

DISCUSSION

To the best of our knowledge, there are only two reported cases of mediastinal emphysema after endoscopic sinus surgery. What made our case unique was the absence of smoking history, pulmonary disease or infection and normal preoperative chest CT scan. We investigated further with postoperative chest CT scan, bronchoscopy and esophagoscopy to rule out anesthesia related laryngotracheal injury. In our case, the pneumomediastinum was successfully treated conservatively; however, it could have proceeded to mediastinitis, septicemia and death if it had not been diagnosed and treated early.

CONCLUSION

Damage to the lamina papyracea can occur during endoscopic sinus surgery and presents as periorbital emphysema. Extension of the emphysema down to the mediastinum cannot be ignored as a possible etiology of the pneumomediastinum. Early diagnosis and proper management are important to avoid mortality.

Incarcerated and eventrated abdominal wall hernia reconstruction with autologous double-layer dermal graft in the field of purulent peritonitis-A case report

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This is the first applied autologous dermal graft for eventrated hernia in an emergency case.

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Terminal ileum and ascending colon were perforated into the hernia sac causing dirty operating field.

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It was impossible to close the 223 cm² gap with sutures, biological mesh was not available.

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Specially prepared grafts were applied to reconstruct the gap in a double- layer tension free fashion.

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No hernia recurrency was observed 8 months after the surgery.

Introduction

Double-layer dermal grafts are used for the management of complicated abdominal wall hernias in obese, high risk patients. The method has not yet been used in case of emergency in septic/dirty environment.

Case report

A 76-year old female patient (BMI 36.7 kg/m²) was admitted with mechanical bowel obstruction and sepsis caused by a third time recurred, incarcerated and eventrated abdominal wall hernia. During the emergency surgery perforation of the terminal ileum and the ascending colon was detected, along with a feculent peritonitis and extended abdominal wall necrosis. Extended right hemicolectomy and necrectomy of the abdominal wall were performed. The surgery resulted in an abdominal wall defect measuring 223 cm², for the management of which direct closure was not possible. Using a specific method, an autologous dermal graft was prepared from the redundant skin. The first dermal graft was placed under the abdominal wall with 5 cm overlap, and the second layer was placed onto the first layer with 3 cm overlap in a perforated fashion. The operating time was 250 min. No significant intra-abdominal pressure elevation was measured. No reoperation was performed. On the fifth postoperative day, the patient was mobilised. She was discharged in satisfactory general condition on the 18th postoperative day. There is no recurrent hernia 8 months after the surgery.

Discussion

Abdominal wall reconstruction was possible in a necrotic, purulent environment by using a de-epithelised autologous double layer dermal graft, without synthetic or biological graft implantation. The advantage of the procedure was cost-effectivity, and the disadvantage was that only in an obese patient is the sufficient quantity of dermal graft available.

Conclusion

A homogeneous internal and perforated outer dermal graft was suitable for bridging the abdominal gap in the case of an obese, high risk patient. Autologous dermal grafts can be a safe and feasible alternative to biological meshes in emergency abdominal wall surgeries. Evaluation of a case series can be the next cornerstone of the method described above.

Total small bowel herniation through the space between the connecting tube of gastric band and abdominal wall: A case report of a surgical emergency

INTRODUCTION

Laparoscopic adjustable gastric banding is one of the most frequently done procedures for morbid obesity. In most reported cases, the band itself is the cause of complications. There are only a few reports of morbidities caused by the connecting tube. This presentation describes a case of acute abdomen due to small bowel herniation between the connecting tube and the abdominal wall. This case report aims to remind clinicians of possible complications caused by the connecting tube of a gastric band.

CASE PRESENTATION

We report about a 24-year-old male patient, who presented with acute abdomen. He had undergone gastric banding three years ago. According to his clinical presentation, the patient was diagnosed as having acute appendicitis. Abdominal exploration revealed, total small bowel herniation between the connecting tube and the abdominal wall.

DISCUSSION

Although a simple procedure, laparoscopic gastric banding could have serious complications. Some of these complications could present years after the application of the gastric band. There are a few reports about complications caused by the connecting tube of the gastric band.

CONCLUSION

Complications caused by connecting tube should always be in mind, when assessing acute abdomen in patients with laparoscopic gastric band.

Preferred reporting of case series in surgery; the PROCESS guidelines

INTRODUCTION

Case series have been a long held tradition within the surgical literature and are still frequently published. Reporting guidelines can improve transparency and reporting quality. No guideline exists for reporting case series, and our recent systematic review highlights the fact that key data are being missed from such reports. Our objective was to develop reporting guidelines for surgical case series.

METHODS

A Delphi consensus exercise was conducted to determine items to include in the reporting guideline. Items included those identified from a previous systematic review on case series and those included in the SCARE Guidelines for case reports. The Delphi questionnaire was administered via Google Forms and conducted using standard Delphi methodology. Surgeons and others with expertise in the reporting of case series were invited to participate. In round one, participants voted to define case series and also what elements should be included in them. In round two, participants voted on what items to include in the PROCESS guideline using a nine-point Likert scale to assess agreement as proposed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group.

RESULTS

In round one, there was a 49% (29/59) response rate. Following adjustment of the guideline with incorporation of recommended changes, round two commenced and there was an 81% (48/59) response rate. All but one of the items were approved by the participants and Likert scores 7-9 were awarded by >70% of respondents. The final guideline consists of an eight item checklist.

CONCLUSION

We present the PROCESS Guideline, consisting of an eight item checklist that will improve the reporting quality of surgical case series. We encourage authors, reviewers, editors, journals, publishers and the wider surgical and scholarly community to adopt these.

Respiratory distress associated with heterotopic gastrointestinal cysts of the oral cavity: A case report

Heterotopic gastrointestinal cysts of the oral cavity are benign lesions usually discovered during infancy. Their pathogenesis is not very clear. They are rare congenital anomalies that result from remnants of foregut-derived epithelium in the head, neck, thorax or abdomen during embryonic development. The majority of these lesions occur in the anterior ventral surface of the tongue and extend to the floor of the mouth. They are confused clinically by surgeons in cases of head and neck masses in children as ranulas, dermoid and thyroglossal cysts, and lymphangioma. We report the case of a 28-day newborn with a 3.6 cm oval mass on the floor of the mouth causing difficulty eating and cyanosis during crying. Complete surgical excision was performed by an oral approach under general anesthesia. Microscopic examination revealed gastric epithelium with tall columnar mucous cells on the surface and numerous short closed crypts, resembling fundal glands and mature gastric epithelium.

Delayed diagnosis of Wernicke encephalopathy with irreversible neural damage after subtotal gastrectomy for gastric cancer: A case of medical liability?

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This case report concerns Wernicke’s encefalopathy occurring in cancer gastrectomy.

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WE is often under-diagnosed and under-treated in gastric cancer patients.

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Other etiologies of WE should be excluded, in order to avoid claims of medical malpractice, which can cause enormous professional and economic costs.

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Monitoring for WE has yet to be recommended in the clinical guidelines.

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Specific guidelines on possible side effects of necessary surgery are needed.

Introduction

Wernicke’s encephalopathy (WE) is a neurological syndrome caused by thiamine deficiency, and clinically characterized by ophthalmoplegia, ataxia and acute confusion. In developed countries, most cases of WE have been seen in alcohol misusers. Other reported causes are gastrointestinal tract surgery, hyperemesis gravidarum, chronic malnutrition, prolonged total parenteral nutrition without thiamine supplementation, and increased nutrient requirements as in trauma or septic shock. WE is a well-known postoperative complication of gastric restrictive surgery for morbid obesity, after which patients often experience protracted nausea and vomiting, leading to malnutrition and massive weight loss.

Presentation of case

This case report concerns WE occurring in a patient who underwent Roux-en-Y subtotal gastrectomy for gastric cancer, and subsequently experienced neurological symptoms that proved irreversible probably due to the lengthy time elapsing between their clinical presentation and the diagnosis of WE.

Discussion

There have been some reports of WE occurring after total or subtotal gastrectomy for gastric cancer in non-obese patients with no history of alcoholism, but monitoring for WE has yet to be recommended in the clinical guidelines in this setting (as it has for bariatric surgery). Because of its rarity and variable clinical presentation, WE is often under-diagnosed and under-treated, and confused with other neurological problems.

Conclusion

There is an urgent need for the specific guidelines to take into account not only the neoplastic follow-up of such patients, but also the possible side effects of necessary surgery, since this could help to ensure the timely diagnosis and management of WE in this setting, and to avoid, when possible, claims for medical malpractice that may cause enormous costs both in economical and professional terms.

A case report of small bowel obstruction from previously undiagnosed lobular breast carcinoma: First in Australian literature

INTRODUCTION

This case report is the first in the Australian literature of a patient, without prior diagnosis, presenting with a bowel obstruction secondary to lobular breast cancer. This highlights a relatively rare cause of bowel obstruction, but also the importance of breast self-examination as a compliment to the current BreastScreen Australia program.

PRESENTATION OF CASE

A 67-year-old female presented to the Emergency Department with a 48-h history of sharp, constant epigastric pain, vomiting and constipation. The patient proceeded to emergency laparotomy for presumed large bowel obstruction, which revealed a stricture in the distal terminal ileum causing a distal small bowel obstruction. A right hemicolectomy was performed. Histopathology revealed the terminal ileum stricture to be metastatic lobular breast carcinoma. Clinical examination of the patient's right breast revealed a lesion suggestive of the primary malignancy despite a normal ultrasound and mammogram in 2014. After failing to progress, a CT scan was performed which revealed progressive small and large bowel distension. A repeat laparotomy was performed revealing dilated large bowel without obstructing pathology and an intact anastomosis. A loop ileostomy was performed. Following a further febrile episode, the patient decided to withdraw care and the patient passed away three weeks into her admission from suspected intra-abdominal sepsis.

DISCUSSION

Breast cancer is becoming the third most common cancer amongst Australian women with a significant burden of disease and mortality.

CONCLUSION

Despite the rare presentation, this case reminds the medical community and general population of the importance of breast self-examination and the BreastScreen Australia program.

Laparoscopic management of severe reflux after sleeve gastrectomy using the LINX® system: Technique and one year follow up case report

INTRODUCTION

Management of severe reflux after sleeve gastrectomy (SG) usually requires converting to Roux-en-y gastric bypass (RYGB). We present a case of managing this problem using the LINX^® system.

PRESENTATION OF CASE

In February 2015, we performed a laparoscopic placement of LINX^® system to treat severe reflux after sleeve gastrectomy on a 25-year-old female. The operative time was 47min. There were no intra or postoperative complications. The hospital stay was one day. The postoperative UGI showed no reflux. Ten days after surgery her Quality of life score (QOL) changed from 64/75 to 7/75 after the LINX^® placement. One year later the patient continued to enjoy no reflux and stayed off medication.

DISCUSSION

Reflux after sleeve gastrectomy is usually managed by conversion to RYGB by most surgeons. This case report opens the door for an alternative management of this problem while maintaining the original sleeve gastrectomy. This technique is reasonably easy to perform in comparison to the conversion to RYGB with less potential post-operative complications. A one year follow up showed good control of reflux without medication.

CONCLUSION

Laparoscopic placement of the LINX^® system to correct severe reflux after sleeve gastrectomy is a safe alternative procedure to conversion to a RYGB.

Extrahepatic biliary obstrution secondary to neuroendocrine tumor of the common hepatic duct

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Extra hepatic biliary obstruction can be frequently caused by tumors.

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Differentiation between cholangiocarcinoma and an unusual bile duct tumor such as a neuroendocrine tumor (NET) is very difficult preoperatively.

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Prognosis of NET of the extrahepatic bile duct is dependent on the grade of the tumor however is markedly better than cholangiocarcinoma.

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Unusual biliary tumors can not be diferentiated preoperatively from cholangiocarcinoma.

Introduction

Primary neuroendocrine tumors (NET) of the extrahepatic biliary tree are a rare entity with less than 100 reported cases in the literature.

Presentation of case

Here, we report a case of NET of the extrahepatic bile duct in a 64-year-old male patient presenting with painless jaundice, direct hyperbilirubinemia, and mildly elevated transaminases. Diagnostic workup with an ultrasound revealed dilation of the intrahepatic biliary ducts, without cholelithiasis or choledocholithiasis. Additional cross sectional imaging identified a stricture at the confluence of the common hepatic and cystic duct junction. Given lack of additional findings presumptive diagnosis of localized klatskin’s tumor was made. The patient subsequently underwent resection of the common bile duct and roux-en-y hepaticojejunostomy reconstruction. Final pathologic diagnosis showed G2 well-differentiated NET of the extrahepatic bile duct, measuring 1.3 × 1.1 × 1 cm.

Discussion

When a patient is evaluated for a primary bile duct neoplasm, differentiation between cholangiocarcinoma and an unusual bile duct tumor, such as a NET is very difficult before surgical resection and histologic review.

Conclusion

NET of the extrahepatic biliary tree are a rare entity. Typical presentation is with painless jaundice and other symptoms related to obstruction of the biliary tree and the diagnosis is usually made post-operatively.

Nodular lymphoid hyperplasia complicated with ileal Burkitt's lymphoma in an adult patient with selective IgA deficiency

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Burkitt's lymphoma in adults can occur on the basis of nodular lymphoid hyperplasia.

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Nodular lymphoid hyperplasia is associated with selective IgA deficiency.

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Nodular lymphoid hyperplasia associates IgA deficiency with Burkitt's lymphoma.

Introduction

Primary lymphomas of the small intestine are rare. Burkitt's lymphoma (BL) occurs sporadically in adults. Nodular lymphoid hyperplasia (NLH) is a rare disorder characterized by diffuse nodular lesions, which represent hyperplastic lymphoid follicles, and it is often associated with immunodeficiency syndromes.

Presentation of case

We present a 38-year-old male patient in a state of surgical emergency, suspected of Crohn’s disease, who had an unusual combination of NLH and BL of the proximal ileum. Furthermore, retrospectively analyzed documentation revealed selective IgA deficiency.

Discussion

Association between NLH and intestinal lymphomas in patients with immunodeficiency syndromes was indicated before. This case report supports the notion on NLH as a transition state between immunodeficiency and intestinal lymphomas.

Conclusion

This is one of the first case reports which presents the combination of NHL and BL. The awareness of the existence of this rare combination, especially in young adult males, can improve the diagnostic accuracy and the treatment management.

Idiopathic chylous ascites simulating acute appendicitis: A case report and literature review

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A rare case of idiopathic chylous ascites in a young female is reported. The management and outcome with long term follow up were discussed.

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The variable nature of presentation of chylous ascites necessitates high index of suspicion. Diagnosis predominately requires abdominal paracentesis and triglyceride levels in the ascetic fluid obtained.

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Management of idiopathic chylous ascites is mostly conservative, once the diagnosis is established. The treatment may include low fat diet and occasional somatostatin use.

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Further research is mandatory as there is a significant rise in reported cases with no standardized guidelines for management.

Acrometastasis following colorectal cancer: A case report and review of literature

INTRODUCTION

Colorectal cancer commonly metastasises to the liver, peritoneum and lungs. Bony metastases are uncommon in colorectal cancer and in particular metastases to the hands or feet (acrometastasis) are an extremely rare occurrence.

CASE PRESENTATION

A 65-year-old male with a colonic malignancy underwent elective anterior resection. Intra-operatively he was found to have a pelvic collection necessitating an end colostomy. Histology confirmed complete Dukes B tumour excision with no evidence of lymph node metastases. The patient underwent chemo-radiotherapy but was unsuitable for reversal of Hartmann's due to elevated CEA levels and asymmetrical thickening of the rectal stump with a solitary lung nodule identified at a one-year surveillance CT. The lung nodule was resected revealing metastatic adenocarcinoma and biopsies from the rectal stump showed chronic inflammatory changes. The patient was offered further chemotherapy. However, six years after his original surgery the patient presented with an acutely painful left foot with radiographic appearances of an infiltrative sclerotic and lucent lesion confirmed as a calcaneal acrometastasis on Magnetic Resonance Imaging (MRI).

DISCUSSION

Diagnosis of acrometastasis is challenging and generally constitutes a wider metastatic process with poor prognosis. Patients are often asymptomatic or present with symptoms mimicking benign lesions such as arthritis, infection or ligamentous sprains of the hands or feet. Therefore, there should be a high index of suspicion and prompt radiological investigation is warranted in order to exclude disease recurrence.

CONCLUSION

Although acrometastasis may indicate a poor prognosis, timely diagnosis and intervention may facilitate improvement of long-term survival and symptomatic management.

Management of a jejunal obstruction caused by the migration of a laparoscopic adjustable gastric banding. A case report

INTRODUCTION

We present a rare case of jejunal obstruction due to the migration of a laparoscopic adjustable gastric band (LAGB) that occurred 10 years after surgery and was successfully treated by laparoscopy. This report is compliant with the SCARE guidelines.

PRESENTATION OF CASE

A 42-year-old woman who underwent LAGB for morbid obesity 10 years ago was admitted with a small bowel obstruction due to the migration of a LAGB in the proximal small bowel. An attempt to endoscopic removal was unsuccessful and resulted in a laparoscopic extraction of the band. The post-operative course was uneventful.

DISCUSSION

Formerly, LAGB was considered the safest technique in bariatric surgery. However, the rate of complication increases in long-term studies. When the IGM of the band is diagnosed, removal is the only issue. Small bowel obstruction caused by a migrated band appears to be a rare complication following IGM, and the only therapeutic option is surgery because an endoscopic procedure is not reliable. Furthermore, LAGB appears to be a less effective technique for weight loss than the sleeve gastrectomy and the gastric bypass.

CONCLUSION

Small bowel obstruction caused by LAGB migration is a rare but serious complication following IGM. In such cases, endoscopy has to be avoided because of the risk of jejunal disruption. The only way to treat it properly is surgery. This type of late complication reinforces the interest in the techniques currently used in bariatric surgery such as sleeve gastrectomy and gastric bypass, providing also a better weight loss than the LAGB.

Neurophysiological monitoring of lumbar spinal nerve roots: A case report of postoperative deficit and literature review

INTRODUCTION

Intraoperative neurophysiological monitoring (IONM) has proven to help reduce the probability of postoperative neurological deficit for spinal deformity correctional surgeries. However, in rare cases new deficits may still happen. We report a surgical case in which the patient had postoperative paralysis. We would like to call for more case reports with postoperative neurological deficits as they present difficult clinical cases.

PRESENTATION OF CASE

A 61-year-old male patient with severe thoracolumbar kyphoscoliosis underwent posterior spinal correction and fusion with segmental T10-L5 pedicle screws and rods instrumentation with IONM. The only intraoperative event was a pedicle breach at left L3 which was detected by triggered electromyography (EMG) testing, and the pedicle screw was repositioned. Left lower extremity paralysis was observed upon patient awakening. He received rehabilitation treatment and had limited recovery of muscle strength. Partial lumbar nerve root injury was likely the cause of the paralysis.

DISCUSSION

This is a case with new lumbar nerve root deficit, with positive EMG signal change, but negative somatosensory evoked potential (SSEP) and motor evoked potential (MEP) findings. We discuss the different neurophysiological modalities for monitoring lumbar spinal nerve root function. We review journal articles from the past two decades which reported lumbar root deficits, and list neuromonitoring events during the surgeries.

CONCLUSION

Multimodality monitoring with spontaneous and electrically triggered EMG combined with SSEP and MEP may provide the best chance to detect lumbar nerve root injuries.

Male breast cancer: Modified radical mastectomy or breast conservation surgery? A case report and review of the literature

INTRODUCTION

Male breast cancer (MBC) is a rare disease that accounts for <1% of breast cancer cases. The most common treatment is modified radical mastectomy (MRM). Recently, breast conservative surgery (BCS) is getting popular for MBC treatment. We report a case and reviewed the literature to investigate whether emerging BCS can be considered as an alternative of a more radical surgery.

PRESENTATION OF CASE

A 46 y.o. patient, presented with a painless left breast lump over a period of six months. The patient underwent a quadrantectomy at another institution. Pathology revealed an intraductal carcinoma in close proximity to the margins of excision. Adjuvant hormonal therapy was proposed to the patient, who refused and was referred to our Institution. We performed a MRM and a sentinel lymph node biopsy (SLNB). A contralateral breast liposuction and an adenectomy were also performed. The patient underwent also a nipple-areolar complex reconstruction. The patient didn't receive adjuvant therapy.

DISCUSSION

Both oncological safety and satisfactory cosmetic outcomes are the goals of MBC treatment. No specific guidelines for MBC treatment have been proposed. MRM is currently the surgical gold standard of MBC (approximately 70% of all cases). Some authors reported that male BCS associated with radiation therapy is a feasible alternative MRM. Taking into account data from the literature and considering the previous surgery, in the case we report, we offered a MRM, SLNB and a contralateral breast symmetrization.

CONCLUSION

MRM with SLNB and reconstruction of male breast asymmetry should be still considered as the treatment of choice of MBC.

Porocarcinoma: A systematic review of literature with a single case report

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Porocarcinoma is a rare but aggressive type of skin malignancy.

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Reporting new cases is mandatory to outline the course of the disease.

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We systematically reviewed the literature with a new case report.

Introduction

Eccrine porocarcinoma is a very rare type of skin cancer. It is an aggressive dermatological malignancy. We presented a 62-year-old male with long history of a mass in left forearm complicated by distant metastasis and death. A rapid review of literature has been presented.

Conclusion

Eccrine porocarcinoma is a rare but aggressive type of skin disease. It may arise de novo or complicate a benign skin lesion. Wide local resection is recommended.

Challenging the limits in pancreatic surgery: A case report

INTRODUCTION

Today, pancreatic surgery can be performed with low mortality and tolerable morbidity in specialized centers. Nevertheless, due to its anatomical localization and proximity to important vascular structures, surgical resection of the pancreas remains challenging in many cases.

PRESENTATION OF CASE

Here, we present the case of a young woman who presented in our department with abdominal pain and a tumor mass located at the pancreatic head. She had undergone explorative laparotomy elsewhere before, in which the pancreatic tumor mass was reported to be unresectable due to infiltration of the mesenteric root. However, biopsies obtained had not revealed malignancy. Moreover, postoperatively a stenting of the portal vein had been performed due to portal vein thrombosis and varices. Upon admission in our clinic, computed tomography revealed a tumor of the pancreatic head, occlusion of the portal vein stent and, more importantly, extravascular dislocation of the stent with perforation into the stomach. Upon explorative laparotomy we initially performed a mesenterico-caval shunt to release portal hypertension. Secondly, the dislocated stent was successfully removed upon gastrotomy, and finally, a partial pancreaticoduodencectomy was performed. Interestingly, the histopathological analysis revealed granulocytic epithelial lesions (GELs) confirming a type-2 autoimmune pancreatitis without evidence for malignancy. The postoperative course was uneventful and the patients was dismissed without any remaining symptoms.

DISCUSSION & CONCLUSION

This interesting and unique case underlines the complexity in diagnosis of pancreatic tumors with unsolved dignity and differential diagnosis of pancreatitis and pancreatic cancer. Furthermore, it demonstrated the challenges in pancreatic surgery for exceptional and uncommon conditions demanding complex surgical approaches.

Total endovascular repair of aberrant right subclavian artery aneurysm using the periscope technique: a case report

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Aneurysmal aberrant right subclavian arteries (ARSA) have a high risk of rupture.

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Treatment options include open surgery or hybrid surgical and endovascular repair.

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The “periscope” technique allows the urgent endovascular repair of aneurysmal ARSA.

Introduction

Aneurysmal degeneration of aberrant right subclavian artery (ARSA) carries a relevant risk of rupture. Timely elective treatment is mandatory. Therapeutic options include open surgery repair or hybrid surgical and endovascular repair. Few reports of total endovascular approach repair have been reported.

Presentation of the case

We report the first case of total endovascular repair of an aneurysmal ARSA using a thoracic aortic endograft with a “periscope” covered stent into the ARSA itself.

Discussion

The total endovascular approach was considered for patient’s age and her poor compliance to the idea of a surgical revascularization of the ARSA, which has to be preserved since the LSA was diseased. The urgent situation did not allow for the use of a custom-made graft, so the idea of a “periscope” covered graft both to preserve the flow of the ARSA and to exclude the aneurysmal lesion seemed to be the best choice.

Conclusion

The “periscope” technique allowed the urgent treatment of aneurysmal ARSA with good clinical results.

Preauricular pilomatricoma: An uncommon entity in a dental pediatric patient

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Pilomatricomas are common lesions although rarely encountered in dental practice. Dental professionals especially oral surgeons and pediatric dentists should be aware of the condition during their practice.

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Common differential diagnosis of preauricular pilomatricoma does not involve temporomandibular joint disease. This condition should be added to differential diagnosis.

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Meticulous examinations should be made and misdiagnosis with temporomandibular joint disease should be eliminated.

Introduction

Pilomatricomas are benign follicular skin appendage tumors, commonly occurring in children and young adults. Most patients admit to dermatologists to seek treatment and are well known by them; however, dental professionals, especially pediatric dentists are not familiar with these tumors.

Presentation of case

This report presents a 16-year-old female with preauricular pilomatricoma, located beneath the overlying skin of the temporomandibular region. Clinical examination revealed an asymptomatic lump, the overlying skin revealed no abnormalities. Patient was unaware of the lesion.

Discussion

Pilomatricomas are commonly encountered in the maxillofacial region, although not considered in differential diagnosis by dental professionals. They usually present as, asymptomatic, subcutaneous masses; although symptomatic cases have been reported. In literature, common differential diagnosis for head and neck pilomatricoma includes sebaceous cyst, ossifying hematoma, giant cell tumor, chondroma, dermoid cyst, foreign body reaction, degenerating fibroxanthoma, metastatic bone formation, and osteoma cutis. We are of the opinion that temporomandibular joint disease should also be considered in differential diagnosis for preauricular pilomatricoma.

Conclusion

Pediatric dentists should be aware of the condition and consider it in the differential diagnosis of pediatric conditions involving the temporomandibular joint.

Postoperative upper extremity deep vein thrombosis in a gynecologic oncology patient: A case report

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Deep vein thrombosis in the upper limb after a surgery is a very rarely seen condition.

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Delay in diagnosis may increase mortality and pulmonary embolism. Surgeons should be aware of this rare complication.

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Upper extremity deep vein thrombosis should be kept in mind in the presence of any symptom on upper extremity during postoperative period even in patients without central venous catheter.

Introduction

Upper extremity deep vein thrombosis (UEDVT) represents approximately 10% of all thromboembolic events. It is a rare condition after a gynecologic surgery and highly related with pulmonary embolism.

Presentation of case

Herein, we present a very rare case of a unilateral left upper extremity deep vein thrombosis in a morbidly obese patient with synchronous primary cancers of endometrium and ovary.

Discussion

Our aim was to underline the relationship between the presence of gynecologic malignancy, oncologic surgery and UEDVT.

Conclusion

Upper extremity deep vein thrombosis should be kept in mind in the presence of any symptom on upper extremity during postoperative period even in patients without central venous catheter.

Continuous infusion of human prothrombin complex in a patient with congenital factor VII deficiency undergoing laparoscopic cholecystectomy: A case report from China

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We describe a case of successful replacement treatment with PPSB, without episodes of bleeding and thrombosis.

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This is the first report of the patient with congenital FVII deficiency undergoing laparoscopic cholecystectomy with repeated administration of PPSB.

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PPSB is made in China, it also provides direction for the use of other similar drugs to solve the same problem.

Introduction

Factor VII deficiency is a rare cause of haemorrhagic syndrome. PRESENTATION OF CASE: The authors describe a case of a 48 years old patient with congenital factor VII deficiency suffering abdominal discomfort diagnosed as gallstone, that successfully underwent laparoscopic cholecystectomy with continuous infusion of Human Prothrombin Complex(PPSB) around the procedure.

Conclusion

The usage of PPSB solved the clotting problems enabling the surgical procedure, without risks for the patient.

Le Fort I osteotomy to enucleation of grand proportions fissural cyst-presentation of case report

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Grand proportions fyssural cyst enucleated with Le Fort I osteotomy and down-fracture.

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The remaining space was filled with BIOSs and bioguide (lyophilized bone and collagen membrane).

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Patient’s follow-up presents no recurrence and favorable osseous formation.

Fissural cysts (FC) are caused by entraped epithelium between nasal and maxilar processes. They are commonly treated with surgical enucleation precedded or not by marsupialization depending on the cyst size. Biopsy of lesion is recommended due to confirm radiographic evaluation. It is rare to observe Le Fort I surgical approach to this type of injury. This study reports the case of an uncommon grand proportions fissural cyst in a female patient, 53, that was referred to the Oral and Maxillofacial Surgery Departament of Hospital XV presenting volume increase in maxilla associated with numbness of palate. Radiograph examination showed an intimate relationship between incisors apexes and FC. Expansion of both buccal and palate cortical was then confirmed as well as its unusual size, approximately 25 millimeters. Due to the abnormal size of lesion and possible impairment of upper incisors, LeFort I osteotomy associated with downfracture to cystic enucleation was the chosen treatment. After enucleation, the remaining space was filled with BIOSs and bioguide (lyophilized bone and collagen membrane). Patients’ twelve months follow-up demonstrate no relapses and maintenance of teeth involved.

Giant primary malignant mesothelioma of the liver: A case report

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Malignant mesothelioma is a rare neoplasm of mesothelial cells.

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It occurs mostly in the pleura or peritoneum and less frequently in the liver.

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Primary intrahepatic mesothelioma is not in the WHO classification of hepatic tumors.

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Mesothelioma is more common in men with a mean age of 58 years.

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We present a rare case of primary liver malignant mesothelioma in a young female.

Introduction

Malignant mesothelioma is a rare neoplasm of mesothelial cells arising most frequently in the pleura or peritoneum and less frequently in the liver.

Case presentation

We present a case of primary hepatic mesothelioma of 41 year old woman. She had no history of asbestos exposure or cancer. Abdominal computed tomography (CT) showed 21 cm intrahepatic mass in the right lobe with many cystic lesions and few small calcifications. Pathology showed a biphasic cellular pattern. In addition, the tumor cells were positive for Calretinin, Creatine Kinase (CK)5/6, CK7, CKAEI 1/3, Wilms Tumor protein (WT-1), and Vimentin, but were negative for Alpha Feto protein (AFP), Thrombotic Thrombocytopenic Purpura (TTP-1), Anti-Hepatocyte Specific Antigen (HSA), Synaptophysin, CK20, and Homeobox protein (CDx-2).

Discussion

Primary intrahepatic mesothelioma (PIHMM) is not included in the classification of the World Health Organization classification of hepatic tumors. Mesothelial cells are not normally found in the liver, but some reported cases suggest it may grow from the mesothelial cells of the Glisson’s capsule.

Conclusion

The probability of hepatic mesothelioma should not be ruled out, even in a young woman without a clear history of asbestos exposure.