An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer

BACKGROUND

Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method.

METHODS

A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α.

RESULTS

Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance.

CONCLUSIONS

The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

Maternal choledochal cysts in pregnancy: A systematic review of case reports and case series

BACKGROUND

Choledochal cysts (CC) are cystic dilatations of the biliary tract, usually diagnosed during childhood, with an estimated incidence in the general population of 1:100000. Complications related to CC include rupture, biliary obstruction, and cholangitis. Maternal CC in pregnancy are rarely reported, and there are no guidelines on optimal management.

AIM

To systematically review maternal CC diagnosed during pregnancy or postpartum with regard to the clinical presentation of CC, the mode of treatment and delivery, and maternal outcomes.

METHODS

A literature search of cases and case series of maternal CC in pregnancy and postpartum was conducted using MEDLINE/PubMed, Web of Science, Google Scholar, and Embase. There were no restrictions on language or publication year. Databases were lastly accessed on September 1, 2022.

RESULTS

Overall, 71 publications met the inclusion criteria, reporting 97 cases. Eighty-eight cases were diagnosed during pregnancy and nine in the puerperium. The most common symptoms were abdominal pain (81.2%) and jaundice (60.4%). Interventions for CC complications were required in 52.5% of the cases, and 34% of pregnancies were induced. Urgent cesarean section (CS) was done in 24.7%. The maternal mortality was 7.2%, while fetal mortality was inconsistently reported. Cholangitis, CC > 15 cm, and bilirubin levels > 80 mmol/L were associated with a higher likelihood of urgent CS and surgical intervention for CC. Bilirubin levels positively correlated with CC size. There was no correlation between age and cyst dimension, gestational age at cyst discovery, and CC size.

CONCLUSION

Although rare, maternal CC in pregnancy should be included in the evaluation of jaundice with upper abdominal pain. Symptomatology and clinical course are variable, and treatment may range from an expectative approach to emergent surgical CC treatment and urgent CS. While most cases were managed by conservative measures or drainage procedures, CC > 15 cm and progressive cholangitis carry the risk of CC rupture and septic complications, which may increase the rates of unfavorable maternal and fetal outcomes. Therefore, such cases require specific surgical and obstetric interventions.

Case report: Sevelamer-associated colitis-a cause of pseudotumor formation with colon perforation and life-threatening bleeding

Chronic kidney disease (CKD) is a very common chronic non-communicable disease. Phosphate and calcium metabolism disorders are one of the most common features of CKD. Sevelamer carbonate is the most widely used non-calcium phosphate binder. Gastrointestinal (GI) injury associated with sevelamer use is a documented adverse effect but is underrecognized as a cause of gastrointestinal symptoms in patients with CKD. We report a case of a 74-year-old woman taking low-dose sevelamer with serious gastrointestinal adverse effects causing colon rupture and severe gastrointestinal bleeding.

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Jejunal Lipoma Causing Intussusception in an Adult

First described by Barbette in 1674, intestinal intussusception represents a telescoping of proximal bowel segment into the lumen of the adjacent aboral segment. Adult intussusception comprises only about 5% of all intussusceptions. We present a case of 28-year male patient who complained of colicky, intermittent epigastric pain for the last one month. Imaging detected specific signs of intussusception. Laparotomy revealed enteric intussusception of the jejunum caused by an intraluminal tumour, confirmed to be a benign lipoma on histology. Small bowel obstruction caused by jejunal lipoma in adults is a rare clinical entity and must be kept in mind when evaluating adult patients with abdominal pain. Key Words: Intussusception, Lipoma, Ileus, Jejunum.

Case report: Urgent liver pathologies: All in one

Ruptured hepatocellular carcinoma (HCC) is a well-known serious complication of this most common primary liver malignancy. However, when HCC rupture is associated with other focal liver lesions, the diagnosis and therapy may be very challenging. Correct differentiation of focal liver lesions is of paramount importance for successful treatment. The aim of this report is to present a unique case of HCC rupture complicated with liver abscess, hematoma and portal vein thrombosis. We discuss possible pathophysiological mechanisms and radiologic findings of such clinical scenarios and review literature related to the management of HCC rupture.

Case report: two cases of spontaneous intramural duodenal hematoma associated with pancreatitis

Intramural duodenal hematoma (IDH) is a rare entity and is generally associated with trauma. Spontaneous (nontraumatic) intramural duodenal hematoma is associated with bleeding disorders, anticoagulation therapy, alcoholism, pancreatitis, tumours  and duodenal ulcers. We report two cases of spontaneous intramural duodenal hematoma in middle-aged men who subsequently developed pancreatitis. The underlying pathophysiology is still unclear. In the cases described, it is not clear whether the intramural duodenal hematoma contributed to the development of pancreatitis or pancreatitis has contributed to the development of IDH.

Extensive Abdominal Skin Necrosis Following Anterior Component Separation for a Large Ventral Hernia: A Case Report

Introduction: Hernia surgery is one of the most common operative procedures, performed in about 20 million cases per year all over the world, with ventral hernia accounting for about 30% of the cases. Although the introduction of the anterior component separation (ACS) method, popularized primarily by Oscar Ramirez, has greatly facilitated the closure of the largest abdominal wall defects, the 30-year experience in this technique has pointed to the risk of ischemic skin complications consequential to the major subcutaneous tissue dissection required. The aim of this case presentation of a patient who developed extensive necrosis of the abdominal wall skin following ACS procedure is to emphasize the importance of preserving rectus abdominis perforator blood vessels in order to preserve skin vitality.

Case Presentation: We present a case of a 58-year-old female patient with a large recurrent ventral hernia. The hernial defect was closed by placing a large (30 × 25 cm) polypropylene mesh in the retro-rectus space using the Rives-Stoppa technique. To facilitate upper fascia closure ACS according to Ramirez was performed bilaterally. The rectus perforator vessels were not preserved. Recovery of the patient was complicated with the extensive abdominal skin necrosis which was successfully treated with negative pressure wound therapy.

Discussion: Transection of the musculocutaneous perforators of the epigastric artery during ACS results with the compromised blood supply of the abdominal skin depending solely upon the intercostal arteries. Skin ischemia following ACS is a serious complication that can be presented with extensive necrosis associated with high morbidity and even mortality, while the treatment is long lasting, complex, and expensive. Considering the ever-increasing prevalence of large ventral hernias, ever greater popularity of the ACS technique, and the growing proportion of surgeons performing large ventral hernia operations independently, we think that the role of preserving perforated rectus vessels has not been emphasized enough. Therefore, the objective of this case study is to stimulate surgeons to preserve skin vascularity and promote it in their routine in order to avoid these severe postoperative complications.

Intramural Stomach Gas with Hepatic Portal Venous Gas Indicating Spontaneous Stomach Necrosis

Intramural gas in the stomach associated with hepatic portal venous gas is a rare entity, which suggests ischemic or infectious pathology of the stomach. We report a case of a 73-year-old man who presented with epigastric pain and nausea of 6 hours duration followed by hematemesis. The patient had pale skin, anemia, and a diffusively tender and distended abdomen. Abdominal radiography and computed tomography (CT) revealed gas in thickened gastric wall and gas in intrahepatic portal vein branches. Surgery was indicated, which consisted of partial gastrectomy with Roux en esophago-jejunal anastomosis. Postoperative course was uneventful, and pathohistological analysis indicated stomach wall necrosis with emphysametous gastritis (EG). The patient was free of symptoms at 2 years follow-up. Intramural gas in the stomach should always be meticulously investigated to differentiate between emphysematous gastritis and gastric emphysema, as this would direct the therapeutic approach to be adopted.

Psychological Effects of "Double Crisis" (COVID-19 Pandemic and Earthquakes) on Croatian Medical Students

INTRODUCTION

In 2020. the COVID-19 pandemic presented an additional source of stress and anxiety not just to the general population but also to medical students who are, even under normal circumstances, constantly under pressure due to demanding student duties. In addition, they experienced a series of devastating earthquakes in and around the Zagreb region which altogether could have had compromised their psychological well-being. The aim of this review was to evaluate the psychological effects of these two natural disasters on the mental health of Croatian medical students.

RESULTS

According to standardized questionnaires for depression and anxiety evaluation, 75.3% of students were anxious and 65.2% were depressive during the "double crisis". No significant difference of these two outcomes was observed regarding genders, but it was found that first year students had a significantly higher anxiety score than older ones.

CONCLUSION

In such stressful situations, we should emphasize the importance of mental health not just of healthcare workers, but also of medical students in order to prevent serious psychological consequences and to alleviate the negative effects on students' motivation and their educational process.

Duodenal diverticulum causing obstructive jaundice - Lemmel's syndrome

The duodenum is the second most common location of intestinal diverticula. Periampullary duodenal diverticulum rarely causes obstructive jaundice and this condition was first described by German surgeon Gerhard Lemmel in 1934. Lemmel's syndrome is defined as obstructive jaundice due to a periampullary duodenal diverticulum in the absence of choledocholithiasis or a neoplasm.

Laser treatment of pilonidal disease: a systematic review

Pilonidal disease (PD) is a common condition, and there is still an ongoing debate on ideal management that should be minimally invasive, safe, and efficient. The use of radially emitting laser in the treatment of chronic PD is a novel minimally invasive technique, and initial studies with a small number of patients showed promising results. This study aimed to assess the efficacy and safety of chronic PD treatment with a laser using a systematic review of the published literature. A systematic review was conducted after PubMed, Scopus, Embase, Web of Science, and the Cochrane database search for studies reporting laser treatment of chronic PD. Also, our unpublished prospective single-center study was included in this review. Ten of 87 studies were eligible for the review, including 971 patients. The median age of the patients was 26 (range 13-68), and the median operative time was 26 (range 6-65) min. With a median follow-up of 12 (range 7-25) months, 917 (94.4%) patients achieved primary healing with a weighted mean recurrence rate of 3.8%. The weighted mean complication rate was 10% (95% CI 5.7-14.3%, I2 = 82.28, p < 0.001), and all were minor. The published literature demonstrates that laser treatment is a promising procedure in the management of chronic PD. Furthermore, the review showed that standardized operative techniques and perioperative steps were used. The results were limited to the mild chronic PD. Classification of PD severity and standardized outcome reporting is required to define indications and contraindications for laser PD treatment. Randomized controlled trials are needed to determine the long-term effectiveness and superiority of laser treatment over other methods.

Concomitant Presence of Hydatid Cyst and Colorectal Liver Metastasis

A 65-year-old man, with signs of acute colon obstruction, was diagnosed with rectal tumour and liver hydatid cyst. Additionally, a focal liver lesion in segment 1 was detected. Moreover, physical examination revealed hepatomegaly and abdominal distension. Thus, rectal resection and small liver lesion biopsy was performed. Serological and pathohistological analyses showed concomitant presence of hydatid cyst and colorectal metastasis in the liver. Hence, the cyst was treated with anthelmintic therapy, and patient lived another year after the diagnosis. To the best of our knowledge, cases of concomitant hydatid cyst and colorectal liver metastasis has never been reported; thus, this article addresses a unique case of coexistence between these two serious liver diseases.

Rare Complication of Necrotizing Pancreatitis: Extension of Retroperitoneal Abscess into Femoral Region

Distant abscesses are uncommon during the episode of acute pancreatitis (AP). However, these are possible sequalae of necrotizing pancreatitis and should be treated appropriately to prevent serious septic complications. We demonstrate a case of a 56-year-old male patient who presented with severe necrotizing pancreatitis and distant retroperitoneal abscess that reached femoral region and was detected on diagnostic imaging scans. Combination of surgical and supportive therapy was employed, and the patient recovered well with no permanent consequences. Our article highlights the importance of quick and accurate diagnosis and timely intervention in this rare type of pancreatitis complication.

Conservative treatment of postintubation tracheal laceration with pneumomediastinum, bilateral pneumothorax, and massive subcutaneous emphysema

Postintubation tracheal laceration (PITL) is a rare, potentially life-threatening complication requiring prompt diagnosis and treatment. Patients typically present with subcutaneous emphysema and pneumomediastinum, whereas concomitant pneumothorax is rarely reported. A conservative treatment is indicated in selected respiratory stable patients with small lacerations. Herein, we reported an unusual case of PITL with bilateral pneumothorax that was treated with chest tube drainage and conservative measures in the intensive care unit. The key success of the PITL management is early recognition of signs and symptoms and an adequate selection of management approaches.

Rupture of suppurated liver hematoma into the anterior abdominal wall in a patient with Rendu-Osler-Weber syndrome

We report a case of ruptured liver hematoma as a result of suppurated arteriovenous malformation (AVM) in a patient with Rendu-Osler-Weber (ROW) syndrome. The patient presented with unexplained fever and upper right abdominal pain associated with microcytic anemia. A computed tomography scan revealed increasing subcapsular liver hematoma and features of liver abscess. Intraoperatively, a left liver hematoma mixed with pus was found that was attached to the anterior abdominal wall. Surgery included left lateral bisegmentectomy, while pathohistological analysis showed AVM and genetic tests confirmed ROW. This is the first such life-threatening surgical case of ROW complication reported in the scientific literature.

Abdominal wall reconstruction after emergent surgery for fistulizing incarcerated ventral wall hernia in morbidly obese patient

Incarcerated abdominal wall hernias may have a variety of manifestations and the most dreaded consequence is strangulation leading to obstruction and perforation of hollow viscus. Very rarely, such a perforation presents with fistulization into the abdominal wall and skin, which is often not considered but may complicate the management approach. &lt;br/&gt;Case presentation: We reported on presentation and management of a 56-year-old morbidly obese male with a fistulizing incarcerated ventral wall hernia and postoperative abdominal wall necrosis. &lt;br/&gt;Discussion: Contained bowel perforations caused by ventral hernia incarceration are a rare and not well recognized problem and are confined to a handful of case reports in the surgical literature. &lt;br/&gt;Conclusion: The most recognized complications of ventral hernias are incarceration and strangulation leading to obstruction and consequent perforation; however, as the case described below reveals, intestinal perforation and bowel-skin fistulization may occur as unusual incident. Management should involve operative reduction, resection of the involved bowel and staged repair of abdominal wall defect.

Fatal Case of Spontaneous Rectus Sheath Hematoma Caused by Anticoagulant and Steroid Therapy during Hospital Admission

Background

Rectus sheath hematoma (RSH) is a rare but potentially dangerous clinical entity that requires medical supervision.

Case Report

Here we discuss one such case which describes the fatal course of spontaneous RSH during hospital admission.

Conclusion

Usually, RSH presents as a minimal abdominal wall swelling with self-limiting course but in the case of hematoma and size progression, specific conservative or invasive measures are necessary to prevent serious complications including hypovolemic shock and death.

Impact of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) on growth of colorectal liver metastases

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy induces an unprecedented liver hypertrophy and enables resection of otherwise unresectable liver tumors. The effect of associating liver partition and portal vein ligation for staged hepatectomy on tumor proliferation, however, remains a concern. This study investigated the impact of associating liver partition and portal vein ligation for staged hepatectomy on growth of colorectal metastases in mice and in humans.

METHODS

The effect of associating liver partition and portal vein ligation for staged hepatectomy and 90% portal vein ligation on colorectal liver and lung metastases was investigated in mice. In vivo tumor progression was assessed by magnetic resonance imaging, histology, and survival experiments. The effects of associating liver partition and portal vein ligation for staged hepatectomy, portal vein ligation, and control sera on cultures of several colorectal cancer cell lines (MC38 and CT26) were tested in vitro. Additionally, the international associating liver partition and portal vein ligation for staged hepatectomy registry enabled us to identify patients with remaining tumor in the future liver remnant after associating liver partition and portal vein ligation for staged hepatectomy stage 1.

RESULTS

Two and 3 weeks after associating liver partition and portal vein ligation for staged hepatectomy stage 1, portal vein ligation, or sham surgery, liver magnetic resonance images showed similar numbers (P=.14/0.82), sizes (P=.45/0.98), and growth kinetics (P=.58/0.68) of intrahepatic tumor. Tumor growth was not different between the associating liver partition and portal vein ligation for staged hepatectomy and portal vein ligation groups after completion of stage 2. Median survival after tumor cell injection was similar after sham surgery (36 days; 95% confidence interval; 27-57 days), completion of associating liver partition and portal vein ligation for staged hepatectomy (42 days; 95% confidence interval; 35-49 days), and portal vein ligation (39 days; 95% confidence interval; 34-43 days, P=.237). Progression of pulmonary metastases and in vitro cell proliferation were comparable among groups. Observations in humans failed to identify any accelerated tumor growth in the future liver remnant within the regenerative phase after associating liver partition and portal vein ligation for staged hepatectomy stage 1.

CONCLUSION

The accelerated regeneration process associated with associating liver partition and portal vein ligation for staged hepatectomy does not appear to enhance growth of colorectal metastases.

A Synchronous Occurrence of Hepatocellular Carcinoma and Echinoccocal Liver Cyst - Can Parasite Promote Carcinogenesis? Literature Review and Classification Proposal

Concomitant presence of hydatid cyst and hepatocellular carcinoma is a very rare clinical scenario especially in a previously non-diseased liver. Including our case here reported, there are 12 cases of synchronous HCC and hydatid cyst found in the scientific literature and 3 of them were found in a patient with non-diseased liver. We provide detailed review of all reported cases with additional highlights on etiology, pathogenesis, diagnosis, treatment and outcomes of both HCC and echinococcal disease. Although there is a small number of patients, possible relation between these 2 liver lesions should be investigated and standardized classification should be established. This will help us to understand the nature of HCC carcinogenesis, identify diagnostic features of liver lesions and choose the most appropriate type of treatment.

Successful Associating Liver Partition and Portal Vein Ligation after Unsuccessful Double TACE Procedure Complicated with Sepsis and Pancreatitis

The associating liver partition and portal vein ligation (ALPPS) is a novel procedure with increasing number of scientific and clinical studies, and by now, it showed to be efficient and safe procedure in selected group of patients. Here we present the first case of ALPPS done after double TACE procedure in a 64-years-old female patient with extensive hepatocellular carcinoma of the right liver lobe. The procedure was successful and liver remnant showed significant 90% hypertrophy which proves that ALPPS sometimes can be performed after palliative procedures in liver malignancies.

Reducing damage to the periosteal capillary network caused by internal fixation plating: An experimental study

BACKGROUND

The importance of the periosteum in fracture healing is well-known. Preserving periosteal vascularisation is essential during internal plate fixation of fractures.

METHODS

This was an experimental randomised, controlled animal study on nine sheep. Standard dynamic compression plate (DCP) and four different newly designed reefed plates, with different plate-bone contact surface areas and different reef directions, were fixated on to the tibia or radius. After two weeks the plates were removed and the underlying periosteum was analysed. Blood vessels were marked by immunohistochemical staining (CD31 and CD34), microphotographs were taken and blood vessels counted to calculate blood vessel density.

RESULTS

Median blood vessel density beneath the standard plate was significantly lower than in the intact periosteum (18.0 vs 27.7mm(3)/cm(3)). Blood vessel density in the periosteum beneath plates with reefs was significantly increased compared with the intact periosteum, and was highest beneath the plate with the lowest bone-plate contact area and crosswise reefs (51.5mm(3)/cm(3)), followed by plates with transverse, oblique and longitudinal reefs, respectively. The direction of the reefs did not have much influence on the periosteal capillary network. Lower contact surface area seems to be the main factor that increases blood vessel density beneath the plates.

CONCLUSIONS

The results show that plates with lower contact surface area stimulate angiogenesis in the underlying periosteum, which results in much higher blood vessel density compared with standard DCP. A randomised clinical trial is needed to prove the clinical relevance of these findings.

H-type Tracheoesophageal Fistula in a Newborn: Determining the Exact Position of Fistula by Intra-operative Guidewire Placement

H-type tracheoesophageal fistula is a rare congenital anomaly that is seldom diagnosed in the neonatal age. Documenting it and then locating it at surgery are both difficult. A case is presented to highlight the diagnostic and therapeutic utility of trans-fistula guidewire placement.

H-type Tracheoesophageal Fistula in a Newborn: Determining the Exact Position of Fistula by Intra-operative Guidewire Placement

H-type tracheoesophageal fistula is a rare congenital anomaly that is seldom diagnosed in the neonatal age. Documenting it and then locating it at surgery are both difficult. A case is presented to highlight the diagnostic and therapeutic utility of trans-fistula guidewire placement.

[A large asymptomatic renal hemangioma as a chance radiologic finding]

The author reports on a large asymptomatic renal haemangioma that was found accidentally in the course of a preoperative CT examination. The radiological visualisation in plain CT, in serial CT as well as in selective angiography is presented. The finding is discussed and compared with the observations reported so far in the literature in respect of this rare benign tumour.