Coeliac artery compression stenosis caused by the median arcuate ligament can lead to aneurysm formation in the pancreatico-duodenal arteries that can eventually result in a spontaneous rupture leading to retroperitoneal haemorrhage. In this case series, we describe the cases of three patients, all presenting with sudden epigastric pain, diagnosed as spontaneous haematoma, complicating a median arcuate ligament syndrome. The pancreatico-duodenal arteries (PDAs) cannot sustain this high flow, leading to true-aneurysm formation, which can eventually result in spontaneous rupture.In this case series, we describe the case presentations of three patients, all presenting with sudden epigastric pain, diagnosed as spontaneous haematoma complicating MALS.A 65-year-old man presented to the emergency department for atraumatic acute abdominal pain and vomiting. He was a chronic tobacco user with no medical or surgical history or any regular medication.Upon arrival, he presented with normal vital parameters. Abdominal examination revealed epigastric tenderness. He was treated initially with intravenous paracetamol before performing an ultrasound (US) which demonstrated the presence of a heterogenous mass in the epigastric region and the presence of a hyperechoic, well-organised heteregenous mass within the right iliac fossa, with no Doppler signal.Thereafter, abdominal computed tomography (CT) with contrast was performed and demonstrated a well-organised and hyperdense mesenteric haematoma measuring with mean density of 57 Hounsfield unit (HU) approximately 9 cm × 5 cm × 4 cm. Two small aneurysms were identified originating from the upper and lower PDAs. There was marked CA compression by the MAL resulting in post-stenotic fusiform dilatation of the CA .A 64-year-old woman with persistent abdominal pain for two weeks was admitted to our emergency department. The patient complained of diffuse abdominal pain and haematemesis; digital rectal exam indicated melena. Clinical abdominal examination revealed a peri-umbilical palpable mass with localised tenderness. Eso-gastro-duodenal endoscopy (EGDE) displayed external compression of the second-part duodenum without any mucosal abnormality. Biochemistry demonstrated regenerative microcytic and hypochromic anaemia.An abdominal US was performed, highlighting the presence of free hyperechoic fluid in the pouch of Douglas. No mass was identified.Subsequent abdominal CT demonstrated a homogenous hyperdense haematoma (43 HU) of approximately 14 cm × 10 cm × 8 cm with haemorrhage within the stomach (average density of 62 UH). There was moderate CA compression by the MAL with no visible PDA aneurysm .A 44-year-old woman was admitted for acute abdominal and back pain, as well as haematemesis and melena. Her previous medical and surgical history was unremarkable and she was not on any regular medication.Upon arrival, the patient had a tachycardia and was tachypnoeic. She was normotensive, had normal oxygen saturation (98%) and was afebrile. Abdominal examination elicited diffuse tenderness.Eso-gastro-duodenal endoscopy did not show any abnormalities. Her blood tests were normal apart from a modestly raised C-reactive protein (20 mg/dL) and mildly decreased haemoglobin levels (9 g/dL).Abdominal CT revealed a retroperitoneal haematoma with rupture of a small aneurysm originating from the inferior pancreatic-duodenal artery (IPDA), secondary to stenosis of the CA. Additionally, there was also a Standford B dissection of the aorta. It is postulated that the above scenario was caused by the decreased blood flow in the CA compressed by the intimal flap (causing dynamic ischaemia), which then resulted in further decreased flow in the coeliac trunk, increased blood flow in SMA branches and finally rupture of the pre-existing aneurysm .4 The mean age at diagnosis is 28 years with a 71% female preponderance.5 However, only 10% – 24% of patients with extrinsic compression of the CA by the MAL will have the syndrome.6Median arcuate ligament syndrome or CA compression syndrome (CACS), also called Dunbar syndrome, is a rare condition in which the MAL causes compression of the CA. It is characterised clinically by weight loss, postprandial epigastric pain, nausea and vomiting.7The relation between the anatomic anomaly and clinical symptoms was first described by Harjola in 1963, in a case study, and then by Dunbar in 1965 in a larger case series of 15 subjects.2 Aneurysm regression or stability is reported after CA reconstruction with stent placement, MAL incision or bypass placement.The pathophysiology is clearly established. In MALS, blood flow to the splanchnic organs is diverted to the SMA and then to the PDA because of decreased flow in the CA. The PDAs cannot sustain this high flow, causing high-flow true aneurysms, which can eventually result in spontaneous rupture.8There are other causes of PDA aneurysms other than MALS such as atherosclerosis, pancreatitis, mycotic and bacterial infection, trauma or fibromuscular hyperplasia.9 but the definitive finding for the diagnosis is focal narrowing of the proximal CA with a characteristic ‘hooked appearance’, best seen on a sagittal image.10 This sign helps differentiating MALS from other causes of CA stenosis, such as atherosclerosis. Associated findings include post-stenotic dilatation or collateral vessel formation from the SMA branches.6The radiological diagnosis of MALS is firstly based on detecting MAL thickening equal to or greater than 4 mm,6Computed tomography and magnetic resonance imaging (MRI) should ideally be performed in the end-inspiratory and expiratory phases. True and permanent compressions persist or increase during end-expiration, whereas transient physiological compression is seen only during end-inspiration.6Percutaneous angiography is the reference standard for the diagnosis of MAL syndrome and shows findings similar to CT such as superior indentation, hooking and post-stenotic dilatation of the CA. Furthermore, angiography can assess the stenosis in both end-inspiration and expiration. Retrograde filling of the CA from the PDA can also be assessed.11Doppler US can demonstrate peak systolic velocities greater than 200 cm/s correlating to a degree stenosis of at least 70% with a sensitivity of 75% and specificity of 89%.13Median arcuate ligament syndrome may cause true post-stenotic aneurysms, which can be located anywhere in the distal arteries, but appear to predominantly involve the PDA and dorsal pancreatic artery (DPA) – the two main collateral networks between the CA and the SMA.13 Almost half of all PDA aneurysms are associated with CA stenosis.14 Compression by the MAL has been shown to be responsible for stenosis in about 10% – 30% of cases.14 They can also be induced by periarterial inflammation, usually associated with pancreatitis, trauma, infection or atherosclerosis.13True aneurysms of the PDA are rare, accounting for only 2% of all visceral aneurysms.13 Rupture risk is not related to the aneurysm size, suggesting that all aneurysms should be treated, regardless of their size.15 In the literature, ruptured aneurysm diameters ranged between 0.7 cm and 2 cm. On the other hand, unruptured aneurysm sizes were between 0.7 cm and 6 cm.16 The rupture risk of PDA aneurysms is about 65%. Among the case histories of 88 patients with PDA aneurysm published in the literature, 53 patients had rupture and 26 of them unfortunately died.15More than 60% of patients with PDA aneurysms initially present with a rupture.In the third reported case, there was a Standford B aortic dissection where the CA originated from the false lumen. We postulate that this caused dynamic ischaemia and reduction of blood flow through the CA. The intimal flap reduces the CA ostium size and potentiates blood reduction caused by the abnormal MAL, resulting in further increased blood flow in the SMA branches, and finally, rupture of the small IPDA aneurysm. To the best of our knowledge, no such case was reported elsewhere.15The issues of treatment options regarding PDA aneurysms are still controversial. Recently, endovascular treatment has become popular but open surgical repair is also an option for young patients with no malignancy, for whom long-term survival is expected.Rupture of PDA aneurysms caused by MALS should always be considered in the differential diagnosis of acute abdominal pain and retroperitoneal haemorrhage, as the condition requires specific management. Embolisation has been proven to be safe with a high success rate, with surgery reserved for unsuccessful embolisation.


Mini-probe endoscopic ultrasonography (EUS) revealed a hypoechoic submucosal lesion, measuring 20 × 15 mm and originating from the superficial muscularis propria layer . It was covered by normal-appearing mucosa. The patient underwent EUS  for further investigation . EUS elastography showed high tissue stiffness with a predominantly blue pattern  and there was no enhancement after injection of intravenous contrast. Overall, these findings were consistent with those of a submucosal tumor (SMT) of the lower esophagus originating in the muscularis propria, possibly a leiomyoma.A 66-year-old female patient underwent esophagogastroduodenoscopy (EGD) in our center because of occasional dysphagia, and a large submucosal tumor (SMT) was identified 32–36 cm from the incisors, occupying nearly half of the luminal circumference en bloc resection of the tumor by submucosal tunneling endoscopic resection (STER). The first step of the procedure consisted of a submucosal injection 5 cm proximally to the lesion. A longitudinal mucosal incision and subsequent submucosal tunneling were performed using the Hybrid Knife . Endoscopic en bloc resection was then carried out using both the Hybrid Knife and the IT Knife . After retrieval of the endoscopic specimen measuring 40 x 20 mm  and adequate hemostasis of the tunnel, the incision site was closed using hemostatic clips.The patient underwent . Immunohistochemistry staining was positive for CD56, synaptophysin, CgA and CK-PAN and negative for SSTR2, SSTR5, and p53. The Ki-67 score exceeded 60%. The patient was suggested to receive further surgical treatment. However, she did not seek any treatment. On a 3-month follow-up, investigation revealed distant metastases to both liver lobes and the left chest wall so the patient was referred for palliative care.However, histology revealed a poorly differentiated neuroendocrine carcinoma  invading the submucosal layer with lymphovascular invasion Esophageal neuroendocrine neoplasms (NENs) are extremely rare tumors, accounting for only 1.0%–1.4% of all gastroenteropancreatic NENs . The WHOThe main endoscopic finding for esophageal NEC is a protruding or localized lesion with or without ulceration in the center . To the en bloc resection was technically feasible through STER, we emphasize that this cannot be routinely recommended in such advanced malignancies. It also arouses a dilemma for those technically resectable SMTs—a pre-procedure EUS-guided fine-needle aspiration (EUS-FNA) for diagnosis is a must or not?Several cases of endoscopically removed small low-grade esophageal NENs have been described, usually through endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) . Since iIn conclusion, our case illustrates that, despite recent advances in the preoperative assessment of gastrointestinal SMTs, a definite diagnosis can only be obtained through histopathologic examination of the resected specimen. In fact, even though, in this case, evidence pointed to a benign lesion such as a leiomyoma, diagnosis turned out to be that of a malignant lesion with poor prognosis. We also describe previously unrecognized features of esophageal NEC—a rare and aggressive disease that remains incompletely understood.


We report a case of a 5-month-old female infant who presented with a cardiorespiratory distress and shock. After thoracic computed tomography (CT) scan, a right sided Bochdalek hernia was diagnosed with massive herniation of the abdominal viscera causing mediastinal shift. The girl underwent emergency laparotomy, which confirmed the right sided diaphragmatic hernia with herniation of small bowel and colon. After reduction of herniated contents, the defect in the diaphragm was closed. The patient had an uneventful post-operative cause. This case demonstrates that an undiagnosed Bochdalek hernia can appear with such a severe, life-threatening and misleading presentation. Bochdalek diaphragmatic hernia (BDH), which was first described in 1848 by the Czech anatomist and pathologist, Vincenz Alexander Bochdalek, is an anatomical defect at the posterolateral part of the diaphragm . Late prAn otherwise healthy 5-month-old female infant, the first child of two young parents without medical problems in their past medical history or a history of congenital malformation in their families, was admitted to our paediatric emergency department. Her parents complained about remarkable anxiety and crying of the patient the last two hours. The mother described that the little patient encountered difficulty in the bowel movements the last two days and had an episode of vomiting the same day. Last but not least, the parents referred that the child had a head injury three hours ago as a result of falling from a sitting position backwards on a soft carpet. On the arrival, the oxygen saturation was 99%, the heart rate was 164 beats per minute and the temperature was 36 degrees of Celsius. The child was first examined by a paediatrician who asked a paediatric surgery consultation due to the referred head injury. From the paediatric surgery clinical examination and estimation, the Glasgow Coma Scale was 14, there were no palpable or visible lesions on the head and the eye´s pupils reacted to the light symmetrically. The abdominal auscultation revealed absence of bowel sounds, but no visible flatulence was present. From the abdominal palpation which was easily conducted, the abdomen was soft and there were not clinical signs of peritoneal irritation. The rectal digital examination had as a result an explosive evacuation of the bowel with diarrhea and was negative for blood.During the examination, the child presented intermittent peripheral acrocyanosis and because of the quick deterioration of the clinical condition, we immediately catheterized a peripheral vein, took blood samples and tried to make a chest and abdominal x-ray. The mother accidentally breastfed the child while waiting for the x-ray to be done and spontaneously the child vomited and lost consciousness. The patient was transferred to the shock room without a diagnosis establishment because the plain x-ray was not performed. An anesthesiologist was called, the child was intubated and after the vital signs’ stabilization and a nasogastric tube insertion, because of the very disorienting medical history and the wide spectrum of the differential diagnosis which included both brain injury, undiagnosed heart disease and gut volvulus, which means that we could not focus our diagnosis on which pathology gave those signs and symptoms, the baby underwent an immediate full body computed tomography scan (CT scan). From the first axial images the diagnosis was established . The rigWith a transverse incision in the right upper quadrant, we accessed the abdominal cavity and found a defect in the right diaphragm . The looIn Bochdalek hernias, also known as posterolateral diaphragmatic hernias or pleuroperitoneal hernias, the anatomical defect is in the posterolateral part of the diaphragm allowing abdominal viscera to herniate into the thoracic cavity ,5. BH reBesides the fact that there is a consensus that BH has to be surgically repaired when is diagnosed even if it remains asymptomatic because of the fatal conditions that may arise and cannot be prevented if it is left untreated, a still controversial point in the management of those patients is the surgical approach, whether transthoracic or transabdominal ,6. We reet al. describe both transthoracic and abdominal approach as accepted techniques for diaphragmatic hernia repair. They underline that while transthoracic approach offers better exposure of the surgical field, facilitates easier liberation of adhesions, identification of the phrenic nerve and resection of the hernia sac, the transabdominal approach facilitates the reduction of the incarcerated viscera and simultaneously gives the surgeon the opportunity to identify and treat a possible malrotation or bilateral hernia [The surgical approach that our team preferred was the transabdominal access because of the length of the bowel that was incarcerated in the right hemithorax as the CT scan revealed, and the high possibility of bowel necrosis preoperatively. The transabdominal approach through an upper transverse incision allows easier reduction of the incarcerated viscera from the thoracic cavity, facilitates possible surgical manipulations such enterectomy and anastomosis performance and gives the surgeon the opportunity for a detailed inspection of the rest abdominal contents and a simultaneous inspection of the contralateral hemidiaphragm for the presence of bilateral hernia. Marhuenda l hernia . BesidesPrenatally undiagnosed congenital diaphragmatic Bochdalek hernia with late onset is an extremely rare entity in the childhood population. The usually misleading symptoms and signs make the diagnosis difficult and tricky. When it presents with acute but non-specific symptomatology, it makes the differential diagnosis both difficult and risky. We advocate the surgical repair through the transabdominal approach when the diagnosis is established and the use of CT scan preoperatively, when the symptoms are atypical and there is a doubt for the diagnosis with the use of a plain x-ray. Among paediatric specialties, a high index of suspicion is recommended to obviate delay in diagnosis which could be fatal. The associated anomalies have to be investigated with a thorough clinical examination and the appropriate radiological techniques.


Liposarcomas constitute rare malignant tumors of the soft tissue, with wide anatomical distribution. The prompt diagnosis of a liposarcoma is extremely challenging since these tumors tend to remain asymptomatic, until they grow enough to displace adjacent anatomical structures. In the presented case, a 55-year-old Caucasian male proceeded to our institution complaining about irreducible swelling of the right iliac fossa and constant discomfort, over the course of a year. His medical history revealed injury of the right groin and pelvis a year ago. The diagnosis was ilioinguinal liposarcoma masquerading as hematoma, due to the previous injury. The patient underwent primary complete tumor resection, and the operation was uneventful. The essential diagnostic and surgical steps for the management of a liposarcoma, mimicking a hematoma are meticulously described. Liposarcomas constitute rare malignant tumors of the soft tissue, with wide anatomical distribution . The pro. Ten months after the accident, due to the irreducible swelling, the patient underwent another ultrasound revealing a nonorganized hematoma with thrombotic features (sized as 25 × 60 × 58 mm) .A 55-year-old Caucasian male proceeded to our institution complaining about irreducible swelling of the right iliac fossa and constant discomfort, over the course of a year. His medical history revealed that he slapped against a blunt surface of a furniture a year ago and injured his right groin and pelvis. Due to the accident and the subsequent painful swelling, the patient underwent immediately a pelvic ultrasound the detected an acute hematoma with a diameter of 52 mm into the fatty tissue of the right pelvic fossa . Ten mon× 58 mm) .. Lab examinations were unremarkable. Subsequent pelvic magnetic resonance imaging (MRI)  and computed tomography (CT) scan identified a tumescent lipomatous tumor, without the presence of any metastatic lesions. Guided biopsy indicated the presence of an ilioinguinal liposarcoma located into the fatty tissue of the right iliac fossa. Following these, the interdisciplinary team decided to schedule a primary complete curative resection of the tumor (R0).At our institution, on clinical examination, surgeons verified the swelling of the ilioinguinal aera and detected at tumescent, palpable and hard mass of the right pelvic fossa . Lab exang (MRI)  and comp. The operation was uneventful, and two drainages were placed into the pelvic fossa. The drainages were removed the sixth postoperative day when the patient was finally discharged with instructions. The pathology report documented a well-differentiated liposarcoma of the right pelvic fossa. Finally, at the 6-month follow-up, the patient had no complication or recurrent lesions and oncologists declared that adjuvant therapy was not essential.During the operation, surgeons exposed meticulously the liposarcoma that was utterly removed, and performed elective resection of the right iliac crest, the upper part of the sartorius muscle, part of the gluteus maximus muscle, and part of the muscles of the anterior abdominal wall in order to eliminate the potentiality of local recurrence of the liposarcoma –7. The oLiposarcomas are rare malignancies, that are classified into five subtypes according to their histologic features: (i) well-differentiated, (ii) dedifferentiated, (iii) myxoid, (iv) pleomorphic and (v) mixed . AlthougLiposarcomas typically present into the retroperitoneum and the tight, arising from the fatty tissue, the spermatic cord or even the omental tissue . HoweverThe diagnosis of liposarcomas may be hindered, since they remain asymptomatic until they grow enough to apply pressure to adjacent structures, with potentially fatal consequences , 3. Neveet al. also reported an extrapleural liposarcoma obscured by the presence of hematoma due to previous injury of the thorax [Indeed, the diagnosis may be extremely challenging, especially when a small tumor component is ducked under a hematoma, as in the presented case. The present manuscript describes an ilioinguinal liposarcoma masquerading as a hematoma of the pelvic fossa. Although rare as a liposarcoma manifestation, Lin e thorax . TherefoFinally, treatment of liposarcomas typically includes meticulous surgical resection, as in the present case, and adjuvant radiotherapy or chemotherapy when appropriate . DespiteConclusively, surgeons’clinical suspicion regarding liposarcoma, is fundamental and crucial when encountering constant swelling and irreducible hematomas of the soft tissue, despite their rarity. Surgeons deep knowledge in addition to emphasis on patient’s medical history is a cornerstone for the prompt diagnosis of liposarcoma, and its successful and safe complete surgical resection.


Retroperitoneal lipoma is exceedingly rare, and due to the difficulty in distinguishing between retroperitoneal lipoma and well-differentiated liposarcoma (WDLS), recommendation is en-bloc resection. A 58-year-old male was investigated for scrotal swelling, ultrasound and computed tomography showed a well-defined lipomatous mass occupying much of the left side of the lower abdomen. At laparotomy, a large left-sided retroperitoneal mass was found. Histology reported a 160 mm × 150 mm × 90 mm fatty tumour weighing 1540 g. MDM2 gene amplification was not present on fluorescence in situ hybridization. No significant somatic signatures were identified on whole exome sequencing. Retroperitoneal fatty tumours represent a diagnostic dilemma. Sampling via core biopsy has been recorded at 85% accuracy for WDLS. Positive amplification of the MDM2 gene supports a diagnosis of WDLS; however, a negative biopsy does not exclude the diagnosis due to varied amplification among different cells in the same tumour. Retroperitoneal lipoma is exceedingly rare, and due to the difficulty in distinguishing between retroperitoneal lipoma and well-differentiated liposarcoma, the treatment recommendation is en-bloc resection. We report the rare and unusual case of giant retroperitoneal lipoma in association with multiple limb and trunk lipoma.A 58-year-old male presented to his general practitioner with right scrotal swelling that developed over a week. He had an ultrasound followed by a computed tomography (CT) scan, which demonstrated a right hydrocoele, but also showed a well-defined lipomatous mass occupying much of the left side of the lower abdomen, extending from the edge of Gerota’s fascia behind the inguinal ligament towards the lesser trochanter. It was posterolateral to the external iliac artery and vein as they exited the pelvis. There was mild dilatation of the left upper ureter likely due to mass effect, but the left pararenal fat did not appear involved in the mass . Subtle He was referred to our sarcoma service. Medical history was dyslipidaemia, four coronary artery stents for ischaemic heart disease, an unprovoked deep vein thrombosis in his left leg 13 years previously, transurethral resection of the prostate for benign prostatic hyperplasia and lumbar discectomy. He was an active smoker (15/day). His medications were clopidogrel, rosuvastatin and perindopril. There was no family history of lipomas. The abdominal mass was easily palpated in his left lower quadrant and had a soft consistency. There was a hydrocele in the right hemiscrotum. Notably, he had Following discussion in the sarcoma multi-disciplinary team (MDT) meeting, en-bloc resection was recommended. Although at laparotomy, a large left-sided retroperitoneal mass was found, macroscopically it appeared to be dark yellow to orange adipose tissue within a semitranslucent capsule, involving the psoas and displacing the L2 trunk . MacroscHistology reported a 160 mm × 150 mm × 90 mm fatty tumour weighing 1540 g. Microscopically, an expert soft tissue pathologist favoured lipoma. MDM2 gene amplification was not present on fluorescence in situ hybridization following testing of multiple sites of the tumour. He underwent whole exome sequencing to further investigate HMGA2 with review at the Queensland Molecular Tumour Board. No significant somatic signatures were identified.HMGA2 gene testing was undertaken to assess for familial multiple lipomatosis, which is a rare disease characterized by multiple lipomas of the trunk and limbs. Its underlying genetic cause is unknown, although literature suggests deregulation of the HMGA2 gene which encodes for aberrant cell proliferation and development of benign tumours may be responsible [Giant retroperitoneal lipomas are remarkably rare, with 20 cases reported in the English literature . Althougponsible . DespiteDr Geoffrey Strutton. Department of Anatomical Pathology, Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.None declared.None.


This case report describes a patient with intellectual disability who presented with a neglected midline nasal mass eroding the anterior skull base, which was found to be a Grade II meningioma likely of the olfactory bulb. Points of interest include differential diagnosis of this atypical mass of the sinonasal tract, as well as decision-making in balancing appropriate management and quality of life in a patient with developmental delay who could not make decisions for herself. Literature review regarding the role of adjuvant radiation based on final diagnosis and extent of disease suggests that radiation can improve locoregional control and overall survival with atypical meningioma. Lack of clear information in the literature on these rare conditions can lead to poor understanding on the part of the treatment team and the healthcare proxies who are making decisions, making goals of care discussions and medical decision-making challenging. This case report seeks to add to the available data on management of atypical meningiomas of the sinonasal tract and olfactory bulb. Meningiomas are the most commonly reported primary intracranial neoplasms in adults, comprising over one-third of all central nervous system tumors . The WorThe patient was a 64-year-old female with a history of severe intellectual disability and seizures who presented with a midline nasal mass that had been steadily increasing in size for the prior four months. On physical exam, the mass was visible and palpable deep to the skin along the left nasal dorsum, leading to left orbital proptosis and severe telecanthus. At baseline, the patient was able to make her needs known with limited vocabulary, was cooperative with her own care, and lived in a nursing facility.CT scan with intravenous (IV) contrast showed 5.8 x 5.4 x 4.8cm homogenously enhancing lobulated mass centered in the midline anterior cranial fossa near the olfactory groove, frontal sinus, and anterior ethmoid sinus, demonstrating marked scalloping and thinning of the bone, with 1.3 x 1.3cm extension into the intracranial space along the anterior cranial fossa  was weakly positive, S100 was diffusely positive, CK7 was positive, and CD99 was positive. Follow-up magnetic resonance imaging (MRI) confirmed the CT findings, and showed that the lesion was hypointense on T1, mildly hyperintense on T2, and had displaced homogeneous avid enhancement Figures .The proposed differential at that time was meningioma, esthesioneuroblastoma, lymphoma, or sinonasal carcinoma. The goals of care discussion with the patient’s family and healthcare proxy was challenging in this case, as it was unclear how to frame the risks and benefits of an aggressive resection and reconstruction in a non-verbal, minimally interactive patient with a mass of uncertain prognosis. It was difficult to determine the best thing for this particular patient’s quality of life. The concern with leaving the mass untreated was for continued growth of the lesion, worsening proptosis and mass effect on the brain and brain stem, leading to death. Given the unknown pathology of the lesion, it was difficult to prognosticate on the timeline of these events, or on the response of this mass to non-surgical management, such as radiation and chemotherapy. The risks of removal included postoperative leak of cerebrospinal fluid (CSF) and meningitis. Given the erosion of the bone of the skull base seen on CT, excision of the mass would certainly require intraoperative repair of the skull base, which can still lead to persistent CSF leak in 1.6% of cases and meningitis in 1.1% of cases, based on the current literature in endoscopic resection of skull base lesions . SurgicaThe patient underwent resection of the mass via modified Weber-Ferguson incision as well as bicoronal flap, bifrontal craniotomy with excision of tumor and anterior cranial fossa base with repair with pericranium and fascia lata grafts in a combined approach by Neurosurgery and Head and Neck Surgery. The tumor was noted to be closely associated with the cranial part of the nasal septum and the medial left orbit, but was not grossly invading these structures. The majority of the destruction of the skull base appeared to be lateral to the cribriform plate on the left. The resected area included left ethmoid air cells, left middle turbinate, right middle and superior turbinate, superior nasal septum, nasal bones, and bilateral medial orbital walls. The anterior skull base defect was repaired with an anteriorly-based pericranial graft and fascia lata grafts harvested from the thigh. Because there was no resection of the overlying skin, the fascial incision was closed primarily with minimal cosmetic defect, other than saddle nose deformity of the nose due to resection of the nasal bones and superior nasal septum. No masses or abnormal enhancement on postoperative CT performed during her hospital say suggested current or residual disease.The final pathology result showed atypical meningioma with positive margins, including bony invasion of the posterior nasal septal margin and cribriform plate as well as submucosal tissue of the anterior septal margin. Immunostaining was positive for S100, EMA, and CD56.At the initial postoperative visit one week after discharge from the hospital, further postoperative management was discussed. Because of diagnosis of atypical meningioma and invasion of bone on final pathology, radiation therapy was recommended; however, given concern over side effects of radiation and desire to limit aggressive care at that time, decision was made by the patient’s healthcare proxies to forgo radiation. There was no residual or recurrent disease noted at the one-year follow-up visit. Postoperative CT findings at one year showed no residual disease or recurrence Figure .At the two-year follow-up visit, the patient was noted to have a recurrence with worsening proptosis. Options of further resection and reconstruction with anterolateral thigh free flap, as well as palliative care and observation were discussed. The patient’s healthcare proxies chose to proceed with surgery. Postoperative course was complicated by poor wound healing and flap breakdown, which was managed conservatively without return to the operating room. The patient subsequently expired within 14 days after discharge back to the nursing home.Recurrent rates for atypical and anaplastic meningioma range between 9% and 50% after gross total resection (GTR) and between 36%-83% after subtotal resection (STR) . Bone inOne meta-analysis showed median five-year progression-free survival (PFS) and overall survival (OS) after adjuvant radiotherapy were 54.2% and 67.5% for atypical meningioma. Most studies failed to demonstrate a statistically significant prognostic benefit for adjuvant radiotherapy in atypical meningioma, but local control was improved, especially after subtotal resection [Based on this data, radiation may have benefited progression-free survival and overall survival in this patient based on bony invasion and pathology of atypical meningioma. Meningiomas can present rarely in the sinonasal tract. The majority of meningiomas are benign; however, atypical and anaplastic meningiomas warrant more aggressive treatment both intraoperatively and postoperatively. Progression-free survival and overall survival are improved with adjuvant radiation to prevent recurrence, particularly in those patients with involvement of bone shown on final pathology. Studies have not shown improvement in PFS and OS after radiation for recurrent disease. Post-operative radiation was not used in the case of this patient, as the patient’s family wanted to forego aggressive treatment in the immediate postoperative period. However, the patient’s healthcare proxies then chose to pursue surgery two years later for treatment of the recurrence, which indicates they were willing to pursue aggressive measures when indicated. Refusing postoperative radiation may have been due to a lack of understanding of its risks and benefits on the part of both the treatment team and the family. It can be difficult to explain the risks and benefits of radiation for a lesion that is pathologically benign but locally aggressive, such as in this case of an atypical meningioma. The rarity of this condition, particularly its presentation in the sinonasal tract, led to difficulty with obtaining and conveying the appropriate information to use to counsel the patient's family. This case report seeks to summarize the available information in the literature to help provide evidence to assist with future patient discussions.


Hystopathological finding: well differentiated liposarcoma. French Federation of Cancer Centers Sarcoma Group: Grade 1 tumor differentiation: 1; mitotic count: 1; tumor necrosis: 0 (C).Retroperitoneal tumors give non-specific symptoms until they have reached a substantial size. Liposarcoma and leiomyosarcoma are the most common retroperitoneal carcinoma amount of 70% and 15% respectively. Hodgkin´s and non-Hodgkin lymphoma and epithelial tumors or metastatic disease are less common. We present a 60-year-old female who was referred to the Emergency Department with acute onset of abdominal distension, nausea, vomiting, right back pain and lipothymia. She had a medical history of essential hypertension and diabetes mellitus. On physical examination, she had a good performance status, arterial blood pressure was 90/60 mmHg, pulse rate was 120 b/min, oxygen saturation of 93%. Blood exams demonstrated no lymphocytes 4x 103/mmc, hemoglobin 7g/dl. Physical examination of the abdomen revealed a giant non-tender mass in the left and midline quadrants. The patient was transfused with 4 units of blood. Abdomen computed tomography (CT) scan revealed a retroperitoneal mass of 35 cm involving the stomach, the spleen, the kidney and surrounding the vena cava (A). He was referred to a Multidisciplinary Team (MDT) to perform a CT scan Fine-Needle-Aspiration (FNA) which confirms a well differentiated liposarcoma. A laparotomy was performed with total excision of retroperitoneal mass (B). At 6


Diffuse proliferative cerebral angiopathy (DPCA) is an uncommon type of cerebral vascular malformation, mostly diagnosed in young females. It is characteristically different from other cerebral arteriovenous malformations and can be differentiated by its peculiar imaging findings. A nidus of normal brain parenchyma is present between the abnormal vascular channels. Therefore, it is crucial to diagnose it as a separate entity because unnecessary treatment of DPCA increases the risk of damage to the normal parenchyma leading to neurological deficits. Here we describe a case of a 60-year-old male who presented with severe neurological deficits and was later diagnosed with DPCA. He was managed conservatively with antiepileptics and almost completely recovered to normal within 2 weeks. A rare case of DPCA confused with other hemorrhagic disorders is discussed here. Rare cases are often overlooked. Correct diagnosis helps to prevent tragic consequences. Diffuse proliferative cerebral angiopathy (DPCA) is an uncommon type of cerebral vascular malformation, mostly diagnosed in young females , 2. PatiA 60-year-old male presented to our institute in the emergency department with a history of loss of consciousness for 20 minutes followed by aphasia, seizures and left-sided hemiparesis without any prior similar history. He was a known case of hypertensive for four years but was not under any medication. He was a regular consumer of homemade alcohol and consuming 250–500 ml/day. He did not have any other significant past medical or surgical history. On examination, he had a Glasgow coma score of 10/15 with normal pupils. Neurological examination revealed normal power in right upper limb with decreased power in the bilateral lower and left upper limbs. His other systemic examinations were normal; however, he was still hypertensive. Plain computed tomography (CT) of the head showed multiple linear areas of hyper-densities (mean attenuation ~50 HU) along cortical sulci of bilateral temporo-parieto-occipital lobes that mimicked subarachnoid hemorrhage (SAH) owing to its distribution pattern and presentation but did not qualify strongly as a SAH because of its marginal attenuation  and hencBrain AVMs are abnormally dilated tortuous vessels characterized by direct connections between arteries and veins without a capillary bed , 4. AVMstrans-dural supply in remote locations  suggesting an unrepressed response to cerebral sub-ischemic manifestations [DPCA is common in young females (mean age ~ 22 years) and is a diagnosis of exclusion [stations , 2, 4.Patients with DPCA mostly present with seizures, headaches and progressive neurological symptoms similar to our patient presenting with loss of consciousness followed by aphasia, seizures and left-sided hemiparesis . HemorrhPlain CT scan findings in our patient mimicking acute SAH could have misled to a wrong diagnosis inviting unnecessary neurosurgical intervention had it not been to the consultation from a radiologist for a CT cerebral angiography. Though DSA is the gold standard for the diagnosis of DPCA, CTA and magnetic resonance angiography (MRA) are quite accurate too in ruling out other AVMs , 6.Classic AVMs require treatment after weighing the disease versus treatment-related risks, whereas DPCA is managed conservatively. A treatment would do more harm than cure a DPCA . TreatmeHavoc acknowledged is havoc prevented. Prior suspicion is critical to diagnosis of DPCA and to rule out other types of AVMs. In our case, the presentation was not acute, and surgery could be delayed, so all necessary investigations were done to correctly identify the disease. Thus, unnecessary morbidity or even mortality was prevented.


Surgical management was contraindicated at that time due to portal and splenic vein involvement. A systemic neoadjuvant treatment was needed in order to manage the disease with the perspective of a future surgical treatment to allow tumor removal and prolong survival of this young patient. Everolimus and sunitinib are approved treatments after SSA failure, but were unavailable at that time. Cytotoxic chemotherapy is indicated as first-line therapy in G2 pNEN, which was not our case. Ablative loco-regional therapies could have addressed liver disease, leaving untreated the pancreatic mass [90Yttrium (90Y)-DOTATOC (10.619 MBq cumulative dose in 9 months), without side effects. The patient was treated with Y-DOTATOC because that was the only PRRT treatment available at the time the patient was addressed to this approach.Neoadjuvant treatment may be useful in inoperable pancreatic neuroendocrine neoplasms (pNEN). A 41-year-old man complained for severe gastrointestinal symptoms ; abdominal ultrasound showed two liver nodules and computerized tomography (CT) showed multiple liver metastases and a 4 cm highly vasularized pancreatic mass, suspected for NEN Fig. . Chromogtic mass . PRRT is68Gallium-DOTANOC PET-CT . Post-surgical abdominal CT showed the absence of liver metastases, portal vein invasion and pancreatic recurrence  after neoadjuvant PRRT of > 108 months, which is threefold to fourfold longer as compared to previously observed results. PRRT indeed caused a tumor down-staging from Stage IV to Stage I, allowing complete surgical resection. Eight years after PRRT and 7 years after surgery, SSA therapy was stopped. Two years after SSA treatment withdrawal, no biochemical nor morpho-functional evidence of recurrence has been detected and the patient is free of disease 11 years after initial diagnosis  and disappearance of liver metastases Fig. , but per-CT Fig. . Calcitonce Fig. , h, as c-CT Fig. . Calcitosis Fig. .Neoadjuvant PRRT has already been reported to reduce NEN bulk in cases that were not eligible for surgery at diagnosis –10 also Our clinical experience is in line with current literature on pNEN and proves the potential efficacy of neoadjuvant 90Y-PRRT in G1 metastatic pNEN. PRRT, indeed, may improve life expectancy and long-term prognosis after surgery, without major side effects. Current guidelines do not provide specific indication concerning adjuvant SSA therapy duration after PRRT: our case underlines the importance of a multidisciplinary evaluation in order to tailor the treatment according to patient’s characteristics.


We present an unusual case of a 60-year-old female who developed subtle, new-onset left upper and lower extremity weakness on day five of perioperative thoracic epidural placement. The onset of a focal neurological deficit after epidural placement usually raises suspicion for the presence of an epidural hematoma, abscess, or traumatic cord lesion. However, in this patient, brain imaging revealed a large, previously undiagnosed intracranial mass. Classically, the risk of mass-related intracranial pressure shifts leading to neurological changes is associated with spinal techniques, including diagnostic lumbar puncture, combined spinal-epidural catheter analgesia, and unintended dural puncture during epidural placement. However, based on this case and our summary of case reports in the literature, we determined that symptom onset associated with an intracranial mass may also arise after apparently uncomplicated epidural placement. Symptom onset in our case series ranged from six hours to ten days and was highly variable depending on tumor location, with reported signs and symptoms including headache, vision changes, focal deficits, or alterations of consciousness. Further studies are required to establish definitive causation between the epidural technique and changes in cerebrospinal fluid pressures leading to symptom onset. Though rare, this is a time-sensitive diagnosis that must be considered for any patient with unexplained neurological findings after neuraxial anesthesia. The differential diagnosis for focal neurological findings after neuraxial anesthesia includes epidural hematoma, epidural abscess, meningitis, traumatic cord lesion, and cauda equina lesion -3. EpiduAlthough the presence of a headache can sometimes help to guide the differential toward an upper versus lower motor neuron lesion, diagnosis is confounded in this situation by the relatively common occurrence of post-dural puncture headache. A high degree of vigilance and an open-minded approach to various differential diagnoses is warranted for patients with headaches after a neuraxial procedure, as intracranial masses can cause rapid decompensation. One case report describes the sequela of a labor epidural complicated by an unintended dural puncture. The initial complaints of headache were followed by fatal deterioration only two hours later. Imaging revealed an intracranial mass, but a tissue diagnosis was not obtained .The contraindication to performing neuraxial anesthesia in the setting of elevated intracranial pressure (ICP), particularly in the presence of an intracranial mass, was initially based on case reports of herniation after diagnostic lumbar puncture procedures with large bore needles and large-volume cerebrospinal fluid (CSF) withdrawal. Indeed, the rate of herniation in the setting of bacterial meningitis is approximately 5% . While iEpidural injections cause a transient increase in ICP, generally lasting three to seven minutes in healthy patients and producing no adverse effects . HoweverA 60-year-old female patient with a past medical history of asthma and hyperlipidemia presented to our tertiary care hospital’s hepatobiliary surgery clinic with symptoms of nausea, vomiting, diarrhea, abdominal pain, and 10-pound weight loss. Magnetic resonance imaging (MRI) of the abdomen and pelvis demonstrated a 6.7 cm hypodense lesion of the pancreas which was concerning for possible neuroendocrine tumor. Biopsy samples collected under endoscopic ultrasound noted atypical cytology consistent with possible mucinous neoplasm. As this tumor type does not metastasize to the brain, but rather only to the chest, computed tomography (CT) of the chest was done and demonstrated no evidence of metastasis. Due to the interval increase in the size of the abdominal mass along with the patient’s progression of symptoms, the patient was scheduled for a pancreaticoduodenectomy (Whipple procedure).For postoperative pain control, a thoracic epidural catheter was placed at the T9-10 interspace via a paramedian approach with loss of resistance to saline using a 17-gauge Tuohy needle. The needle placement was uncomplicated, and there was a loss of resistance at 6 cm with no return of CSF or blood. The catheter was threaded to a depth of 12 cm.The operation proceeded uneventfully. Microscopic sections of the specimen demonstrated fascicles of spindled cells, some of which had epithelial features and background collagen Figure . The tumPostoperatively, an epidural infusion of 0.0625% bupivacaine with 2 µg/mL of fentanyl was initiated at a rate of 6 mL per hour. The epidural functioned well, providing analgesia without motor block. The next day, the patient was started on enoxaparin 40 mg daily for deep venous thrombosis prophylaxis. The patient was ambulating on postoperative day two. On postoperative day four, enoxaparin was held in anticipation of possible epidural removal. Platelet counts were within normal limits.On postoperative day five, with the epidural infusion stopped, the patient noted subtle left upper and lower extremity weakness and complained of a mild headache. Nursing staff and physical therapists noted unequal gait phases on ambulation. Neurology was consulted and examination showed 4-/5 foot dorsiflexion, 4/5 foot plantarflexion, 4+/5 grip strength, and 4-/5 elbow extension on the left side. There were no other deficits on a complete neurological examination. The epidural was gently removed without difficulty and noted to be intact.Unilateral deficit raises concern for either prolonged local anesthetic action or epidural hematoma. However, it was unlikely that either of these could be extensive enough to reach the upper extremity dermatomes but still only affect one side. Furthermore, the patient had no risk factors for epidural hematoma such as coagulopathy, renal dysfunction, or difficult epidural placement, and all guidelines were followed regarding the periprocedural timing of anticoagulant drugs. Due to the early time point and lack of any fever, leukocytosis, or tenderness at the epidural site, an epidural abscess was also thought to be unlikely. Thus, an upper motor neuron lesion was suspected. However, the patient had minimal risk factors for stroke, and no severe headache, mental status changes, aphasia, or cranial nerve deficits. The possibility of brain metastases was also considered but the incidence is extremely rare for GISTs.Ultimately, a CT of the head without contrast demonstrated a 5.9 × 6.5 × 5.2 cm heterogeneously enhancing mass in the right frontoparietal lobe with a small amount of surrounding edema. There was a mass effect causing a midline shift of 2.5 cm at the level of the lesion, and mild effacement of the lateral and third ventricles. Neurosurgery was consulted and the patient was started on dexamethasone 4 mg every six hours to decrease edema around the tumor. Ten days after the initial Whipple procedure, a right parietal craniotomy was performed for intraventricular tumor resection.Postoperative MRI Figure  demonstrThis case report describes a rare incidental diagnosis after epidural analgesia. Compared with other reports summarized in Table Although meningioma is the most common nonmalignant brain tumor, accounting for 37.6% of all central nervous system tumors , the proOnce recognized, various measures to reduce ICP may be required. Such measures may include elevation of the head of the bed, dexamethasone, mannitol, hypertonic saline, and optimized sedation . HypovenThe successful management of this complication ultimately hinges on an open-minded approach to the differential and early recognition, brain imaging, and neurology and neurosurgery consultation. The onset of neurological symptoms may occur after any form of neuraxial access, including intrathecal, inadvertent dural puncture, and bolused or continuous infusion thoracic or lumbar epidural catheters. Though intracranial pathology has long been considered an absolute contraindication to spinal anesthesia, it is time to broaden the consideration to epidural techniques as well. At present, the implementation of screening CT or MRI prior to neuraxial analgesia is likely cost-prohibitive, with a low risk-benefit ratio. However, there may be utility in performing ophthalmoscopy or ultrasound of the optic disc diameter. Primarily, there is no substitute for a thorough history and neurological examination before and following neuraxial procedures. Manifestations of an intracranial process may be quite difficult to distinguish from other possible postoperative or postprocedural complications. Alterations of consciousness in previously reported cases were often initially presumed to be due to polypharmacy or delirium, and attempts to treat with various pharmacologic reversal or sedating agents delayed brain imaging and diagnosis in three of the cases. Further investigations would be necessary to determine whether there is a causative relationship between the CSF pressure shifts of neuraxial access and the onset of signs and symptoms of an intracranial mass.


The improved prognosis of Crohn’s disease may increase the opportunities of surgical treatment for patients with Crohn’s disease and the risk of development of colorectal cancer. We herein describe a patient with Crohn’s disease and a history of multiple surgeries who developed rectal stump carcinoma that was treated laparoscopically and transperineally.A 51-year-old man had been diagnosed with Crohn’s disease 35 years earlier and had undergone several operations for treatment of Crohn’s colitis. Colonoscopic examination was performed and revealed rectal cancer at the residual rectum. The patient was then referred to our department. The tumor was diagnosed as clinical T2N0M0, Stage I. We treated the tumor by combination of laparoscopic surgery and concomitant transperineal resection of the rectum. While the intra-abdominal adhesion was dissected laparoscopically, rectal dissection in the correct plane progressed by the transperineal approach. The rectal cancer was resected without involvement of the resection margin. The duration of the operation was 3 h 48 min, the blood loss volume was 50 mL, and no intraoperative complications occurred. The pathological diagnosis of the tumor was type 5 well- and moderately differentiated adenocarcinoma, pT2N0, Stage I. No recurrence was evident 3 months after the operation, and no adjuvant chemotherapy was performed.The transperineal approach might be useful in patients with Crohn’s disease who develop rectal cancer after multiple abdominal surgeries. As the treatment of Crohn’s disease (CD) has progressed, its prognosis has improved. Accordingly, the opportunity for patients with CD to undergo surgical treatment has increased. However, the longer duration of Crohn’s colitis may increase the risk of cancer . The relLocal recurrence is a potential complication after surgery for low rectal cancer. Complete total mesorectal excision (TME) with a negative circumferential resection margin (CRM) is important to prevent local recurrence. However, achieving TME with a negative CRM is difficult in patients with obesity, a contracted pelvis, or a bulky tumor , 6. TranIn this report, we describe a patient with CD who developed rectal cancer at the residual rectum after multiple abdominal surgeries. The rectal cancer was successfully treated with transperineal(Tp)-TME.The patient was a 51-year-old man with a history of renal failure due to acute rapidly progressive glomerulonephritis that had been diagnosed 2 years earlier and required treatment with artificial hemodialysis. He had been diagnosed with CD 35 years earlier and underwent ileocecal resection. He developed a CD-induced vesicoileal fistula and vesicosigmoid fistula and underwent right colectomy, sigmoid colectomy, closure of the bladder fistula, small bowel resection, and ileostomy 23 years earlier. After this operation, the estimated length of the remaining small bowel was 1 m. Since then, he had received home parenteral nutrition because of short bowel syndrome. He also underwent total colectomy 13 years earlier because he had developed extensive colitis. He currently desired renal transplantation for chronic renal failure and was examined in our hospital. Pre-transplantation colonoscopic examination led to a diagnosis of rectal cancer of the remaining rectum. He was then referred to our department.2. A single ileostomy at the right lower abdomen and a scar from a midline incision extending from the epigastric to suprapubic region were observed. Digital examination could not be performed because of stenosis of the anus secondary to the previous anal fistula, which had cured and showed no evidence of canceration. On hematological examination, his blood urea nitrogen concentration was 43 mg/dL, creatinine concentration was 12.16 mg/dL , carcinoembryonic antigen concentration was 1.8 ng/mL, and CA19-9 concentration was 24.4 ng/mL. Colonoscopy showed a circumferential tumor at the remaining rectum , and body mass index was 16.8 kg/mSevere intra-abdominal adhesions were expected because of the patient’s history of multiple surgeries; therefore, we performed an operation with both laparoscopic transabdominal and transperineal approaches. The transabdominal procedure and transperineal approach were carried out concomitantly. For the transabdominal approach, three ports were placed in the abdomen. One of the ports was placed in the umbilicus for scope insertion, and the other two were placed on the left side of abdomen for the laparoscopic operator. The transperineal approach was concurrently implemented. First, two purse-string sutures were placed to close the rectal lumen and prevent cancer cell dissemination. The scar due to the previous anal fistula existed, but could be easily dissected. After dissecting the perianal skin and perirectal soft tissue, a GelPOINT Path transanal access platform  was inserted and an AirSeal System  was used for carbon dioxide insufflation during the transperineal approach. In the transabdominal approach, adhesion of the small intestine and greater omentum to the abdominal wall was observed. Even after dissection of the intestinal and omental adhesion, it was difficult to recognize the wall of the remaining rectum because of the pelvic adhesion due to previous operations. Careful dissection of the rectum progressed laparoscopically. In the transperineal approach, the correct plane could be recognized and TME smoothly progressed. The influences of the inflammation of CD or chronic renal failure were none or very little to dissect the correct plane. The rectal dissection progressed along with the levator ani muscle, and the anococcygeal ligament was resected in the transperineal approach Fig. a. RendezOn gross examination of the resected specimen, the tumor was a flat and villiform mass classified as type 5 Fig. a. The siDuring the postoperative course, the patient developed a fever due to an intra-abdominal infection 3 days after the operation, which might be due to a retrograde drainage tube infection estimated by CT, and it was treated with antibiotics. He was discharged 21 days after the operation. No recurrence was evident 3 months after the operation, and no adjuvant chemotherapy was performed.We have herein presented a case of CD with rectal cancer at the residual rectum after multiple abdominal surgeries; the cancer was successfully treated with Ta-TME. Approximately 70 to 80% of patients with CD reportedly undergo surgical treatment , 12 and Cancer at the defunctioning residual rectum or rectal stump is also reportedly problematic in patients with Crohn’s coloproctitis after total colectomy , 4, 14, Since Ta-TME was at first reported by Lacy and Adelsdorfer in 2011 . In addiTa-TME is technically demanding and requires a proper anatomical perspective from the anal side. The data of the international registry of first Ta-TME cases revealed that misdirection of the correct layer occurred in 7.8% of cases and that injury to adjacent organs, including the urethra, occurred in 1.5% of cases . RecentlWe experienced a case of residual rectal cancer treated by combination of a laparoscopic and transperineal approach in a patient who had undergone several surgeries for Crohn’s enterocolitis. The development of rectal cancer might be a concern in patients with extensive Crohn’s coloproctitis, especially in those who were diagnosed with CD at < 30 years of age or who have had a long duration of CD. Increasingly more patients with CD are undergoing multiple abdominal operations as the prognosis of CD has improved, and Ta-TME or Tp-TME might be useful in patients with CD who develop rectal cancer after undergoing multiple abdominal surgeries.


The mass was evaluated using magnetic resonance imaging/computed tomography and the histology was confirmed by biopsy. Wide surgical resection of the mass was done and the patient was referred to another center for radiotherapy and further treatment. The large size of the sarcoma and the possible pulmonary metastasis poses a risk of significant morbidity and mortality in this patient. This case showcases the scenario of many patients in developing countries where the patients are lost to follow-up due to various reasons and present later with grave consequences.Sarcomas can present differently in different parts of the body and showcase varied histopathological features and tend to recur locally and metastasize to distant sites. We discuss a case of a 37-year-old male with local recurrence of spindle cell sarcoma of the paraspinal muscles of size 20 × 20 cm Sarcomas are a rare group of malignant tumors arising from the mesenchymal tissue, which make <1% of all adult malignancies . World HSpindle cell sarcoma is one of the rare varieties of undifferentiated soft-tissue sarcomas . Due to 2), which was excised as liposarcoma in another hospital and referred to a cancer hospital for further evaluation. On revision biopsy, spindle cell sarcoma was diagnosed and the patient was advised follow-up in the same hospital for radiotherapy of the tumor bed. Due to his ignorance and financial problems, he did not follow-up and ignored the growing mass and presented to our hospital only after having pain and ulceration over the mass.We present a case of a 37-year-old male presenting to the surgery out-patient department with a mass in the left upper back, which had grown into present size in 1 year. He had a history of a mass in the same location (5 × 4 cm2 tender hard mass at left upper back with overlying ulceration and discharge (On local examination, he had a 20 × 20 cmischarge . Magnetiischarge . Biopsy The tumor was surgically excised by a team of surgeons . The patThe evaluation of a patient with a suspected soft-tissue sarcoma includes history, imaging and biopsy . MRI is et al. and Smith et al. showed the median age at presentation of 57 years [et al., the median tumor size found was 9.87 cm [2 at the first presentation while it grew into a massive size of 20 × 20 cm2 when it recurred later after the surgery. This sort of presentation is quite rare as patients generally tend to present earlier with the mass with a median duration of 20 weeks [Spindle cell sarcomas affect people of almost any age and sex . Two sep57 years , 10. In 20 weeks .Due to their rarity, delay or misdiagnosis is common for sarcomas especially in settings with limited facilities. , 13. In et al. and Diageler et al. reported local recurrence after surgery within a median duration of 19 months and 15.7 months, respectively [Two separate studies by Swamsura ectively . Our patectively .In our case, the lack of proper communication between involved hospitals and doctors might be one of the reasons for his loss to follow-up , 19. BesThe management of soft-tissue sarcomas is best done in a center with appropriate expertise in multiple fields. In absence of appropriate expertise or resources, patients do not get adequate treatments in time. This may lead to grave consequences like metastasis or recurrence causing significant problems to the patients. Regular follow-up after treatment with history, physical examination and chest imaging is of utmost importance.None declared.None.


Introduction: Cystic liver lesions may be benign cysts, parasitic infestations, or malignant tumors requiring surgical resection. Hilar location and relation to major vasculature present challenges in conventional surgical access and resection.Materials and Methods: We describe totally robotic excision of a cystadenoma in a 55-year-old woman without complication. Time points in the accompanying video (https://youtu.be/Tn_QPgpSHA4) are embedded within the text.Results: Advantages of the robotic technique lie in overcoming the natural restriction of conventional laparoscopic instruments, easier repair, and control of intraoperative vascular injuries using EndoWrist® instruments, ergonomic dissection close to major vasculature and reduced intraoperative blood loss as dissection is easier.Discussion: Indications for robotic surgery included the large size of the cystic lesion, its intrahepatic location, and compression of the inferior vena cava (IVC) and right and middle hepatic veins. Had robotic removal of the lesion not been feasible, the entire lobe of the liver would have required resection. Cystic liver lesions are frequently encountered in clinical practice. They represent a spectrum of differential diagnoses from benign cysts to parasitic infestations and malignant tumors , 2 that Since 2012, however, with the establishment of the Robotic Program for Liver Surgery at Beilinson Hospital, the Robotic Da Vinci Si System has revolutionized liver resection. The more favorable ergonomic features of the robotic approach further extended the selection of patients for minimally invasive surgery as major liver resections, right and left hepatectomy, right extended hepatectomy, radical cholecystectomy for cancer, and, crucially, central liver resections close to major vasculature—traditionally resected through the open approach—were performed safely and with greater ease. All liver cysts are now resected using robotic surgery, regardless of size, location, and complexity as experience of the robotic approach has widened the selection criteria.In the case presented below, we explain our approach to robotic resection of liver cysts, in particular, cysts that present challenges in surgical access because of their location or relation to major vasculature. Such lesions, close to the hilum constitute at least 50% (6 out of 11) of all cyst excisions (at the time of writing) at Beilinson Hospital. These cysts would otherwise be resected through the open approach as the laparoscopic approach does not afford the same level of safety in access to the hilum and control of major liver vasculature. We explain the advantages of the robotic approach over both the open and laparoscopic approaches in terms of selection criteria, operative procedure, reduced postoperative pain, reduced opiate analgesia, reduced blood loss, and absence of need for blood transfusion.The patient was a 55-year-old woman in good general health who undertakes daily sporting activity. She presented initially with epigastric pain with no history of jaundice, weight loss or previous surgery. Her comorbidities include well-controlled diabetes, hypertension, and hyperlipidemia. Liver function tests were slightly elevated  but tumor markers  were within normal limits (00:05–00:15). Echinoccocal serology was negative.Ultrasonography showed a thin-walled cyst, 9 cm in diameter, located in segment 8, lying on the IVC inside the liver. No bile duct dilatation was seen. Tri-phasic computer tomography (CT) scan of the liver confirmed the 9 cm multi-lobulated cystic lesion in the liver. The IVC and right and middle hepatic veins were compressed (00:15–00:45) while the bifurcation of the portal vein abutted the cyst from above. At this stage, the differential diagnoses included biliary cyst adenoma and Echinococcal cyst. Although pre-operative radiology demonstrated no malignant features, until the time of surgery Echinococcal cyst remained a possibility, and the patient was, therefore, treated with a 2-month course of albendazole prior to surgery. Surgery was performed in July 2013. In the video we present a robotic approach for surgical excision by opening the liver through the parenchyma across the inter-lobar plane: the “open book” approach. This approach does not require entering the hilum and obviates the need to remove the gallbladder. Surgery was performed under general anesthesia. Deep muscle relaxation was important in order to obtain the largest available space (pneumoperitoneum) within which to work in the abdomen. The patient was placed in the supine position with 30-degree head up elevation and 15-degree left table tilt.The pneumoperitoneum was applied through a GelPOINT device  inserted through a small Pfannenstiel incision, safely under direct vision. The GelPOINT device contains a wound protector, silicone membrane, and trocars. The trocars are fixed in the membrane and may be used for additional access to the abdomen for the surgical assistant. The surgical assistant assists with additional traction on the tissues, inserts and withdraws sutures and performs suction. During the final step of the procedure the specimen—placed within the Endobag™  device —is extracted through the membrane of the GelPOINT device.Four trocars are used for the robotic arm instruments and there is one trocar for the assistant. This permits access for additional manipulation of tissues by the assistant. Trocar placement was along a transverse line with maximum possible distance between the insertion points in order to prevent external arm collisions. The camera port was placed 2–3 cm lateral to and above the umbilicus, overlying the IVC as far as possible in front of an imaginary liver transection line—Cantlie's line. Division of the two liver lobes was planned from the diaphragmatic surface of the liver without entering the hilum.® grasper were used for liver retraction. Access to the hepatic veins was facilitated by retracting the round ligament toward the left (01:06–01:10).The lesion was covered by normal liver parenchyma and could not, therefore, be visualized directly within the abdominal cavity. Although, preoperative investigation suggested an absence of hydatid disease, the pericystic area, and operating field were covered with pads soaked in hypertonic saline. Under ultrasound guidance the cystic lesion was aspirated and injected with hypertonic saline. Clear, bile-stained fluid was aspirated. Aspiration reduced cyst tension . After exploration of the liver the falciform ligament was divided, reaching and dissecting the suprahepatic IVC and right and middle hepatic veins further defined by intraoperative ultrasound (01:16–01:20). Intraoperative ultrasound findings supported the preoperative diagnosis and assisted the localization of the middle hepatic vein on the surface of the liver. Using monopolar diathermy, the liver transection line was etched on the surface of the liver . The third arm and the EndoWristNext, adhesions to the gallbladder were divided in order to access the posterior surface of the right lobe of liver and the IVC (01:21–01:40). Transection of the liver parenchyma was commenced in the line drawn along the capsule of the liver. A harmonic scalpel was used to cut and seal small vessels. The waterjet dissector device was introduced by the assistant surgeon through the assistant port under the guidance of the console surgeon, and facilitated the identification of intrahepatic vascular structures—preventing unintentional injuries (01:49–02:25). One of the main branches of the middle hepatic vein pushed up and compressed by the tumor was encountered, identified, dissected, clipped using 10 mm endoclips, and cut (02:04–02:20).Dissection to “open the liver” was begun with orientation of the surface of the cyst. The trunk of the middle hepatic vein was carefully approached and dissected away from the cyst, causing the cyst to emerge out of the liver parenchyma (02:24–02:30). In the same manner, small connecting branches were carefully ligated off the middle hepatic vein . Dissection was continued around the cyst until the posterior wall had been exposed and anterior wall of the IVC, right hepatic vein and portal bifurcation were clearly visualized (03:22–04:48). Finally, the cyst was dissected off the IVC and right hepatic vein. Small tears were repaired with 6/0 polypropylene sutures. The cyst was placed within an Endobag™  (05:28–05:35) and removed through the GelPOINT device. The cyst bed was lavaged using a suction-irrigation system (05:36–05:50). Small bile leaks were sutured using 5/0 polydioxanone sutures (05:55–06:09). The procedure was completed with the placement of a 10F Jackson-Pratt drain in the cyst bed (06:13–06:21). Total blood loss was <100 ml. No blood transfusion was required.in situ for a further 5 weeks draining a low volume bile leak. In this time, she made a full recovery and resumed daily activities. After removal of the drain, she resumed swimming and sport. Histopathological examination confirmed biliary cystadenoma (mucinous cystic tumor) of the liver with no evidence of malignancy. Three months after surgery, follow-up CT scan showed no evidence of residual collection and the patient has good functional and cosmetic results (06:21–06:50). At follow up, more than 6 years later, the patient remains well.The patient was able to walk on the first postoperative day. From the second day, she required no further opiate analgesia and was discharged from hospital on the fourth day with the Jackson-Pratt drain ® instruments allow easy repair and control of intraoperative vascular injuries. Experience in major HPB surgery and laparoscopic liver resection is essential and cases such as this should be performed in centers with expertise in both. Indications for this particular procedure included the large size of the cystic lesion, its intrahepatic location, and compression of the IVC and right and middle hepatic veins. If this patient, had robotic removal of the lesion not been feasible, the entire lobe of the liver would have required resection. This has obvious implications for the morbidity to the patient. Preoperatively, the patient required a minimum of preparation (monitoring of blood sugars) with an enhanced recovery protocol. Postoperatively, she was able to mobilize on the first postoperative day and required no opiate analgesia from the second day, eating a full diet and mobilizing fully until discharge from hospital on the fourth postoperative day.With careful selection of cases, cystic, and malignant liver lesions may be safely excised laparoscopically , 5. IndeThe original contributions presented in the study are included in the article/Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.ES, IT, and SB wrote and revised the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Colonic anisakiasis is rare because most cases of anisakiasis occur in the stomach. An accurate diagnosis is sometimes difficult because of the rarity and symptom nonspecificity. We should consider the possibility of colonic anisakiasis when examining patients who have a history of consuming raw fish. Colonic anisakiasis is rare because most cases of anisakiasis occur in the stomach. An accurate diagnosis is sometimes difficult because of the rarity and symptom nonspecificity. We should consider the possibility of colonic anisakiasis when examining patients who have a history of consuming raw fish. In Japan, gastric anisakiasis is relatively common because of the tradition of consuming raw fish. Furthermore, the number of anisakiasis cases may reportedly increase throughout the world as the Japanese style of eating raw fish becomes more popular.A 63‐year‐old man presented to our hospital for further examination of slight abdominal discomfort and a positive fecal occult blood test at his annual health check‐up. We proceeded to perform a colonoscopy, which revealed an approximately 20‐mm grayish‐white worm penetrating the mucosa of the sigmoid colon Figure . The larThe authors state that they have no conflict of interest.HN and KT: drafted the manuscript. RM, AS, YH, and YK: were involved in the patient's care. SK: supervised the study.This study does not require any ethical committee approval.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


An 8-year-old Ragdoll cat was admitted to our hospital after its owner noticed sudden lethargy. Abdominal ultrasonography showed a large amount of blood in the abdominal cavity, and the cat was diagnosed as having hemorrhagic shock caused by the rupture of an intra-abdominal mass. Blood transfusion was performed on the 1st day of hospitalization. On the 2nd day, contrast-enhanced computed tomography (CT) was performed, and hemorrhage from a mass originating in the caudate lobe of the liver was noted. Transcatheter arterial embolization (TAE) was performed to stop the bleeding from the mass using Gelpart to embolize the feeding artery. The following day, fever and elevation of liver enzyme levels were observed, but these subsided within a few days. At discharge 5 days after TAE, no fluid was found in the peritoneal cavity, and no further intra-abdominal bleeding occurred. Sixty-six days after TAE, we were able to perform resection surgery with the cat in good condition. A partial response was observed on CT performed before surgery. Histopathology revealed cholangiocellular adenoma. The cat was doing well as of postoperative day 549. This case indicates that TAE may be effective for initial hemostasis and stabilization of conditions in animals with tumor-induced hemorrhage. Non-traumatic intra-abdominal hemorrhage often results from the rupture of a neoplasm, such as in the spleen or liver, leading to a reduction in a patient's circulating blood volume and shock; therefore, rapid and appropriate treatment is important. In veterinary medicine, surgery for hemostasis is often performed after stabilizing the patient's condition, but the prognosis is poor. In contrast, in human medicine, transcatheter arterial embolization (TAE) is often used as the first-choice treatment to achieve rapid hemostasis and better prognosis. In this study, TAE was performed for hemostasis in a cat with hemorrhagic shock caused by the rupture of a liver tumor.An 8-year-old neutered male cat weighing 4.9 kg was brought to Kawamura Animal Hospital for a sudden loss of energy and inappetence that developed on the same morning.Physical examination at the first visit revealed a body condition score of 3/5, body temperature of 38.3°C, heart rate of 216 beats/min, tachypnea, visible pallor, and capillary refill time of 2.0 s.Based on the above physical examination findings, hypovolemic shock, cardiogenic shock, obstructive shock, respiratory diseases, etc. were suspected, and blood examination, chest and abdominal radiological examination, and abdominal ultrasound examination were performed.Blood test results revealed severe anemia  but no other major abnormalities.There were no obvious abnormalities in the chest on radiological examination. However, the presence of a mass in the upper abdominal region was suspected, and a decrease in serosal detail was observed on abdominal radiographs.Abdominal ultrasonography revealed a 40-mm-sized mass in the right upper quadrant and fluid accumulation in the abdominal cavity. The fluid was aspirated, and blood was found on analysis of the aspirate. This finding along with the cat's symptoms suggested shock owing to sudden bleeding from the intra-abdominal mass.On the first day of hospitalization, oxygenation in an oxygen cage with 30% oxygen concentration and blood transfusion (100 mL of whole blood expected to increase PCV approximately 10%) were performed to stabilize the cat's condition. On day two, contrast-enhanced computed tomography (CT) was performed. The cat was premedicated with atropine sulfate , midazolam , and fentanyl . Intravenous propofol (3.0 mg/kg) was used to induce anesthesia. An endotracheal tube (ID 4.0 mm) was placed, and anesthesia was maintained with isoflurane (1.6–2.0%) in oxygen. Ephedrine hydrochloride  was used to maintain blood pressure. For CT examination, a 16-row multi-slice CT scanner  was used. The cat was administered 2.0 mL/kg iohexol contrast medium (300 mgI/mL) , which was injected intravenously at 0.25 mL/s. Images were acquired during the arterial phase (20 s), portal phase (40 s), and equilibrium phase (120 s) (slice thickness: 1.2 mm). An intra-abdominal mass originating from the caudate lobe of the liver was confirmed . AdditioAfter consultation with the owner, TAE was scheduled after CT examination to reduce hemorrhage from the tumor.Cefovecin sodium (8 mg/kg) was administered subcutaneously to the cat as a perioperative antibiotic. The cat was held in the supine position, and the right groin was shaved and disinfected.The following procedure was performed using a flat-panel-type X-ray fluoroscope . A 4-Fr short sheath  was inserted into the right femoral artery using a cut-down technique. A 4.2-Fr RIM-S guiding catheter  was then inserted. The catheter was advanced beyond the celiac artery in the abdominal aorta and the celiac artery was isolated by slowly pulling back with the catheter tip directed ventrally, and the catheter tip was placed proximal to the celiac artery for angiography . A 1.7-FGelpart , composed of fine grains of gelatin sponge (1-mm grain), was used for hemostasis. Before use, the particle size of Gelpart was reduced by the following method. After injecting 10 mL of iohexol contrast medium (300 mgI/mL) into a vial containing Gelpart, mixing was performed by inversion; the mixture was aspirated into a 2.5-mL syringe, which was then connected to another empty 2.5-mL syringe and a three-way stopcock at a 90° angle. The particle size was reduced by reciprocating the inner cylinder of the syringe 20 times with the three-way stopcock open. We reconfirmed the presence of the microcatheter tip in the target vessel with a test injection of the contrast agent. After confirmation, the embolizing agent was slowly injected into the target vessel under fluoroscopy guidance. Care was taken to prevent the flow of the embolization agent into vessels other than the target vessel . The infOn day 1 after TAE, the cat's body temperature increased to 39.5°C, and the serum alanine aminotransferase (ALT) level increased to 303 U/L . Therefore, lactated Ringer's solution was infused intravenously (3.0 mL/kg/h). On day 3 after TAE, the body temperature decreased to 38.6°C, and administration of lactated Ringer's solution was stopped. The cat was discharged 5 days after TAE. The ALT level, which was at its highest on postoperative day 1, gradually decreased from day 2 and eventually normalized to 66 U/L on day 11 after TAE. Moreover, there was no significant increase in alkaline phosphatase levels after embolization. Abdominal ultrasonography showed gradual disappearance of fluid in the abdominal cavity, and there was no fluid in the peritoneal cavity at discharge. At the time of discharge, the general condition of the cat was stable, both vigor and appetite were good„ and PCV had increased to 25%. After discharge, the cat's condition remained stable, and no further intra-abdominal bleeding occurred. The remaining mass was surgically removed 66 days after TAE. CT performed before resection revealed a reduction in the mass's longest diameter from 32 × 45 × 52 mm to 22 × 43 × 32 mm  . HistopaIn a previous study on dogs, approximately 70% of non-traumatic intra-abdominal hemorrhages were attributable to mass lesions, which are most likely to occur in the spleen, liver, adrenal glands, kidneys, intra-abdominal blood vessels, and abdominal wall , 4. MostIn a previous study in cats, only 46% 30/65) of non-traumatic hemorrhage cases were a result of neoplasia. The spleen was the most common location of neoplasia , followed by the liver . Moreover, only eight of the 65 cats in that study survived, and the prognosis for intra-abdominal hemorrhage was considerably worse in cats than in dogs  could not be confirmed by preoperative CT examination. However, bloody ascites was observed around the tumor, and the tumor was stained more intensely in the arterial phase than in the portal phase. Even in human medicine, it has been reported that extravasation is only observed on angiography in 13.2–35.7% of patients . In manyIn human medicine, platinum microcoils, polyvinyl alcohol or acrylic polymeric beads, and gelatin sponges are used as embolic materials for hemostasis of bleeding hepatic tumors . In the A previous study reported complications of TAE in a cat owing to the sharp angle between the aorta and celiac artery in cats . They usIn this case, a fever of 39.5°C and an increase in the ALT level were observed on the 1st day after TAE, but treatment with intravenous fluids improved the cat's condition in approximately 72 h. The symptoms are similar to those of post-embolization syndrome in human medicine, and it is likely that the cat developed a corresponding condition. Post-embolization syndrome is a potential complication of TAE that can be caused by tumor cell necrosis. This complication is particularly common with a sufficient embolus, and it is caused by tumor necrosis . Major sThe limitation of this report is that extravasation was not confirmed as described above. Based on the circumstantial evidence, the peritoneal fluid accumulation was assumed to be a hemorrhage from the hepatic mass, and treatment was performed accordingly.In our case, we performed TAE for the initial management of intra-abdominal hemorrhage from a hepatic mass in a cat. The condition of the cat was stabilized, and no further intra-abdominal bleeding occurred. The tumor was reduced in size, and surgical resection could be performed in good general condition. In human medicine, it is common to stop bleeding from an intra-abdominal tumor using TAE, stabilize the patient's condition, and then perform surgical resection. In veterinary medicine, it may be possible to improve the outcome of bleeding from an intra-abdominal mass by first stopping bleeding with TAE and then performing surgery, if necessary, after the animal's condition has stabilized. We would like to further investigate the effectiveness of TAE in treating intra-abdominal hemorrhage in cats.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Ethical review and approval was not required for the animal study because this is a case report of a single cat that received veterinary diagnostics and treatments as clinically indicated. Written informed consent was obtained from the owner for the participation of their animal in this study.YK, HI, AK, HS, and KK helped with the diagnosis and participated in clinical case management. YK participated in the review and editing of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.