Neuroendocrine tumors (NET) are very uncommon, though when seen, they are typically found within the gastrointestinal tract. Rarely NETs can be seen within the lumen of the gallbladder. An 83-year-old woman presented to our hospital with vague abdominal pain and distention. She was found to have a mass within her gallbladder on imaging, and she was treated with surgical resection. Pathology revealed a gallbladder NET with lymphovascular involvement. NETs of the gallbladder remain a rare occurrence with a limited number of previous case reports. Neuroendocrine tumors (NET) are a form of neoplasia that has previously been described with an incidence of 5.25 per 100,000 . The galAn 83-year-old Spanish-speaking female with a past medical history of non-insulin-dependent diabetes mellitus and hypertension presented for evaluation. She presented to our hospital as a transfer from a local community hospital. She reported a history of intermittent sharp right upper quadrant (RUQ) pain and diffuse lower pelvic pain that had been worsening over the past six months. Six months ago, when the pain initially started, she was diagnosed and treated for a UTI. She denied any recent fever, chills, unintentional weight loss, nausea, vomiting, constipation, diarrhea, hematuria, vaginal bleeding, dysuria, melena, or hematochezia. Additionally, the patient had never had any screening mammograms, Pap smears, or colonoscopies.Before transfer, a CT abdomen was done, which showed a distended gallbladder with an intraluminal 3 x 3.1 x 3.7 cm gallbladder mass . There was a palpable mass present in the RUQ with a negative Murphy sign. The rest of the exam was benign. Laboratory studies were completed, and the CA-125 level was found to be 139 units/mL  #2. The final pathology revealed high-grade neuroendocrine carcinoma of the gallbladder with extensive necrosis, extending 5.0 cm into the muscularis and perimuscular tissue. There was no involvement of the serosa, liver, or cystic duct. However, there was a lymphovascular invasion present. Microscopic analysis and staining revealed neoplastic cells with the following immunophenotype: synaptophysin+, CD56+, AE1/AE3+, and CAM5.2+ . The classifications are further described by the Ki-67 proliferation index. Grade G1 lesions have a Ki-67 index <3%, G2 lesions have a Ki-67 index of 3%-20%, and G3 lesions with a Ki-67 index >20% . Thus, tThe prognosis for gallbladder NECs remains relatively poor due to the often late clinical presentation and the high propensity for malignancy. Chen et al. found their 1-, 2-, and 3-year survival rates to be 20%, 10%, and 0%, respectively [Treatment remains difficult for patients diagnosed with gallbladder NETs with the most preferred and chosen treatment being surgical resection. The difficulty and complexity of the resection increase with lymphovascular involvement or metastases. Because most patients are diagnosed at a late stage, surgical resection is often not a viable option. For patients who are candidates for surgery, adjuvant chemotherapy is often employed following resection. Elahi et al. described an average survival time of 46 months when patients received adjuvant chemotherapy with a combination of gemcitabine, cis-platinum, docetaxel, and sunitinib . This suGallbladder NECs remain a rare and clinically devastating diagnosis. As there are no classic clinical findings and the presence of carcinoid syndrome occurs in such few patients, the patient often presents late in the disease course. This leads to further difficulty in treatment and poor clinical outcomes. Initial studies have shown improved results when combining surgical resection, chemotherapy, and possibly radiotherapy. However, with such a limited number of cases, further studies are needed to determine how best to treat these tumors.


The rare form and mildest variant of Langerhans cell histiocytosis is eosinophilic granuloma (EG). In the clinical presentation, EG can be monostotic, polyostotic, or can encompass many organs. The parietal bone is the most common location of the skull bones that are affected by EG. So far, there have been no reported cases of EG with skull odor as an unexplained presentation.An 8-year-old girl presented with a 4 months history of a right parietal bone swelling of the skull with an offensive odor. There was no discharge and no history of vomiting or trauma. An MRI scan of the brain showed swelling with a bone lesion of the right parietal bone. Infection was the source of the swelling and the bad odor. Treatment was done by surgical excision of the lesion.EG has a variety of presentations and should be suspected when tenderness and local swelling are present. Radiography was found to be helpful in the diagnosis and surgical treatment was done to manage the case. •Most common site to be affected by EG in the Skull is the parietal bone.•EG may be infected and present with an offensive odor.•EG cells Stains positive for S-100 and CD1a.•Most of the Cases are reported among children and most of them present with Headache. LCH is rare, but it is more common in children than in adults This case has been reported in line with SCARE criteria which is mentioned in Methods section.2An 8-year-old girl presented with a 4 months history of right parietal bone swelling with an offensive odor. There was no discharge and no history of vomiting or trauma. She has taken no medications lately and had no allergic reactions. In the clinic, she had a mild headache with no fever, no symptoms of increased intracranial pressure, and no neurological abnormalities. A head computed tomography (CT) scan showed a parietal bone lesion. After that, an MRI scan of the brain showed a 2.5 × 1.5 cm bone lesion extended as swelling and suggested the diagnosis of EG . Histopa3Eosinophilic granuloma (EG) is one type of Langerhans cell histiocytosis (LCH) that involves any bone. The most frequent sites of EG vary with age. The skull (40 %), rib, femur, humerus, and vertebra are the most common sites in children The presence of eosinophilic granuloma may be indicated by its location, symptoms, or radiologic appearance. The evaluation of EG includes radiographic tests, laboratory tests, and histopathology to confirm a diagnosis The pathophysiology of eosinophilic granuloma is unclear. However, the proliferation of Langerhans cells may be induced by viral infection, immune dysfunction, or bacterial infection. As a result, interleukin-1 and interleukin-10 may be elevated Treatment and prognosis for eosinophilic granuloma of the skull depend on age and number of bones involved at the time of diagnosis After reviewing the literature, there was only one case with EG that presented with an offensive odor. In that case, the mandible was the affected site 4We present here a case report of an extremely rare eosinophilic granuloma in the parietal bone of a pediatric patient. Noteworthy, EG should be suspected when tenderness and local swelling are present. Our case was presented with an offensive odor with no clear reason. After reviewing the literature, we did not detect any cases to have a similar finding. In our case, radiography was found to be helpful in the diagnosis. Furthermore, surgical treatment was done to manage the case.This case has been reported in line with SCARE Criteria The study did not receive any funding.This study is exempt from ethical approval at our hospital.Written informed consent was obtained from the patient for reporting this case. The consent is available for review on request.Data collection: Osama N. Dukmak, Mohammad Emar.Writing the manuscript: Osama N. Dukmak, Sulaiman M. S. Abualia, Yara J. I. Meqbil.Study concept or design: Osama N. Dukmak, Sulaiman M. S. Abualia, Yara J. I. Meqbil.Review & editing the manuscript: Osama N. Dukmak, Yara J. I. Meqbil, Sulaiman M. S. Abualia, Mohammad Emar.N/A.Dr. Saeed Idkedek.Not commissioned, externally peer-reviewed.There is no conflict of interest to declare.


An ovarian fibroma is a rare entity and a diagnostic dilemma due to its solid nature and ultrasound findings being similar to a uterine fibroid. An ovarian fibroma, being parasitic, is extremely rare. We report the case of a 35-year-old, multiparous woman who presented with a ‘wandering’ abdominal mass of six months duration. Clinical examination revealed a 16-week size, solid, firm, well-defined mass in the right lumbar and iliac regions, separate from the uterus on bimanual examination, suggestive of a pedunculated subserous fibroid uterus. Ultrasound abdomen with color Doppler evaluation was suggestive of the non-uterine origin of the tumor, probably a gastrointestinal stromal tumor. In view of the diagnostic dilemma, MRI was done, which showed that the lesion had features characteristic of ovarian fibroma, however, bilateral ovaries were normally visualized. An exploratory laparotomy was performed. There was a solid parasitic tumor adherent to the bladder peritoneum and attached to the right ovary by a thin band, which was excised. Histopathology confirmed ovarian fibroma. To conclude, a parasitic ovarian fibroma is rare and a careful clinical approach with imaging and surgery helps in solving this diagnostic dilemma. Ovarian fibroma is an uncommon sex cord-stromal tumor, accounting for around 1-4% of all ovarian tumors . OvarianA 35-year-old multiparous woman presented with an abdominal mass of six months duration. The mass was gradually increasing in size for the last four months and in her words, was ‘wandering’ in her abdomen. It was also associated with mild abdominal pain. Her menstrual cycles were regular, with average flow and mild dysmenorrhoea. Her last menstrual period was eight days back. She was multiparous, with previous two cesarean deliveries and her last childbirth was seven years ago. She was not on any contraceptives. There was no history of loss of appetite or recent weight loss. Her past history and family history were unremarkable.On general examination, she was of average build and nutrition. There was no pallor, and her vitals were stable. Abdominal examination revealed a firm, solid mass corresponding to 16 weeks of gestation. It was felt on the right lumbar and iliac regions and was mobile from side to side. Its lower edge was not palpable. On bimanual examination, the mass was felt separate from the uterus in the right fornix, measured approximately 10x4 cm, and was mobile. The left fornix was free. With a provisional diagnosis of pedunculated subserous fibroid uterus, she was worked up further.Transabdominal USG revealed a normal-sized uterus with thin endometrium. There was the presence of a large, lobulated, hypoechoic mass lesion in the abdominal cavity, measuring 9.6x8.4x7.9cm, with an anechoic center, which was superior to the uterus and indented the urinary bladder Figure .On color Doppler USG, there was no internal vascularity present in the lesion. The bridging vascular sign with the uterus was absent, suggestive of the non-uterine origin of the tumor, probably a GIST Figure . The canIn view of the diagnostic dilemma and the large size of the lesion, an exploratory laparotomy was planned and performed after discussion with the multidisciplinary team (MDT) with general surgery and onco-surgery. Intraoperatively, the uterus and bilateral ovaries were normal in size. A large, firm, bilobed solid tumor, tan-white in color with peripheral vascularity was present, which was adherent to the bladder peritoneum and attached to the right ovary by a thin band, suggestive of a right ovarian parasitic tumor Figure .The mass was excised in toto and measured 12x8 cm Figure . HistopaThe differential diagnosis of a solid and mobile adnexal tumor in a woman of reproductive age is a pedunculated subserous fibroid, ovarian tumor, and GIST ,2. Our pClassification of adnexal lesions using the international ovarian tumor analysis (IOTA) group models helps in the preoperative assessment of the type, nature, and extent of the ovarian lesion . This haThe presence of a large abdominal lesion with central degeneration in a woman with abdominal pain raised the possibility of GIST in our case. GIST is a common malignant lesion of the gastrointestinal tract arising from the interstitial cells of Cajal located within the muscle layer of the gastrointestinal tract. On USG, GIST usually appears as a hypoechoic solid mass with irregular borders, a heterogeneous echo pattern, and anechoic spaces . In a fiAn ovarian fibroma is an uncommon sex cord-stromal tumor and commonly affects women in the fifth decade of life . However Still, the ovarian fibroma being parasitic was only discovered intra-operatively. Very few case reports of auto-amputation of ovarian fibromas with subsequent parasitic attachment have been previously reported . In our To conclude, ovarian fibroma is a rare benign solid tumor of the ovary, and its being parasitic is even rarer. It may grow to a large size before becoming symptomatic. Misdiagnosis is common preoperatively, leading to a diagnostic dilemma. In our case, the patient complained of a 'wandering' mass in her abdomen. In retrospect, this was probably because the fibroma was attached to the ovary by a thin band only. The differential diagnosis in our case was a subserous pedunculated uterine fibroid, GIST, and ovarian tumor. A careful clinical approach and USG helped us rule out subserous pedunculated uterine fibroid, but the possibility of GIST was there. MRI pelvis showed a band of T2 hypointensity separating the lesion from the uterus on all planes, characteristic of ovarian fibroma. However, this being parasitic was discovered only during exploratory laparotomy. Surgery is curative.


Olfactory neuroblastoma, or esthesioneuroblastoma, is an uncommon malignant tumor originating from the neural crest that commonly occurs in the upper nasal cavity. Its ectopic origin is extremely rare, especially when located in the optical pathways. This paper reports the case of a giant ectopic esthesioneuroblastoma of the optic pathways that were surgically treated through a cranio-orbital-zygomatic (COZ) craniotomy with extensive resection, in addition to a literature review. The patient is a 46-year-old female presenting with a 4-month history of visual loss in the left eye. Since she was previously blind in the right eye from a traumatic injury, it was evolving to loss of bilateral vision. Imaging depicted an expansive infiltrating lesion involving the entire path of the right optic nerve, extending to the optic chiasm, cisternal portion of the left optic nerve, bilateral optic tract, and hypothalamus. Investigation of pituitary function was unremarkable. Esthesioneuroblastoma is a rare tumor with poorly defined standard clinical management. Its ectopic presentation makes the diagnosis even more challenging, making it difficult to manage these cases properly. Surgeons should be aware of this rare possibility, as early aggressive treatment is likely to be associated with better results. Olfactory neuroblastoma, or esthesioneuroblastoma, is a malignant rare tumor that usually occurs in the upper aspect of the nasal cavity due to its origin from the olfactory neuroepithelium with neuroblastic differentiation . It freqWe report the case of giant ectopic esthesioneuroblastoma that extended along the optic nerve, leading to visual loss, and requiring neurosurgical treatment.The patient is a 46-year-old female presenting with a 4-month history of visual loss in the left eye. Since she was previously blind in the right eye from a traumatic injury, it was evolving to loss of bilateral vision. Imaging depicted an expansive infiltrating lesion involving the entire path of the right optic nerve, extending to the optic chiasm, cisternal portion of the left optic nerve, bilateral optic tract, and hypothalamus . Investivia Transylvanian and pre-temporal routes  approach l routes .After the procedure, the patient showed visual improvement in the left eye, with transient diabetes insipidus on the first postoperative day. Pathology showed an olfactory neuroblastoma grade III of Hyams . TreatmePostoperative imaging showed gross total resection, in addition to the absence of metastatic foci along the neuroaxis or lymph node involvement, characterizing a T4N0M0 tumor according to Dulguerov et al. , or stagEsthesioneuroblastoma is a rare tumor with sparse data in the literature. It predominantly occurs in young adults, and the age of presentation varies from 40 to 70 years, with men and women equally affected . AlthougClinical symptoms depend on the location and extension of the tumor, and, therefore, nasal symptoms, such as epistaxis, nasal obstruction, and anosmia, are the most common . HoweverNeither of the two clinical staging systems, TNM by Dulguerov et al. or the modified Kadish classification is ideally geared to the staging of ectopic olfactory neuroblastoma. The most critical information seems to be whether the tumor extends to the anterior cranial fossa and orbit and whether it is related to lymphadenopathy, as this has the greatest impact on treatment planning and prognosis .The theory to explain the ectopic origin of these tumors is speculative and is based on the idea that there may be ectopic cell debris during embryologic development . The theAnother possible theory, provided by Zappia et al., describes a model of blocked migration of neuronal cells from the olfactory placode that may provide the origin of these tumors in a case of Kallman syndrome, which is a congenital condition defined by the absence of olfactory bulbs and pituitary hypoplasia. Even patients, who do not have Kallman's syndrome, may exhibit less disorderly migration along the pathway, which may progress to an esthesioneuroblastoma in the future .The treatment of esthesioneuroblastoma is controversial, mainly due to its rarity and lack of data in the literature to support therapeutic regimens, with surgical resection followed by postoperative radiotherapy, being the option that showed better treatment results in retrospective reports, compared to isolated radiotherapy, although orbital invasion is associated with adverse survival outcomes , 10. TheThe role of chemotherapy in the treatment of these patients is still questionable. Neoadjuvant chemotherapy has been reported to show positive responses in locally advanced cases and appears to play an important role, especially in tumors with difficult resection . In the Esthesioneuroblastoma is a rare tumor with poorly defined standard clinical management. Its ectopic presentation makes the diagnosis even more challenging, making it difficult to manage these cases properly. Surgeons should be aware of this rare possibility, as early aggressive treatment is likely to be associated with better results.The original contributions presented in the study are included in the article/Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.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.


We present an effective and easily applied technique for cisterna magna reconstruction with arachnoid suturing in brainstem surgery. Suturing with 10-0 monofilament was done in a patient with a medulla oblongata hemangioblastoma (diagnosed von Hippel-Lindau disease). Seven years later, follow-up imaging revealed a new lesion close to the previous one and the patient underwent reoperation. The craniotomy and dural incision were repeated, and the intact arachnoid was visualized with no meningocerebral adhesions. This technique preserves normal anatomic landmarks and facilitates and shortens dissection in reoperations, almost like a virgin case. We propose this technique for every lower brainstem and fourth ventricle procedure.https://youtu.be/RKMcSoK6ycY.The video can be found here:  The art of microneurosurgery relies on atraumatic exploration, total removal of a lesion without harming normal structures, and, as much as possible, reconstruction of the normal anatomy.Here, we present a simple, effective and easily applied technique to prevent dense meningocerebral adhesions. This technique preserves normal anatomic landmarks, facilitates and shortens dissection during reoperation.In this video, we demonstrate cisterna magna reconstruction with arachnoid suturing for state-of-the-art brainstem surgery .This is the case of a 28-year-old female previously diagnosed with von Hippel-Lindau disease. She came to our institution in January of 2008 with a monthlong history of left-sided hemihypesthesia, numbness, and dysphagia.The patient’s preoperative MRI (magnetic resonance imaging) revealed a solid lesion on the left posterior medulla oblongata with a macrocystic component. The solid component showed contrast enhancement on T1-weighted postcontrast images. The MRI findings revealed a hemangioblastoma of the medulla oblongata.With preoperative vertebral angiography, major feeding arteries and draining veins were determined. In this case, the lesion’s major feeding artery originated from the left PICA.For surgery, the patient was placed prone and a median inferior suboccipital craniotomy was done.The dura was opened in Y-shape fashion.The arachnoid of the cisterna magna was cautiously opened in the midline with microscissors.Opening with sharp dissection and microneurosurgical techniques is important for successful arachnoid closure.This technique has been described by Professor Yaşargil, and we utilize it in every brainstem and fourth ventricle surgery whenever possible .After cutting the arachnoid trabeculae, the arachnoid was reflected laterally and fixed to the dura with hemoclips.A second microlesion was noticed on the posterior midline surface of the medulla oblongata. This lesion was not seen on preoperative studies.Before tumor dissection, this video angiography gave us detailed information on feeding arteries intraoperatively.Tumor dissection started with coagulation of the feeding arteries one by one.All vessels related to the lesion except the main draining vein were coagulated and cut.Tumor dissection continued circumferentially along the cleavage plane. Transsection of the tumor must be avoided because of the difficulty in controlling its profuse bleeding.The main draining vein was cut at the end of the dissection.The lesion was removed in one piece after the last attachment was cut.Frequent warm saline irrigation protects the arachnoid from drying out and helps maintain hemostasis during surgery.When necessary, bipolar coagulation on a very low setting is enough for dissection and hemostasis.The vessels related to the second lesion were coagulated and cut. This lesion was also removed in one piece.After tumor removal, the integrity of the normal vasculature was visualized with ICG video angiography.Then, the hemoclips were removed and the edges of the arachnoid were brought together.The first stitch was placed in the middle of the arachnoid incision with 10-0 monofilament nylon sutures.After the first knot, the cranial part of the incision was sutured with a continuous suturing technique.Small arachnoid defects close to the edge of the arachnoid can be included in the suture line.The caudal part of the incision was also closed with the same suturing technique.After appropriate arachnoid suturing, the dura was closed with a dural graft in a watertight fashion.The patient’s postoperative course was uneventful, and she was discharged on postoperative day 5.Histopathological analysis revealed a hemangioblastoma of WHO grade I.The 3-month follow-up MRI showed total removal of the tumor.The patient was neurologically intact.After 7 years, in January of 2015, a follow-up MRI revealed a new lesion located at the medulla oblongata. The patient was neurologically intact.In this case, the main feeding artery originated from the left PICA.The patient was placed prone, and we used the same skin incision and craniotomy.During the dural opening, the cisterna magna seemed to be intact, almost as if it had been untouched.This clean surgical area without meningocerebral adhesions is invaluable for reopening in such cases.The arachnoid of the cisterna magna was carefully opened with sharp dissection at the midline. At this stage, dissection was much easier than anticipated because there were no adhesions between the arachnoid and medulla oblongata.The location of the new lesion was more superior than that of the previous lesions, confirming that this was a new hemangioblastoma.Before tumor dissection, the major feeding arteries and draining veins were identified with ICG video angiography.Then we coagulated and cut each feeding artery one by one.Because the lesion was well encapsulated, the tumor cleavage plane was easily recognized. With bipolar coagulation on a low-power setting, the tumor and normal tissue were separated along the cleavage plane.The cystic component of the lesion was opened and its contents evacuated.After detaching the tumor from the cerebellar tonsil, the main draining vein was coagulated and cut. The tumor was removed in one piece.While exploring the surgical cavity after tumor removal, we noticed a very small new lesion. This lesion was not seen on preoperative studies. We coagulated and removed this lesion.As in the previous surgery, we needed to keep in mind that there may be new lesions that were not recognized on preoperative studies.Adequate hemostasis was achieved with low-power bipolar coagulation and warm saline irrigation.ICG video angiography was repeated, and the integrity of normal vascularization and total removal were confirmed.The arachnoid edges were brought as close as possible and partially reconstituted with 10-0 monofilament nylon sutures.Previously, we have described the benefit of placing a thin layer of gelatin sponge subdurally during the closure. This practice prevents meningocerebral adhesions .The dura was closed in watertight fashion with a dural graft.The patient’s postoperative course was uneventful and she was neurologically intact.She was discharged on postoperative day 4.The histopathological diagnosis was the same as the previous report, a WHO grade I hemangioblastoma.Early postoperative and 3-month follow-up MRI showed total excision of the lesion and no other lesions.As we demonstrated in this video, reconstruction of the cisterna magna with arachnoid membrane suturing is an easy, effective technique to prevent postoperative meningocerebral adhesions.We strongly recommend this technique for each brainstem and fourth ventricle surgery that uses a posterior midline approach.1:01 Case presentation and preoperative MRI (first surgery)2:00 Patient positioning and craniotomy2:15 Cisterna magna arachnoid dissection3:11 Removal of the hemangioblastoma4:39 Arachnoid suturing5:36 3-month postoperative MR images5:55 Case presentation and preoperative MRI (second surgery)6:25 Cisterna magna arachnoid dissection7:06 Removal of the hemangioblastoma9:23 3-month postoperative MR imagesThe authors thank Aylin Akçaoğlu for the medical illustration and Julie Yamamoto for editing the narration and the abstract.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.


Despite the use of technology, recurrent diabetic ketoacidosis (DKA) prevention remains an unmet need in children and adolescents with T1D and may be accompanied by life-threatening acute complications. We present a rare case of non-occlusive mesenteric ischemia (NOMI) with overt manifestation after DKA resolution and a discussion of recent literature addressing DKA-associated NOMI epidemiology and pathogenesis in children and adolescents.A 13-year-old female with previously diagnosed T1D, was admitted at our emergency department with hypovolemic shock, DKA, hyperosmolar state and acute kidney injury (AKI). Mildly progressive abdominal pain persisted after DKA correction and after repeated ultrasound evaluations ultimately suspect for intestinal perforation, an intraoperative diagnosis of NOMI was made.The diagnosis of DKA-associated NOMI must be suspected in pediatric patients with DKA, persistent abdominal pain, and severe dehydration even after DKA resolution. Diabetic ketoacidosis (DKA) is the most serious life-threatening acute complication of Type 1 Diabetes (T1D). Although the cause of gastrointestinal involvement has not been fully elucidated, delayed gastric emptying, paralytic ileus, electrolyte disturbances and metabolic acidosis may be involved , 4. A laWe therefore present a rare case of non-occlusive mesenteric ischemia (NOMI) that presented as mild persistent abdominal pain in the context of progressively resolved severe DKA. An appraisal of recent literature regarding epidemiology and physiopathology of DKA-associated NOMI in children and adolescents will also be provided.A 13-year-old female with previously diagnosed T1D, was admitted to the emergency department presenting incoercible vomiting since the previous day, oligo-anuria and deteriorating state of consciousness. The girl had been diagnosed with autoimmune T1D at the age of 9 years (no DKA at onset). Past medical history was unremarkable. Sensor-augmented pump therapy (SAP) was started, and her follow-up was characterized by suboptimal glucose control (latest HbA1c of 60 mmol/mol).On admission, the child presented in hypovolemic shock with an altered state of consciousness GCS 12) without evident focal neurological signs, pale skin and Kussmaul respiration. Her physical examination was unremarkable except for decreased and tachycardic distal pulses, cool extremities, prolonged capillary refill (> 2 sec). Venous blood gas analysis and lab tests showed severe DKA, hyperosmolar state, and acute kidney injury (AKI) with hyperkaliemia, confirmed at ECG analysis Table 1. without Despite a recent Italian study has shown a decrease in the frequency of DKA at T1D diagnosis in children during the last years, DKA frequency remains unacceptably high.  Data on DKA is characterized by relative or absolute insulin deficiency and increased levels of counterregulatory hormones, such as glucagon, adrenaline, cortisol, growth hormone, and proinflammatory cytokines.  High plaIt tends to occur mostly in elderly patients who have low-cardiac output and other risk factors, but several pediatric cases have been previously described. These children usually present with underlying diseases such as familial dysautonomia, Addison’s disease, situs inversus, burns, chemotherapy for hematological malignancies, encephalitis, and septic shock. –34 AlthoDespite the use of technology, recurrent DKA prevention remains an unmet need in children and adolescents with T1D and may be accompanied by life-threatening acute complications. The diagnosis of DKA-associated NOMI must be suspected in pediatric patients with DKA, persistent abdominal pain, and severe dehydration. Importantly, our case underlines how NOMI may exhibit a very subtle onset with mildly progressive abdominal pain, and unremarkable ultrasound imaging over days until overt symptoms and signs of complications  manifest.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.GF and RT share first authorship due to equal contribution. GF, RT and VC reviewed the case data and literature and contributed to manuscript drafting. GF and RT are responsible for final revision of the manuscript and significant intellectual content. All authors issued final approval for the version to be submitted. 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.


Central retinal artery occlusion (CRAO) is a rare condition. It is a diagnostic and therapeutic emergency. CRAO is analogous to an acute stroke of the eye. The disease usually affects patients after 60 years of age, and rarely young persons. The risk factors for a CRAO are similar to ischemic stroke. It is due to embolic, thrombotic, or coagulation disorders. Typically, patients with acute CRAO present monocular, painless, and severe loss of vision. We report a rare case of a young 33-year-old woman who presented an atypical ischemic stroke revealed by a unilateral CRAO. This case reports a rare condition affecting a young patient, and highlights the interest of ophthalmologic examination in the diagnostic of a neuro disease and the early management of ischemic stroke. Central retinal artery occlusion (CRAO) is a rare condition, affecting approximately one of 10,000 people, and two men for every woman, after the age of 60, rarely young people  requirinPatient information: we report the case of a 33-year-old woman, with no particular antecedents, who arrived at the ophthalmology emergency presenting sudden painless loss of vision of the left eye in the morning.Clinical findings: general examination found a high Body Mass Index (BMI) at 35 kg/m2. On the ophthalmologic examination of the left eye, visual acuity was reduced to minimal light perception. The pupillary light reflex was absent. Intraocular pressure was normal. Slit-lamp biomicroscopic examination found a good anterior segment with filamentous vitreous. Funduscopy of the left eye objectives white retinal edema of the posterior pole with a reddish reflection of the macula (e macula . The rigDiagnostic assessment: fluorescein angiography revealed a slow and progressive filling of the arteries with interruption of the flow at the level of the peri-macular arterioles and widening of the central avascular zone (lar zone . Macularlar zone . The dialar zone . Echo-dolar zone . A cardiTherapeutic intervention: the patient was hospitalized in the neuro-ophthalmology department for initiation of the treatment and the management of her cardiovascular risk factors.Follow-up and outcomes: after two weeks of hospitalization, visual acuity improved to 1/10. Follow-up after 1 month was uneventful.First described by von Graefes in 1859 , CRAO isTreatment of CRAO aims acute reperfusion of the central retinal artery, prevention of ocular complications, and vascular review to prevent ischemic diseases. Currently, conventional therapy consists of dislodging emboli, reducing intraocular pressure and increasing retinal blood flow, improving retinal circulation, vasodilating the ocular blood supply, decreasing retinal edema, maintaining retinal oxygenation until spontaneous reperfusion, and acting on the thrombus . None ofPatients presenting with features of CRAO require a thorough systemic evaluation. It is a diagnostic and therapeutic emergency. There is a high association between CRAO and vascular stroke. Treatment of CRAO must aim reperfusion of the central retinal artery, and prevention of vascular complications.


To report a sporadic astrocytic hamartoma simulating retinoblastoma in a newborn. Clinical data was reviewed retrospectively.A 3-month-old baby with a history of perinatal asphyxia was referred to our ocular oncology clinic with suspected retinoblastoma in the left eye. Dilated fundoscopy revealed a solitary tumor covering the optic disc at the left eye. The whitish-yellow lesion was well-defined, opaque, and minimally calcified. High internal reflectivity and posterior shadowing due to the intralesional calcification, and intratumoral cystic spaces were observed in B-scan ultrasound imaging. Optical coherence tomography imaging showed an intraretinal tumor with cystic spaces and posterior shadowing. The tumor was diagnosed as an astrocytic hamartoma. The systemic evaluation was negative for phacomatoses. The lesion has been observed with multimodal imaging for six years without significant changes. Retinal astrocytic hamartomas are benign tumors that arise within the retinal nerve fiber layer. Differential diagnosis constitutes high importance since they may be misdiagnosed as retinoblastoma, and therefore may be overtreated. Whereas retinoblastoma requires immediate treatment, retinal astrocytic hamartomas are commonly followed-up. Multimodal imaging with B-scan ultrasonography and optical coherence tomography are useful in distinguishing those two entities. Retinal astrocytic hamartomas (RAHs) are benign, glial tumors that arise within the retinal nerve fiber layer. They can occur as isolated sporadic lesions or may be associated with genetic neurocutaneous syndromes such as neurofibromatosis or tuberous sclerosis . The funA 3-month-old female patient was referred to our ocular oncology clinic with suspected retinoblastoma in the left eye. She was born at 36 weeks of gestation because of increased perinatal asphyxia risk due to a nuchal cord. She was incubated and had been treated with oxygen for fifteen days. The tumor had been detected at the retinopathy of prematurity screening visit.In our first examination, the patient’s vision was central, steady, maintained (CSM) at the right eye (OD), and uncentral, unsteady, unmaintained (UCUSUM) at the left eye (OS). There was a relative afferent pupillary defect at the left eye. Slit-lamp biomicroscopy and intraocular pressure measurement were normal in both eyes. Dilated fundoscopy was normal at the right eye, but revealed a solitary tumor covering the optic disc at the left eye. It was a well-defined, opaque, minimally calcified, whitish-yellow lesion. Distances from the fovea and the optic disc were 3 mm and 0 mm, respectively. On B-scan ultrasonography, the dimensions were 3x3x2 mm. High internal reflectivity and posterior shadowing due to the intralesional calcification, and intratumoral cystic spaces were noted Figure 1 . There wObservation was recommended for the management. Regular comprehensive eye examination was applied for six years with six-month intervals. At each visit, binocular indirect ophthalmoscopy, fundus photography, and B-scan ultrasonography were performed. Biomicroscopy was bilaterally normal. Fundoscopic findings or ultrasonography measurements did not significantly change throughout the six-year follow-up period. Optical coherence tomography scans showed the intratumoral cystic spaces as well, with posterior shadowing due to the intralesional calcification. The final vision was 20/20 OD and hand movement OS. Likewise, periodical screening had not revealed any systemic involvement.Retinal astrocytic hamartomas (RAHs) are benign tumors that arise from glial astrocytes. They usually present as well-demarcated, mulberry-like lesions with intratumoral calcification . When thDifferential diagnosis of RAH includes retinoblastoma, choroidal osteoma, chorioretinitis, amelanotic melanoma, and von Hippel angiomas . Drewe eUnilateral, solitary RAHs are risky of misdiagnosis. Multimodal imaging of tumors can be helpful in identifying the true pathology. In recent years, optical coherence tomography (OCT) technology proved that RAH is confined to the retinal nerve fiber layer (RNFL), and the outer retinal segments are anatomically normal. There may be intratumoral empty spaces, posterior shadowing, and vitreoretinal traction . In an oTo summarize, a six-year follow-up without any change confirms the benign nature of retinal astrocytic hamartomas. Differential diagnosis from retinoblastoma is of utmost importance. Otherwise, periodical follow-up is sufficient for their management. Our patient is young and may yet develop the signs of a phakomatosis. The child should be referred to a pediatrician for systemic screening and follow-up.0000-0002-9729-2577Bilge Batu Oto: 0000-0001-7919-9099Aslihan Yilmaz Çebi: 0000-0003-4061-2047Oguzhan Kiliçarslan: 0000-0002-9061-4385Ahmet Murat Sarici: The authors declare that they have no competing interests.


Tracheal papillomatosis is a relatively rare condition with limited data on successful treatment modalities. To our knowledge, this is the first report to describe a papilloma arising from an accessory bronchus. Furthermore, this case report demonstrates successful treatment with clinical and patient-centered improvements after use of Spray Cryotherapy.A 71-year-old woman presented with one year history of recurrent fevers and intermittent hemoptysis. Imaging and video bronchoscopy revealed an obstructing papilloma of an accessory tracheal bronchus to the right upper lobe. She was treated with debridement followed by multiple cryotherapy treatments resulting in complete clinical and radiographic resolution of her post-obstructive pneumonia.This case report not only supports existing literature on the use of cryotherapy for airway diseases but also presents a unique form of obstructing papilloma confined to an accessory bronchus, the only report of its kind based on extensive literature review. Symptoms of tracheal papillomatosis are largely non-specific, ranging from dyspnea to hemoptysis. Several treatment modalities have been suggested in the literature including probe-directed cryotherapy, CO2 laser ablation, interferon-a injection, and surgical excision Tracheal papillomatosis is characterized by papillomatous growth of the bronchial epithelium associated with Human Papilloma Virus (HPV). Occurring in either the larynx or trachea, this is a relatively rare condition with bimodal expression in children and adults in their 5th–6th decade [1]71-year-old lifelong nonsmoker with history of asthma and rheumatoid arthritis in good state of health presented to her pulmonologist with one year of cough, fevers, night sweats, and intermittent hemoptysis. She underwent CT scan of the chest which demonstrated a multiloculated density in the RUL Figs. a. DiagnoThere have been several case reports describing success of various methods to treat recurrent respiratory papilloma as well as some retrospective studies. However, given the rarity of this condition, there have been no randomized control trials comparing efficacy of different treatment modalities. In our case, the degree of obstruction necessitated endoscopic excision followed by treating remaining tissue with cryotherapy to maintain patency of the airway. While cryotherapy was our treatment method of choice, there are several available options for ablating the remaining tissue endoscopically including laser ablation and electrocautery, but there is limited data comparing these modalities. Given the low risk for malignant transformation of airway papillomas, major lung resection with potential need for complex airway reconstruction may not be justified if effective, endoscopic treatment such as cryotherapy proves to be durable. The role of post treatment surveillance with outpatient bronchoscopy is well tolerated and repeat treatments could be offered as needed for local recurrence.Regarding surgical management particularly in this patient, cryotherapy has provided a lung sparing treatment modality that otherwise would have necessitated upper lobectomy with partial tracheal resection and tracheoplasty to achieve negative margins. Use of cryotherapy is especially relevant in patients with compromised lung function who cannot tolerate lung resection. While our patient didn’t have compromised lung function at baseline, her unique anatomy made surgical excision more difficult, and cryotherapy offered a preferrable alternative.There have been several articles published on adjuvant medical therapy, particularly bevacizumab, in patients with recurrent respiratory papillomatosis


Massive retinal gliosis (MRG) is a rare condition of non-neoplastic glial proliferation, which forms massive lesions that fill the eye. MRG is commonly associated with phthisis bulbi , congenital anomalies, or malformations. Herein, we report a case of massive retinal gliosis associated with a traumatic phthisis bulbi, which was initially mistaken as a malignant intraocular tumor and confirmed only after an eye enucleation. A 70-year-old woman presented with a protruding ocular mass in her left eye which had slowly grown for a year. She had phthisis bulbi in her left eye due to trauma during her childhood. An orbital CT revealed an intraocular mass lesion with calcifications, raising the possibility of retinoblastoma or other malignant intraocular tumors. Enucleation of the left eye globe was performed. Histopathologic examination revealed exuberant proliferation of the glial cells, metaplastic bone formation, hyalinized vessels, and hyperplasia of the retinal pigment epithelium, confirming the diagnosis of MRG. Although rare, the possibility of MRG should be considered as a differential diagnosis when encountering an intraocular mass lesion, as it can be misdiagnosed as a malignant tumor.


IDH-wildtype glioblastoma was treated with radiochemotherapy per EORTC 26981/22981  resulting in complete remission on follow-up imaging (A). On admission, repetitive EEG was negative for patterns on the ictal-interictal continuum. Brain MRI revealed faint gyriform contrast-enhancement (arrowheads) and enlarged vessels (arrows) in gadolinium-enhanced T1-weighted imaging, left temporo-occipital edema adjacent to radiation-induced white matter-hyperintensity on T2-weighted imaging with corresponding diffusion restriction, and temporo-occipital elevation of the left cortical blood volume (CBV) of the previously irradiated left temporo-occipital brain region in comparison to the contralateral hemisphere in perfusion MRI sequences . [18F]fluorethyltyrosine ([18F]FET)-PET detected corresponding gyral tracer uptake with moderate signal intensity and increasing time-activity-curves, not typical for tumor recurrence (C) [stroke-like migraine attacks after radiation therapy (SMART) syndrome was given [D). ([18F]FET)-PET 1 year after symptoms showed complete regression of the gyral tracer uptake. SMART syndrome represents a rare, delayed complication of brain-directed radiotherapy involving impaired cerebrovascular autoregulation [18F]FET-PET imaging in a patient with ongoing SMART syndrome, which could potentially improve diagnostic accuracy by exclusion of important differentials such as tumor recurrence.A female 60-year-old long-term survivor of high-grade glioma presented with progressive migraine-like left-sided cephalgia and expressive aphasia for three days. Ten years ago, a left temporo-occipital


Cholangiocarcinoma is a rare type of cancer disorder. The case report is of a 55-years-old male patient who came to the output patient department (OPD) with complaints of abdominal pain and weight loss for 15 days and later was diagnosed with Klatskin tumor after mandatory investigations. After the approval of the tumor board committee, he is under chemotherapy, to which he is responding positively. Klatskin tumor is a type of cholangiocarcinoma occurring at the convergence of the right and left lobes of hepatic bile ducts, forming the common bile duct. The source of cholangiocarcinoma is idiopathic, and most cholangiocarcinoma is treated with the help of either surgical resection or chemotherapy. Surgical resection is performed in initial cases, but most patients present with the advanced stage of Klatskin tumor. CA-19-9 is a tumor marker that indicates the presence of a Klatskin tumor. Klatskin tumor is a cholangiocarcinoma (CCA) that occurs at the intersection of the right and left lobes of hepatic bile ducts forming the common bile duct. The disease is named after Gerald Klatskin, who in 1965 elaborated on 15 cases, and features were found similar to cholangiocarcinoma ,3. CholaThe spread of tumors in bile ducts can be divided into the following types according to the classification of Bismuth-Corlette, which are as follows: Type I: tumors below the convergence of the left and right hepatic ducts; Type II: tumors reaching the junction but not including the left or right hepatic ducts; Type III: tumors obstructing the common hepatic duct and either the right or left hepatic duct; Type IV: multicentric tumors involving the convergence and the right and left hepatic ducts -7. The sA 55-year-old male came to the outdoor patient department (OPD) complaining of jaundice for 15 days, weight loss (approximately 2 kgs) over the past 15 days, and generalized weakness for 15 days. The patient was well oriented with time, place, and person. On general examination of the patient, his respiratory rate was 18 breaths/min, oxygen saturation (SpO2) level was 98%, Blood pressure 110/70 mmHg, Glasgow coma scale (GCS) 15/15, and random blood sugar was 153 mg/dl. The patient gave a history of dark-colored urine. Pallor was present in the patient while he had a negative history of icterus, cyanosis, clubbing, lymphadenopathy, and edema. The patient presented no history of abdominal pain, constipation, loose stools, fever, backache, and cough/breathlessness. The patient is not recognized with chronic disorders like diabetes mellitus, hypertension, tuberculosis, or bronchial asthma. Also, there was no other significant surgical history in the past. Also, the patient is not a known case of Hepatitis B and human immunodeficient virus. On palpation, there was the presence of hepatomegaly.Radiologic investigation resultsMagnetic Resonance Cholangiopancreatography (MRCP)MRCP reveals the biliary hilar butterfly-shaped infiltrating neoplastic mass lesion which causes the gross dilatation of right and left hepatic ducts resulting in dilatation of intra-hepatic biliary radicles which indicates Type IV Bismuth Figure .Ultrasonography (USG) Whole AbdomenUltrasonography (USG) whole abdomen reveals mild hepatomegaly with the possibility of neoplastic lesion involving biliary hilum and congestive heart defect (CHD) causing obstructive dilatation of intrahepatic biliary radicals (IHBR). This finding led to a suspicion of cholangiocarcinoma/Type II lesion as shown in Figure Contrast-Enhanced Computed Tomography (CECT)Grossly dilated IHBR, right and left hepatic ducts with no obvious hepatic or hilar mass lesion periductal infiltration or intraductal cholcarcinoma were observed as shown in Figure Table This case report is not only regarding the rare case of Klatskin tumor but also aims for the medical sciences to publish more articles on this topic. Until now, only a few cases regarding cholangiocarcinoma have been published. Some of the comparable aspects of cholangiocarcinoma reports with published cases are included here. In one of the reported cases, Giron and Alcantar reported that CA-19-9 levels become high in advanced cholangiocarcinoma . Also, tKlatskin tumor is the presentation of a rare disease. Usually, the presentation of this disease is in an advanced stage, but the diagnosis and treatment of these tumors will have better consequences in the early stage of these tumors because surgical removal of the tumor can be performed in the initial cases. Also, a lot of investigation methods such as MRCP, USG, and CT scans can be helpful for the better diagnosis of a patient. The present report is a Klatskin tumor case. The patient in the reported case is undergoing chemotherapy after proper analyses, diagnosis, and approval by the tumor board committee. After starting the therapy, the patient is responding to the treatment. The publication of such cases will be helpful to the medical sciences for early detection and diagnosis of the disease, helping them provide people with better health care. Thus, improving the health ratio of the society. The primary cause of failure in early diagnosis of this disease is because of the presentation of these conditions in advanced stages, where the survival chances of patients are less.


Gastric hepatoid adenocarcinoma and hepatic choriocarcinoma are rare diseases in clinical settings, and the case we report here is a combination of both. A 66-year-old woman presented with a chief complaint of abdominal discomfort. The patient was examined using gastroscopy and computed tomography (CT) scan, and these revealed an irregular surface ulcer on the wall of the gastric antrum. A mass, 2.0 cm in diameter, was found in the liver in April 2020. The endoscopic biopsy findings were consistent with a diagnosis of moderately to poorly differentiated hepatoid adenocarcinoma. She was then referred to our hospital for further treatment. Initially, neoadjuvant therapy was initiated for the patient. The CT scan showed that the liver metastases had progressed; hence, surgery was performed. Postoperative pathology showed that the gastric lesions were mostly hepatoid adenocarcinoma with no choriocarcinoma, while the liver lesions comprised approximately 10% hepatoid adenocarcinoma and 90% choriocarcinoma. One month later, the patient developed tumor recurrence in the liver as observed on CT imaging. Subsequently, a variety of chemotherapy regimens were tried with no obvious results. The patient eventually developed multiple organ metastasis and died in July 2021. The overall survival was 16 months. Based on findings from this case report, it appears that initial neoadjuvant therapy was not effective and radical surgery may be the best treatment for patients with hepatoid adenocarcinoma of the stomach. Hepatoid adenocarcinoma of the stomach (HAS) is a rare type of primary gastric malignant neoplasm that exhibits both adenocarcinomatous and hepatocellular differentiation and mostly produces alpha-fetoprotein (AFP). It accounts for approximately 1% of all gastric cancers. The stomach is the most commonly affected organ, and it often occurs in the antrum accompanied by vascular invasion, lymph node metastasis, and liver metastasis . ChoriocThis was a case of a 66-year-old female patient with a complaint of abdominal discomfort for a month with no other associated symptoms. Physical examination revealed no pathological findings. Gastroscopy and computed tomography (CT) examinations revealed an irregular surface ulcer on the wall of the gastric antrum  and a maLaboratory tests showed that the blood cell and biochemical values were almost within the normal range. However, serum AFP was dramatically elevated . Further examination revealed the remaining tumor markers, including the carbohydrate antigen 199 (CA199) >1200 U/ml, carcinoembryonic antigen 38.17 ng/ml, and hCG 795.14 mIU/ml.Based on the guidelines of the Chinese Society of Clinical Oncology (CSCO), the disease was classified as advanced gastric cancer with liver metastasis, and the patient underwent SOX chemotherapy regimen, which is the first-line treatment recommendation, consisting of oxaliplatin, gimeracil, and oteracil potassium capsules.After three cycles of chemotherapy, CT revealed progression of liver metastasis . The patOne month later, CT imaging revealed liver metastasis and recurrence . ConsideAfter two cycles of the chemotherapy regimen, on September 14, 2020, CT reexamination showed that liver and lung metastases occurred . We chanTwo months later, CT examination showed that the liver and lung metastases were more and larger than before . We chosOn March 18, 2021, the magnetic resonance (MR) scan showed that the patient had developed brain metastases . Then, sOverall, a variety of chemotherapy regimens were tried, and the patient developed systemic multiple organ metastasis. During the whole chemotherapy period, the indexes of tumor markers remained at high levels, including AFP, CA199, and hCG.Finally, the patient suffered from repeated low fever, trilineage cytopenia, and her physical condition gradually worsened. She eventually rejected treatment and died in July 2021.With an increasing number of articles reporting cases of HAS, the diagnosis of hepatoid adenocarcinoma is no longer a problem through laboratory examination, gastroscopy, and pathological biopsy. HAS is a rare type of primary gastric malignant neoplasm and it is accompanied by vascular invasion, lymph node metastasis, and liver metastasis. Extragenital choriocarcinomas, on the other hand, are less common, often exist with other carcinomas, and tend to occur in midline organs . FernándThe patient's condition was diagnosed as HAS with liver metastasis; hence neoadjuvant therapy was initiated first. To date, there is still no clear criterion for the treatment of HAS. Some studies have reported radical surgery as the main treatment option for patients with HAS , 12. HowThere is no standard treatment for mHAS at present. This case report discusses its clinical treatment and prognosis and helps get further knowledge and understanding of mHAS and the treatment of this rare aggressive tumor. However, a limitation of this case report may be that molecular studies were not performed; thus, HER2 gene amplification and overexpression and EGFR, KRAS, and BRAF mutation-associated tumorigenesis and gastric carcinomas that may respond to specific treatments were not able to be explored in this case report.In summary, HAS and hepatic choriocarcinoma are rare and aggressive diseases; the combination of the two is even rarer, and the diagnosis and treatment are full of challenges. Although radical surgery may be the best treatment for HAS patients, the specific systemic chemotherapy principles for patients with advanced metastasis resulting from HAS are still flawed. There is an urgent need for a large number of clinical reports to improve the understanding of HAS and hepatic choriocarcinoma.


Ultrasound technology with or without color Doppler allows a real-time evaluation of the entire female pelvis including gynecologic and non-gynecological organs, as well as their pathology. As ultrasound is an accurate tool for gynecological diagnosis and is less invasive and less expensive than other techniques, it should be the first imaging modality used in the evaluation of the female pelvis. We present a miscellany of non-gynecological pelvic images observed during the realization of gynecological ultrasound. Transvaginal and transabdominal ultrasound is the first choice among diagnostic techniques for the study of the female pelvis, providing information about gynecological and extra-gynecological organs, allowing for an orientation toward the pathology of a specific organ or system as well as for additional tests to be performed that are necessary for definitive diagnosis. Ultrasound is a less invasive and less expensive diagnostic imaging technique than other diagnostic imaging modalities. Ultrasound is the imaging diagnostic technique of choice in the diagnosis of the female pelvis . The AmeThe evaluation of the female pelvis includes the study of the uterus and both ovaries but also the evaluation of the bladder, rectum, and the vascular structures and ligaments of this area. Evaluation of the uterus, the central organ of the pelvis, should comprise the assessment of the uterine size and position, including the uterine body with the endometrium, the isthmus, and the cervix. The study of ovaries should include the visualization of both ovaries, generally in the ovarian fossa of what is related anteriorly by the medial umbilical ligament, the ureter and internal iliac posteriorly, and the external iliac vein superiorly. Both the uterus and the ovaries vary in size and characteristics throughout the menstrual cycle and according to menopausal status .(1)Imaging of the digestive system;(2)Imaging of the uro-renal system;(3)Vascular imaging;(4)Lymphatic imaging;(5)Neurological imaging;(6)Cutaneous images;(7)Others.There are some papers that evaluate the use of ultrasound in the study of the female pelvis, with the majority related to gynecological diseases. In this paper, we present the value of pelvic ultrasound for diagnosing non-gynecological pathology, classifying these features in:Evaluation of the most caudal segment of the digestive tract should be included in the study of the female pelvis because of its close relationship with the uterus, cervix, and vagina. In addition, during a pelvic ultrasound, it would be possible to demonstrate digestive diseases such as appendicitis, diverticulitis, mucocele, appendicular plastron, GIST, and colon cancer that should be known. In some cases, it could be difficult to make a differential diagnosis between some of these pathologies and endometriosis, which is a benign gynecological condition that can affect some pelvic organs such as the intestine, in addition to the genital system.Appendicitis is inflammation of the vermiform appendix, which can progress to an abscess, ileus, peritonitis, or death in case of the absence of treatment . PatientThe presence of a non-compressible concentrically layered, blind-ending tubular structure in the right adnexal region with thickened and smooth appendiceal walls, marked hyperemia, and no sign of cog wheel or incomplete septum is consistent with acute appendicitis. Using these indicators, transvaginal ultrasound is useful in detecting an inflamed appendix and in distinguishing acute appendicitis from pelvic inflammatory disease  10]. Ul. Ul10]. A plastron is a progressive form of acute appendicitis, with a low frequency (2–6%). A pelvic ultrasound allows the diagnosis by the presence of a mass in the right iliac fossa surrounding the small loops with the inflammatory signs. The evolution could be toward an abscess in cases of no treatment or ineffective treatment  11]..11].Appendiceal mucocele is the accumulation of mucoid material in the lumen of the appendix. Although there are no differences between benign and malignant cases, it is crucial recognizing this entity in order to prevent the spillage of the mucus during surgery for avoiding grave complications such as pseudomyxoma peritonei .The appendiceal mucocele shows at ultrasound a well-defined, thin-walled cystic mass with an ovoid, oblong, or pear-shaped morphology. The echogenicity of a mucocele depends on the composition of the mucus, ranging from an anechoic or hypoechoic cyst with low-level internal echoes and posterior acoustic enhancement to a heterogeneous avascular mass without posterior acoustic enhancement. Mucocele often shows a pattern of concentric echogenic layers within a cystic mass called the “onion skin” pattern, and it is fairly specific for appendiceal mucocele. Calcifications may be present in the wall  13]..13].Transvaginal and transabdominal ultrasound may be useful for the evaluation of diverticulitis, most cases of which occur in the sigmoid colon, which is in the pelvis.In normal conditions, colonic diverticula are not evident at ultrasonography because of the colon’s thin wall. However, in cases of an inflamed diverticulum, it has a hyperechoic shadowing center surrounded by a thick hypoechoic edge, which represents the thickened wall. The wall is surrounded by inflamed hyperechoic paracolic fat. The characteristic hypertrophy of the circular muscle layer of the muscularis propria in cases of colonic diverticulosis is evident on ultrasound as circumferential thickening of the outer hypoechoic layer of the colon wall  14]..14].Tumors that affect the small intestine, cecum, sigmoid colon, and rectum may be seen on transvaginal sonography. Colorectal cancer is the third most common cancer in the Western Hemisphere, and the incidence increases with increasing age. Screening has been shown to reduce colorectal cancer incidence and mortality, but organized screening programs are still to be implemented in most countries . In thisThe ultrasonographic image varies according to the type of tumor: carcinomas and lymphomas generally appear as a focal mural thickening, whereas mesenchymal tumors and metastases appear as intra- or extraluminal localized round solid masses that are hypoechoic or heterogeneous .Recognizing these characteristics, it is necessary to make a differential diagnosis with benign gynecologic diseases such as deep endometriosis affecting the recto-sigmoid bowel.Gastrointestinal stromal tumors (GISTs) are rare tumors that account for a small percentage of gastrointestinal neoplasms. Gastrointestinal stromal tumor is the most common gastrointestinal mesenchymal tumor. Some GISTs develop outside the gastrointestinal tract, such as in the omentum, mesentery, and retroperitoneum, and this type of tumor is called an extra-gastrointestinal stromal tumor (eGIST). GISTs developing outside the stomach are associated with a higher malignancy potential. Generally, GISTs are an incidental, asymptomatic finding, but if GISTs present symptomatically, they can produce nausea, vomiting, abdominal distension, abdominal pain, or peritonitis. Ultrasound manifests as solid, non-uniform, pelvic, or abdominal tumors of mixed echogenicity with or without cystic areas, with abundant vascularization, and without acoustic shadowing. The presence of a tumor with these characteristics without connection to the intestinal wall and that does not originate in the uterus or adnexa is highly suspicious of being an eGIST  16,17].,17.16,17The evaluation of the kidneys, the bladder, and the ureters are mandatory in benign gynecologic diseases such as endometriosis affecting the anterior and posterior compartments, especially the uterosacral ligaments. In these cases, it is possible to diagnose pyelocaliceal dilation for ureteral obstruction.In other cases, the incidental detection of urological findings such as megaureter, benign and malignant bladder pathology, pelvic kidney, and ureterocele may occur.The megaureter could be congenital or acquired. A diameter of a ureter more than 7–10 mm should be considered a megaureter  18]..18].Ureterocele represents cystic dilatation of the intravesical segment of the ureter, it may be associated with either a single or double ureter. The congenital defect is the obstruction of the meatus, and the ureterocele is a hyperplasic response to this obstruction. Ureteral duplication is present in about 75% of patients with ureterocele .The ultrasonographic image of the ureterocele is an anechoic cyst within the posterior aspect of the urinary bladder . During The differential diagnosis should be performed with tubal pathology as hydrosalpinx or pyosalpinx, which show septa or thickened mucosal folds, whereas ureterocele may demonstrate peristalsis .There is a wide range of benign  and malignant lesions , which can develop in the bladder.Adenocarcinoma of the bladder is an uncommon tumor, the diagnosis of which is important in order to rule out the possibility of secondary involvement of the bladder by an adenocarcinoma from a different site .Ultrasound shows whit the filled urinary bladder in cases of carcinoma an irregular solid, usually polypoid intravesical lesion, which presents highly vascularized  22]..22].The pelvic kidney occurs when the kidney does not ascend normally to reach the renal fossa. Most are asymptomatic. The most frequent accompanying anomaly is reflux vesicoureteral. In the absence of other abnormalities, the prognosis for patients with renal ectopy is good. Their incidence range between 1:12,000 and 1:900 cases .In most cases, an ectopic kidney appears in the pelvis as a solid mass, and it could be confused with a tumor of gynecological origin, so it is extremely important to know its presence to make a differential diagnosis .The knowledge of vascular anatomy structures is fundamental to understanding some imaging, especially the color Doppler study of the pelvis.The abdominal aorta is divided into two common iliac arteries at the level of the fourth–fifth lumbar vertebra. These arteries are divided into external and internal iliac arteries at the level side of the sacroiliac joint. The external iliac artery supplies the lower limb, and the internal iliac artery mainly supplies the pelvis. The internal iliac artery passes medially over the pelvic brim and descends into the pelvic cavity. At the upper margin of the greater sciatic foramen, it divides anteriorly and posteriorly. The ureter is located on the medial aspect of the internal iliac artery, and the pararectal space is seen between the ureter and the internal iliac artery. It is the main blood supply to the pelvic organs, the gluteal muscles, and the perineum, with the anterior and posterior trunks .The uterine artery and vein are branches of the internal iliac artery and are located parallel to the uterus, and at the level of the isthmus, the uterine artery enters the uterus, forming the arcuate and radial branches. These uterine vessels anastomose with the ovarian vasculature in the pampiniform plexus, a network of arterial and venous flow suspended between the fallopian tube, ovary, and uterus .Pelvic congestion is a cause of chronic pelvic pain, but it has also been reported in imaging studies of asymptomatic women. It is usually associated with intra-pelvic varicose veins in women with unexplained pain in the hypogastrium or pelvis that last’s more than 6 months. The nature of varicose pelvic veins is unknown, most certainly multifactorial, and due to mechanical and hormonal issues. Doppler ultrasound is widely used with good results. Diagnostic criteria include ovarian vein diameter larger than 4 cm, dilated and tortuous arcuate uterine vessels communicating with varicose pelvic veins, slow venous flow, and retrograde venous reflux  25]. Du. Du25]. A thrombotic lesion may occur if an injury to the vessel wall or endothelial dysfunction, a decrease in blood flow, and thrombophilia of the blood (Virchow’s triad) are present. Systemic alterations in the hemostatic mechanism typically produce local thrombotic lesions in discrete segments of the vascular tree. Areas of decreased flow, stagnant zones, turbulent flow, and cell damage, including hemolysis, can lead to platelet adhesion and aggregation, as well as fibrin formation  26]..26].Thrombosis of the ovarian vein is a rare occurrence. Ovarian vein thrombosis is most frequently observed in the puerperium state when Virchow’s triad is present. It can be associated with other conditions such as post-abortion infection, pelvic inflammatory disease, recent pelvic surgery, and gynecological cancer. Moreover, there are other risk factors such as alterations in various coagulation factors related to this entity. The color Doppler ultrasonography allows physicians to reach a diagnosis by demonstrating an anechoic or hypoechoic mass without flow on Doppler examination . ComputeIsolated iliac aneurysms are rare, with a prevalence of around 2% of patients with aortoiliac aneurysms. Is less frequent in females than in males, with a ratio of 1:6, and more frequent in young women who have undergone pregnancy and delivery.Around 25% of all patients present with a rupture of an isolated iliac aneurysm, resulting in a contained pelvic hematoma, which may result in compressive symptoms or intraperitoneal rupture. Ruptures into adjacent pelvic viscera including rectum and bladder and perianal ecchymosis have been reported because of dissection through the retroperitoneal tissues. Bleeding may be catastrophic, and the septic complications of surgery and subsequent mortality are likely high. Although the exact incidence remains unclear, it seems likely that a significant proportion of patients with an isolated iliac aneurysm are asymptomatic and have their aneurysm discovered on routine clinical examination or imaging  28]..28].Transvaginal and transabdominal ultrasound may show a range of lymphatic pathology, in cases of gynecological or extra-gynecological diseases.Pathologic lymph nodes generally appear as solid lesions related to the iliac vessels . In someLymphocele is a collection of lymphatic liquid inside a thick, fibrous, non-epithelial wall and with no vascularization, arising from the retroperitoneum to the pelvic or abdominal cavity. Ultrasound shows lymphocele as an oval, round, or hourglass-shaped, and uni- or multilocular tumor with a thick wall. The contained fluid may be anechoic, low-level, ground-glass, hemorrhagic, or mixed echogenicity. It may present with intraluminal septations or debris  29]..29].Cystic lymphangioma is a benign disease due to an incorrect embryological connection of the lymphatics in case of primary lymphatic cysts fail to converge with the main lymphatic system. It may develop in a wide range of anatomic lesions, with less frequency in the abdominal location. Differential diagnoses from a pancreatic pseudocyst, ovarian cyst, renal cyst, or other diseases should be carried out.Ultrasound shows an abdominal unilocular or multilocular cyst with thin echogenic walls and hypoechoic or echogenic content. A hemorrhagic pattern is demonstrated in cases of internal bleeding  30]..30].Ultrasound provides images of neurologic structures, in some cases, as perineural cysts and neurogenic tumors.The perineural cysts or Tarlov cysts appear on dorsal nerve roots, commonly in the sacral spine. Most are benign and asymptomatic, but occasionally, they can be symptomatic, producing compression. Tarlov cysts are incidental findings on MRI, which is considered the gold standard imaging technique .In ultrasonography, Tarlov cysts are characterized by the presence of cystic lesions in one of both adnexal regions usually well-defined and sometimes completely anechoic or with the presence of some echoes or a network of very fine walls inside. It can be difficult to differentiate from other adnexal imaging such as hydrosalpinx, ureteral pathology, or pseudoperitoneal cysts .Schwannomas are rare tumors that arise from the Schwan cells of the peripheral nerve sheath. Most cases are sporadic, but familial clustering may be seen in association with von Recklinghausen’s disease. Clinical features are non-specific, depending on the location and size of the lesion, the most common abnormalities of which are abdominal pain and neurological deficit. Radiological studies are fundamental for diagnosing Schwannomas .Neurofibroma is another benign tumor composed of neoplastic Schwann cells, but unlike schwannoma, it also contains additional non-neoplastic components, including fibroblasts, mast cells, and perineurial-like cells, as well as residual axons. Sporadic cutaneous neurofibroma is the most common type, in contrast to neurofibromatosis type 1, which is characterized by the presence of multiple neurofibromas, in which there may be involvement of multiple cutaneous sites, peripheral nerves, and spinal roots  33]..33].Although the MRI is the gold standard for diagnosing these diseases, the lesions caused by these tumors could be observed as lesions in routine pelvic scans.The pilonidal sinus is an acquired or congenital cutaneous disease that typically occurs in the intergluteal region and is mainly observed in young adults. Some authors demonstrated that ultrasound is useful for evaluating the margins, extensions, sinus tract, branches, and openings of the pilonidal sinus .Transvaginal ultrasound demonstrates the typical characteristics of hair content in the cyst, showing mixed echogenicity and hyperechoic areas with acoustic shadows .There is a miscellaneous group of images that can be viewed in the pelvis. Within this group, it is important to recognize the presence of forgotten foreign bodies due to the legal consequences of their findings. Gossypiboma is the term used to describe the forgotten cotton/gauze piece in the body after surgical procedures. These foreign bodies, which are forgotten in the abdomen, produce ileus, intra-abdominal masse effect, postoperative abdominal pain, nausea, and vomiting. It should be differentiated from malignancies with mass-like images .Ultrasound may show a well-delineated hypoechoic mass containing an echogenic structure with pronounced posterior acoustic shadows  14]..14].The female pelvis is a complex anatomical region, in which a multitude of both gynecological and extra-gynecological images can be diagnosed.Transvaginal ultrasound, complemented by transabdominal ultrasound, is the first choice among diagnostic techniques for the study of the female pelvis, providing information on the gynecological organs as well as the extra-gynecological organs.This allows for an orientation toward the pathology of a specific organ or system as well as for additional tests to be performed that are necessary for a definitive diagnosis.


Clitoral epidermal cysts are benign lesions that can be excised surgically and carry good prognosis after treatment. They are usually slowly growing tumors that arise due to invagination of epidermis into dermis either spontaneously or following trauma. The differential diagnosis of clitoral cysts depends on the age of presentation. When these cysts present in children, they mimic clitoromegaly and can be confused with virilization due to hyperandrogenic states. Non-hormonal differential diagnosis includes neurofibromatosis (NF) and nevus lipomatous cutaneous superficialis.We present images of a female who developed this cyst post-partum.A 31-year-old woman presented to our team 18 months post-cesarean section after her first child, with a slowly but progressively enlarging clitoral lump first noticed about a month postpartum. The cesarean was uneventful and not associated with any trauma. She had not undergone any form of trauma to the clitoral area such as female genital mutilation (FGM) previously.Perineal examination was normal except for an 8 cm, soft and fluctuant, mildly tender clitoral swelling with no evidence of involvement or obstruction to the urethral and vaginal openings. Magnetic resonance imaging (MRI) pelvis Figs.  and 2 coHistology showed a thin-walled, lobulated tense cyst containing beige creamy material, measuring 65 × 28 × 32 mm, confirmed to be epidermal cyst (Fig. Clitoral epidermal cysts are very rare with only a few cases reported in literature , 2 inclu


Leiomyomas are benign mesenchymal tumours that rarely arise in the bladder. We present a case of a 53-year-old female who was incidentally diagnosed with a bladder leiomyoma identified on CT imaging performed for investigation of a urachal remnant. We discuss the investigation and management of this lesion in the context of modern urology practice. An awareness of this unusual tumour is important for urologists, who may encounter similar cases in their general urology practice. Bladder leiomyomas represent less than 0.5% of all bladder tumours . These aA 53-year-old female was referred for outpatient urological assessment because of persistent microscopic haematuria, urinary frequency and dysuria. Past-medical history included hypercholesterolemia, gastro-oesophageal reflux disease and haemorrhoidectomy. She was an ex-smoker. There was no relevant urological family history. She had been investigated for storage lower urinary tract symptoms 20 years ago and had had normal flexible cystoscopy and ultrasound.2, Creatinine 64 umol/L and urea 4.5 mmol/L. Urine cultures were negative for infection. Ultrasound revealed a normal-appearing urinary tract, with both kidneys normal in size, shape and echopattern. Flexible cystoscopy revealed only a cystic lesion near the bladder dome which instigated further investigation; subsequent contrast-enhanced Computerized Tomography (CT) abdomen-pelvis scan showed a potential urachal remnant consistent with the flexible cystoscopy finding. In addition, a 1.5-cm-soft tissue structure was identified near the bladder neck which was not clearly seen initially at cystoscopy  but also may be intramural (7%) or extravesical (30%) . Intrave3% but alet al. [The underlying cause of bladder leiomyoma remains uncertain. However, numerous theories of their pathophysiology have been proposed, summarized by Khater et al. .(i) Development is initiated by hormonal influences.(ii) Dysontogenesis.(iii) Perivascular inflammation results in metaplastic transformation of bladder vasculature.(iv) Infection of bladder results in inflammation and tumorigenesis.T1-weighted images and an intermediate to low signal intensity on T2-weighted images. After contrast administration, the tumours will show a variable pattern of enhancement, with some enhancing homogeneously and others showing little enhancement [The sonographic appearances of leiomyomas consist of a smooth, homogeneous, solid mass, although partially cystic-appearing leiomyomas have been reported . Computeancement .When leiomyomas grow intravesically, cystoscopy (either flexible or rigid) may reveal the presence of a sessile tumour protruding into the bladder lumen. Histopathology from transurethral resection and biopsy is definitive and will exclude malignant tumours .It is worth highlighting that the overlying bladder mucosa often appears normal, and therefore, there may be difficulty in diagnosing the abnormality on routine flexible cystoscopy. In this case, the bladder leiomyoma was identified as a result of further investigation of a suspected urachal lesion. We note that this patient had a previous normal flexible cystoscopy some years prior to her presentation.en bloc. Asymptomatic patients can be followed up without invasive treatment as to date there are no reported cases of malignant transformation of bladder leiomyomas.Bladder leiomyomas can be managed conservatively after diagnosis with transurethral resection and biopsy or can be removed surgically en bloc surgical removal of bladder leiomyomas may be performed in patients who are symptomatic. The tumour size, extent and location determine the preferred surgical route. The transurethral route is preferred in small intravesical tumours, while a partial cystectomy performed open, laparoscopically or robotic-assisted is indicated for larger intravesical, intramural or extravesical tumours [Transurethral resection or  tumours , 10.The prognosis after surgical treatment is favourable and no malignant transformation has been reported to date.In our case, due to its favourable position and the absence of significant symptoms, transurethral resection was sufficient for diagnosis and the patient is due to be followed up with an MRI scan in 6 months.None declared.None.


Jejunostomy is often indicated for patients with oral intake difficulties and unresectable gastric cancer, patients at risk of postoperative complications, and patients who require nutritional management after gastrectomy. In this report, we discuss the cases with laparoscopic jejunostomy in our department.Case 1: An upper gastrointestinal endoscopy performed for close examination in a 60-year-old male revealed upper gastric cancer with extensive invasion and lower esophageal stenosis. He had difficulty with esophageal transit and, consequently, underwent a laparoscopic jejunostomy and staging laparoscopy.Case 2: Upper gastrointestinal endoscopy in a 62-year-old male revealed type 3 tumor in the gastric antrum. He had a history of chronic obstructive pulmonary disease requiring home oxygen therapy, pulmonary hypertension, and heart failure, and was at a high perioperative risk. Consequently, both laparoscopic distal gastrectomy and laparoscopic jejunostomy were performed.Enteral nutrition has many advantages over venous nutrition, including maintenance of immunity and intestinal mucosa, avoidance of bacterial translocation, and decreased risk of catheter infection. Although there are a few reports of cases with laparoscopic jejunostomy, it is expected that the technique will become more widespread and safe in the future.Laparoscopic jejunostomy is considered a useful, minimally invasive, and safe technique. •We report two cases wherein laparoscopic jejunostomy was useful in gastric cancer.•Laparoscopic jejunostomy is useful, minimally invasive, and safe.•This technique may become more widespread and safer in the future. Jejunostomy is performed to manage enteral nutrition in patients who have oral intake difficulty due to upper gastrointestinal tract obstruction or who are at increased risk due to surgical, therapeutical, or iatrogenic complications. Noting the rarity of reported cases, we describe two cases in which laparoscopic jejunostomy was useful in gastric cancer patients. This work has been reported in line with the SCARE criteria 22.1Chief complaint: lightheadedness.Current medical history: The patient was referred to our department with a diagnosis of advanced gastric cancer with extensive esophageal invasion.Upper gastrointestinal endoscopic findings: A type 4 tumor with circumferential stenosis in the gastric cardia was observed, which was barely passable through a narrow scope A, B. BioContrast-enhanced computed tomography (CT) scan: There was no obvious evidence of distant metastasis.Blood tests: albumin concentration: 3.0 g/dl, hemoglobin (Hb) level: 9.2 g/dl, and ChE: 134 U/l.Tumor markers: CEA: 227.7 ng/ml and CA: 19–9 3.8 U/ml.Clinical diagnosis: Gastric cancer, UME, Circ, type 4, por, cT4aN0M0, and cStage IIB . A staging laparoscopy was scheduled to evaluate local invasion and peritoneal dissemination. If radical resection was difficult, we planned a simultaneous laparoscopic jejunostomy to avoid malnutrition caused by transit disturbance.Surgical findings: A 12-mm camera port was placed in the umbilicus, a 5-mm port (surgeon's left hand) and 12-mm port (surgeon's right hand) were placed at the right side of the abdomen, and a 5-mm port (assistant) was placed at the left side of the abdomen A. Intra-Postoperative course: Enteral nutrition using a jejunostomy was started the day after surgery. The patient was discharged on the 10th postoperative day without complications, along with instructions on how to manage the jejunostomy at home, and was promptly transferred to chemotherapy as an outpatient. Palliative chemotherapy was continued; however, the patient died 9 months after surgery. Jejunostomy was used, without complications until the end of the patient's life.2.2Chief complaint: lightheadedness.Current medical history: The patient had chronic obstructive pulmonary disease (COPD), pulmonary hypertension, and heart failure, and was receiving nasal 3 l/min home oxygen therapy while visiting the Department of Cardiology. A blood test was performed after he felt lightheaded, which revealed prominent anemia (Hb level: 6.4 g/dl). An upper gastrointestinal endoscopy was performed for close examination, which revealed a type 3 tumor on the anterior wall of the gastric antrum . He was History: COPD (on home oxygen therapy), pulmonary hypertension, heart failure, and deep vein thrombosis .Upper gastrointestinal endoscopy revealed a type 3 tumor 40 mm in size on the anterior wall of the gastric antrum. Biopsy results showed a moderately-differentiated adenocarcinoma.Contrast-enhanced CT scan: There was wall thickening with contrast effect in the lesser curvature of the gastric horn, but no obvious lymph node metastasis or distant metastasis was observed.Tumor markers: CEA: 1.6 ng/ml and CA: 19–9 8.3 U/ml.Preoperative diagnosis: Gastric cancer, M, Ant, type 3, tub2, cT2N0M0, and cStage I . The patient was considered to be at a high risk for perioperative complications due to respiratory and cardiovascular comorbidities; thus, we decided to perform a simultaneous jejunostomy for postoperative nutritional management.Surgical findings: A 12-mm camera port was placed in the umbilicus, 12-mm ports were placed at the right and left sides of the abdomen, and 5-mm ports were placed at the right and left sacral ribs B, as in Postoperative course: Enteral nutrition using jejunostomy was started on the second postoperative day. The patient was discharged home on the 15th postoperative day after instruction on jejunostomy catheter management. Four weeks after surgery and as soon as oral intake stabilized, the enterocutaneous fistula was removed on an outpatient basis. The patient has been free of jejunostomy-related complications for 12 months.3Enteral nutrition reportedly has many advantages over intravenous nutrition, including immune and intestinal mucosa support, avoidance of bacterial translocation, and decreased risk of venous catheter infection In the primary endpoint of overall survival, the randomized, controlled, phase III REGATTA trial (JCOG 0705/KGCA1) of in situ resection before chemotherapy in patients with unresectable advanced gastric cancer did not demonstrate superiority over the standard of care  Since laparoscopic Witzel suture is rather complicated, we guided the small intestine out of the body cavity through the umbilical port, inserting a jejunostomy catheter under direct vision, and we performed a Witzel to ensure fixation. These procedures can be performed with only a slight lengthening of the umbilical opening and are considered to be useful. We have not had any cases of postoperative intestinal obstruction to date.The number of laparoscopic procedures for various diseases and organs has been increasing in Japan in recent years 4Laparoscopic jejunostomy is considered a useful technique that is minimally invasive and safe.Written informed consent was obtained from the patients for publication of this report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The authors declare that they have no competing interests.


With the development of 3D printing and surgical techniques, various defect reconstruction methods after tumor resection have been applied not only in humans but also in veterinary medicine. This report describes a case of reconstruction after hemipelvectomy for an osteoma in a cat using a 3D-printed pelvic endoprosthesis and micro total hip replacement (mTHR). A 5-year-old spayed female Turkish Angora cat was referred for a 1-month history of constipation and intermittent weight-bearing lameness in the left hindlimb. An osteoma in the pelvis measuring 4.5 × 3 × 5.4 cm was identified based on diagnostic examinations. A left mid-to-caudal partial and right caudal partial hemipelvectomy, and a left femoral head and neck osteotomy, were planned to remove the mass. Reconstruction of the bone defect using 3D-printed metal endoprosthesis and mTHR in the left hindlimb was intended. During right caudal partial hemipelvectomy, right femoral head and neck osteotomy was performed because there was infiltration in the medial wall of the acetabulum. Histopathological examination confirmed the diagnosis of an osteoma. Two weeks post-surgery, surgical debridement and femoral stem removal were performed because of delayed wound healing and sciatic neurapraxia, leading to femoral stem dislocation from the cup. The delayed wound healing and sciatic neurapraxia were appropriately addressed. The cat regained normal weight and defecation 4 weeks post-operatively. Two years post-surgery, the patient recovered with an almost normal gait. Hemipelvectomy with 3D-printed endoprosthesis provides a safe surgical option with favorable outcomes for neoplasms in the pelvis of cats. Primary bone tumors, including osteoma, osteosarcoma, chondrosarcoma, multiple myeloma, and fibrosarcoma, are less commonly reported in cats ,2. OsteoAlthough it is reported that post-operative complications after hemipelvectomy in dogs and cats were uncommon and usually minor, hemipelvectomy is still a difficult and extensive procedure. Amputation of the ipsilateral hindlimb for complete resection of the pelvic tumor requires consideration of the regional anatomic circumstance of the patient with regard to the orthopedic, neurologic, and oncologic aspects ,10,11,12With the advancements in surgical techniques and various reconstruction methods for defects after bone removal, the feasible application of an endoprosthetic reconstruction in humans has been recently reported with favorable outcomes in terms of stable fixation, early mobilization, and osteointegration ,15. AddiThis report describes a 3D-printed resection guide and pelvic endoprosthesis for hemipelvectomy as a viable surgical method in an osteoma of a cat, with a good long-term outcome.A 5-year-old spayed female Turkish Angora cat weighing 3.4 kg was referred with a 1-month history of constipation and intermittent weight-bearing lameness in the left hindlimb. Upon physical examination, a mass was palpated in the pelvic cavity through rectal palpation. Abdominal radiographs revealed a spiculated periosteal reaction around the left acetabulum and expansion of the colon. In addition, the rectum was laterally oppressed and displaced by the mass in the pelvic cavity . ThoraciA patient-specific surgical resection guide and an endoprosthesis were designed. CT  images were obtained with a slice thickness of 1 mm and operating parameters of 120 kV and 12 mA, and were processed using the digital imaging and communication in medicine (DICOM) file format. Segmentation and 3D model reconstruction in the design of the prosthesis were processed using a computer-aided design software program .The region to be resected to achieve an incomplete surgical margin (<2 cm) was identified using the computer-aided design software  6]. Lef. Lef6]. The pelvic endoprosthesis has two extension arms attached with a screw to the contralateral ischium and the ipsilateral ilium . It has A bone model for rehearsal surgery and endoprosthesis was produced. For accurate surgical planning, rehearsal surgery was performed using a 3D-printed bone model . The bonThe operation sequence was hemipelvectomy, pelvis reconstruction with metal 3D-printed prosthesis, and mTHR. General anesthesia was induced prior to surgery. The patient was stabilized with fluid therapy and was premedicated with 0.1 mg/kg IV hydromorphone  and 0.2 mg/kg IV midazolam . General anesthesia was induced with 4 mg/kg IV propofol  and maintained with 2% isoflurane  in 100% oxygen. For prophylaxis, 22 mg/kg IV cefazolin  was administered at 90 min intervals throughout the surgery. The surgical technique used in this case was based on a previous study [The skin incision extended from the iliac crest and ended just caudally and distally to the greater trochanter. Soft tissue attachments, such as origin and ligament insertion, were removed from the pelvis to acquire a sufficient window for bone resection. Left mid-to-caudal and right caudal partial hemipelvectomy and resection of the pelvic tumor were performed using the resection guide. During right caudal partial hemipelvectomy, right FHNO was performed because of the infiltration of the osteoma in the medial wall of the acetabulum, unlike the pre-operative plan in the 3D program. The bony defect after tumor resection was reconstructed using the pelvic endoprosthesis. In addition, a titanium mesh  was fixed between the metal implants and the bone for further fixation with the fascia of the surrounding muscle, due to the large defect after bone tumor excision. mTHR in the acetabulum cup (12 mm), and femoral stem (#3 with a 3.6-mm diameter tip and 46-mm length) insertion with polymethylmethacrylate (PMMA) cement  were performed. The ligaments and surrounding muscles were sutured with polydioxanone  to a similar site. The resected tumor was commissioned for histopathological examination and bacterial culture. After the surgery, the cat was hospitalized in the intensive care unit. Fluid therapy, antibiotic treatment, analgesia, and additional treatment were provided as indicated.The patient had delayed wound healing due to serosanguinous discharge after surgery. There was no infection, as confirmed by the bacterial culture of the exudate. Moreover, proprioceptive deficits and knuckling of the left hindlimb were consistent with sciatic neurapraxia, leading to femoral stem dislocation from the cup. Surgical debridement and femoral stem removal were performed 2 weeks after surgery. The delayed wound healing was successfully treated, and the sciatic neurapraxia gradually improved. The cat regained normal weight and defecation function 4 weeks post-operatively. The final histologic diagnosis was similar to that of the pre-operative interpretation . Local tTo the best of our knowledge, this is the first report to describe the total resection of an infiltrative osteoma in the pelvis of a cat, with the preservation of both hindlimbs, using a 3D resection guide and endoprosthesis. The patient had good long-term clinical outcomes. Although mTHR failed with neurapraxia, the patient showed normal gait through reconstruction using a 3D endoprosthesis; thus, its applicability in cats was confirmed.The most-reported tumors in the pelvises of cats are osteosarcoma and chondrosarcoma, which are fast-growing and have a survival rate of less than 2000 days ,9,20. HoHemipelvectomy is the conventional treatment for patients with problems in the pelvic and proximal femur ,18. The An accurate resection of the hemipelvis through pre-operative assessment and planning is important for good outcomes, including sufficient surgical margins and survival times. Pre-operative examination involving CT, biopsy, and tumor staging to predict the duration of post-operative recovery and the degree of post-operative mobility is important for planning the surgery ,11,22. HThe most commonly reported post-operative complication after reconstruction with an endoprosthesis is infection . Due to The limitations of our technique include the prolonged preparation and surgical time. In this case, it took a month to diagnose and operate. These surgical methods need to be avoided if a malignant tumor requires immediate surgery due to severe clinical symptoms. Therefore, it is necessary to examine the prognosis and complications of such surgeries for malignant tumors.The surgical excision of osteoma is simple and could be curative without recurrence. Early treatment could be recommended for cats with osteoma, but aggressive surgical excision can result in an unacceptable quality of life. The use of 3D-printed pelvic prostheses for reconstructing bony defects after resection is safe and does not cause additional complications. Although there were complications, such as neuropraxia and dislocation of the stem of THR associated with THR, and minor complications such as delayed wound healing with serosanguinous discharge, they all healed well. Therefore, these techniques can provide satisfactory results for both patients and cats in terms of the endoprosthesis and the limb’s function. Although this treatment concept has already been applied in dogs, it is worth reporting in cats.