A common surgical condition caused by inadequate closure of the embryonic umbilical defect is an umbilical hernia. The paraumbilical hernia sac usually contains the omentum and bowel loop, although the caecum is infrequently present. The rare incidence of the caecum being present in the paraumbilical hernial sac is described in a few case reports in the literature. In this article, we'd like to discuss a case of a 71-year-old woman who presented with a paraumbilical hernia with strangulated caecum, appendix, and terminal ileum. Right hemicolectomy, end ileostomy, and transverse colon mucus fistula have been performed with uneventful recovery achieved. A congenital or acquired condition called paraumbilical hernia is brought on by an inadequate closure of the embryonic umbilical defect. Paraumbilical hernia represents 10% of abdominal wall hernias; the occurrence being 90% in Africans and 10% in Caucasians. Although strangulation is not common, the majority of paraumbilical hernias are reducible and manifest as a lump . The sacA 71-year-old female presented to Accident and Emergency feeling increasingly unwell for a week with vomiting, abdominal pain, and anuria for the past four days. She required fluid resuscitation on admission and was noted to have fast atrial fibrillation secondary to sepsis. The patient had a history of Henoch-Schönlein purpura, hypertension, chronic venous leg ulcers, and chronic kidney disease stage two. On examination, the patient was noted to have a paraumbilical mass and the abdomen was distended and tender all over with gargling bowel sounds on auscultation. Blood tests showed raised inflammatory markers with white blood cells of 25.5 x 10^9 g/L. CT abdomen and pelvis with intravenous contrast showed a large paraumbilical hernia approximately 12cm in size containing intestinal contents , and it's arguable that CT is still the optimum investigation of choice in uncertain situations, particularly when there is a suspicion of malignancy in the elderly. However, surgery is the only effective treatment for strangulated hernia, and a careful inspection of the contents of the sac before reduction and/or resection-anastomosis .Embryologically, the posterior peritoneum typically attaches to the cecum and the ascending colon retroperitoneally . The rigA rare but serious occurrence is caecal wall necrosis related to incarcerated Richter's femoral hernia. This has been reported in one case presentation earlier, which, in comparison to our case, is similar in terms of unusual caecum mobility .A very similar case has been published recently that describes a large, incarcerated umbilical hernia in an obese, 80-year-old patient. Over a period of more than 15 years, the hernia persisted and grew bigger and bigger. The pain, which lasted for almost two hours before the patient arrived at the hospital, was the only symptom. Gangrenous ascending and transverse colon was discovered after an emergency laparotomy. Without hernia repair, a subtotal colectomy with the formation of a terminal ileostomy was performed. The patient was discharged on the fifth postoperative day after a full recovery .it is rare that a paraumbilical hernia contains caecum and appendix. As demonstrated in our case, the condition is not necessarily fatal; high index of suspicion, proper clinical evaluation, and urgent management are crucial. Our case suggests that right hemicolectomy with ileostomy and mucus fistula are the options of choice to limit contamination and enhance early recovery. Strangulated paraumbilical hernia can be successfully managed with early surgical intervention; hence, it is essential to be aware of this condition and its misleading clinical presentation.


A 78-year-old man complaining of left leg swelling was diagnosed with an abdominal aortic aneurysm with an irregular margin. A four-dimensional computed tomography (CT) showed an aortoiliac vein fistula. An AFX stent graft was urgently implanted, and a Viabahn VBX was inserted into the left iliac vein. The aneurysmal sac was embolized. After the procedure, enhanced CT confirmed a patent stent graft without any endoleak or fistula. The patient was discharged ambulatory. An aortoiliac vein fistula is a differential diagnosis for leg edema, and a four-dimensional CT is beneficial in diagnosing the condition. In AVF cases, 68% have an aorto-caval fistula, and 20% have an aorto-left iliac vein fistula. Herein, we report a case of AAA with an aorto-left iliac vein fistula diagnosed using four-dimensional computed tomography (4DCT).An abdominal aortic aneurysm (AAA) with an aorto-venous fistula (AVF) is uncommon. Aorto-caval fistulas are found in 0.22–6.04% of infrarenal AAA cases,9/µL, high C-reactive protein of 34.3 nmol/L, and mild anemia (hemoglobin of 106 g/L). Enhanced computed tomography (CT)  showed an AAA 41 mm in diameter with an irregular margin  was urgently implanted. Before insertion, aortography revealed the AAA and enhancement of the left iliac vein and inferior vena cava  its irregular margin can trigger AVF formation, and (2) the aneurysm originated from the median sacral artery, not from the aorta. A median sacral artery aneurysm is an extremely rare condition without any trauma or iatrogenic reason, and the location of the aneurysm in the present case can be recognized as either an AAA or a median sacral artery aneurysm. Either way, a stent graft was the first choice to treat the aneurysm in the present case, considering the patient’s general status.We encountered an AAA with AVF, which was diagnosed using 4DCT and repaired via endovascular technique in an emergency setting. Maeda et al. reported that all AAA with AVF cases presented with abdominal or back pain, 60% of cases were in shock, and 80% of cases had heart failure. Akwei et al. reported four cases of endovascular repair for aorto-caval fistula associated with AAA, and 75% of cases died because of failure in early diagnosis. It has also been reported that early diagnosis improved the mortality after endovascular treatment to 3.8%. It was also challenging to diagnose the present case as an AVF due to its uncommon presentation. The AVF was suspected on enhanced CT; however, a definitive diagnosis was made using 4DCT, confirming the fistula communicating between the AAA and the left iliac vein. Goto et al. reported that a multidetector row CT was useful in finding the fistula in AVF cases. 4DCT also had the benefit of visualizing a sequential change from light to deep enhancement in the left iliac vein. In the present case, it was difficult to diagnose the location of the fistula because the aneurysm had an irregular margin, and 4DCT was more useful than three-dimensional CT. Additionally, 4DCT revealed that the arterial flow in the left iliac vein was more strongly enhanced in the distal part than in the proximal part of the AVF due to the stenotic change formed by the aneurysmal pressure . The arterial flow in the direction of the inferior vena cava was decreased, which could be the reason why the patient did not present the symptoms of heart failure.In a literature review from 1999 to 2014, Orion et al. reported that the mortality rate was higher with endovascular therapy (19%) compared to open surgery (12%) when treating aorto-caval fistulas with AAAs. Recently, endovascular therapy has been used more frequently for ruptured arterial disease. A presence of an endoleak remains to be the main problem after inserting a stent graft. The endoleak rate after endovascular management of an AAA with aorto-caval fistula was estimated to be 15–50%, and the rate of fistula persistence was 9%. Since the risk of endoleak in the present case was considered high, the aneurysmal sac was embolized with Impede-FX after stent graft insertion. Unfortunately, given the emergent situation, the median sacral artery was not identified preoperatively, and sac embolization was the first choice management to prevent an endoleak. Plugging the median sacral artery, if recognized preoperatively, is considered the better choice. No endoleak was observed in the final aortography.Open surgery has classically been used to repair AVFs with high mortality rates. A few reports have argued the benefit of stent grafts for injured or perforated veins. However, the advantages of the Viabahn or Viabahn VBX for venous use should be further verified prior to allowing regular use in emergency situations. Cilostazol was reported to be effective in preventing stenosis of polytetrafluoroethylene-covered stents in veins. Cilostazol was added to the present case, and the Viabahn VBX inserted in the left iliac vein was patent 1 month after surgery. This case should be followed up carefully, with emphasis on the CT findings.The left iliac vein was covered using Viabahn VBX as off-label use in Japan. Zahradnik et al. reported that the Viabahn stent graft was valuable for repairing the left common iliac vein injured iatrogenically.An AAA with AVF is a differential diagnosis of leg edema. 4DCT has the benefit of visualizing a sequential change in the vein, enabling diagnosis of the AVF. The use of stent graft for injured veins should be verified further.Informed consent was obtained from the patient for publication of the case report and the accompanying images. The Ethical Guidelines for Medical and Health Research Involving Human Subjects is applicable to this case report because of using the unapproved medical supply (intravenous use of the Viabahn VBX). Therefore, an ethical approval, which was issued by the ethical committee of Tokai University Hachioji Hospital, was obtained on July 29, 2022 .


The source of excess androgen can be obscure in postmenopausal women with new-onset hyperandrogenism. If serum dehydroepiandrosterone sulphate (DHEAS) is raised, it is presumed to be of adrenal origin because DHEAS is exclusively produced from adrenal cortical cells. This reports an elderly female presenting with new-onset hyperandrogenism due to an ovarian sex cord-stromal tumour, associated with increased serum DHEAS levels.A 76-year-old female with long-standing diabetes and hypertension presented with hirsutism and male type alopecia for six months. She had menopause at 55 years of age. There was a pelvic mass on examination. Total testosterone was 6.106 ng/ml (0.124–0.357) and DHEAS was > 1000 µg/dL (35–430). Contrast-enhanced computed tomography of the abdomen and pelvis showed a heterogeneously enhancing complex mass measuring 11 × 8 cm in the left adnexal region. Adrenal glands were normal. She underwent total abdominal hysterectomy, bilateral salphingo-oophorectomy, and omentectomy. Both testosterone and DHEAS normalised following surgery. Histology revealed a sex cord-stromal tumour, likely a steroid cell tumour with malignant potential. Fluorodeoxyglucose-Positron emission tomography did not show any additional lesions.Due to the lack of sulfotransferase in ovarian tissue, markedly elevated DHEAS originating from an ovarian neoplasm is unusual. This phenomenon has not been described except in a patient with a steroid cell tumour causing Cushing syndrome and hyperandrogenism. The mechanism of this rare occurrence remains elusive. Knowledge of this unusual presentation would enable the clinicians to be cautious in localising the androgen source in women with hyperandrogenism. New-onset hyperandrogenism is extremely rare in postmenopausal women compared to that of premenopausal women. Common causes in postmenopausal women include androgen-secreting tumours of the ovary or adrenal and ovarian hyperthecosis , 2. TypeDifferentiation of the cause of hyperandrogenism is mandatory in these women to recognise underlying endocrine disorders. In a postmenopausal woman with new-onset hyperandrogenism, imaging of the adrenals and ovaries guides the localisation of the source of androgen excess. However, small ovarian tumours producing androgens can be missed during imaging. Adrenal incidentalomas can further complicate the diagnostic workup . Though This report describes a postmenopausal woman with an ovarian sex cord-stromal tumour causing new-onset hyperandrogenism associated with markedly elevated serum DHEAS.A 76-year-old female presented with new-onset gradually worsening hirsutism over the face, upper chest, upper abdomen, and arms and frontal balding for six months. She had not noticed acne, clitoromegaly, or changing voice. There was no abdominal pain, bloating, bowel or urinary symptoms. She had attained puberty at 13 years and had regular menstruation up to 55 years. Her two childbirths were uncomplicated. She had not experienced postmenopausal bleeding or hot flushes. There was no exposure to exogenous androgenic substances.Past medical history included satisfactorily controlled diabetes and hypertension for 15 years and right total hip replacement for osteoarthritis 10 years ago. There was no history of microvascular or macrovascular complications of diabetes.On examination, she was of average built and looking well. She had thick terminal hair over her face, upper chest, upper abdomen, and arms and there was no clitoromegaly. Abdominal examination revealed a firm pelvic mass up to the level of the umbilicus. The examination was otherwise normal.Total testosterone and serum DHEAS were markedly elevated and confirmed on repeat testing. Serum DHEAS was performed using the chemiluminescence method on the IMMULITE platform. The results of her blood investigations are summarised in Table Contrast-enhanced computed tomography of the abdomen and pelvis revealed a heterogeneously enhancing complex mass measuring 11 × 8 cm in the left adnexal region. There was no calcification, fat content, or air-fluid level within (Fig. She underwent total abdominal hysterectomy, bilateral salphingo-oophorectomy, and omentectomy. A left ovarian tumour adherent to the lateral pelvic wall, measuring 16 cm × 8 cm × 9 cm showing a yellowish-brown cut surface with haemorrhagic and necrotic areas was removed completely Fig. . The tumFigure The patient showed improvement of alopecia and hirsutism three months after surgery. Considering the malignant potential of the tumour, options of chemotherapy and pelvic radiotherapy were discussed with the patient and she opted for radiotherapy.Normal adrenal imaging and complete normalisation of serum DHEAS following surgery in our patient confirm that marked elevation of DHEAS was due to the androgen-secreting tumour of the ovary. Measurement of DHEAS using immunoassays is known to be accurate with minimal effect of assay interferences due to very high serum concentrations compared to other androgens and the presence of highly specific antibodies , 6.Marked elevation of serum DHEAS is characteristically seen in patients with an adrenal origin of hyperandrogenism. An adrenal tumour must be strongly considered in a postmenopausal woman with DHEAS > 700 µg/dL [Lack of elevation of serum DHEAS in a patient with an ovarian source of hyperandrogenism could be explained by the female androgen synthetic pathway. In a postmenopausal woman, both ovaries and adrenal glands would contribute to the androgen levels in the blood. In the descending order of serum concentration, the main androgens in a female include DHEAS, DHEA, androstenedione, testosterone, and dihydrotestosterone . Figure As described earlier, SULT2A1 is only expressed in adrenal zona reticularis cells. However, there are cases of paraendocrine manifestations such as Cushing syndrome, hypercalcaemia, and erythrocytosis in patients with steroid cell tumours of the ovary –13. ThesOvarian neoplasms producing postmenopausal hyperandrogenism are rare compared to all the types of ovarian neoplasms. Sex-cord stromal tumours, including steroid cell tumours, Leydig cell tumours, Sertoli cell tumours, and Sertoli-Leydig cell tumours, are known to produce androgens . CompareIn addition, the key lesson that must be taken from this patient’s history is that localising the source of hyperandrogenism in a postmenopausal woman has to be performed carefully. While it is well known that clinical presentation, imaging, or catheter studies have their limitations, DHEAS, which is considered to be a strong indicator of adrenal androgen excess, also can mislead the clinician.This reports the presentation of new-onset postmenopausal hyperandrogenism due to a sex-cord stromal tumour, unexpectedly associated with markedly elevated serum DHEAS levels. Further studies to understand its pathophysiological mechanism are warranted. Clinicians should play extreme caution in utilising available modalities in localising the source of excess androgen in postmenopausal women.


Inguinal endometriosis is a rare clinical disease with an unclear etiology and pathogenesis, and its diagnosis requires accurate medical history-taking and histological examination. However, surgical treatment for the condition has not yet been standardized. This report presents two cases of inguinal endometriosis.The first patient was a 36-year-old woman who complained of pain and swelling in her right inguinal region. Physical examination revealed a soft, tender right inguinal mass. The size of the mass repeatedly increased and decreased during menstruation and did not show swelling with abdominal pressure. Magnetic resonance imaging showed a 3.5 × 2.5 cm mass with high intensity on T2-weighted imaging in the right inguinal canal, and no communication was found between the lesion site and the abdominal cavity. We diagnosed this case as inguinal endometriosis and managed it using an anterior approach and laparoscopic observation. The second patient was a 51-year-old woman who presented with an intermittently painful mass in her right inguinal region. The mass tended to increase in size, with worsening pain before menstruation. Abdominal computed tomography revealed a 2 × 2 cm cystic mass in the right inguinal region. We made a diagnosis of inguinal ectopic endometriosis and decided to operate via the totally extraperitoneal (TEP) method for excision plus transabdominal observation. The postoperative course in both cases was uneventful with no recurrence.Inguinal endometriosis is a rare entity that should be suspected in patients with cyclical symptoms of inguinal pain and swelling that correlate with their menstrual cycle, which might otherwise be attributed to inguinal hernia. It is crucial to make a preoperative diagnosis based on a careful medical review, physical examination, and imaging studies, and to make an appropriate surgical plan. Particularly, in the case of ectopic inguinal endometriosis involving the canal of Nuck, laparoscopic observation is useful for the intraoperative diagnosis of inguinal endometriosis to help rule out the involvement of other abdominal sites. However, it is important to select and modify the surgical technique to avoid rupturing the endometrisis mass and prevent postoperative recurrence. Endometriosis is defined as the presence of normal endometrial mucosa outside the uterine cavity; its incidence in the inguinal region is reported to range from 0.07% to 0.8% , 2. ClinA 36-year-old woman complained of pain and swelling in her right inguinal region, which appeared 5 months prior to presentation. Physical examination revealed a soft, tender right inguinal mass. A key historical feature was that the mass repeatedly increased and decreased with menstruation. The mass did not show swelling with maneuvers that increase abdominal pressure, such as coughing. Ultrasonography showed 3.0 × 2.0 cm cystic lesion and magnetic resonance imaging showed a 3.5 × 2.5 cm mass with high intensity on T2-weighted imaging in her right inguinal canal Fig. , and no Intraoperative laparoscopy revealed the dilatation of the hernia gate in the right lateral abdominal wall similar to a slit. However, as the patient was a young woman, fertility preservation was prioritized, and we decided to not repair the hernia, but only to remove the mass Fig. a. BloodyHistopathological examination revealed ectopic endometriosis in the canal of Nuck Fig. . The patA 51-year-old woman presented with an intermittently painful mass in her right inguinal region. The mass tended to increase in size, and the pain worsened before menstruation. Abdominal computed tomography revealed a 2 × 2 cm cystic mass in her right inguinal region Fig. . LaparosInguinal endometriosis is a rare condition, and its etiology and pathogenesis remain unclear. Several etiological theories exist regarding the developmental mechanism of endometriosis in the inguinal region. The first is the “transplantation theory” of lymphatic or hematogenous spread. The second theory is the “direct extension theory” of direct invasion to the inguinal region. The third is the “metaplasia theory,” in which endometrial tissue from the Müllerian ducts causes metaplasia of the peritoneal epithelium , 4. In tIn the preoperative diagnosis of inguinal ectopic endometriosis, it is important to interview the patient to determine whether inguinal pain becomes more severe with menstruation. Although we did not measure CA125 (a blood marker for endometriosis) in our study, CA125 was elevated in approximately half of the cases . It may In this report, the first case was managed using the anterior approach plus laparoscopic observation, and the second case was managed using the TEP method plus abdominal observation, which combines the merits of both the transabdominal peritoneal approach (TAPP) and TEP. An advantage of laparoscopic surgery is that it can be used to detect pelvic endometriosis, which can lead to the recurrence of inguinal ectopic endometriosis . LaparosIt is important not to rupture the mass, but to remove its contents without seeding the surrounding tissue . If the Finally, laparoscopic observation of the abdominal cavity is useful for the preoperative diagnosis of inguinal endometriosis to help rule out the involvement of other abdominal sites, as the disease has the potential to recur or undergo malignant transformation , 11.Inguinal endometriosis is a rare entity that should be suspected in patients with cyclical symptoms of inguinal pain and swelling that correlate with their menstrual cycle, which might otherwise be attributed to an inguinal hernia. It is crucial to make a preoperative diagnosis from a careful medical review, physical examination, and imaging studies, and to make an appropriate surgical plan. When performing surgery for inguinal endometriosis, laparoscopic observation of the abdominal cavity is useful for the preoperative diagnosis to help rule out the involvement of other abdominal sites, considering the possibility of recurrence or malignant transformation. It is important to select and modify the surgical technique to avoid rupturing the mass and prevent postoperative recurrence.


In the original article, the age of the woman in the case study was wrongly written as 76. Instead, the correct age should be 63.Sections which have been changed:63-year-old woman, with clinical, radiological, macroscopic, and microscopic correlation. The outbreak of the Coronavirus pandemic delayed her treatment. We review the literature on proliferating trichilemmal cysts, which are relatively rare tumors, which generally are considered benign. However, we found a high rate of malign cases, which stresses the importance of rapid surgical excision and histological diagnosis. Even though our proband had delayed treatment, the tumor did not transform to a malignant form.We report a case of a large, ulcerating proliferating trichilemmal cyst in a IntroductionProliferating trichilemmal cysts (PTCs) are relatively rare tumors that may appear all over the body but most frequently on the scalp in middle-aged women (1). PTCs occur in a benign and malignant form, but the differentiation between malignant PTC and benign PTC has been debated, implying that all PPT should be treated with the expectation that it could transform into a malignant tumor (2). There are no absolute clinical criteria that can differentiate between benign and malign PTC, why surgery is necessary to give a correct histopathological diagnose. The malignant form may metastasize (3).63-year-old woman with a large PTC, where surgical treatment was delayed due to the outbreak of the Coronavirus pandemic and a review of the relevant literature on PTCs.We here report the case of a Case description63-year-old woman, with ASA 3 status, who rarely left her home due to sequelae from previous apoplexy. She had some minor tumors on the scalp for many years, for which she had not seen a doctor because they did not bother her. When one of them grew within a few months, she went to her General Practitioner (GP) for treatment. Her GP referred her, to the Department of Otorhinolaryngology and Maxillofacial Surgery at Zealand University Hospital (ZUH), Koege, in October 2019, for a lipoma on the scalp measuring approximately 5 cm in diameter . She had no B-symptoms. There was no familiar history of tumors, besides her dad, who had a lipoma on the scalp removed. At first consultation in October 2019, a sizeable painless tumor of 4x5x5 cm and two smaller tumors were found on the scalp . The tumors were movable from the underlying structures and resembled lipomas. Surgery was recommended.The proband is a The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.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.


Neuroblastoma (NB) is an undifferentiated malignant tumor of the sympathetic ganglia, occurring in children under 5 years of age. However, it is a rare histology in adult patients, occurring once per every 10 million patients per year. We present the case of a 68-year-old male patient presented to our department for right lumbar pain, asthenia, loss of weight and altered general status. The contrast-enhanced abdominal computer tomography revealed bilateral adrenal tumoral masses of 149 mm and 82 mm on the right and left sides, respectively, with invasion of the surrounding organs. The patient underwent right 3D laparoscopic adrenalectomy and right radical nephrectomy. The pathological result concluded that the excised tumor was a neuroblastoma of the adrenal gland. The patient followed adjuvant oncological treatment; however, due to disease progression, he passed away 22 months after the surgery. To our knowledge, less than 100 cases of adrenal NB in adult patients have been published, the eldest case being diagnosed at 75 years of age; meanwhile, the largest reported tumor measured 200 mm, and was excised through open surgery. Minimally invasive techniques have been limited so far to smaller, organ-confined diseases, thus making the present case the largest adrenal NB removed entirely laparoscopically. Neuroblastoma in the adult population is a rare finding, with worse prognosis compared to pediatric patients. The available literature does not provide enough data for standardized, multimodal management, as the patients are treated following adapted pediatric protocols, thus reinforcing the need for international, multidisciplinary boards for rare tumors. Neuroblastoma (NB) is an undifferentiated tumor of the peripheric sympathetic nervous system, being most often located in the paravertebral sympathetic ganglia (chest and retroperitoneum), as well as in the medulla of the adrenal gland . It is tHowever, in the adult population, it is a rare occurrence, being estimated as 1 in 10 million adults/year . It is cWe hereby present the case of an adult patient diagnosed incidentally with NB of the adrenal gland, along with a literature review of similar cases.This is the case of a 68-year-old male patient, who was referred to our department in September 2020 for right lumbar pain, asthenia, loss of weight and altered general status. His past medical history revealed hypertension and peripheral venous insufficiency of the lower limbs, associated with a venous ulcer of the right calf.Upon examination, a mass could be palpated in the right upper quadrant. The abdominal ultrasound showed a parenchymatous tumor at the upper pole of the right kidney with a diameter of approximately 140 mm.The patient underwent contrast-enhanced, thoraco-abdominal, and pelvic computer tomography (CECT-TAP), which confirmed a 149 × 106 mm tumoral mass with inhomogeneous structure and necrotic content, located in the right suprarenal region and extending into the upper renal pole, while compressing the right hepatic lobe and adhering at the level of the right diaphragmatic crus. The radiological characteristics indicated its adrenal origin, rather than an upper pole renal carcinoma. A similar mass of 82 × 63 mm was identified contralaterally, extending into the posterior gastric wall, spleen, pancreas, and upper left renal pole. No signs of lymph node involvement or distant metastases have been detected .A full endocrinological evaluation was conducted, showing an ACTH-dependent Cushing Syndrome, with an ectopic secretory pattern . PituitaThe case was analyzed by a multidisciplinary uro-oncological board and the surgical indication for right adrenalectomy was established based on the size, the radiologic description and hormonal profile. We proposed a 3D laparoscopic approach. The preoperative blood work revealed moderate anemia (hemoglobin 9.8 g/dL) and urinary tract infection, treated with a full course of antibiotics adapted according to the provided antibiogram.The patient was placed in left lateral decubitus, with the surgical table bent at a 45-degree angle. The intervention was performed using a 5 trocar transperitoneal approach  and the The ascending colon and duodenum were medialized, exposing the inferior vena cava (IVC). The tumoral mass was identified in the right lumbar area, being adherent to the upper pole of the right kidney, diaphragm, and visceral side of the liver , thus adThe renal pedicle comprised of 1 artery and 2 veins was identified, clipped, and divided, as well as the central adrenal vein. The circumferential dissection of the surgical specimen was difficult due to the tumoral invasion of the liver and IVC, but uneventful. The surgical specimen was retrieved through a modified Gibson incision. A peritoneal drainage was placed. The operative time was 210 min and was carried out entirely laparoscopically, with minimum blood loss.The patient was mobilized on the first post operative day (POD). The drainage was removed on the third POD and the patient was discharged on the seventh POD.Macroscopically, the tumoral mass measured 155 × 110 × 70 mm and appeared as a grey mass of hard consistency, polylobate, with multiple areas of necrosis identified on the transversal section.From a microscopical standpoint, a proliferation of small polyhedric cells was observed in standard hematoxylin—eosin stain, with nuclear atypia and up to 3 mitosis per high power field. The intercellular matrix was fibrillar and poorly represented. Tumoral emboli could be identified in lymphatic and venous vessels, as well as perineural infiltration . ApproxiFurther, immunohistochemical stains were carried out in order to rule out possible differential diagnostics . CytogenTM Gmbh., Schindellegi, Switzerland) that indicated pembrolizumab as being suitable in this case, based on the immunologic profile identified at immunohistochemical analysis. The patient underwent three cycles of pembrolizumab . However, 9 months after the surgery, the CECT-TAP revealed tumoral progression  and local recurrence at the level of the right tumoral bed , as well as para-aortic and interaortocaval lymph node metastases. Subsequently, the patient received third line palliative treatment, comprised of three cycles of docetaxel. As the disease progressed, fourth line treatment was initiated, including a combination of doxorubicin, cyclophosphamide, and vincristine, between November 2021 and March 2022. Eventually, the patient needed fifth line therapy, consisting of weekly gemcitabine administration; however, he passed away in July 2022, 22 months after the surgery, due to multiple organ insufficiency caused by the metastases.The patient was referred to the oncologist for adjuvant treatment, starting 2 months after the surgery. He received three cycles of carboplatin and etoposide combined therapy, over the course of 4 months. Due to the rarity of the diagnosis in his age group, an artificial intelligence-based decision support tool was employed  and L2  have the possibility of being managed through a multimodal scheme, comprised of surgery, radiation and chemotherapy (most frequently adapted from pediatric protocols), associated with radioactive iodine meta-iodobenzylguanidine I131 MIBG) therapy  MIBG the, percutaSince no standardized protocol is available, personalized oncological assessment has been attempted, however it did not prevent the disease progression. Further chemotherapy protocols have been conducted according to Pediatric Neuroblastoma Protocols, including docetaxel, cyclophosphamide, and doxorubicin, with dose adjustment . SimilarThe overall survival reported in the literature is heterogenous, due to the scarcity of cases in the adult population. For the full multimodal protocol, the estimated overall survival at 5 years for stage I and II masses is 83%, while for stages III and IV it drops to 28% . In our The main limitation that we encountered in the management of the presented case was the fact that the final diagnosis was made by ruling out other small blue round cell tumors. Other limitations were the lack of access to I131 MIBG imaging and therapy, as well as the lack of widely applied therapeutic protocols. Regarding the review process, few cases have been published, thus making it difficult to draw solid conclusions regarding incidence, treatment protocols—and how they were adapted from the pediatric population—as well as survival rates.Adrenal neuroblastoma is a rare occurrence in the adult and elderly population, with heterogenous and atypical clinical presentation, and worse outcome than those diagnosed in early childhood.


A 58-year-old woman presented with restless-legs syndrome and symmetrical disturbance of sensibility for both feet and the fingers of both hands. As part of an extended neurological work-up, a magnetic resonance imaging (MRI) of the head was performed. The cranial MRI revealed an incidental finding of a mass in the left cerebellopontine angle Figs.  and 2. TDue to the size of the lesion of unknown etiology with incipient mass effect on the adjacent brainstem, surgical removal of the lesion was decided. Surgery was performed with the patient under general anesthesia in a semi-sitting position. The tumor was microsurgically resected along a retrosigmoid approach under intraoperative neurophysiological monitoring of the CN. Macroscopically the tumor was soft and of brown-grayish color and was adherent to the caudal CN, but not to CN VII/VIII. The lesion extended into the lateral aperture of Luschka. After complete resection of the tumor, the fourth ventricle and choroid plexus were clearly visualized.Postoperatively, the patient had no neurological deficit and preserved CN function. There was an event of cardiac arrhythmia in the postoperative course, that could be sufficiently treated. The patient was discharged in a good clinical condition.The cranial MRI upon admission Fig.  and 2 reTumors of the cerebellopontine angle (CPA) are quite frequent and represent about 6–10% of all intracranial tumors . In thisVestibular schwannomas (VSs) are benign extra-axial neoplasms arising from the nerve sheath of the vestibulocochlear nerve (CN VIII), usually from its vestibular division strictly following its anatomical course. They are by far the most common masses in the CPA (~ 70–80%) . The peaOn CT imaging widening of the osseous porus acusticus is a common feature that may reflect tumor aggressiveness. Calcifications are not present and therefore useful in differentiating it from other lesions, especially meningiomas , 7.On MRI the lesion is usually isointense relative to the cerebellar parenchyma on T1WI and may rarely show small hyperintense foci in case of intralesional microhemorrhages with correlating low signal on T2*GRE/SWI. On fat-saturated heavily T2 weighted constructive interference in steady state (CISS) sequences the lesion shows a hypointense filling defect within the surrounding high signal CSF in the CPA cistern or IAC. On post-contrast T1WI, the lesion typically demonstrates avid and homogeneous enhancement. In the cystic subtypes that represent approximately 10% of all VSs, there is usually a strong marginal enhancement around a central low signal focus with correlating heterogeneous signal on T2WI. For further differentiation from other tumors, it is important to mention that VSs do not reveal any restriction on DWI , 7, 8.The normal audiogram confirming no SNHL as well as the mild calcifications seen on CT imaging and inhomogeneous contrast enhancement on MRI made this diagnosis less likely in our patient.Although meningiomas are most commonly located supratentorially, they represent about 10–15% of all masses in the CPA . The peaOn CT imaging, the mass is mostly hyperdense (70%), less commonly isodense (30%) relative to the brain parenchyma and may contain intralesional calcifications (20–25%) in a diffuse, focal or sand-like (psammomatous) manner. The adjacent bone occasionally shows hyperostosis (5%) or an irregular cortex along the inner table of the skull .On MRI, the lesion is usually isointense to slightly hypointense relative to the cortex of the brain parenchyma on T1WI while it may show a variable signal intensity on T2WI depending on its texture and fibrous components. The so-called CSF cleft sign on T2WI is a typical feature seen in meningiomas 80%), which helps to distinguish extra-axial from intra-axial tumors. It shows a thin rim of hyperintense CSF between the tumor and the adjacent brain parenchyma. Apart from the intense homogeneous enhancement, meningiomas commonly reveal a dural tail sign on post-contrast imaging (60–72%), which appears to be a result of reactive thickening of the dura due to vascular congestion and edema. DWI restriction is not common but may present in the more locally aggressive atypical or malignant meningiomas 0%, which–13.In our case, we considered meningioma a valid differential diagnosis based on its location and close proximity to the dura as well as the mild intralesional calcifications on CT imaging despite the rather inhomogeneous contrast enhancement.Epidermoid cysts, also called pearly tumors due to their macroscopic pearl-like appearance , are uncOn neuroimaging, epidermoid cysts show characteristic irregular and multilobulated margins. They commonly mimic or have slightly lower density/higher signal intensity than CSF, i.e. hypodense on CT (approx. 0 HU) and hyperintense in T2WI on MRI, due to the accumulation of cholesterol and keratin, breakdown products derived from desquamated epithelial cells. Very rarely, marginal calcifications or slight contrast enhancement may be seen. A key feature that helps differentiate epidermoid cysts from other lesions, especially from the otherwise indistinguishable arachnoid cysts, is the characteristic hyperintensity on DWI with ADC values equal to the brain parenchyma , 8, 15.In our case, the contrast enhancement and missing diffusion restriction as well as the more advanced age made this diagnosis very unlikely.Metastases in the CPA disseminate through CSF infiltrating the subarachnoid space and most commonly originate from systemic tumors, such as breast or lung carcinoma, very rarely the primary tumor lies within the central nervous system (CNS). Altogether, they represent only about 0.3–0.7% of all lesions in this particular area . The peaMetastases should always be considered as a differential diagnosis in a patient of advanced age with an enhancing intracranial lesion. In our case no underlying tumor was known and the patient had no B symptoms.Along with the atypical choroid plexus papilloma (aCPP), choroid plexus papilloma (CPP) and choroid plexus carcinoma (CPCa) represent the other two recognized subgroups of choroid plexus tumors that in about 40% of the cases arise as lobulated cauliflower-like, contrast-enhancing masses within the 4th ventricle and/or foramina of Luschka at the CPA. CPP and aCPP are indistinguishable on imaging alone while CPCa may be more heterogeneous and is more likely to invade the adjacent brain , 21. On A tissue biopsy was obtained for intraoperative neuropathological examination. A hematoxylin and eosin (H&E) stained cryostat section revealed a tumor with a papillary growth pattern Fig. a. TherefIn accordance with the intraoperative (H&E) slide, the H&E stained FFPE tissue showed a tumor with a papillary growth pattern Fig. b. A singThe tumor cells showed positivity in the immunohistochemical reaction for the pan-cytokeratin marker MNF116 (PanCK, Fig. Due to the location of the tumor and the suspected clinical diagnosis, a schwannoma has been discussed as differential diagnosis; however, a biphasic growth pattern and spindle cells could not be observed in the specimen. Therefore, the histological features did not fit to a schwannoma. Moreover, the histological characteristics did not resemble those of a meningioma. EMA negativity also speaks against the presence of a meningeal tumor. The presence of a metastasis of an adenocarcinoma was discussed due to the papillary growth pattern. Nevertheless, the immunohistochemical profile including transthyretin positivity did not match an adenocarcinoma metastasis. The tumor was graded as atypical choroid plexus papilloma based on the increased mitotic activity. The criteria of a choroid plexus carcinoma such as increased nuclear pleomorphism, necrotic areas or more than 5 mitoses in 10 HPF were not fulfilled .The fifth edition of the WHO classification of central nervous system tumors defines atypical choroid plexus papilloma as a choroid plexus papilloma with an increased mitotic activity that is not fulfilling the criteria for choroid plexus carcinoma . AtypicaChoroid plexus papillomas in general are thought to arise from progenitor cells of plexus epithelium . Consequ


Adenosine is widely used for the diagnosis and treatment of supraventricular tachyarrhythmia. We report a rare case of adenosine use associated with the development of 1:1 atrial flutter with aberrancy. The diagnosis was further complicated by a newly described ECG artifact associated with Wireless Acquisition Module (WAMTM) ECG acquisition mimicking rhythm irregularity. Supraventricular tachycardia (SVT) is a commonly encountered condition in emergency departments. SVT is used as an umbrella term to describe the ECG of several specific pathologic entities that can result in regular, narrow-complex tachycardia. While each of these underlying causes of SVT have their own nuances in long-term and definitive management, acute management is algorithmic and described in published joint societal guidelines. Intravenous adenosine carries a class I recommendation as one of the first interventions for acute SVT because of its efficacy and rare serious adverse effects . Here, wA 26-year-old woman experienced sudden onset of palpitations and rapid heart rate immediately after sipping a frozen margarita and experiencing a cold stimulus headache or “brain freeze”. She is a healthcare worker and noted her smart watch recording a pulse of 150 beats per minute. She self-initiated vagal maneuvers with no resolution. She presented via emergency medical services to the emergency department and upon arrival had blood pressure 156/94 mmHg, heart rate 148 beats/minute, respirations 18/min, and oxygen saturation 99% on room air. Physical examination revealed tachycardia, regular rhythm, no rubs, murmurs, or gallops, clear lung sounds, and no peripheral edema. The patient had no past cardiac history and was taking no medications.The initial differential diagnosis included tachycardia from physiologic stress, hyperthyroidism, panic, anxiety, and cardiac dysrhythmia including atrial fibrillation (AF), atrial flutter (AFL), SVT, and ventricular tachycardia. The initial electrocardiogram Figure  showed rIn the emergency department, an initial diagnosis of SVT versus 2:1 AFL was made. In line with current SVT guidelines, vagal maneuvers were attempted with a reported increase in heart rate to 300 beats/min [This case presented multiple diagnostic difficulties including AFL presenting in an uncommon patient demographic, rare paradoxical response to adenosine, and morphological change in QRS with the perception of irregularity on ECG. These confounders initially clouded the diagnosis between AFL, SVT, pre-excited AF, and ventricular tachycardia.AFL in the young is uncommon and far less common than SVT in this demographic ,3. AmongAdenosine use is associated with multiple adverse reactions but these are typically short-lived and rarely serious making its use generally considered safe ,5,6. AltThe diagnosis was further complicated by the development of rate-related aberrancy with conversion to 1:1 AFL further broadening the differential to include causes of wide-complex tachycardia.Further confounding the diagnosis is an ECG artifact that is newly described and reported here. This artifact, demonstrated best in Figure This case describes an exceptionally rare response to adenosine and underscores appropriate caution and the importance of readily available resuscitative equipment when using this drug. We highlight features complicating diagnosis in this case with emphasis on recognizing an ECG artifact that may become more commonly encountered with routine use of wireless ECG acquisition technology.


Lymphatic fistula as a rare entity particularly emerges after head and neck cancer surgery. It may lead to delayed wound healing, electrolyte loss, malnutrition, dehydration, and immune suppression. Therefore, rapid diagnosis and treatment are of the utmost importance. We aimed to present a lymphatic fistula case who was treated successfully by lymphangiography with percutaneous embolization of the thoracic duct. We believe that minimally invasive techniques could be an alternative to the conservative approach as the first-line choice. The largest lymphatic vessel in the body is the thoracic duct (TD), and it drains about 75% of the body's lymph fluid . AlthougThere is still no gold standard for management and can range from conservative to surgical approaches. A conservative approach is usually preferred, especially for low output fistulas (<500 ml/day), but high output fistulas may necessitate surgical intervention . HoweverBesides conservative approaches and surgery, interventional radiological procedures have been increasingly applied in recent years. In this report, we present a case of a lymphatic fistula formed after cervical lymph node excision. As it was refractory to the treatment, the lymphatic fistula was treated with percutaneous embolization through TD.A 50-year-old, heavy-smoker male patient presented with weakness, fatigue, cough, night sweating, fever, and dyspnea and had lost two kg during the last two months. Besides his cachectic appearance, physical examination revealed multiple pathologic cervical lymphadenopathies. PET-CT reported FDG avid lymph nodes with the biggest measuring 68 × 55 × 29 mm (SuvMax: 19) and 85 × 150 × 95 mm (SuvMax: 28) in the left supraclavicular region extending to the anterior mediastinum . The labOn the postoperative second day, a lymphatic fistula was observed with an output up to 1400 ml daily . ConsideTD injuries and lymphatic fistulas are rare surgical complications, which may arise mostly after lateral cervical dissection for malignant or metastatic diseases and in patients with a previous radiotherapy history . The necDue to protein, fat, essential elements, and lymphocyte loss, hypovolemia, electrolyte imbalance, malnutrition, and immunosuppression may evolve. These adverse effects are more pronounced in high-output fistulas. Expanding lymphatic fluid in the surgical site has also a negative impact on skin flaps and impairing their perfusion pressure effect may even cause flap necrosis. This fluid can also drain into the mediastinum and pleura, and related complications may develop. Since lymphatic fluid drainage increases with physical activity, conservative treatment should be started with activity restriction. High-volume fluid, protein, and electrolyte losses should be closely monitored and replaced . ProteinAlthough surgery is recommended in a high-output fistula (>500 ml/day), it remains subjective per the clinical conditions of the patient and with the surgeon's experience . ConsideIntranodal lipiodol lymphangiography has been described recently for the diagnosis and treatment of lymphatic injury in the abdomen and thorax. In persistent cases, thoracic duct catheterization via a cisterna chyli and embolization with coils or liquid agents could be performed –9. We peHerein, we present a lymphatic fistula case that was treated successfully by lymphangiography with percutaneous embolization of the thoracic duct. We concluded that minimally invasive techniques could be used as a therapeutic alternative to redo duct ligation surgery and even might be considered as an alternative to the conservative approach as the first-line choice.


Neuroendocrine tumors (NETs) causing carcinoid syndrome are very rare. Patients can have very general symptoms and tumors can be missed especially in the elderly where many symptoms may be attributed to the aging process. It is of the utmost importance to do a full workup on elderly patients even if the symptoms can be explained by aging alone. Neuroendocrine tumors (NETs) are rare neoplasms that arise from enterochromaffin cells and are usually found in the gastrointestinal tract or bronchopulmonary system. Clinical symptoms tend to be very generalized and are therefore often attributed to other conditions or just the aging process in general . SymptomA 93-year-old male with a past medical history of hypertension, hyperlipidemia, coronary artery disease status post coronary artery stenting, and hypothyroidism, and a past surgical history of a coronary artery bypass graft and a cholecystectomy, presents with a chief complaint of chronic, intractable watery diarrhea for three months. He reports approximately eight bowel movements a day. He often has a sudden urge to move his bowels immediately after starting to eat a meal, and he is particularly troubled by incontinence when he is unable to reach the bathroom fast enough. He has tried many over-the-counter remedies and several courses of antibiotics without relief. He denies any relieving factors. He endorses a 40-60 lbs weight loss in the past three months. He also endorses an unproductive cough during this time as well. He admits to a 40-pack-year smoking history but he states that he quit 20-years-ago. A physical exam revealed a well-nourished appearing man in no acute distress. Pupils were equal, round, and reactive to light. No tonsilar exudates were appreciated and no lymphadenopathy was observed. Auscultation of the heart revealed a normal rate and rhythm with normal heart sounds and no rubs, gallops, or murmurs. Lung sounds were diminished bilaterally. An abdominal exam revealed loose skin and a right upper quadrant scar consistent with a previous cholecystectomy. All four quadrants had frequent bowel sounds and were soft and non-tender to palpation. The patient was wearing a diaper filled with well-masticated food but looked undigested as some lettuce was easily noticeable in the stool. A digital rectum exam revealed a normal muscular tone of the external anal sphincter.Clostridium difficile, bacterial and parasitic infection, vasoactive intestinal peptide tumor, and carcinoid syndrome. The fecal fat test and Clostridium difficile antigen screen were both negative. Stool culture and a stool test for ova and parasites were negative. The vasoactive intestinal peptide was within normal limits. Chromogranin A was elevated to 405.9 ng/ml . A 24-hour urine 5-hydroxyindoleacetic acid (5-HIAA) was elevated to 62.4 mg/24 hours .The patient was admitted with a differential list including pancreatic insufficiency, Abdominal computed tomography (CT) showed multiple lesions in the liver and spleen, as well as a calcified mesenteric mass, which was suggestive of a carcinoid tumor Figures , 2.The patient ultimately underwent a liver biopsy and the diagnosis of carcinoid tumor was confirmed. The patient was referred to oncology for further management.Carcinoid tumors are the most commonly documented manifestation of gastrointestinal NETs. These tumors are most commonly thought of to have an indolent, asymptomatic presentation, however, it has been shown that these neoplasms often can exhibit a malignant clinical course. Typical symptoms depend on the location of the NET, as described in the introduction, precipitated by biologically active secretagogues. Carcinoid tumors have the capacity to secrete a menagerie of biologically active substances. The most commonly secreted peptide is serotonin. The release of serotonin into the systemic circulation can cause what is known to be carcinoid syndrome, which can include intractable diarrhea, flushing of the skin, broncho-constriction, and, later in the disease course, right-sided valvular heart disease. In the presence of localized disease, carcinoid tumors produce serotonin, which is sequestered in platelets while the remainder is metabolized in the liver and lung and transformed into 5-HIAA. In the context of liver metastases of carcinoid tumors, however, patients may develop the systemic symptoms of carcinoid syndrome, which is when these secretagogues produced by the carcinoid tumor escape the ability of the liver to metabolize and proceed to seed into the systemic circulation .In a study that included a series of over 13,000 cases of carcinoid tumors reported to the Surveillance, Epidemiology, and End Results program with the National Cancer Institute, the incidence rates for caucasian men and women were 2.47 and 2.58 per 100,000 individuals. Statistics were somewhat higher for black men and women  [The diagnosis of suspected carcinoid disease is typically first investigated by measuring serotonin metabolites in the patient's urine, namely, 5-HIAA, which can be quantified in a 24-hour urine sample. This modality has been found to have high specificity but has lower sensitivity. Once the biochemical diagnosis of carcinoid disease is established, imaging studies can be performed to establish tumor localization. Abdominal CT has been the standard means of imaging to localize carcinoid tumors and potential metastatic disease. The sensitivity of abdominal CT is poor, however, the use of radiolabeling and scintigraphy offers increased information in patients with carcinoid tumors if abdominal CT is insufficient and there is a high clinical suspicion of carcinoid syndrome. Effective treatment of carcinoid disease includes surgical resection of the primary tumor, debulking, and medical therapy for symptomatic relief. Specific treatments are detailed and individualized to the case, the location of the primary tumor, and the presence of metastases, the standard for treatment of carcinoid tumors remains surgical intervention [Elderly patients with concerning symptoms should be worked up as opposed to just attributing the symptoms to the aging process. Serious conditions can be missed if a comprehensive examination is not performed. It is imperative to view symptoms independent of a person's age and only after should you weigh the risks and benefits before doing any diagnostic tests.


There was no local pain or weight loss. The physical examination showed a painless hardened mass fixed to deeper layers, measuring about 4 cm diameter.A panoramic radiograph of the jaw revealed a well-defined lytic expanding lesion with fine inner septa and no periosteal reaction, located on the right mandibular body .Figure 1Tomography of the face showed extensive an expanding bone lesion with well-defined borders, bone septa and a calcified matrix, implanted in the alveolar processes .The patient underwent surgical curettage; pathology diagnosed the lesion as a giant cell reparative granuloma. Four months after surgery, a mass was observed on the same site. A second tomography revealed an osteolytic lesion in the right mandible. Surgical curettage was again carried out, and the pathological diagnosis was fibroses, which did not confirm the possibility of recurrence. The patient is being monitored, and no local recurrence has arisen in the first year of follow-up.,GCRG are expanding, rapidly destructive bone lesions located mostly in facial bones; they comprise less than 7% of all benign tumors of the jaw. They may be central when originating directly from bone, or peripheral when its growth originates from soft tissue.Although the term granuloma is widely used for GCRG, this lesion is neither granulomatous nor reparative from a pathological standpoint; its behavior is neoplastic.These tumors generally occur in the first to third decades, affecting preferably females 2.1:1).:1.1, 2, ,The etiology remains controversial. Jaffé's original hypothesis (1953) that the tumor was a hyperplasic reaction to trauma has been abandoned.,Radiology presents certain specific findings, albeit not pathognomonic. Computed tomography may reveal a uniloculated or multiloculated osteolytic lesion with septa and calcifications in the matrix.,,The differential diagnosis is made with the brown tumor of hyperparathyroidism, aneurismatic bone cysts, and mainly with the true giant cell tumor.6 Histologically, true giant cell tumors have little or no intercellular material; giant cells are uniformly distributed, containing many nucleoli and a sparse cytoplasm. GCRG contain less uniformly arranged giant cells with fewer nucleoli and more cytoplasm, which is closely intertwined with microcysts or areas of hemorrhage.GCRG should be considered in the diagnosis of slowly growing increased volume of the jaw in young patients.


Rosai-Dorfman disease (RDD) is a rare and self-limiting condition caused by the non-neoplastic proliferation of histiocytes/phagocytes in the sinusoids of lymph nodes and in extranodal tissues. Of the extranodal involvement, laryngeal involvement is extremely rare. Because of its rarity and nonspecific clinicoradiologic features, RDD is often difficult to differentiate from other benign or malignant lymphoproliferative diseases. We present a case of RDD with infiltration of IgG4-bearing plasma cells manifesting laryngeal and nasal masses with cervical lymphadenopathy.A 45-year-old male patient presented with recurrent epistaxis and airway disturbance.On endoscopy, there were submucosal masses in both nasal cavities and both sides of subglottic larynx. On neck CT, there were well-defined, enhancing soft tissue masses in both nasal cavities and both sides of subglottic larynx, resulting in mild airway narrowing. In addition, multiple enlarged lymph nodes showing homogeneous enhancement were noted in both parotid glands and both internal jugular chains. All lesions demonstrated marked FDG-uptake on PET/CT. Therefore, the initial radiologic differential diagnoses included lymphoma and IgG4-related disease. Biopsy was performed on the nasal and laryngeal lesions, and they revealed RDD with infiltration of IgG4-bearing plasma cells.The patient underwent surgical resection of the masses in the nasal cavity and larynx to relieve airway narrowing.After surgery, airway obstruction was much improved and the patient was asymptomatic. On outpatient follow-up, he exhibited a stable condition and had no dyspnea on exercise.Clinical awareness and suspicion are important for the accurate diagnosis and management of patients with homogeneous masses in the larynx or nasal cavity, even if there is no combined cervical lymphadenopathy. Surgical resection of laryngeal RDD is recommended as it may cause life-threatening dyspnea, making early awareness of laryngeal RDD important for proper management.The major manifestation of RDD is painless bilateral cervical lymphadenopathy.,12 Awareness of this association may lead to the correct diagnosis of RDD without being confused with IgG4-related disease.In recent studies, it has been reported that a subset of patients with RDD have increased levels of IgG4-positive plasma cells on immunohistological examination. This makes differential diagnosis somewhat difficult from IgG4-related disease.Herein, we present a case of RDD with infiltration of IgG4-bearing plasma cells manifesting laryngeal and nasal masses with cervical lymphadenopathy. We additionally reviewed the literature to understand the clinical manifestations, image findings, pathologic features, and treatment options, which may assist in the diagnosis and proper management of RDD.2This was purely an observational case study that cannot alter the patient's management and clinical outcome. Thus, no ethical approval was required for this case report. We obtained the written informed consent from the patient for publication of this case report and accompanying images.A 45-year-old male patient with complaints of recurrent left epistaxis for 6 months and dyspnea on exercise for 4 months. He had no medical history and there were no significant abnormalities on physical and laboratory examination. Nasal endoscopy revealed well-defined soft tissue masses in both nasal cavities Fig. A. SubmucBiopsy was performed for both nasal cavity masses and subglottic masses through a nasal endoscopy and bronchoscopy to achieve a confirmative diagnosis. Histopathological examination of both nasal cavity and subglottic masses showed infiltration of lymphoid cells and numerous histiocytes with preservation of lymphoid follicles Fig. . Under hAfter the RDD diagnosis, he had been treated with corticosteroids for several months. However, his breathing difficulty did not improve. Therefore, the patient underwent surgical excision of the masses in both nasal cavities and left subglottic larynx to relieve the airway obstruction. After surgery, airway obstruction was much improved and the patient was asymptomatic. On outpatient follow-up, he exhibited a stable condition and had no dyspnea on exercise.3,6 In 1972, RDD was named sinus histiocytosis with massive lymphadenopathy after performing clinicopathological analysis.,6 Most patients with RDD are younger than 20 years (80%) with increased incidence among male patients ranging from 1.4:1 to 3:1.,13,14 Generally, RDD involves the lymph nodes (95%), predominantly presenting as painless cervical lymphadenopathy with approximately 43% cases involving extranodal sites.,6,9 The most common sites of extranodal involvement include the skin, paranasal sinuses, nasal cavity, central nervous system, salivary glands, and orbit.–9 RDD patients with paranasal sinus or nasal cavity masses present symptoms of progressive nasal obstruction, recurrent epistaxis, facial pain, or hyposmia. RDD with laryngeal involvement, as in our case, is extremely rare; fewer than 30 cases have been reported in the English literature.,10 The main clinical manifestations of laryngeal RDD include foreign body sensation, voice change, dyspnea, and cough.,10 Although laryngeal RDD is a rare manifestation, awareness of laryngeal RDD can lead to early diagnosis and proper management, preventing life-threatening dyspnea. Therefore, it is recommended that RDD patients with respiratory symptoms undergo a careful laryngoscopy to exclude laryngeal involvement.Rosai and Dorfman first described a benign histiocytic proliferative disorder in 1969.,15 MRI reveals homogeneous isointensity relative to the muscles on T1-wighted images and hyperintensity on T2-weighted images with homogenous enhancement.,7,15 Differential diagnoses for this finding include lymphoma, infectious nodal disease, and metastatic lymphadenopathy.,15 CT findings of extranodal RDD involving paranasal sinuses, nasal cavity, and larynx show homogeneously enhancing polypoid masses, mucosal thickening, or soft tissue opacification in the involved sites with or without associated bone erosion.,13,15 On MR images, paranasal sinus lesions may show marked T2 hypointensity. Affected sites typically show hypermetabolism of F-18 FDG on PET/CT.,15 Because of these nonspecific image findings, clinical suspicion is important for the accurate diagnosis of RDD in patients with homogeneous masses in the nasal cavity or larynx, even if there is no combined cervical lymphadenopathy.The radiologic diagnosis of RDD is often difficult because of the nonspecific imaging findings. Nodal involvement of RDD demonstrates massive bilateral cervical lymph node enlargement showing homogeneous enhancement on CT.,5,7,8,13 Extranodal involvement looks similar, but is usually associated with more fibrosis, fewer RDD histiocytes, and less emperipolesis.,6,12 In immunohistochemical analysis, RDD histiocytes are characterized by S100 and CD68 positivity, and when combined with lymphophagocytic histocytes, give a strong indicator of RDD.,13 The absence of CD1a immunopositivity differentiates RDD from Langerhans cell histiocytosis.,17The pathologic feature of nodal RDD is the sinus expansion with large histiocytes. Emperipolesis, the histopathologic characteristic of RDD, is the presence of lymphocytes, plasma cells, red blood cells or polymorphonuclear leukocytes within the cytoplasm of histiocytes.,18 Although the number of IgG4-positive plasma cells needed to make the diagnosis, an IgG4/IgG ratio greater than 0.4 has been suggested as a more reliable and mandatory histologic criteria for the differential diagnosis of RDD and IgG4-related disease.,19 In our case, the pathologic results demonstrated abundant emperipolesis which highly suggested RDD and the levels of IgG4-bearing plasma cells and IgG4:IgG ratio were insufficient to make a diagnosis of IgG4-related disease. Furthermore, other major histologic criteria for IgG4-related disease, such as storiform fibrosis and obliterative phlebitis, were not detected in our case. However, the significance of IgG4-bearing plasma cells in RDD remains to be further elucidated.In addition, as demonstrated in our case, some patients with RDD present increased levels of IgG4-positive plasma cells on immunohistological examination, making differential diagnosis with IgG4-related disease difficult. A variety of treatments have been applied for the management of RDD, including observation, corticosteroids, surgical resection, sirolimus, and radiotherapy. Observation is proper management for patients with uncomplicated lymphadenopathy or asymptomatic cutaneous RDD. However, debulking surgery may be warranted for patients with upper airway obstruction, spinal cord compression, or large lesions causing end-organ compromise, such as in our case.,8 Therefore, clinical suspicion and early diagnosis of RDD is necessary for the selection of appropriate therapies tailored to the individual situation.No uniform treatment has been established for RDD; treatment is tailored to the individual clinical circumstances.We described a rare case of RDD with extranodal involvement of the larynx and nasal cavity. Although it is extremely rare, awareness of laryngeal involvement in RDD is necessary for clinicians and radiologists as laryngeal RDD may be life threatening. Clinical awareness with meticulous pathologic review are important to provide accurate diagnosis and management in patients with homogeneous masses in the nasal cavity or larynx. We also highlight the histologic association between RDD and IgG4-bearing plasma cells even though the significance of IgG4-bearing plasma cells in RDD still remains controversial.Conceptualization: Kyeong Hwa Ryu, Hye Jin Baek.Data curation: Miji Lee, Kyeong Hwa Ryu, Hye Jin Baek, Seokho Yoon, Hyo Jung An, In Chul Nam.Formal analysis: Miji Lee, Kyeong Hwa Ryu, Hye Jin Baek, Hyo Jung An, In Chul Nam.Investigation: Jin Il Moon, Seokho Yoon.Methodology: Jin Il Moon, Seokho Yoon.Supervision: Kyeong Hwa Ryu.Writing – original draft: Miji Lee, Kyeong Hwa Ryu.Writing – review & editing: Kyeong Hwa Ryu, Hye Jin Baek, Jin Il Moon, Seokho Yoon, Hyo Jung An, In Chul Nam.


Lymphovascular invasion is a hallmark of malignant neoplasms, however the presence of benign epithelium within vessels has been reported in benign processes, albeit infrequently. The proposed mechanism to explain this phenomenon entails mechanical displacement of benign epithelium into the vascular spaces during surgical manipulation or diagnostic interventions. We report a case of numerous benign epithelial vascular emboli in a cholecystectomy specimen. A 29-year-old male presented with acute calculous cholecystitis. Surgery was delayed for several weeks due to COVID-19 infection. Histologic examination of the gallbladder showed subacute cholecystitis, widespread vascular epithelial emboli with associated fibrin deposition and bile embolism supporting an in vivo process. The epithelial emboli were localized in small veins and arterioles with D2–40−/CD31+/CD34+ endothelium. The displaced epithelium showed benign cytologic features, was negative for p53 expression, and had a Ki-67 labelling index like the benign background mucosa, supporting a benign process. There was no evidence of dysplasia or malignancy in the specimen after thorough sampling. Persistent inflammation, mucosal ulceration, transmural mucosal herniation (Rokitansky-Aschoff sinuses), and protracted surgical manipulation secondary to adhesive disease are favored to be the underlying causes of this unusual histologic finding. Although we presume an uneventful outcome, clinical follow up was recommended. COVID-19 infection likely contributed to this phenomenon by causing a delay in the surgical management. In surgical pathology, the microscopic presence of epithelial cells in vascular or lymphatic spaces is almost invariably associated with malignant processes and reported as lymphovascular, lymphatic, and/or angiovascular invasion. For surgeons and oncologists, reporting of this finding by pathologists is considered a risk factor for tumor relapse and metastatic disease, and often an indication for adjuvant therapy. However, the presence of benign epithelium in vessels has also been rarely reported in non-malignant processes. We describe the presence of numerous intravascular deposits of benign gallbladder epithelium in a cholecystectomy specimen of a patient who underwent a delayed cholecystectomy due to a COVID-19 positive test.A 29-year-old male presented to the emergency department with a one-week history of abdominal pain accompanied by nausea and emesis. The pain was intermittent, located in the right upper quadrant with radiation to his back, and was exacerbated by food intake. He had presented several times in the past 6 years with similar episodes. An 11 mm cholelith impacted within the gallbladder neck and multiple additional choleliths were identified on abdominal CT scan along with thickening of the gallbladder wall, consistent with acute calculous cholecystitis. The patient was started on intravenous antibiotics, morphine, and antiemetics. Surgical intervention was postponed due to a positive pre-operative COVID-19 test and the patient was discharged on oral antibiotics. Elective laparoscopic cholecystectomy was performed 4 weeks after initial presentation. During the procedure dissection was tedious due to dense adhesions and fibrous changes. Gross examination of the gallbladder revealed multiple choleliths up to 2.2 cm. The wall thickness ranged from 0.1 cm to 0.8 cm and the mucosa was roughened and focally disrupted but without discrete lesions.Microscopic examination showed transmural thickening and fibrosis, prominent Rokitansky-Aschoff sinuses, subacute inflammatory infiltrate and focal ulceration. Within a localized area of the wall, numerous intramural vessels containing intraluminal fragments of biliary epithelium were discovered. Several epithelial groups were closely associated with fibrin thrombi and bile emboli supporting an in vivo process rather than a grossing artifact. The intravascular epithelium appeared benign, lacking cytologic atypia or architectural complexity. Immunostains for p53 and Ki-67 showed no difference between the intravascular epithelium and the benign background mucosa, further supporting a benign process. Generous sampling of the gallbladder performed after identifying this abnormality showed additional foci of intravascular epithelium but did not reveal evidence of dysplasia or malignancy. Some vessels within the involved regions showed organizing thrombosis and fibrin emboli. The involved submucosal vessels included thin-walled and thick-walled muscular vessels Fig. . ImmunosThe presence of numerous intravascular deposits of biliary epithelium in this case was striking and unexpected, and elicited concern for an occult malignancy which prompted thorough sampling of the specimen and review of the case by several pathologists. The lack of cytologic atypia or architectural complexity in the intravascular epithelium and absence of dysplasia or precursor lesions in the specimen after thorough sampling were strong arguments against a malignant process. Additionally, the demographics of this patient: male, 29-y.o., did not conform to the epidemiology of gallbladder cancer   (McFarland et al. Gallbladders are common surgical specimens; pathologists are fully aware of the possibility of discovering an incidental carcinoma and the need to extensively sample specimens with any unusual histologic findings. A recent meta-analysis describes an incidence of incidental adenocarcinoma in cholecystectomy specimens of only 0.6–0.7% (Pyo et al. Several possible explanations for the observed epithelial intravascular emboli were considered: First, we considered artifactual angioinvasion: the emboli were limited to a specific region of the gallbladder wall, they were present in multiple blocks and levels and there was no epithelial displacement in non-vascular spaces to suggest that they represented displaced epithelium during grossing. The epithelium often conformed to the shape of the vascular spaces and was associated with fibrin thrombi and bile emboli supporting an in vivo process.Second, true angioinvasion was considered: vascular infiltration not related to medical intervention, in the context of benign processes, has been described in benign proliferative processes of the breast (Eusebai and Azzopardi Finally, mechanical pseudoangioinvasion due to manipulation of the gallbladder during surgery was a much logical explanation for the observed pathologic findings. Artefactual displacement of benign epithelium into lymphovascular spaces after invasive procedures has been reported in other organs such as breast (Koo et al. In summary, we describe a case of pseudoangiovascular invasion by benign gallbladder epithelium in a cholecystectomy specimen of a patient who had a delayed cholecystectomy due to a COVID-19 positive test. We favor that this extremely uncommon phenomenon, not previously described, is the result of mechanical, iatrogenically caused displacement of epithelium into abnormally dilated vessels due to an unusually prolonged and difficult surgical manipulation of the gallbladder, in the context of abnormal intraluminal and intravascular pressures. COVID-19 infection likely contributed to this phenomenon by causing a delay in the surgical management.


Meckel's diverticulum is a congenital anomaly that is often detected incidentally. When it presents symptomatically, it causes painless gastrointestinal bleeding. Nevertheless, in rare instances, it can cause acute intestinal obstruction, often obscuring the true clinical picture.A 31-year-old male presented to the emergency department with a 24-h history of unremitting nausea, biliary emesis, abdominal distension, and absolute constipation. After ruling out the most common etiologies of acute bowel obstruction, radiological imaging was obtained and was suggestive of meckel's diverticulum. Laparoscopic meckel's diverticulectomy was performed, with the subsequent histopathological analysis confirming ectopic gastric tissue.Meckel's diverticulum occurs consequent to incomplete obliteration of the vitelline or omphalomesenteric duct, which connects the developing intestines to the yolk sac. It is found in roughly 2% of the population, of which only about 4% may become symptomatic due to any number of complications. Specifically, small bowel obstruction (SBO) and diverticulitis secondary to ectopic gastric or pancreatic tissue are the most common presentations of symptomatic MD.Although relatively rare in adults, MD should be considered in the list of differentials in patients with intussusception leading to SBO, especially on a background history unremarkable for the most common etiologies causing SBO including post-operative adhesions and hernias. •Meckel's diverticulum, a rare congenital abnormality, usually presents with painless bleeding. However, in rare instances, it might cause acute intestinal obstruction, often obscuring the clinical picture.•In patients presenting with acute intestinal obstruction on a background history unremarkable for the most common etiologies, meckel's diverticulitis should be considered in the list of differentials.•In such instances, meckel's diverticulectomy remains the mainstay of surgical management, yielding a prompt resolution of obstructive symptoms. Acute bowel obstruction usually presents with a vague constellation of symptoms, often characterized by bilious/non-bilious emesis, nausea, vomiting, anorexia, and abdominal pain . While p2A 31-year-old male presented to the emergency department with a 24-h history of unremitting nausea, biliary emesis, abdominal distension, and absolute constipation. Notably, the patient's last regular bowel movement had been three days prior to the current presentation, with the patient erroneously attributing his altered bowel habits to his recent onset of anorexia of unknown origin. The patient reported no red flag symptoms, affirmatively denying recent fevers, previously altered bowel habits, infectious urinary symptoms, or weight loss. The patient's prior medical and surgical histories were unimpressive, and he reported no other comorbidities. Pertinently, the patient had had an episode similar to the current one four years ago; at the time, his condition was managed conservatively and resulted in a prompt resolution of his symptoms within 24 hours of his presentation to the hospital. The patient remained asymptomatic thereafter with no consequent episodes till the current presentation.Upon clinical examination, the patient appeared profusely unwell, with excruciating, 7/10, vague, non-localized abdominal pain that caused significant distress to the patient. Abdominal examination revealed a soft, distended abdomen that was non-tender with no evidence of rigidity, peritonitis, or guarding. Pertinently, bowel sounds were audible and were noted to be tinkling in nature, raising the initial suspicions for an obstructive etiology underlying the patient's clinical presentation. The murphy's sign, along with the psoas, obturator, and rovsing's signs, were all negative and unimpressive, effectively ruling out acute cholecystitis and acute appendicitis as plausible etiologies. The patient's past surgical history was also unimpressive, further precluding post-operative adhesions as the likely etiology. Upon clinical examination, there was no evidence of hernial protrusions, and the genital orifices were unremarkable. Furthermore, clinical examination of the abdomen did not reveal any rigidity or guarding, and no signs of peritonitis were appreciated. The patient's C-reactive protein was raised to 15; however, his remaining labs were unremarkable for any pertinent derangements. In order to better delineate the etiology underlying the patient's presentation, an abdominal x-ray was obtained and revealed multiple air-fluid levels in the small bowel .Fig. 1AnBased on the patient's x-ray findings, an obstructive pathology was deemed plausible. However, given that the patient demonstrated an unremarkable surgical history and did not show signs of a possible gastrointestinal malignancy, adhesions, and tumor as causes of acute intestinal obstruction were effectively ruled out. Further radiological investigation through the means of a computed tomography (CT) scan divulged a transition point in the terminal ileum, with mesenteric band cut-off, strongly alluding to the presence of a diverticulum in the specified region .Fig. 2CTThe CT imaging of the abdomen further revealed the presence of the classical meckel's loops, thereby confirming the presence of meckel's diverticulum .Fig. 3CTConsidering the impression obtained from the patient's radiological work-up, a multidisciplinary team meeting (MDT) was conducted. The presence of meckel's diverticulum due to an acute small bowel obstruction was deemed exceedingly plausible. Consequently, the patient was managed using conservative measures for the next 24 hours; however, the patient refused a nasogastric tube, which would have been pivotal in relieving the obstruction. During this time, the patient had an episode of nominal bowel motion once but did not pass any flatus. Conservative treatment was thus continued, and the patient was prepared for a laparoscopic diverticulectomy.During the operation, meckel's diverticulum in close proximity to the ileocecal valve was confirmed. Per-operative evaluation divulged meckel's diverticulitis with the tip attached to the ileal mesentery through the means of a band .Fig. 4PeGiven this intraoperative finding, tip and band release was performed .Fig. 5InAdditionally, given the presence of meckel's diverticulitis and the fact that the patient had been symptomatic four years prior to the current episode, meckel's diverticulectomy was performed .Fig. 6PeThe surgery was conducted unremarkably, with no intra- or perioperative complications encountered during the process. Postoperatively, the patient remained well and symptom-free except for a minor wound infectious from the hypogastric port used for specimen delivery during the surgery. Daily wound dressings were advised without the need for antibiotics.The subsequent histopathology report confirmed the presence of diffusely inflamed ectopic gastric mucosa in close proximity to the ileocecal valve, reinforcing meckel's diverticulum as the culprit etiology underlying the patient's episode.The present paper was reported in line with the SCARE guidelines .3Meckel's diverticulum (MD) is one of several congenital abnormalities that can result from incomplete obliteration of the vitelline or omphalomesenteric duct, which connects the developing intestines to the yolk sac during development, and is a true diverticulum composed of all intestinal layers . It is fThe present study elucidates a case of a 31-year-old male patient with acute onset of symptoms consistent with obstruction. The patient presented with the classical tetrad of bowel obstruction involving nausea, emesis, abdominal distension, and constipation . DiagnosInterestingly, volvulus of the MD was not suspected as a mechanism of obstruction in our case as there was no fibrous band connecting the MD to the umbilicus. We also did not suspect intussusception of the small bowel due to the absence of inversion of the diverticular outpouching into the ileum or cecum. The subsequent histopathology report showed unremarkable intestinal tissue. The lack of ectopic tissue thus suggests diverticulitis as a cause of inflammation, and subsequent obstruction was not a likely differential. Instead, the tip of the Meckel's diverticulum with a band attached to the ileal mesentery was discovered per-operatively during the diverticulectomy. Thus, mesodiverticular band (MDB) of Meckel's diverticulum was determined to be the cause of SBO in this patient. The MDB is a remnant of the vitelline artery, which supplies Meckel's Diverticulum and provides a bridge for bowel loops to herniate and become strangulated, gangrenous, ischemic, or otherwise mechanically obstructed ,17.Surgery, in specific meckel's diverticulectomy, remains the mainstay of treatment in such cases. The most common forms are diverticulectomy, wedge, or segmental resection, and the rationale for which procedure to form depends largely on the integrity of the diverticular base and proximal ileum and the location of ectopic tissue if any . Wedge oIn order to better elucidate the etiology underlying the obstructive symptoms seen in our case, we conducted a literature search using the digital databases  to search for relevant material and articles implicating MD as a cause of SBO. The literature search in our search was conducted using the terms(s): “small bowel obstruction” AND “meckel's diverticulum” OR “diverticulitis” OR “volvulus” OR “intussusception”. The symptomatology, imaging findings, treatment employed, and the follow-up are delineated by 4The present study discusses a case report and delineates a single-center experience dealing with an unusual etiology underlying acute small bowel obstruction. While the study yields important evidence surrounding this etiology and prompts the clinicians to aptly recognize this congenital aberration as a cause of acute small bowel obstruction, it is limited by its sample size. Further multi-centric cross-sectional studies evaluating the true, unadjusted incidence of MD as the causative etiology underlying acute small bowel obstruction will further yield robust data to support the presented conclusions.5MD is the most common congenital abnormality of the gastrointestinal tract, presenting in 1–3% of patients, of which about 4% may become symptomatic. When asymptomatic, it is discovered incidentally during surgical exploration or through diagnostic imaging. Various hemorrhagic, inflammatory, and obstructive complications can arise, leading to an array of presentations. Nevertheless, the presence of MD as the causative etiology underlying acute SBO remains a clinical enigma, with most cases erroneously attributed to post-operative adhesions and/or abdominal hernias. Early diagnosis and a high index of suspicion are imperative to deliver the most optimal treatment. Although relatively rare in adults, MD should be considered in the list of differentials in patients with intussusception leading to SBO, especially on a background history unremarkable for the most common etiologies causing SBO.None.Not commissioned, externally peer-reviewed.NA.NA.TA, AKA, DA, MU, ESA: conceived the idea, designed the study, and drafted the manuscript.KA, MA, TA, OK, MA, EA: conducted comprehensive literature search, screened the studies for relevant content, and created the literature review table.AS, MO, FSA, MK: revised the manuscript critically and refined the literature review table.AB, MMA, MS, RA: drafted the discussion part of the manuscript, revised the final version of the manuscript critically based on the reviewer and editorial comments.TA, SH, MFM, EM: Conceived the initial study idea, diagnosed the case, and gave the final approval for publication.Name of the registry: NAUnique Identifying number or registration ID: NAHyperlink to your specific registration (must be publicly accessible and will be checked): NAWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Talal Almas.RCSI University of Medicine and Health Sciences.123 St. Stephen's Green.Dublin 2, Ireland.Talalalmas.almas@gmail.com.NA.


The vitelline circulation connects the fetus and yolk sac in the first few weeks of fetal development. Its components are the vitelline duct, vitelline arteries and vitelline vein. This gradually breaks down as the placenta grows and overtakes the function of yolk sac as the primary nutrition source. In the event of persistence of these structures, multiple anatomical anomalies can arise such as a Meckel´s diverticulum, fibrous bands and others. We report on a rare finding of an ileal-mesenteric fibrous band remnant of a vitelline artery causing small bowel obstruction in an adult female. Our patient, a 40-year-old female presented with both clinical and radiological signs of small bowel obstruction. She had had no previous abdominal surgery or abdominal trauma. Intraoperatively we found an isolated ileal-mesenteric fibrous band situated at approximately 7 cm from the ileocecal junction. It spanned from the antimesenteric border of the terminal ileum to the border of the mesentery at a 15 cm breadth. In the snare-like loop that was created, part of the small bowel was trapped, creating a strangulated internal hernia which presented as a small bowel obstruction. The fibrous band was transected and the viable small bowel was freed during a laparotomy procedure. The post-operative period was uneventful and the patient was discharged on day 5. A fibrous band should be considered one of the rare causes of small bowel obstruction in a virgin abdomen in adults. In the first few weeks of life, the essential source of nourishment to the developing fetus is the yolk sac. During the early stages this connection is via the vitelline circulation , which lAlthough a MD in its anti-mesenteric position is the most common malformation of the omphalomesenteric duct, the aforementioned abnormalities have been reported in literature. This has furthermore been reported even with the MD located at the mesenteric edge . The aimPresenting complaint and past history: a 40-year-old female presented to our emergency department as a referral from a local clinic. She had a 4-day history of obstipation, a 3-day history of vomiting with associated loss of appetite and generalized colicky abdominal pain. The patient had no previous abdominal surgery or significant medical history.Physical examination and clinical findings: on physical examination she was acutely ill-looking, with the following vitals: blood pressure of 104/68 mmHg, pulse rate of 105 beats per minute, respiratory rate of 20 breaths per minute, saturation of 95% on room air, and temperature of 36.2°C. Her abdomen was found to be mildly distended, hyperesonant on percussion, with voluntary guarding to palpation that was most severe in the epigastrium, and increased bowel sounds on auscultation. Notably, no signs of peritoneal irritation were present. Digital rectal examination revealed she had soft stools high in the rectum and no palpable mass. A urine pregnancy test was negative.Imaging and blood tests: radiological investigations included an erect chest X-ray and erect and supine abdominal X-rays. They demonstrated dilated small bowel loops and multiple air-fluid levels with no free air under the diaphragm ; volvulus ; and internal herniation (caused by a band attached to another viscus) .et al. anomalous bands (CAB) into two categories [Very few articles report small bowel obstruction caused by an isolated fibrous band at the ileal mesenteric location in an adult as illustrated in this case report. Furthermore, of those reported, most are found in the pediatric population . A recentegories . The firtegories . CABs artegories ,9.et al. the mesodiverticular band may or may not be associated with an MD [This case is comparable to a mesodiverticular band considered to have originated from a vitelline artery. This has also been reported by other authors to be a cause of bowel obstruction ,10. For th an MD ,10.Strength and limitation: if diagnosed earlier, management is relatively simple and consists of splitting the FB with the release of the entrapped bowel. There was no delay in the diagnosis and the surgical decision to operate. This could be considered as strength of this case presentation. In the event of a delayed diagnosis, a bowel resection with primary anastomosis might have been needed, regardless of the age of the patient. The limitation was the lack of a functional laparoscopic unit as the patient could have benefited from a laparoscopic approach.We have presented the case of a 40-year-old female with bowel obstruction secondary to an entrapped small bowel in a fibrous band remnant of the vitelline artery. The FB spanned from the antimesenteric border of the terminal ileum to the mesenteric edge of the ileum at a breadth of 15 cm. The FB was transected and the post-op period was uneventful. FBs are a rare yet possible cause of small bowel obstruction in an adult with a virgin abdomen.