Fibroepithelial polyp is a rare benign tumor of the urothelial system that originates from the mesoderm. Polyps are usually small and located in the upper urinary tract and ureteropelvic junction. However, in the pediatric population, such polyps are more common in the posterior urethra and will present with symptoms of urinary tract obstruction. Some will present with flank pain and hematuria, resembling symptoms of ureteric stones. In this case, we discuss a nine-year-old boy presenting with complaints of flank pain and hematuria for one year. Following laboratory and radiological investigations, the left ureter was dilated at the mid-lumbar region with an anteroposterior diameter of 2.3 x 0.6 cm and a left renal pelvis anteroposterior diameter of 2.2 cm. An ultrasound scan identified an intraluminal lesion suspected to be a fibroepithelial polyp. Management was carried out via retroperitoneal surgery with upper ureteral resection and end-to-end anastomosis. Postoperatively, the patient’s symptoms improved, and a subsequent ultrasound scan and renal function test showed improvement of the left hydroureter and hydronephrosis. Fibroepithelial polyps are rare benign tumors that can occur in the urinary tract. It is an uncommon pathology in children, as most cases are reported in adults. Furthermore, most polyps are usually small, short, and located in the upper ureter and ureteropelvic junction . DiagnosA nine-year-old boy presented to the clinic with a history of flank pain and hematuria for the past year. He was not known to have any medical illness and had normal developmental growth milestones. Physical examination revealed no evident abnormality. Routine laboratory workup showed a healthy complete blood count and renal function. On an ultrasound scan, left-sided hydronephrosis was seen. There was no evidence of cortical thinning, but the left ureter was dilated. This was traced to the mid-lumbar region. At that point, there was an oval-shaped isoechoic, mildly heterogeneous lesion within the ureter measuring 2.3 x 0.6 cm. This intraluminal lesion in the mid-left lumbar ureter was causing a mild hydroureter and hydronephrosis, suggestive of a fibroepithelial polyp. Assessment with color Doppler ultrasonography was difficult, but there appeared to be some internal vascularity within the lesion. The anteroposterior diameter of the left renal pelvis measured 2.2 cm. An intravenous pyelogram (IVP) was done and showed a left upper ureteric filling defect <1 cm (Figure The patient underwent open retroperitoneal surgery with upper ureteral resection and end-to-end anastomosis. Creating a fish-mouth-like opening of the distal end of the ureter was done. Our intraoperative findings included a dilated upper ureter with no aberrant vessels. The fascia around the upper ureter was dissected, and transection was done between the proximal and distal parts of the polyp. Upon opening the ureter, a large ureteral polyp with smooth surfaces was seen Figure . HistopaAn ultrasound scan four months following the surgery showed a significant improvement of the upper urinary tract dilation in comparison to the preoperative ultrasound. The anteroposterior diameter of the left renal pelvis was 1.9 cm. The cortical thickness was preserved, measuring 1.8 cm in the upper pole, 1.2 cm in the interpolar area, and 1.4 cm in the lower pole. The upper left ureter was collapsed, as it was on the preoperative studies Figure . FurtherFibroepithelial polyp of the urinary tract is a rare benign tumor, with a reported incidence of 0.5% . In the The diagnosis of a ureteral polyp is done via imaging. The choice of ultrasonography as an imaging modality is the most appropriate course of action as it is readily available, inexpensive, and does not expose the patient to ionizing radiation. It will show hydronephrosis secondary to the obstruction as well as a mildly echogenic non-acoustic shadowing with well-defined margins. Coupling ultrasonography with color Doppler could also show us blood flow in the polyp ,5. Wang Treatment of ureteral fibroepithelial polyps can be done endoscopically, laparoscopically, or surgically. The surgeon’s choice depends on the patient’s age, polyp size, number, and location. Previously, polyps within the ureter were treated by nephroureterectomy because of potential malignancy; however as they are benign lesions, a conservative approach is now preferred ,7. In chA fibroepithelial polyp is a rare benign tumor in children and challenging to diagnose and manage. A good outcome is expected if diagnostic workup and choice of management are optimized to the patient. Per our experience, simple ultrasonography coupled with IVP can be sufficient to show and localize the lesion. In our patient, management was successful with upper urinary tract resection and end-to-end anastomosis. Postoperative improvement of ultrasound findings and renal function tests were reassuring.


High-grade glioma is also called a malignant glioma because it is fast-growing and spread rapidly through brain tissue. Due to the rarity of high-grade glioma, its diagnosis and management are multi-faceted. We present a case of a 10-year-old girl presented with headache, seizure, and right-sided weakness of upper and lower limbs. Neurological exam revealed reduced power in both upper and lower right limbs with reduced sensation and reflexes. Magnetic resonance imaging revealed an ill-defined altered signal intensity mass involving the left temporal lobe with parenchymal involvement and surrounding perilesional vasogenic edema. Biopsy of the lesion confirmed high-grade glioma. The patient underwent external beam radiation therapy with concomitant daily temozolomide treatment, followed by adjuvant standard temozolomide. However, progressive neurological worsening and an increased lesion size led to partial tumor resection through a craniotomy to remove intracranial hypertension, which was unsuccessful, and the patient could not survive after the procedure. High-grade gliomas are the neoplasms of the glial cells found in the central nervous system. These neoplasms are fast-growing and spread rapidly through the brain tissue. These tumors are uncommon, especially in children . High-grA 10-year-old girl with a family history of colon cancer presented to the emergency department with generalized tonic-clonic seizure. She also complained of a similar episode two weeks ago. Her past medical history was associated with a prolonged morning headache, which was generalized, dull, non-radiating associated with nausea for the last two months. She reported difficulty in walking and weakness in the right upper and lower extremity associated with reduced sensation in both upper and lower limbs. She had no history of trauma or fall.Initial evaluation revealed a temperature of 98°F, blood pressure of 120/70 mmHg, heart rate of 95 beats per minute, respiratory rate of 20/minute, and oxygen saturation of 99% on room air. On physical examination, she was confused with incoherent speech. On neurological examination, her power was 2/5 in both upper and lower right limbs, and coordination was intact with reduced sensory sensation. Her toes were down going, and the reflexes were also reduced on the right side of the body. Her cranial nerve examination was not significant, with no evident deformity on her face.Her signs and symptoms were suggestive of the central lesion, and magnetic resonance imaging (MRI) of the brain was performed, which revealed an ill-defined altered signal intensity mass involving the left temporal lobe, retrieving hypointense signal on T1-weighted image (T1W1), isointense to hyperintense on T2/FLAIR (fluid-attenuated inversion recovery) , Ki-67 cellular proliferation antigen, and S-100 protein. The patient underwent external beam radiation therapy with daily temozolomide, followed by adjuvant standard temozolomide, for five consecutive days, every 28-day cycle. However, her condition worsened over the month with hemiplegia and a fluctuating level of consciousness. An increased lesion size led to partial tumor resection through a craniotomy to remove intracranial hypertension, which was unsuccessful, and the patient could not survive after the procedure.High-grade gliomas are the most challenging tumors in terms of treatment. Cerebral tumors are the most common solid neoplastic tumors in childhood and are the prime cancer-related cause of death . Of all Gliomas are graded on cytogenic features and degree of malignancy after hematoxylin and eosin staining. Currently, gliomas are graded via the World Health Organization (WHO) grading scale Figure  4]. Thi. Thi4]. The clinical presentation of high-grade glioma chiefly depends on the patient’s age and the tumor localization. These neoplasms present with different signs and symptoms, and neurological impairment is predominately quick, varying from months to days. A seizure can be the presenting symptom and may herald the onset, particularly when neoplasms are adjacent to the cerebral cortex. A headache, visual deficit, and hemiparesis are the other clinical manifestations in gliomas. In our case, the first clinical manifestation was seizure with chronic headache and signs of hemiparesis . The diaSymptomatic management of high-grade gliomas is mandatory. Seizures and cerebral edema can cause adverse neurologic symptoms that are life-threatening. Antiseizure medications are used to control seizures caused by brain tumors. Cerebral edema is managed with glucocorticoids, most commonly dexamethasone. The dexamethasone dose is decreased gradually to the lowest level to minimize the side effects by controlling symptoms. Hydrocephalus is uncommon in gliomas. However, treatment may be required in the form of surgery to place a shunt. Deep vein thrombosis is usually managed with anticoagulant medicines .The use of adjuvant chemotherapy for the treatment of high-grade gliomas was reputable in the 1980s. In a study by Sposto et al., it was reported that lomustine and vincristine showed significant results against high-grade glioma . SimilarHigh-grade gliomas are rare tumors associated with an unfavorable prognosis, despite the development of treatment options. Our patient developed intracranial hypertension, and we chose to perform both chemotherapy and radiotherapy. The unfavorable tumor progression prohibited the use of chemotherapy and led us to partial tumor resection, which was eventually unsuccessful. Poor prognosis despite the evolution of treatment warrants further research to improve the quality of life and better disease management.


Unilateral retinal pigment epithelium dysgenesis (URPED) is a rare condition and is characterized by a unilateral and solitary lesion in the peripapillary region. The lesion presents with central atrophy, peripheral fibrosis, and hyperplastic changes in the retinal pigment epithelium (RPE). Herein, we report the first case of URPED in a Chinese individual using multimodal imaging techniques such as en-face optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA).A 10-year-old girl presented with 20/40 vision in her left eye. Presented as a solitary, unilateral, large and yellowish-white lesion, with fringe-like margins was observed in the posterior pole and lower middle periphery of the left eye continuous with the optic nerve, indicated URPED. Infrared fundal (IR) images showed that the fringe-like contour of the lesion was visible, with diffuse hyperreflective signals specifically in the fovea, while with peripheral dark spots, having a typical leopard-spot like appearance. Fundus autofluorescence (FAF) revealed a markedly scalloped lesion containing a hypoautofluorescence area mixed with an isoautofluorescence area. Spectral-domain optical coherence tomography (SD-OCT) revealed the outer segments of photoreceptors presented with an inhomogeneous signal in the fovea, with a weak local signal. The ellipsoid and interdigitation zones were thinner than normal, while the RPE/Bruch’s complex was not flat, with locally visible protrusions. En-face OCT image at the level of the RPE zone showed a mottled hyperreflective signal with peripheral hyporeflective spots, fringe-like margin lesions. OCTA of the avascular area of the fovea in the superficial, deep, and outer retinal layers appeared to be oval in shape, the choroid capillary layer revealed an increase in the density of the choroidal vasculature in the fovea.This is the first report on URPED in China. Both en-face OCT and OCTA were essential in observing and studying the disease. Further investigation is required to better define the en-face OCT and OCTA features of URPED and clarify the disease characteristics and prognosis. Unilateral retinal pigment epithelium dysgenesis (URPED) is a rare entity and is characterized by a unilateral and solitary lesion in the peripapillary region. The lesion presents with central atrophy and peripheral fibrosis, along with hyperplastic changes in the retinal pigment epithelium (RPE) . It was A 10-year-old girl presented with a painless reduction in visual acuity in her left eye, incidental finding on the school routine examination. The fundus revealed a unilateral solitary lesion of the RPE with fibrosis and hyperplastic changes at its periphery and thinning in the center. No family or trauma history was noted. The medical and ophthalmic history of the patient were negative. General pediatric physical examination results were normal for all systems. The initial best-corrected visual acuity (BCVA) was 20/20 in the right eye and 20/25 in the left eye. The diopter of both eyes was 0 DS OD and, − 2.0 DS OS. The anterior segment and intraocular pressure were normal. Funduscopic examination of the right eye was unremarkable. A solitary, unilateral, large, scalloped and yellowish-white lesion, with fringe-like margins was observed in the posterior pole and lower middle periphery of the left eye continuous with the optic nerve. Furthermore, we noted the presence of fibrosis and hyperplastic changes in the RPE at the periphery and thinning at the center of the lesion Fig. . The outThe treatment for this patient was closely observed. At the last follow-up examination, after 18 months, there were no changes in the fundus, and her BCVA remained 20/20 OD and 20/25 OS.URPED is a rare, unilateral, benign, well-defined, and congenital RPE dysgenesis that was first described by Cohen et al. in 4 patients in 2002  further The etiology of this condition remains unclear. Renz et al.  hypothesThe lesion presented in the fundus photography is by far more pale than in previous cases published . We consAutofluorescence signals are predominantly derived from lipofuscin within the RPE . Here, FSD-OCT outcomes suggested that the outer segments of photoreceptors demonstrated an inhomogeneous signal in the foveal region, with a weak local signal. The ellipsoid zone and interdigitation zone were thinner than normal. The RPE/Bruch’s complex was not flat, and demonstrated locally visible protrusions that may have negatively influenced the patient’s BCVA. Cohen et al.  observedIn normal eyes, structural en face OCT image on the RPE layer is homogeneous and hyperreflective, which makes it easier to distinguish from the surrounding and better resolved tissues. The only hyporeflective elements at this level are the optic disc and the tomographic shadowing of the normal retinal vessels above . In our OCTA is a recently developed technique that facilitates non-invasive visualization of vascular structures. It was proven to document in vivo choriocapillaris and choroidal vasculature in a reproducible and non-invasive manner, which is an invaluable tool to examine the choroid in either physiological or pathological conditions . MicrovaDespite the very distinctive fundus features of URPED, it is important to address other similar clinical differential diagnoses. First, peripapillary acute zonal occult outer retinopathy (AZOOR) may appear as a rounded or U-shaped whitish lesion around the optic disc . In periHowever, this study has several limitations. We lacked the FFA information due to the child’s parents did not agree to perform the examination. The sample size of the study was relatively small. Additionally, the follow-up time needed to be longer since the disease reportedly probably progresses gradually .In conclusion, this is the first report on URPED in China, both en-face OCT and OCTA are useful tools to observe the disease. The processes associated with the natural development of URPED remain unclear. Further studies and longer follow-up times would be required to better define en-face OCT and OCTA features of URPED and clarify the characteristics and development of this rare disease.


Borderline ovarian tumor (BOT) refers to a distinct tumor of the ovary of epithelial origin and typically has a favorable prognosis. However, these tumors are not exempt from risks of recurrence and malignant transformation, which can arise from the remaining ovarian tissue, peritoneal implants, or distant localization. Here, we report a case of a mucinous BOT with multiple pulmonary cystic nodules without evidence of pulmonary metastasis even after two fine needle biopsies. Staging surgery was performed, and no evidence of peritoneal implants or invasion to adjacent organs found. At the end of the 7-year monitored follow-up after surgery, the pulmonary lesions were found to be increased in size. The transbronchial lung biopsy and pleural biopsy confirmed transformation into malignant mucinous adenocarcinoma with pleural metastasis. In the current case, we observed potential pulmonary metastasis of the BOT with malignant transformation and a latency as long as 7 years, which reminds us that multiple pulmonary cystic changes in patients with BOTs should be screened carefully to evaluate the pulmonary involvement of BOTs and potentially false-negative results after fine needle biopsy. Thus, a thorough check-up for complete staging of the disease and a close long-term follow-up to monitor potential recurrence and malignant transformation are advised. Borderline ovarian tumor (BOT) refers to a group of ovarian epithelial tumors officially defined by the International Federation of Gynecology and Obstetrics (FIGO) in 1961 and by the World Health Organization (WHO) in 1973. Histopathologically, the behavior of this group of neoplasms is intermediate between the behavior of benign cystadenomas and invasive carcinomas; however, the morphological changes are diverse, and the behavior is therefore heterogenous. The serous and mucinous subtypes are the most common forms  value: 15 Hounsfield units (HU)] with slight peripheral enhancement, which were under close monitoring after cytoreductive surgery for a BOT.Seven years prior, she had suffered from progressive abdominal distention. Abdominal contrast-enhanced CT  and a thDuring the following 7 years, CA-125 was within the normal range after the risk-reducing cytoreductive surgery, and the size and morphology of the pulmonary nodules were stable.2 of docetaxel per cycle] with 3-week intervals were completed, the pulmonary solid metastasis progressed with the development of pleural effusion and pleura thickening  for the publication of any potentially identifiable images or data included in this article.GH and YY made substantial contributions to the conception and design of the work. YM, C-nL, and Q-yW helped to collect the data of the case. GH, YY, and J-wM write the manuscript. J-wM, GH, and YY carried out interpretation of data for the work. NW performed the laparotomy. GH, J-wM, BJ, and JK performed the transbronchial lung biopsy and pleural biopsy. All authors contributed toward acquisition of data for the work. All authors revised the paper critically for important intellectual content. All authors carried out final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Soft tissue sarcomas in the head and neck are rare malignancies. They occur in this area in less than 1% of all malignant tumors. Some authors have described the development of sarcoma from the mesenchymal tissue in the larynx. The histological diagnosis of a sarcoma depends on the immunohistochemical investigation. In particularly difficult diagnoses, electron microscopy has to be used. The treatment recommendation depends on the histological type of sarcoma. We analysed and summarized data on the diagnostic criteria and therapy for sarcoma of the larynx presented in the literature. We present three new cases of laryngeal sarcoma and describe the analyses of the published diagnostic and treatment schedules of laryngeal sarcomas. We developed a treatment protocol recommendation for laryngeal sarcoma based on an analysis of literature data and case reports. This recommendation is based on histological type, staging, grading, size, and survival data. Laryngeal carcinoma accounts for 95–98% of laryngeal malignant tumors. Primary sarcoma of the larynx is a rare disease . . More thThe first two documented examples of laryngeal myofibroblastic sarcoma (low-grade form) in the world literature were described by MacGregor et al. in 2002 as a rare new subtype in the laryngeal area .Low-grade myofibroblastic sarcoma (LGMS) is an atypical myofibroblastic tumor with fibromatosis-like features with preference predominantly in the head and neck area. LGMS generally was described mostly as a malignant sarcoma (low-grade type) with a considerable tendency to recur with low metastatic potential ,8. Only Myofibroblastic sarcomas (MFS) or myofibrosarcomas are very rare. They are identified by the structure of the cells and are characterized by special immunohistochemical markers: desmin, vimentin, alpha-smooth muscle actin. The challenging histological diagnosis of sarcoma depends on immunohistochemical investigation. In controversial cases, laryngeal sarcomas diagnosis has to be substantiated by electron microscopy . There is a minimum of information in the literature regarding recommended therapeutic protocols for laryngeal sarcoma. The new paper by de Juan Ferré et al. (2021) on clinical guideline of management of soft-tissue sarcoma  is certaIn the present work, the diagnostic-therapeutic procedures were analyzed in a review of published cases of malignant sarcoma of the larynx.A 63-year-old man, smoker, presented to our clinic with complaints of shortness of breath and dysphonia that had been ongoing for 3 months. This patient was referred to the Otorhinolaryngology (ENT) outpatient department with edema of the right vocal cord with a history of hoarseness. He denied any alcohol consumption.A laryngeal examination revealed an exophytic mass in the right vocal cord. There was fixation of the right vocal cord and a tumor (size 12 mm × 15 mm × 12 mm) arising from the anterior commissure and ventral part of vocal cord.Laryngoscopy showed the tumor of the vocal cord, the mobility of the right vocal fold had reduced with excursion of the vocal cord by the tumor mass, but the mobility was 2 mm more in the lateromedial direction. The vocal cord on the left side was completely functional. See Direct microlaryngoscopy was performed under general anesthesia with a representative biopsy taken from the lesion. The result of the histopathological examination was myofibroblastic sarcoma of the larynx (MFS).2 Laser (8 W), and the section of the margins of the resection was histologically tumor free (frozen section and full investigation).We performed a partial laryngectomy—extended chordectomy with partial resection of the laryngeal ventricle (Morgagni’s sinus), partial resection of the perichondral layer of the thyroid cartilage, and a resection of the anterior commissure 3 mm on the left vocal cord. The resection was done with a CORadical surgery was sufficient for the treatment. We followed-up the patient, who has been without signs of recurrence or persistence of the disease for 36 months.A 67-year-old man presented to our ENT department with complaints of shortness of breath and dysphonia that had been ongoing for 2 months. This patient was referred to the ENT outpatient department with a growing tumor on the right side of the larynx. Histology of a biopsy sample verified a benign tumor. Because the biological behavior of the tumor was described as aggressive growth, a new biopsy was performed. The sample was analyzed, and histology showed a suspicious fibrosarcoma. He had not been smoking and denied alcohol consumption. Respiration was difficult.A laryngeal examination revealed an exophytic mass in the right vocal cord and anterior commissure. The mobility of the right vocal cord was maintained, and there was a tumor of approximately 12 mm × 15 mm × 17 mm arising from the commissure and ventral part of the vocal cord. Direct microlaryngoscopy was performed under general anesthesia with a representative biopsy taken from the lesion. The result of the histopathological examination was myofibroblastic sarcoma of the larynx. The laryngoscopy showed the tumor of the vocal cord, the mobility of the right vocal fold was with reduced excursion of the vocal cord by the tumor mass, but the mobility was more than 2 mm in the lateromedial direction. The vocal cord on the left had complete function.Given the respiratory distress, an urgent tracheostomy with general anesthesia was performed.CT scans showed the transglottic location of the tumor mass being 40 mm × 22 mm × 16 mm into the base of the epiglottic cartilage. No infiltration to the cartilage was evident. No lymph nodes were described, as the largest lymph node was not over 5 mm. See We performed a total laryngectomy. The tumor in the larynx was completely obstructed by the laryngeal lumen. Revision of the lymph nodes on both sides was performed, and no evidence of enlargement was detected. A histopathological diagnosis of myofibroblastic sarcoma of the larynx (MFS / LGMS) was performed.The next step involved beam therapy because the tumor margin was near the surgical board of the sample. The dose was 66 Grays. The patient is still alive, and no evidence of recurrence of the tumor or persistence of the disease had been detected to date.A 80-year-old man presented to our ENT department with the following health problems: shortness of breath and growing of neck tumor mass ongoing for 2 months. This patient was referred to the ENT outpatient department with a large tumor on the jugular region and thyroid gland. He had stopped smoking 40 years ago. He denied alcohol consumption. He had urethral cancer 10 years ago.A laryngeal examination revealed an exophytic mass with spread into the larynx, thyroid, and soft tissue. The infiltration of the chest aperture was evident, and multifocal metastases in the lung were detected. Multifocal skin metastases were also detected. There was fixation of the right vocal cord and a tumor of approximately 12 mm × 15 mm × 12 mm arising from the commissure and ventral part of the vocal cord. See An urgent complicated tracheostomy for respiration distress was done. Death occurred 20 days after tracheostomy. We waited for the results of rare histology for 3 weeks. The definitive result of histology, a rare finding, was laryngeal undifferentiated sarcoma, which not announced until after the patient’s death. The immediate cause of death according to the autopsy protocol was thrombotic embolism of the pulmonary artery branch. The definitive result of the histopathological examination was undifferentiated epithelial sarcoma of the larynx (UNEP/UDES). The sarcomas are uncommon malignant tumors of the larynx. Some reports describe an incidence of soft tissue sarcomas in adults in the head and neck area below 5%. Laryngeal sarcomas are less than 1% of all malignant laryngeal tumors generally ,15.Sarcoma of the larynx commonly presents as hoarseness. Laryngoscopy shows a painless submucosal mass. The tumor may grow fast, with dyspnea and/or stridor following in the short period of time.Sarcomas are described with a wide range of histological results and clinical activity from relatively slow-growing tumors (chondrosarcoma) to hostile tumors . This undifferentiated epithelial sarcoma (our Case 3) was loco-regionally destructive and had great metastatic ability.The early symptoms of the presented cases of sarcoma were hoarseness, dyspnea, or suffocation. These have been described in many publications as well. The growth potential of sarcomas is high. Sarcomas may grow in any part of the larynx but are most often located in the vocal cords and/or cricoid cartilage .We support these data with three new published cases. Our group of three patients indicates that the etiology of laryngeal sarcomas is still unclear. Their incidence is more common in men and in older age.The treatment of LGMS is still not precisely determined. Most papers supported surgical treatment—excision of the localized tumor, radiation therapy of the primary area, or a use of both treatment methods.Most patients were treated surgically. Either by local excision or some broad excision (laryngectomy). Only a few cases have been reported where patients were treated with additional radioactive treatment or chemotherapy . Many authors recommend a broad wide local excision of LGMS and subsequent careful dispensarization ,8.If the sarcoma grows slowly, the tumor is often small in size and has a late recurrence. In tumor recurrence, the tumor does not report increased cellularity, proliferation, or increased number of atypia compared to the primary tumor. In contrast, however, one case of metastatic sarcoma exhibiting these features has been described in the literature.In our two cases we used the wide  surgical therapy despite the size of the tumor mass, age, and histology type of sarcoma. In the case with near-tumor margin we added radiotherapy.Covello et al. published case of laryngeal LGMS  surgically treated by supracricoid partial laryngectomy with cricohyoidoepiglottopexy (without block neck dissection). No further additional therapy was given. One year after surgical treatment, the patient is free of tumor recurrence/persistence . Our twoOne case of total laryngectomy for LGMS has been reported in the literature. For our one case, it was also necessary to perform a total laryngectomy ,15. The The analysis of published data and our experience supported the following treatment protocol recommendation.Indirect laryngoscopy to provide evidence of laryngeal status and decision of type of larynx obstruction.CT, MRI scan show size, spread, and metastases of tumor mass.Exact diagnosis of sarcoma by biopsy under a laryngoscope needed.Histopathology.Complete investigation by an experienced pathologist and extensive immunohistochemistry tests are necessary. The poor cases for any histological subtypes of laryngeal sarcoma were associated with poor data of immunochemistry markers for laryngeal sarcoma diagnostic set.Surgery. Surgical therapy must be radical total laryngectomy or less radical laryngeal resection. The surgical margins are very important for grading of laryngeal sarcomas in general.Radiotherapy. Beam therapy depends on the oncological protocol including staging, grading, histological type of sarcoma, and radicality of surgery if it has been done.Chemotherapy. For aggressive histological subtypes, chemotherapy  was used. The effect of chemotherapy did not influence the survival data ,17.Indirect laryngoscopy every 4 months.MRI once yearly.Direct laryngoscopy if necessary.In our group of three cases, two patients were treated surgically , and one patient died of tumor generalization. One of our patients received a full dose of radiotherapy.We did not perform block neck dissection because no pathologically altered cervical lymph nodes were seen on CT and ultrasound. According to the literature, 88–90% of sarcomas  do not have metastases in the neck area . The accThe staging system of soft tissue sarcoma described Ryan ,19 involBaker published a staging system (based on grading) according to the recommendation of AJCC/UICC classification . The UICMetastatic type—evidence of far metastasesLocalized type—tumor is evident in the germinal area onlyLevel 1Kaposi sarcomaDermatofibrosarcomaFibromatosis (desmoid)Sarcomas growing from meninges, brain, parenchyma of organs Level 2The soft tissue classification is used for head and neck sarcomas. ,20,22.For the sarcoma (head and neck), a division into stages of disease has not yet been established.The laryngeal sarcomas were classified using this recommendation in this paper, which supported the aim of the authors of this paper. We need more information and cooperation on an international basis for a better classification of sarcomas in the head and neck region. Improving the classification can be lead to more exact and stronger evidence for modification of the treatment protocol and improving patient outcomes in the future. The treatment and prognosis can be divided according to the biological behavior of sarcomas in three subtypes. Our data for laryngeal sarcomas and the literature overview data can be used for dividing laryngeal sarcomas in three groups depending of the malignant potential of each histological subtype of laryngeal sarcoma:Chondrosarcoma Myofibroblastic sarcoma ,14Leiomyosarcoma ,15Hemangiosarcoma (angiosarcoma) Group 1. Subtype 1 Laryngeal Sarcomas with Good PrognosisKaposi sarcoma Fibrosarcoma Liposarcoma Group 2. Subtype 2 Laryngeal Sarcoma with Moderate Survival DataRhadbomyosarcoma Pleomorphic non-differentiated sarcomaSynovial sarcoma Alveolar soft-tissue sarcomaUnclassified/non-differentiated sarcoma Group 3. Subtype 3 Laryngeal Sarcoma with Poor PrognosisThe general recommendation for treatment and planning protocol for laryngeal sarcoma unfolds according to the size and biologic behavior.In the literature, the type of surgery recommended is  laryngectomy depending on the size of tumors. We can use the endoscopy approach, vertical partial laryngectomy (laryngofissure), or total laryngectomy for large tumors with infiltration of a large area of laryngeal structures. On the other hand, for any other histological types (chondrosarcoma) we can use reduced surgery . The literature described that because many of these tumors are pedunculated, show less tendency to infiltrate the surrounding structures, and metastasize later than laryngeal carcinomas, they may remain operable for a considerably longer period after diagnosis compared to squamous cell carcinoma . ItalianFrom our group of three patients, two patients underwent surgical treatment , with one receiving a full dose of radiotherapy as adjuvant therapy because of the proximity of the surgical margins at the tumor border.Surgical treatment is the main treatment method in the planning of therapy for laryngeal sarcoma. Preservation of the larynx is feasible, as most laryngeal sarcomas are detected early. According to the literature, 10–12% of sarcomas  develop early metastases in the neck area ,24. In oIn our study, one surgically treated patient with a neck mass  had a block neck dissection (10%), which proved to be a metastasis in the neck area.Radiotherapy in the treatment protocol for head and neck sarcomas has shifted significantly over the last 30 years. The literature indicated that sarcomas demonstrate considerable radio-resistance. By contrast, some authors cited radiotherapy as a substantial supplement in the treatment protocol of soft-tissue sarcoma to reduce the incidence of local recurrence ,24,25.The main indications for postoperative radiotherapy (recommended in the literature) are high-grade sarcoma, positive surgical edges, large sarcoma (over 5 cm), and tumor recurrence. In our study, adjunctive postoperative radiotherapy was given in one patient with high-grade sarcoma, expecting to improve local control.The outcome of chemotherapy on different sarcomas of the larynx has not been verified statistically. None of the published cases were given chemotherapy. On the other hand, we have introduced non-surgical therapeutic oncological protocols including chemotherapy and radiotherapy leiomyosarcoma .We accept that neoadjuvant chemotherapy and radiotherapy have been reported for rhabdomyosarcoma only . Under tOn the other hand, a chondrosarcoma is often well differentiated  and has better prognosis . UsuallyDue to the rarity of laryngeal sarcomas, no survival data have yet been available. The absence of a large group of laryngeal sarcomas is due to the fact that laryngeal sarcoma is an especial tumor.A surgical solution is the therapeutic method of choice. Early diagnosis of laryngeal sarcoma makes it possible to choose surgical treatment with the protection of the larynx in the treatment protocol. Adjuvant radiotherapy (postoperative) is applied to high-grade sarcoma and/or positive surgical edges. The prognosis is comparatively favorable when compared with sarcoma arising from other anatomical areas. A report from the year 2020 by de Juan Ferré et al. provides a current view of the diagnostic-therapeutic model for soft-tissue sarcoma. The diagnostic-therapeutic management should be executed by multi-disciplinary team. MRI/CT of the tumor-area and biopsy is compulsory before the initiation of treatment. Radical surgery with tumor-free tissue edge is the treatment pillar for the localized lesion. RT is recommended in big-size, deep, high-grade sarcomas, or after marginal resection not suitable for re-excision. Perioperative chemotherapy should be used for high-risk sarcomas of the extremities and trunk-wall. In the case of oligometastatic disease, patients should be recommended local therapies .Based on the staging of sarcoma  and our Level 1 Localized type—surgeryLevel 2 Metastatic type—no surgeryT1 tumor less than 2 cm in main diameter—larynx preservation procedures limited and/or partial laryngectomy if necessary.T2 tumor over 2 cm but less than 4 cm in main diameter—partial or total laryngectomy.T3 tumor over 4 cm localized type into larynx—total laryngectomy.N0—no evidence of nodal metastases, no block lymph nodes dissection.N1—evidence of lymph node metastases, block  neck dissection.M0—no evidence of far and organ metastases.T4a tumor of the brain wraps, brain, orbit, masticatory muscles, and face skeleton.T4b tumor growing into brain, surrounding the carotid, infiltrating prevertebral space or central nervous system through perineurial growing.N—any/arbitraryM—any/arbitraryAdjuvant radiotherapy (postoperative) is only applied to high-grade sarcoma and positive surgical edges.Neoadjuvant chemotherapy and/or radiotherapy is recommend for rhadbomyosarcoma only.


Case Presentation. Case 1: a 55-year-old male presented to us with a 3-day history of severe right lower quadrant pain. Computed tomography (CT) showed penetration of terminal ileum diverticulitis. Following a 7-day conservative treatment, he underwent ileocecal resection. Pathology results revealed a false diverticulum and two in five points of perforated terminal ileum diverticulum. Case 2: a 77-year-old male presented to us with severe right lower quadrant pain and unconsciousness. CT showed penetration of terminal ileum diverticulitis and air in the mesentery. Ileocecal resection was performed 2 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 3: a 61-year-old male presented to us with a right lower quadrant pain for 10 days and fever for 6 days. CT showed penetration of terminal ileum diverticulitis and abscess of the psoas muscle. Puncture and drainage of abscess were performed. Laparoscopic ileocecal resection was performed 30 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 4: a 39-year-old female presented to us with right lower quadrant pain for 9 days, suspicious of appendicitis. CT showed abscess of pericecal area. Puncture and drainage were performed. A drainage tube was located into the cecum through the terminal ileum. Conservative therapy was effective, and she was discharged 23 days postadmission.  Terminal ileum diverticulitis is a rare clinical disease. It can frequently mimic other processes, such as acute appendicitis. Diagnosis and therapeutic decision making  can be complex. We report four interesting cases of terminal ileum diverticulitis.  All four cases had right lower quadrant pain. Three cases were diagnosed by CT, whereas one was diagnosed by abscess drainage. Two cases required surgical treatment within 3 days, one within about 1 month, and one case did not require surgery. The decision of whether to manage a patient surgically or conservatively is difficult. It is critical not to delay the decision of performing a surgical treatment until each patient reaches a stable general condition. Terminal ileal diverticulitis is a very rare type of ileum diverticulitis, with the exception of Meckel's diverticulum. An important characteristic of these diverticula is that they are false diverticula. Most patients with terminal ileum diverticulosis are asymptomatic. When the diverticulosis becomes diverticulitis, patients may present with right lower quadrant pain and a clinical picture that leads to suspicion of acute appendicitis. Computed tomography (CT) is very useful for the diagnosis of terminal ileum diverticulitis. However, because of abscess formation, diagnosis may be very difficult. To date, a standardized treatment has not been established in diverticulitis patients. Conservative treatment  may be useful at times. However, surgical treatment may be necessary in case of an unstable patient. Here, we present four cases of terminal ileum diverticulitis. For these patients, both surgical and conservative treatments have been used.μL and C-reactive protein (CRP) of 18.06 mg/dL. Contrast-enhanced CT revealed the inflammation of mesenterium caused by penetration of a terminal ileum 2-cm diverticulitis. These were at least two parts of diverticulum. Additionally, the CT detected air in the terminal ileum's mesentery, whereas no free air was found in the abdominal cavity  count of 17,900/l cavity . A 7-dayl cavity . Of notel cavity . The patμL and CRP of 8.82 mg/dL. CT showed penetration of terminal ileum diverticulitis and air in the near mesentery  could be the treatment of choice, given a stable general condition of the patient. Two cases required surgical therapy within 3 days, one case within about 1 month, and one case did not need surgery. Several earlier reports suggested that a conservative management may be sufficient to treat uncomplicated terminal ileum diverticulitis without perforation , 9. HoweSurgical treatment was necessary for three cases. Specifically, one was performed laparoscopically and two with an open approach. Of note, of the surgically treated cases, an acute inflammation status was observed in the two open approach cases, and a chronic status was found in the laparoscopic case. Specifically, Case 3 had an abscess from the terminal ileum through the psoas muscle until the inguinal area. Although surgical therapy may be required, a stable inflammation status would be of preference. Laparoscopic surgery was performed only in Case 3. Cases 1 and 2 might be possible by laparoscopic approach, but the operator in charge chose open surgery because of its skill and safety.One case underwent drainage therapy. If the patient reached a stable status only by drainage, it would be acceptable. In that case, no surgical operation was required. In general, surgical therapy faces the possibility of complications both during and after surgery. This case underwent a safe drainage and experienced good progress. However, future diverticulitis recurrence is possible. Similarly, bowel stenosis may develop after repeated diverticulitis. As a consequence, patients should receive follow-up.We experimented four cases of terminal ileum diverticulitis perforation and penetration. Terminal ileum diverticulitis mimicked appendicitis. CT was a useful tool for diagnosis. Surgical treatment or abscess drainage may be required until the patient reaches a stable status. Laparoscopic surgery will be technically safe and feasible where expertise of laparoscopy is available. The precise method for the surgeon to determine is safe should be selected.


Recurrent spontaneous abortion (RSA) is a problem that faces women for a variety of reasons. Although leiomyomata is relatively common, calcified leiomyomata which is called “womb stones” is a very rare cause of RSA. These womb stones are correlated with retained products from conception and osseous metaplasia. We report a very rare case of a large calcified leiomyomata which caused secondary infertility and pregnancy loss of 7 pregnancies due to spontaneous abortions. Recurrent spontaneous abortion (RSA) occurs in approximately 1% of females in the reproductive age and is of a wide variety in nomenclature  .Calcification in the endometrium of the uterus is not very common in infertility cases, and it has a correlation with the products retained from conception and with osseous metaplasia. Ultrasonography is the most reliable method of diagnosis for endometrial calcifications . InfertiThe term “womb stones” refers to calcified appearance of leiomyomata in radiological imaging –8; such A married couple presented to our fertility clinic complaining of recurrent pregnancy loss for ten years. The wife was 32 years old and had pregnancy loss for seven times occurring in the second trimester in each pregnancy with the last one being a year from the date of the clinic visit. In each pregnancy, her pregnancies were monitored by an obstetrician and the loss of pregnancy was verified by ultrasonography in each case. There was no history of primary infertility or any delay of conception. Menstrual cycles were regular with no dysmenorrhea or any other symptoms. Gynecological physical examination was unremarkable, and the uterus was normal in size, contour, and no tenderness was noted. It was also anteverted and anteflexed, all adnexae were normal, and hormonal and chemical parameters were also within normal range. The medical history was otherwise unremarkable. She had a surgical history of dilation and curettage (D&C) and an open ovarian cystectomy. An abdominal ultrasonography was conducted and showed a normal anatomy of the uterus with subendometrial calcifications in the frontal wall of the uterus, spanning 2 cm in diameter .A later abdominal ultrasonography showed normal ovulation with both ovaries showing as normal in bulk, echotexture, and follicle maturation, and the calcified endometrium was also seen. The patient underwent hysterosalpingogram which showed partial obstruction of the fallopian tubes. The patient was referred to conduct hysteroscopy for diagnosis and treatment. Hysteroscopy showed a large calcification with multiple calcific protrusions in the endometrium , and it Endometrial calcification is an uncommon finding, and the presence of uterine bone tissue has been reported in several reports in the past years –23, and Calcific endometritis has also been correlated with Asherman's syndrome , 9. Howe∗∗∗∗Endometrial ossification was described to cause many gynecological disturbances such as symptoms of menorrhagia, metromenorrhagia, abnormal vaginal discharge, pain in the pelvis, and bone fragments passing through the vagina spontaneously [Calcification of the endometrium has also been reported without a history of an intrauterine device (IUD) or malignancy , 10. Ossaneously , 22–28. aneously , 25, 28,aneously . It has aneously , 30–33. aneously , 32.


Avulsion is one of the most serious dental traumatic injuries with a reserved prognosis. This case report describes multiple trauma lesions in permanent central incisors of an eight-year-old girl and a four-year follow-up. The right upper incisor suffered avulsion, remained 16 h extraorally, and was replanted after extraoral endodontic therapy. The left maxillary central incisor suffered a noncomplicated crown fracture with concomitant subluxation. The present case adds to the literature a rare occurrence of success in a severe case with poor prognosis. For this reason, the International Association for Dental Traumatology (IADT) guidelines should be followed and, even in extreme situations, replantation should always be considered. Tooth avulsion is a complete loss of attachment between the tooth and the socket with complete rupture of the periodontal ligament and cemental damage ,2. The pTrauma can affect several tissues such as periodontal ligament, cementum, alveolar bone, and pulp. Additionally, some healing complications are strongly related with the presence of bacteria around the traumatized tooth. In this sense, antibiotics might be indicated due to their moderate effectiveness in the control of infection .In severe avulsion cases, the periodontal ligament suffers dehydration, and if it lasts more than 60 min is unlikely to heal ,12. TherIn this paper, we report a case of multiple dental trauma on upper central incisors in an eight-year-old girl. Considering its uniqueness, this report will focus on the replantation of the right upper central incisor that suffered avulsion and remained 16 h out of mouth. Additionally, we present a clinical follow-up of four years without any common after-effects of avulsion. We want to highlight the importance of the International Association for Dental Traumatology (IADT) Guidelines, in order to obtain the best possible prognosis.Informed consent was obtained from her parents so that case records could be made available for teaching purposes, including scientific publication. All procedures followed the Helsinki Declaration, as reviewed in 2013, approved by the Egas Moniz Ethics Committee .An eight-year-old girl was attended to by the Pediatric Department at Egas Moniz Dental Clinic , for an emergency appointment after multiple orofacial trauma. The patient presented no relevant medical history. Regarding the trauma event, her mother reported it having occurred 16 h ago, “where the tooth popped out of the mouth” (sic). After being identified as upper right central incisor (1.1), it stayed six hours in dry conditions and the remaining 10 h laid in milk. Intraoral and radiographic examination detected avulsion of the upper right central incisor (1.1) and uncomplicated crown fracture of the upper left central incisor (2.1) . During After determining the diagnosis, delayed replantation of 1.1 was suggested. This option was suggested given the possible functional and esthetic consequences to the patient with this tooth missing. Additionally, with the tooth present, bone volume would be preserved for future rehabilitation with dental implants. For this reason, the following steps were performed: (1) extraoral pulpectomy; (2) replantation; (3) splint with flexible orthodontic wire and composite.Firstly, tooth 1.1 was cleaned and wiped with gauze. Next, root canal treatment was performed extraorally prior to replantation, with apexification with Mineral Trioxide Aggregate (MTA), obturation, and final restoration . Root caBefore replantation, the tooth was kept in a 2% sodium fluoride (NaF) solution for 20 min, because of the possibility to slow down osseous replacement ,12. SimuAt two weeks of follow-up, the splint was removed and pulp status remained unchanged in both teeth. At three months of follow-up, we performed clinical, radiograph, and sensibility tests. No resorption or infection was observed in 1.1. Pulp necrosis was diagnosed in pulp status of 2.1, and apexification with MTA was carried out in a single appointment.Every six months, clinical and radiographic exams were performed. At four-year follow-up, we observed minor ankylosis-related (replacement) root resorption at the apical zone of the avulsed tooth  and someThis case stresses the importance of the potential of replantation procedures, even in severe borderline cases such as this one. Even though, dental traumas are clinically unpredictable and a clinical challenge .Successful replantation demands a rapid and strict fulfilled criteria to minimize periodontal and pulpal impact . NeverthConcerning the ankylosis after replantation in young patients, readers must bear in mind the growth phase, because the avulsed tooth may be placed in an infra-position and disturb the alveolar and facial growth ,9,24. InRegarding the poor esthetic as a consequence of MTA ,27, indiThe present case demonstrates that an avulsed central incisor showed satisfactory clinical outcomes after delayed replantation at four years of follow-up. The present case adds to the literature a rare occurrence of success in a case with reserved prognosis. For this reason, the IADT guidelines should be always followed and, even in extreme situations, replantation should always be considered, even if it is a temporary treatment in order to allow the most appropriate plan for each case.


Ganglioneuroblastoma, neuroblastoma, and ganglioneuroma (GN) are the tumors that arise from the neural crest cells. Of these, GN has the most benign origin without metastatic potential. The most common sites of their origin are the posterior mediastinum and retroperitoneum. Although the imaging studies, including CT, are available to detect these tumors, the definitive diagnosis can only be made by histological examination. We present a case of a 40-year-old woman with a retroperitoneal GN causing longstanding, gradually increasing, uncontrolled abdominal pain due to its pressure effect on the pancreas, duodenum, and right kidney with the displacement of the inferior vena cava. An exploratory laparotomy was performed, and the mass was removed. Histopathology confirmed the benign nature of the mass (a GN). These tumors are rarely malignant and mostly asymptomatic. However, in our case, abdominal pain was affecting the patient’s life. After a discussion with the patient, an elective surgical procedure was performed, and the patient was symptom-free postoperatively and able to resume her regular routine. Ganglioneuromas (GN) originate from the neural crest tissue and are composed of gangliocytes and mature stroma. They are very rare and benign in their course . The posA 40-year-old woman presented to the hospital with vague, gradually increasing abdominal pain for the past two to three months. She denied radiation of pain and nausea/vomiting. Her last menstrual period was a week prior to presentation, and her past medical history and family history were noncontributory. She had no evidence of an acute abdomen. On physical examination, the abdomen was soft and mildly tender, and the rest of the physical findings were unremarkable. During her stay in the hospital, routine investigations were performed, and the results of which were within reference ranges. Urine dipstick and culture were negative. A pregnancy test was negative. A contrast-enhanced CT scan of the whole abdomen showed a retroperitoneal, well-circumscribed soft tissue density lesion containing subtle fluid attenuation areas and internal septation on the right side Figures , 2.The lesion measured 6.8 x 5.4 x 5.0 cm in craniocaudal, transverse, and anteroposterior dimensions, respectively. In addition, it was abutting the right kidney, compressing it. It was also indenting the duodenum and pancreas and slightly displacing the inferior vena cava without frank invasion. It was decided to observe the patient.On her subsequent visit approximately 3.5 months later, she was still experiencing pain; however, its intensity was increasing each day. Her physical examination showed moderate tenderness, and the rest of the findings and the laboratory investigations were insignificant. However, the repeated CT scan depicted a well-defined mixed density lesion in the retroperitoneum on the right side along with the renal pelvis closely abutting with the duodenum and inferior vena cava anteriorly without invasion measuring 8.5 x 5.3 x 5.0 cm. These findings were suggestive of a benign etiology, and the possible differential included gastrointestinal stromal cell tumor, neurofibroma, or nodal lesion.The patient’s symptoms had progressed and were influencing her daily routine. Therefore, an exploratory laparotomy was planned, the lesion was excised, and the specimen was sent for histopathology. The report depicted features consistent with GN. Since then, the patient has been monitored via regular follow-up, and her symptoms have been alleviated.GN contains mature sympathetic ganglion cells, Schwann cells, stroma, and nerve fibers along with fibrous tissue. The origin of GN tumor is usually from the great sympathetic chain, which extends from the base of the skull, neck, in the chest posterior mediastinum to the retroperitoneum along with the adrenal gland ,7. Such GN is a benign tumor and generally asymptomatic, but occasionally can produce hormones and manifest with symptoms. Careful evaluation by imaging studies is vital for the diagnosis. A definitive diagnosis can be made by histopathological evaluation of the excised lesion. Overall, the prognosis is good following the surgical removal of the tumor.


No abstract available. We present a rare case of adult Lhermitte-Duclos disease (aLDD) in the setting of Cowden syndrome in a 37-year old female patient. Clinical history together with neuroimaging and neuropathological findings are presented. th ventricle and signs of ipsilateral tonsillar herniation. Ophthalmologic examination revealed a marked bilateral papillary edema. A subsequently performed MRI scan confirmed a demarcated, striated lesion with alternating T1-isointense and hypointense bands (The patient was admitted to Neurosurgery because of blurred vision and severe headaches associated with nausea and vomiting, persisting for 2 weeks. She also reported tremor and paresthesias in the left upper extremity. A CT scan revealed a 6 × 5 × 3 cm space-occupying posterior fossalesion on the left side with distortion of the 4se bands A, B. ConNeuropathological evaluation revealed small portions of adjacent normally configured cerebellar tissue and a marginally pleomorphic and slightly hypercellular tumor. The tumor replaced the cerebellar cortex in a band-like fashion and contained multiple gangliocytes with distinct nucleoli D and conaLDD is diagnostic for Cowden syndrome . ReassesThis case underscores the importance of clinical, imaging, and neuropathological synopsis in order to adequately diagnose and counsel the patient as well as monitor carcinoma recurrences or other manifestations in this patient, such as endometrial carcinoma. No funding received for this study. The authors declare no conflicts of interest.


Its relative rarity results in mortality between 20 and 50% 2 because of delayed diagnosis and consequent obstruction, strangulation, and bowel ischemia. Our case series describes three patients before and after operative fixation of paraduodenal hernia. Only one of the three was identified by preoperative radiologist interpretation. Subsequent diagnosis and definitive treatment were completed by surgical staff to resolve undiagnosed undulating abdominal pain and obstructive-type symptoms. We further analyze left-sided paraduodenal hernias after laparoscopic and robotic repair to define common symptomatology, typical CT findings, and preferred laparoscopic repair techniques.Internal hernias are an uncommon cause of small bowel obstruction and present a challenging clinical diagnostic scenario. They result from the abnormal protrusion of an abdominal organ through a peritoneal defect and can cause intermittent obstructive symptoms, diffuse abdominal discomfort, and postprandial pain. Paraduodenal hernias comprise 53% of all internal hernias  Internal hernias are a rare cause of small bowel obstruction that result from the abnormal protrusion of an abdominal organ through a peritoneal defect. Paraduodenal hernias (PDH) arise as a result of the failure of fixation of either the left or transverse mesocolon to the posterior abdominal wall and account for 53% of all internal hernias . AlthougSymptoms of PDH are often nonspecific, intermittent, and encompass many acute and chronic obstructive-type abdominal complaints. Patients can be entirely asymptomatic or describe symptoms ranging from intermittent abdominal pain due to spontaneous hernia reduction  to an acComputed tomography (CT) is the gold standard for diagnosis for PDH  but onlyTime from onset of initial symptoms to diagnosis does not differ significantly between right- and left-sided PDH . DefinitLeft paraduodenal hernias occur more frequently than right paraduodenal hernias. They result from herniation of the small bowel behind the forth portion of the duodenum into the fossa of Landzert due to incomplete fusion between inferior mesentery to the parietal peritoneum . There aRight paraduodenal hernias occur with small bowel herniation through the Waldeyer's fossa. Although infrequent, they are more likely to occur in setting of nonrotated small bowel or malrotated right colon . SimilarA 29-year-old male patient presents with 24 hours of postprandial mid and left upper quadrant abdominal pain. The patient endorsed nausea without emesis, prior laparoscopic appendectomy 2 years ago, and concerns for recurrent small bowel obstruction previously evaluated on multiple occasions. During prior workup, CT imaging showed concerns for partial small bowel obstruction; however, repeat studies after hospitalization showed free flow of contrast and subsequent symptom relief. There was no suggestion of internal hernia per official radiology reports. Patient lab work on presentation was unremarkable, and repeat CT scan showed a large amount of small bowel in the left upper quadrant with swirling of the mesentery and retention of oral contrast. The patient was diagnosed with internal hernia and taken to the OR for diagnostic laparoscopy. During evaluation, the small bowel was run from the cecum to the ligament of Treitz and a 45 cm segment of the small bowel was found to reside behind the transverse mesocolon. After reduction, the patient was noted to have a 4 cm defect along the left lateral side of the fourth portion of the duodenum just distal to the ligament of Treitz. The defect was repaired with an Endo Stitch in typical fashion, and the patient was discharged on postoperative day #3 following an unremarkable postoperative course. Follow-up over the next 18 months showed complete relief of previous recurrent intermittent abdominal pain and no suggestion on repeat imaging for return of the paraduodenal hernia.A 39-year-old female patient with a past medical history only notable for GERD, anxiety, and tubal ligation presented to the emergency department multiple times over the course of 5 days for worsening epigastric abdominal pain with associated nausea and gastric emesis. The patient admitted to radiation of her pain to the left upper abdomen and worsened symptoms with meals. The patient endorsed a history of chronic epigastric and left upper quadrant abdominal pain that has been going on for many years, was evaluated multiple times, and felt to be related to GERD. CT abdomen and pelvis with IV and oral contrast during the last ER visit showed the small bowel contained in the lesser sac with anterior displacement of the lesser curvature of the stomach without obstructive-type appearance on imaging. According to the radiologist, it was an unremarkable scan. The diagnosis of left PDH was made following surgical evaluation and secondary review of imaging. The patient was subsequently taken to the operating room for diagnostic laparoscopy and was found to have a 3-4 cm defect and approximately 30 cm of small bowel behind the mesentery of the transverse colon. This was subsequently reduced, and the Endo Stitch was used to repair the defect in typical fashion. The patient had a benign follow-up visit 1 month after the procedure and in the 9 months since has been entirely asymptomatic.A 29-year-old female patient presented to the acute care service with 1 day of periumbilical and right lower quadrant abdominal pain and complaints of nausea, gastric emesis, and nonbloody loose stools. Labs upon initial evaluation were unremarkable, and radiologist review of CT scan of the abdomen and pelvis was notable for a nonvisualized appendix without concerning signs for obstruction or internal hernia. Transvaginal ultrasound was unremarkable. It was felt that the patient's thin nature made CT diagnosis of appendicitis difficult. Due to the patient's extreme tenderness on physical exam, she was taken to the operating room for a laparoscopic appendectomy with corresponding periumbilical, suprapubic, and left lateral quadrant port placements. During subsequent evaluation, the appendix was noted to be normal in nature without signs of inflammation. The appendix was taken in typical fashion, and the remainder of the bowel was evaluated for possible underlying pathology. Upon evaluation near the ligament of Treitz, 2 loops of small bowel were noted near the fourth portion of the duodenum entering what appeared to be a defect left lateral to the duodenum with one loop of bowel exiting and one entering. 40 cm of injected and dilated small bowel was manually reduced from the left-sided paraduodenal hernia defect. A fourth trocar was placed in the right supraumbilical region to provide greater retraction. However, due to poor initial port placement as a result of planned laparoscopic appendectomy, inability to progress, and lack of experience with PDH disease process, the repair of the paraduodenal hernia defect was not performed during that procedure.The patient was discharged 24 hours later with plans for outpatient evaluation and repair; however, she returned approximately 72 hours later with similar complaints of abdominal bloating, nausea emesis, and persistent right lower quadrant abdominal tenderness. Due to the prior established diagnosis, the patient underwent a robotic left-sided paraduodenal hernia repair using the prior supraumbilical, right lower quadrant, and suprapubic ports with two additional ports placed on the left side for 4-arm docking. The 4 cm defect was identified after elevation of the transverse mesocolon, and multiple loops of small bowel were reduced out of the paraduodenal hernia with repositioning in reverse Trendelenburg position. The defect was closed with interrupted silk suture between the peritoneum alongside the inferior mesenteric vein and the wall of the duodenum as it exited the ligament of Treitz. Follow-up evaluation in the year since operation has showed complete resolution of all symptomatology.It should be noted that the choice to not complete the repair of the PDH at the index operation placed the patient at increased risk for reoccurrence and possible strangulation of bowel. Simple reduction without repair of internal hernia defects is not recommended. A preferred approach if unable to complete the repair laparoscopically secondarily due to port positions is to place more ports. Another approach is to convert to an exploratory laparotomy. The repair of PDH from a midline incision does not differ from the principles of laparoscopic repair with obliteration of the defect with a primary repair remaining the goal.Due to relative rarity of paraduodenal hernias, the identification and repair of PDH is less common in general surgical practice. They have a mean age of diagnosis of 38.5 years , with apIn our case series, one left PDH was repaired robotically and two were repaired laparoscopically. The single robotic case was completed with the da Vinci Si surgical system with a 12 mm periumbilical trocar and four total 5 mm trocars  placed aA total of 4 trocars were placed during laparoscopic repair of left paraduodenal hernias: one 12 mm periumbilical and three 5 mm . The 5 mInternal hernias are an uncommon cause of small bowel obstruction. Paraduodenal hernias represent a subset of internal hernias and are found on autopsy in 0.2-0.9%  of the p


Isolated onset of intracranial hypertension due to spinal cord tumor is rare, thus, easily leading to misdiagnosis and delay in effective treatment.Herein, we describe a 45-year-old female patient who manifested isolated symptoms and signs of intracranial hypertension and whose condition was initially diagnosed as idiopathic intracranial hypertension and transverse sinus stenosis. The patient received a stent implantation; however, no improvements were observed. One year later her symptoms exacerbated, and during rehospitalization a spinal imaging examination revealed a lumbar tumor. Pathologic evaluation confirmed schwannoma, and tumor resection significantly improved her symptoms, except for poor vision.Space-occupying lesions of the spine should be considered in the differential diagnosis of idiopathic intracranial hypertension, even in the absence of spine-localized signs or symptoms. Intracranial hypertension (ICH) secondary to spinal cord tumor is a relatively rare, but well-described manifestation. With a concomitant diagnostic ratio of 47% , its diaWe describe a patient who manifested isolated symptoms and signs of ICH. Her condition was initially misdiagnosed as IIH and venous sinus stenosis. However, one year later a confirmed diagnosis of lumbar schwannoma was made. We also review the literature describing previous similar cases and share our views on associated pathophysiology and therapies.A 45-year-old female patient presented with blurred vision for 13 months and was initially diagnosed with papilledema at the ophthalmology department of another hospital. With no effective treatment, her condition deteriorated over the next 2 months. Consequently, she was admitted to the neurology department of our hospital. No other symptoms of ICH  or any other neurologic deficits were present on admission. The medium-build patient had no previous medical history or family history of venous thromboembolism or hematological diseases, and she denied any drug history including the use of oral contraceptive pills.2O. Laboratory examination of cerebrospinal fluid (CSF) indicated a normal cell count of 4 × 106/L  and a significantly increased protein level of 382.6 mg/dL . Given the other negative results of CSF ink stain, blood T-SPOT tuberculosis, and normal computed tomography (CT) scan of the lung, the neurologists excluded intracranial tuberculous and cryptococcal infection. Meningeal carcinomatosis was also not considered due to the slow progression, though CSF cytology was not investigated.Physical examination revealed a slower light reflex of the left eye, decreased visual acuity of bilateral eyes (more severe on the left) and left nasal hemianopsia. On neurological examination, no neurological localizing signs were observed. Fundus examination showed bilateral papilledema. Brain magnetic resonance imaging (MRI) showed no occupying lesions, only mildly dilated ventricles Fig. a and b. A diagnosis of cranial venous sinus thrombosis (CVST) was then suspected and contrast-enhanced magnetic resonance venography (CE-MRV) was performed. The examination showed relatively thin transverse sinus on both sides but no obvious evidence of CVST. Considering the possibility of elevated CSF protein caused by extracranial, and not intracranial, tumors, the neurologists planned for lumbar MRI but failed to perform the examination because of a metal intrauterine device (IUD). Instead, a lumbar CT scan was performed, revealing no abnormalities Fig. c and d. 2O. Further examinations were suggested but the patient refused and was discharged.A few days later, the patient received a percutaneous intracranial right transverse sinus stent implantation. DSA showed that the well-dilated stent was in position, and venography identified a smooth venous reflux Fig. c and d. 2O with fast-flow leakage of CSF at first, which slowed to no leakage within a short time. Repeated adjustment of the puncture needle was not successful and the Queckenstedt-Stookey test was positive. The CSF test showed a significantly increased protein level of 384.5 mg/dL. By then we highly suspected an intraspinal obstruction, or more precisely, a spinal tumor. Since the patient’s metal IUD had been taken out, a total spinal MRI examination was soon arranged. Imaging indicated an intramedullary tumor at the L1–L3 level and no abnormalities in the cervical or thoracic vertebrae (Fig. One year later, the patient returned to our hospital due to an exacerbated condition. Her vision had worsened and she had been experiencing severe headaches accompanied by frequent nausea and vomiting for over 1 month. A brain MRI revealed obvious hydrocephalus, which was much more serious than that 1 year ago Fig. a and b. One week after admission, the patient underwent resection of the L1–L3 tumor Fig. c and d. Compared with typical neurological symptoms due to spinal lesions, such as backache, radiculalgia, sphincter dysfunction, and peripheral neurologic deficits, ICH and hydrocephalus secondary to intraspinal tumors are well-known but rare. According to a study published in 2004  reportinWe reviewed the literature on cases of spinal tumors that were initially misdiagnosed as IIH with absence of spinal symptoms or signs and found three similar cases Table . Ahmed eInterestingly, our patient was misdiagnosed as having IIH accompanied by TSS. TSS generally represents a common sign of ICH , 6. EarlIt is worth mentioning that the Queckenstedt-Stookey test plays a critical role in the final diagnosis. If the Queckenstedt-Stookey test would have been performed at her first admission, it might have been possible to diagnose the underlying lumbar tumor earlier, so as to improve her deteriorating vision. Hence, the present case also highlights the importance of an overall clinical examination in clinical practice.As yet, the pathophysiological mechanism underlying the association between spinal tumors and ICH is not well established. Prevailing hypotheses include intraspinal neoplastic suppression, intracranial metastasis, increased CSF viscosity, increased CSF fibrinogen, reduced CSF compliance, and neoplastic arachnoiditis. Almost any type of spinal lesion can manifest signs of ICH. The relationship between ICH and cervical tumors can be explained. Any obstruction in the upper spinal canal could result in a rise in venous pressure and subsequent ICH, because venous reflux of the upper trunk mainly proceeds in the superior vena cava that localizes near the third thoracic vertebra. However, interpreting the pathophysiology in lower spinal tumors is not so easy and led us to question the present case manifesting as a lumbar schwannoma. A possible explanation regarding CSF dynamics is that a spinal obstruction could compromise lumbosacral region compliance, which is also known as an “elastic reservoir” for CSF flow, thereby isolating the spinal subarachnoid space from the intracranial region and impacting normal CSF compensation due to pressure alterations . The finFurthermore, a significant increase in CSF protein is a common sign in these patients. Several researchers have correlated the increased CSF protein with increased CSF viscosity, which would in turn increase the resistance to CSF absorption by arachnoid villi , 16, 17.For treatment of such cases, resection of the primary spinal lesion is the first choice. Many patients can benefit from this surgery, even though some may have refractory hydrocephalus and may need to undergo shunt surgery. Moreover, if shunt surgery is performed first, there is a risk of carcinomatous spread in malignant cases.In conclusion, this rare case highlights that clinicians should always maintain a broad differential spectrum of Idiopathic intracranial hypertension, even with the absence of intracranial lesions or neurologic deficits. Abnormal CSF compositions and imaging signs of hydrocephalus in cases with ICH may indicate spinal pathology. Misdiagnosis might result in unnecessary treatments, or more importantly, lead to permanent damage in patients.


We report a case of an encapsulated fat necrosis without significant medical history. To differentiate from liposarcoma, it should be recognized that a half of abdominal encapsulated fat necrosis cases have a history of inflammation and surgery. We report a case of an encapsulated fat necrosis without significant medical history. To differentiate from liposarcoma, it should be recognized that a half of abdominal encapsulated fat necrosis cases have a history of inflammation and surgery. However, according to the patient's medical documents, there was no abdominal mass 4 years ago on computed tomography (CT) scan. He had no history of pancreatitis, trauma, or abdominal surgery. The physical examination did not reveal any abdominal tenderness or a palpable mass. Laboratory tests were normal, including hepatobiliary function, renal function, inflammatory response, and urinalysis. CT scan showed a round and encapsulated 4 × 4 cm mass without any contrast enhancement in the upper left abdomen Figure . There w3Encapsulated fat necrosis can exist as an intra‐abdominal mass without pancreatitis, trauma, or abdominal surgery. Laparoscopic resection of encapsulated fat necrosis is acceptable if liposarcoma cannot be ruled out by clinical history and imaging findings.Although encapsulated fat necrosis usually occurs after pancreatitis, trauma, or abdominal surgery, the etiology in the patient described is unclear. A PubMed database search was performed using the terms “encapsulated” OR “nodular” AND “fat necrosis” up to February 2020 and nine articles were retrieved.Laparoscopic resection of encapsulated fat necrosis is acceptable if there are no signs of pancreatitis, trauma, and abdominal surgery, and imaging findings do not rule out liposarcoma. Although encapsulated fat necrosis can be monitored as an alternative to resection due to its nature of shrinking in size over the time, pathological analysis with surgical resection is critical in making the final diagnosis.Because the natural progression is to decrease in size over time, pathological analysis with surgical resection is critical in making the final diagnosis.In conclusion, encapsulated fat necrosis can present as an abdominal mass with no significant history and laparoscopic resection is indicated. We should be aware that half of the encapsulated fat necrosis mimicking liposarcoma can manifest as an intra‐abdominal mass with histories of pancreatitis, trauma, and abdominal surgery. Encapsulated fat necrosis with a well‐defined cause may allow for careful follow‐up.None declared.JW and KE: conceived and designed the study. KG, TO, and TS: revised the manuscript. SN and YH: were involved in overall supervision of the paper. All authors read and approved the final manuscript.Ethics approval was not necessary for this case report. All patient's data and photographs are de‐identified.Written informed consent was obtained from the patient for publication of this case report and any accompanying images.


Appendix epiploica (AE) in an incarcerated inguinal hernia sac is very rare. We herein report the case of a 57-year-old man admitted to the emergency department with complaints of nausea, swelling, and pain in the left inguinal area. He was diagnosed with left incarcerated inguinal hernia and treated laparoscopically with transabdominal preperitoneal (TAPP) mesh hernioplasty. During the operation, AE, lodged in the direct hernia sac, was seen to originate from the sigmoid colon. The narrow internal inguinal ring was incised at the 2 o'clock position using a monopolar hook, and the hypertrophic AE was reduced to the abdomen and resected. The patient was discharged uneventfully on the second postoperative day. Irreducible or incarcerated omentum and intestinal loops are frequently found in the inguinal hernia sac. Rarely, AE, adnexa, and appendix vermiformis can also be detected in the incarcerated hernia sac. AE in the inguinal hernia sac is rare, with very few cases reported in the literature .In this case report, we investigated the role of laparoscopic TAPP for the emergency treatment of inguinal hernia with AE incarceration, the latter of which was diagnosed during the TAPP procedure itself.A 57-year-old man was admitted to the emergency department with complaints of swelling and pain in the left inguinal area. He had nausea but no vomiting. On physical examination, a painful, irreducible mass of about 2 cm to 3 cm in size was palpated in the left inguinal area; no other abnormality was detected. Laboratory tests revealed leukocytosis. Other laboratory and biochemical tests were normal. Edematous, hypertrophic adipose tissue was identified in the hernia sac during abdominal ultrasonography as ultrasonographic confirmation was adequate for diagnosis. We planned a laparoscopic TAPP surgery considering laparoscopy's superiority to the open technique for visualization of the hernia contents.With the patient under general anesthesia, a 12 mm trocar was inserted directly under the umbilicus, and the abdomen was insufflated. Two 5 mm trocars were inserted through the right and left midclavicular lines at the level of the umbilicus. During exploration, AE of the sigmoid colon was observed in the left hernia sac . Other aEpiploic appendices (EA) are small, adipose structures covered by the colon serosa. Measuring 1 cm to 2 cm in width and 2 cm to 5 cm in length, EA can be observed on the peritoneum, small intestine, and, most commonly, throughout the colon, except for the rectum . AlthougIt is possible to come upon unexpected structures within the irreducible inguinal hernia sac. Therefore, a detailed anamnesis and physical examination, together with radiological and laboratory tests, will help the surgeon to plan the surgery. In this case, we planned a laparoscopic operation due to its diagnostic and treatment-related advantages over open laparotomy. Despite advanced imaging tools, contents of the hernia sac cannot always be accurately identified preoperatively. The contents of the hernia sac may get reduced to the abdomen during anesthetic induction or surgery, in which case laparotomy may be necessary to observe and check the contents of the sac. While laparotomy increases the risks of postoperative wound infection and incisional hernia, failing to notice ischemic or necrotic bowel contents by not performing laparotomy will have serious postoperative consequences . TherefoOur aim was to investigate the role of laparoscopic procedures in the emergency treatment of inguinal hernia. A longer learning curve, increased risk of iatrogenic organ injury during the reduction of hernia content, and technical difficulty compared with the open technique are limiting reasons for TAPP . HoweverIncarcerated inguinal hernia with AE content is rarely reported in the literature. To the best of our knowledge, this is the second case report of laparoscopic TAPP hernioplasty in an emergency setting. The report also brings the treatment of some rare diseases with laparoscopic TAPP to the attention of the academic community. In addition to elective hernia surgery, laparoscopic TAPP hernioplasty can also be safely performed in irreducible or incarcerated inguinal hernia, such as this case of incarcerated AE.


Here, we present a case report of a woman who presented with a large sacral rheumatoid nodule. This patient failed conservative treatment and presented in search of a surgical solution. We successfully removed her rheumatoid nodule using a surgical approach typically reserved for traumatic coccydynia. We show how coccygectomy, although a rare surgical procedure, was effective in treatment of a large rheumatoid nodule. Rheumatoid arthritis is a chronic inflammatory disease that is predominately characterized by a variety of extra-articular manifestations. The development of disease-modifying antirheumatic drugs (DMARDs) has altered the treatment paradigm of rheumatoid arthritis; however, extra-articular rheumatoid nodules (RNs) may become refractory to DMARD treatment. In such cases, RNs may progress to severe joint destruction and prevent individuals from attaining an active lifestyle. Synovectomy and nodule resection have been previously described for treatment refractory RNs in most joints. However, due to the rarity of sacral RNs, no previous cases have been reported describing surgical options for severe refractory cases. Here, we present a case of a woman with a large sacral rheumatoid nodule that caused discomfort and was resistant to conservative treatment. We present our surgical approach to removal of this nodule as well as a brief description of the surgical procedure and a review of its use for paracoccygeal masses.A 77-year-old woman with a history of rheumatoid arthritis with numerous nodules and a previous C1-C2 posterior fixation and fusion for atlantoaxial instability presented for evaluation with a ten-year history of a painful mass in the region between her lower back and intergluteal cleft. The mass had been intermittently drained by another physician for some time with recurrence and persistent symptoms. Computerized tomography and magnetic resonance imaging were performed which demonstrated a large, multilobulated cystic nodule in the region of the sacrococcygeal joint . The patAfter evaluation, the patient underwent surgery for removal of the lesion. A posterior sacrococcygeal approach was utilized for en bloc resection of the cystic nodule and coccyx . PlasticThe patient was not able to follow up in our clinic due to transportation issues. However, in a telephone follow-up one year post surgery, she reported doing well without recurrence of the painful sacral nodule.Also called necrobiotic nodules, RNs are a common complication of rheumatoid arthritis and effect between 30-40% of patients , 2. RiskCoccydynia secondary to sacral RN is a rare entity with only four case reports previously described in the literature , 7. Of tDescribed in 1972, the Gardner method for coccygectomy is often employed and has been associated with good results. From the posterior approach, the patient is placed in the jack-knife position. A 7.5 cm cut is made from above the sacrococcygeal joint down the lien of the buttocks. After cutting through to the coccyx, the tip of the coccyx is raised and the tip of the coccyx is cut away from the tissue around the anus. Using a wet sponge, the rest of the coccyx is separated from the tissues underneath it all the way to the sacrococcygeal joint, and the sacrococcygeal joint is transected . Minor dThough coccygectomy has traditionally been utilized for management of traumatic coccydynia refractory to conservative measures, this technique has been reported as useful in the treatment of paracoccygeal masses. Nonidiopathic causes of coccydynia are rare, and including the patient reported here, we found 10 case reports in the literature describing coccygectomy for nonidiopathic coccydynia. The age of 8 female and 2 male patients ranged from 20 to 77 years (mean 51.1 ± 20.6). Diagnoses included carcinoid tumor , paracoc


Transomental hernias are a rare type of internal hernia. We report two cases of successful cases of laparoscopic repair. One required laparotomy due to concern for intestinal viability.The first patient was a 67-year-old man who presented with abdominal pain and vomiting. He had no history of laparotomy or abdominal injury. Computed tomography suggested small bowel obstruction and possible intestinal strangulation. Emergent laparoscopy found approximately 200 cm of small bowel was strangulated around the greater omentum. The strangulation was released laparoscopically, but because of the color of the strangulated bowel, laparotomy was performed to evaluate viability. The involved portion of intestine was not resected. The patient experienced transient postoperative paralytic ileus and was discharged on postoperative day 14. The second patient was a 56-year-old man who presented with abdominal pain. Abdominal computed tomography revealed dilatation of the small intestine and a closed loop suggesting ileus due to intestinal strangulation. An emergency laparoscopy found a transomental hernia, and the strangulation was released laparoscopically. Recovery was uneventful, and the patient was discharged on postoperative day 6.Transomental hernia can be successfully treated laparoscopically. In cases where bowel viability is a concern, laparotomy should not be hesitated. Transomental hernia is a rare cause of small bowel obstruction that may occur in patients without a history of abdominal surgery or trauma. It is an internal hernia in which the intestine is inserted into a transomental hiatus that is congenital or the result of trauma or atrophy of connective tissue. The incidence of internal hernias has been estimated as 0.2–0.9% in autopsy studies. Transomental hernias involving the greater or lesser omentum are rare, accounting for approximately 1–4% of internal hernias . PreoperA 67-year-old man with a history of hypertension and diabetes presented with abdominal pain, bloating, and vomiting. He had no history of abdominal injury or abdominal surgery. There were no signs of peritoneal irritation, and he had no fever. Blood tests showed mild dehydration, and the initial laboratory evaluation revealed no abnormalities, but indicated a minimal inflammatory reaction with a white blood cell count of 10.4 K cells/mm3  and C-reactive protein of 0.06 mg/dL . Plain abdominal computed tomography (CT) revealed dilatation and content retention in the small intestine, but the origin of the obstruction was not clear. The diagnosis was small bowel obstruction, and the patient was admitted for fasting. The abdominal tenderness increased, and abdominal contrast-enhanced computed tomography (CE-CT) on the day after hospitalization showed small bowel obstruction with a fat notch sign that suggested strangulation ileus caused by an internal hernia Fig. , and the3  and C-reactive protein of 0.51 mg/dL . Abdominal CE-CT revealed dilatation of the small intestine and a closed loop suggesting strangulated ileus (Fig. A 56-year-old man presented with acute abdominal pain and bloating after 12 months from the first case. He had no history of laparotomy or abdominal injury. There were no signs of peritoneal irritation and no fever. Blood tests showed a mild inflammatory response with increase of white blood cell count of 14.4 K cells/mmA transomental hernia is a rare cause of Not only in virgin cases small bowel obstruction that is occasionally diagnosed during surgery –6. PreopThe best approach for the surgery of small bowel obstruction with strangulation is controversial. In case 1, the color of the intestinal tract under the observation by laparoscopy led to a concern of its viability. That was why the procedure was switched to a laparotomy. The viability of a strangulated intestine can be judged by the color and the presence of swelling resulting from ischemia and compression of the intestinal wall. Palpation with gazing for pulsation of the small mesenteric arteries and tactile evaluation of the wall thickness are possible only under the laparotomy. Visible light spectrophotometry and laser Doppler flowmetry can help to determine whether bowel preservation is possible without a need of laparotomy . The useThe laparoscopic approach to small bowel obstruction has been expanded these days . Based oWe report two cases of strangulated transomental hernia to which laparoscopic surgery was applied. Although strangulated small bowel was released laparoscopically in both cases, it was difficult to confirm the viability of the intestine by laparoscopy in the first case. Our experience showed laparoscopic approach should be applied even in strangulated hernia. However, in cases that necrosis cannot be ruled out under the laparoscopy, conversion to laparotomy should not be hesitated.


Inverted Papilloma is a benign sinonasal tumor with a high recurrence rate and potential for malignant transformation, it typically presents as an obstructing unilateral nasal mass, atypical presentations include bilateral involvement which occurs in up to 5 % of cases.Here we present two different cases of bilateral inverted papilloma, both presented complaining of bilateral nasal obstruction, the second case also had associated nasal polyposis and history of multiple previous endoscopic sinus surgeries, both cases were managed with endoscopic medial maxillectomy and tumor removal, with no signs of recurrence on follow up.Bilateral involvement is an uncommon, atypical presentation of inverted papilloma, endoscopic surgery is a safe, reliable approach and it is the mainstay of treatment, regular endoscopic and clinical follow up is important for detection of recurrence. It is aggressive tumor which typically presents as a unilateral lesion originating from the lateral wall of the nasal cavity; therefore, it is quite rare to be seen bilateral with a reported frequency range from 0 to 5 %  bilatera22.1A 58 years old healthy male. presented with history of left nasal obstruction started five years back then progressed to bilateral nasal obstruction associated with recurrent attack of left sided epistaxis. His physical examination findings; external nasal deformity, bulging left lateral nasal wall, fleshy mass seen through left nostril , mass wi2.265 years old male, a known case of DM, HTN, dyslipidemia. With past surgical history of multiple endoscopic sinus surgeries for recurrent nasal polyps. He presented to ENT clinic with history of bilateral progressive nasal obstruction for the past few months, associated with nasal discharges, and anosmia. He was found to have bilateral grade 4 nasal polyps. Throat, ear, head and neck examination were unremarkable.CT scan of the paranasal sinuses showed homogenous opacities filling both nasal cavities and the left maxillary, frontal and sphenoid sinuses , Fig. 7.The patient remained symptoms free, with no signs of recurrence for 3 years of follow up.3Inverted papilloma (IP) is benign sinonasal tumor, the other variants of papilloma include the oncocytic and exophytic variants, it is the second most common benign sino-nasal tract tumor after osteoma . usuallyTraditional simple intranasal removal was frequently followed by recurrence with a rate reported to be as high as 78 %.  this higInverted Papilloma with bilateral involvement is rare, with a reported rate of up to 5 % . The treMalignant transformation and concurrent malignant disease are well recognized in this benign sinonasal tumor with rates in the literature ranging from 6 to 14.5 % . The risThey concluded that certain histological features, namely increased mitotic count and dyscariosis, along with male gender and older age group put patients at a higher risk of malignant change.Endoscopic surgery alone is not suitable for all cases. In one series of 104 cases when used in isolation the rate of recurrence was 22.4 % which dropped to 16.2 % when combined with open procedures for more extensive disease . It has W. S. Kim et al. in a retrospective study on the treatment outcome of IP according to surgical approach suggested using an endoscopic approach in patients with Krouse stage 1 or 2, and mid-facial degloving approach for stage T3 as it has a lower recurrence rate compared with the endoscopic approach .S.H. Ahn et al. in a retrospective study comparing the treatment outcome of IP using endoscopic approach with and without navigation assistance, and suggested the navigation assistance to be considered as it has helped reducing recurrence rate and surgical complications .In our cases, as the lesions were not extensive or involving the naso-frontal duct, orbit and frontal sinus, endoscopic surgery alone was enough. Outcome studies have suggested that endoscopic and combined endoscopic/external approaches are at least equal in their effectiveness as more traditional techniques but are associated with a reduced hospital stay and decreased morbidity . FortunaQ.Lisan et al. in a systemic review and meta-analysis investigating the potential association between the Krouse classification and the recurrence rates of sinonasal inverted papilloma, revealed a 51 % increased risk of recurrence for SIP classified as Krouse stage T3 disease when compared with stage T2 .Risk factors for recurrence are still unclear, male sex which has an influence on incidence with a 3:1 male predominance, has been found to affect the rate of recurrence in several studies ,1, histoBoth our presented cases, noticeably the second one was associated with nasal polyps and previous history of multiple sinonasal surgeries, all of which are factors associated with increased recurrence rate, both patients were managed successfully with complete endoscopic endonasal excision, with no sign of recurrence of follow up.4Bilateral involvement is an atypical, rare variation of inverted papilloma. Because of the high recurrence rate and potential of malignant transformation, IP is considered an aggressive invasive lesion. The definitive treatment is complete surgical excision. Endonasal Endoscopic approach is an effective, reliable and safe method of treatment, Careful preoperative planning coupled with meticulous surgical technique are absolute requisites for successful management of Inverted papilloma. Regular clinical follow up is essential after surgery to identify any sign of recurrence.There is no financial support of sponsorship involved in this study.Case reports are exempt from ethical approval at our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on requestHaifa Al Enzi: data collection, writing the original manuscript draft.Mohammad AL Eid: review and editing of the manuscript, literature review.Ali Al Momen: study concept, data analysis, final approval of manuscript.Not applicableDr. Ali Al MomenNot commissioned, externally peer-reviewedThe data used to support the findings of this study are included within the article. Also, they are available from the corresponding author upon request.The authors declare that there is no conflict of interest regarding the publication of this paper.