Gastric hematoma is a rare disorder. Here we report a case of a large gastric intramural hematoma mimicking an impending rupture of a visceral artery aneurysm.A 60-year-old Japanese woman complained of left flank pain. Computed tomography with intravenously administered contrast agent showed a solid mass of 5 × 5 × 8 centimeter in the left middle abdominal quadrant. On completion of computed tomography, the working diagnosis was an impending rupture of an aneurysm located in a branch of the superior mesenteric artery. Transcatheter arterial embolization was performed, but angiography of the superior mesenteric artery and the inferior mesenteric artery did not indicate extravasation of the contrast agent and we did not observe any aneurysmal structure. We decided to perform surgery. The operational findings revealed that the mass was a gastric intramural hematoma.On encountering an intra-abdominal mass found to be attached to a gastric wall, a gastric intramural hematoma should be considered. Gastric hematoma is a rare disorder. The precise incidence of gastric hematoma is unknown. Gastrointestinal intramural hematoma is well described in the esophagus and duodenum. The etiology of gastric intramural hematoma includes coagulopathy, anticoagulant therapy, trauma, and aneurysm. It can also be idiopathic or iatrogenic (endoscopic therapy and surgery) in nature. Here we report a case of a large gastric intramural hematoma mimicking an impending rupture of a visceral artery aneurysm.A 60-year-old Japanese woman was brought to the emergency department of our hospital, complaining of left flank pain. The pain had started the previous day and had gradually increased in severity. On examination, she was found to be alert, with a blood pressure of 173/101 mmHg, heart rate of 110 beats/minute, oxygen saturation of 95% (on room air), and respiratory rate of 20/minute. Her past medical history included myelodysplastic syndrome (MDS), hypertension, and cerebral infarction, leading to left hemiplegia. She had no history of pancreatitis and abdominal surgery. She was taking antihypertensive and acid-reducing medications, but no antiplatelet or anticoagulant medication. Her abdomen was flat, but there was moderate tenderness in her left flank. Her laboratory findings included hemoglobin level of 7 g/dL, hematocrit level of 20.8%, platelet count of 118,000/microL, prothrombin time of 13.3 seconds, activated prothrombin time of 31.9 seconds, and fibrinogen level of 209.4 mg/dL. Her normal hemoglobin level was approximately 8 g/dL. Blood chemistry findings were almost within normal limits. A computed tomography (CT) scan of her abdomen with intravenously administered contrast agent showed a solid mass of 5 × 5 × 8 cm in the left middle abdominal quadrant (Fig. Subsequently, pathological findings indicated that the mass had not included tumor cells and was simply filled with a large amount of clots. The etiology of the hematoma was not proven by pathological findings. She was admitted to the general surgical ward after surgery, and she was transfused with six units of packed red blood cells postoperatively. She was discharged from our hospital to a nursing home on day 63 after rehabilitation.et al. reported a case of gastric intramural hematoma successfully treated by TAE [Here we report a case of large gastric intramural hematoma mimicking an aneurysm. Gastric hematoma is an uncommon disorder. This case was diagnosed only after surgical exploration, but it is possible that TAE could also be effective. At first, we did not recognize that the mass was such a large gastric intramural hematoma. The mass was found to be located far from the stomach. CT showed leakage of the contrast agent in the mass; therefore, we considered it to be a large partially thrombosed aneurysm. With CT angiography, the mass seemed to be fed by a branch of SMA. But angiography of SMA and IMA did not show the feeding artery or the leakage of contrast agents and any aneurysmal structure. An important finding of this study was that an angiography of the celiac artery would have provided a clearer diagnosis. Imaizumi d by TAE . The masDiagnosis of the gastric intramural hematoma was difficult. In this case, the preoperative diagnosis was an impending rupture of a visceral artery aneurysm. Even after surgery, the diagnosis was intra-tumor bleeding of the submucosal gastric tumor. Interpretation of the CT findings was difficult because of the location of the mass, which was found to be next to the greater curvature of the stomach, but located much inferior to the stomach. If the mass had been located in the upper quadrant, the diagnosis would have been easier. In the published case reports, there were similar difficulties in diagnosing gastric intramural hematomas. Out of the 10 cases in which surgeries were performed for gastric hematoma, the pre-surgical diagnosis was correct in four cases. In the other six cases, the pre-surgical diagnoses were gastric tumor in two , 3, pancThe etiology of the gastric intramural hematoma in this case is unknown. The pathological findings did not reveal the cause. We therefore considered this case to be an idiopathic hematoma. The causes of gastric hematoma include anticoagulant medication, coagulopathy, upper gastrointestinal endoscopy, trauma, and aneurysm; however, none of these apply to this patient. The medical history of this patient included MDS, which could have led to coagulopathy, but her platelet count of 118,000/microL was not low enough.The chief complaints in the published case reports on gastric hematoma are various. Epigastralgia was the most frequent complaint. Abdominal pain and hematemesis were also common. In one case, in which the patient complained of chest pain, acute coronary syndrome was suspected and coronary angiography was performed. Subsequently, gastric intramural hematoma was diagnosed . It shouTreatment of gastric hematoma was various, including an operation and TAE, endoscopic and percutaneous drainage, and conservative. All cases with coagulopathy and anti-coagulant therapy or anti-platelet therapy were successfully treated conservatively. The type of the surgery was total gastrectomy in three cases , 9, 10, Here we reported a case of a large gastric intramural hematoma mimicking an aneurysm of a branch of SMA. On encountering an intra-abdominal mass found to be attached to a gastric wall, a gastric intramural hematoma is one of the differential diagnoses.


Gastric carcinosarcoma with severe venous invasion is extremely rare, and to the best of our knowledge, this is the first reported case.A 79-year-old man visited the Onomichi General Hospital following abnormal upper gastrointestinal series findings. Laboratory data demonstrated no anemia, and the serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were not elevated. Endoscopy identified a Borrmann type III lesion in the cardiac end of the stomach. Abdominal contrast-enhanced computerized tomography (CT) indicated that the lesser curvature of the stomach wall was modestly enhanced with bulky lymph nodes. Pathological biopsy examination identified a group 5, papillary adenocarcinoma. We diagnosed advanced gastric cancer with bulky lymph nodes . Following neoadjuvant chemotherapy, the patient underwent open total gastrectomy with D2 lymph node dissection. Histopathologically, the tumor consisted of two components: a tubular adenocarcinoma and a sarcoma. The tumor cells were mainly intravenous and were not detected in the gastric wall stroma; this resulted in a venous invasion. Immunohistochemical analysis revealed that the tumor was positive for vimentin and partly positive for desmin and cytokeratin CAM5.2. We diagnosed a true gastric carcinosarcoma with severe venous invasion. Abdominal CT 2 months after surgery showed a low density area in the liver, suggesting metastasis.Carcinosarcomas with lymph node metastasis are sometimes reported, but progression into the vasculature is very rare. We present a case of carcinosarcoma with unusual progression characteristics. Carcinosarcomas are biphasic tumors that are composed of both carcinomatous and sarcomatous cells , which aUpper gastrointestinal series, abdominal contrast-enhanced computerized tomography (CT), and endoscopy demonstrate no specific findings and as such do not play an important role in determining the precise diagnosis . The golGastric carcinosarcoma is rare  and has We present herein a surgical case of gastric carcinosarcoma with severe venous invasion.A 79-year-old man was admitted to the Department of Surgery at the Onomichi General Hospital following abnormal upper gastrointestinal series findings. He did not have any complaints such as epigastric pain, nausea, or weight loss. He had no comorbidities and his previous surgical history included right cataract removal. Laboratory data showed that his white blood cell (WBC) count and C-reactive protein (CRP) levels were within the normal range. He had no anemia and his serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were not elevated. Endoscopic findings showed a Borrmann type III lesion in the cardiac end of the stomach and irregular wall thickening in the lesser curvature Fig. . AbdominAbdominal CT 2 months after surgery showed a low-density area in the liver, which was a suspected metastasis. A month later, the low-density area increased. Abdominal contrast-enhanced CT revealed a low intracellular density and ring enhancement Fig. .Fig. 5AbCarcinosarcomas are classified into two subtypes: true carcinosarcoma and so-called carcinosarcoma. It has been reported that true carcinosarcomas have three histological features . The firIn the upper gastrointestinal tract, carcinosarcomas are frequently observed in the esophagus . HoweverIn this case, the tumor cells were mainly intravenous inside and outside of the stomach wall; however, tumor cells were not found in the stomach wall stroma. In addition, the adenocarcinoma component formed a severe venous canal invasion in the submucosa showing that the tumor had progressed into the vasculature. It can be inferred that the reason for early postoperative liver metastasis was severe venous invasion. The bulky lymph nodes in the lesser curvature identified by preoperative abdominal CT also suggest that the tumor progressed into the vasculature. The bulky mass along the lesser curvature of the stomach identified by preoperative CT turned out to be the vein involved with tumor cells. The biopsy suggested papillary adenocarcinoma; this may be because the tumor cells in the mucosa showed carcinomatous components, and we took mucosa from the stomach where only carcinomatous components could be found. As such, this case was very difficult case to diagnose preoperatively.Gastric carcinosarcomas have very poor prognosis. Gastric carcinosarcomas have a low incidence of metastasis; however several cases have occurred wherein liver metastasis was detected , 12. TheWe identified a rare case of gastric carcinosarcoma that showed a specific progression pattern, which necessitates further study of gastric carcinosarcoma.


Angioleiomyoma is a very rare benign solitary soft tissue neoplasm originating from smooth muscle layer of blood vessels. The tumor is usually located in the subcutis or the superficial fasciae, but less often in the deep fasciae, especially rare in the knee joint cavity. Diagnosis is frequently delayed or misdiagnosed as loose body or anterior knee pain because of its rare occurrence and poor awareness of physicians. Few studies have presented intra-articular angioleiomyoma and such cases become rarer and more difficult to diagnose when it presents as loose body.Two patients, a middle-aged man and an old woman, presented to our outpatient clinic with persistent anterior knee pain and both of them suffered from a solitary mass in the right knee that had slowly enlarged. One of two patients showed negative in the routine radiographic imaging and the other showed a “loose body” beside the lateral femoral condyle in the knee. MRI showed both a well-demarcated intra-articular mass of isointense signal to muscle on T1-weighted images and heterogeneous intensity on T2-weighted images. Their tumors were excised under arthroscopy finally, with the pathological results revealed vascular leiomyomas. They both recovered well with pain free after operation and no signs of recurrence were seen at the 7-year follow-up.This case report illustrates the atypical locations of angioleiomyoma in the knee joint should arouse our attention and be included in the differential diagnosis of nodular lesions mimicking loose bodies. Angioleiomyoma, also known as vascular leiomyoma, is a rare benign soft tissue tumor of smooth muscle origin arising from the muscular layer of vessel walls . The mosA healthy 41-year-old man presented with a mass in his right knee that had slowly enlarged over the past 15 years. Physical examination revealed a solid, glossy and mobile swelling beside the lateral upper pole of the right patella which was approximately 2 cm in the largest dimension and was mildly tender to palpation. Routine radiographic imaging was negative, magnetic resonance imaging (MRI) demonstrated a well-demarcated oval lesion measuring 1.5 cm in diameter within the soft tissue abutting the lateral upper pole of the patella, which presented isointense signal to muscle on STIR T1 sequence and slightly hyperintense signal on T2 weighted images (T2WI) and STIR T2 sequence, and the edge of the mass was heterogeneously strengthened on enhanced T1 weighted images Fig. . GrosslyA 72-year-old lady was referred to our hospital with a slowly growing, painful mass located on the right knee that had been presented for over 20 years. Clinical examination disclosed a tender, movable and smooth mass about 2 cm in diameter. X-ray showed a “loose body” beside the lateral femoral condyle in the knee Fig. . MRI demAngioleiomyoma can occur anywhere in the body and is most often seen in the extremities, particularly the lower limbs , but verIntra-articular tumors are very unusual and physicians are apt to misdiagnose conditions like meniscus tear or arthritis . To avoiThere are no specific imaging techniques for vascular leiomyomas. Radiograph plain film has little value in diagnosis except for the calcification of the tumors. MRI is helpful for diagnosis but still not specific. Angioleiomyoma is difficult to be diagnosed before surgery and it should be considered a possible diagnosis when a well-demarcated mass of isointense signal to muscle on T1WI, heterogeneous high signal intensity on T2WI, heterogeneous strong enhancement, and an adjacent tortuous vascular structure is seen in the extremities . Alta YTAs the symptoms were nonspecific, the final diagnosis was made only after arthroscopic removal. Macroscopically, angioleiomyomas are oval, covered with full fibrous capsule, firm, yellow or red on the cut surface, and may be calcified or ossified. Microscopically, the lesions are composed of varying amounts of smooth muscle bundles surrounding vascular channels contained within a thin fibrous capsule. Immunohistochemically, Matsuyama et al. analyzed 122 angioleiomyoma cases and showed tumor cells strongly reactive to SMA, muscle-actin monoclonal antibody (HHF35), and actin associated antibody (CALP) in all of cases. Desmin was diffusely stained in 63.1%, partially positive in 19.7%, and not stained in 17.2% [Many reports have proved successful arthroscopic resection of benign intra-articular lesions of the knee, such as localized PVNS, synovial chondromatosis, synovial angioma, osteochondroma, lipoma arborescens and synovial lipoma –22. CompAs this case report illustrated, the atypical locations of angioleiomyoma in the knee joint should arouse our attention and be included in the differential diagnosis of nodular lesions mimicking loose bodies.


Proximal-type epithelioid sarcoma is a rare soft tissue neoplasm which arises from the more proximal part of body and occurs more often in young people; the definite diagnosis depends mainly on the pathological examination; early detection and complete excision remain the foundation of treatment. Due to its aggressive behavior, high capacity of recurrence and the great ability to metastasize, a careful clinical long-term monitoring is required. We report a new case of a 20 years old girl, presented with proximal-type epithelioid sarcoma in her right scapular region, confirmed by pathological examination and removed surgically without recurrence or metastasis at eighteen months of follow-up. Proximal-type epithelioid sarcoma (PES) is a rare high grade soft-tissue sarcoma , typically presenting as a subcutaneous or deep dermal mass, with slow growing and high potential for distant metastasis in adolescents and young adults [A 20 years old girl presented with a red and farm nodule since 2 years in her right scapular region; a first simple excision was performed and was in favor of a benign lesion (fibrous histiocytoma). The lesion recurred clinically six months later as two farms painless nodules and a solid plaque measuring 3.5cm in diameter . There wEpithelioid sarcoma was first described by Enzinger in 1970 ; usuallyPES is a rare disease with aggressive behavior and poor prognosis. Early detection, radical surgical excision and histopathological examination are crucial to provide a chance of a cure. The wide variability of clinical expressions and totally unpredictable evolutionary nature require regular long-term monitoring in detecting local recurrence and distant metastasis.


Pulmonary artery intimal spindle cell sarcomas are rare and carry with them a poor prognosis and high rate of recurrence. In extremely rare cases, this tumor can infiltrate the pulmonic valve and manifest as adult-onset pulmonic stenosis.We report an unusual case of a patient with symptomatic, adult-onset severe pulmonic stenosis who was referred for possible balloon valvuloplasty but was subsequently found to have pulmonary artery intimal sarcoma infiltrating the pulmonary valve leading to progressive exertional dyspnea.The presence of adult-onset pulmonic stenosis should prompt the clinician to investigate further as most cases of pulmonic stenosis are congenital in nature and present early in life. Careful diagnostic evaluation in concert with multimodal imaging should take place to arrive at the correct and challenging diagnosis of sarcoma-induced adult-onset severe pulmonic stenosis. Given the poor prognosis and rapid progression of disease, early diagnosis is crucial.The online version of this article (10.1186/s13019-017-0654-9) contains supplementary material, which is available to authorized users. In the majority of cases, pulmonic stenosis is congenital in nature and is commonly diagnosed and treated in the pediatric population. The diagnosis of acquired pulmonic stenosis in adulthood is unusual and may represent an oncologic phenomenon and warrants a thorough workup to identify the etiology of the stenosis. Here we present a case of a patient with adult-onset pulmonic stenosis due to pulmonary artery intimal sarcoma and the multimodal and multidisciplinary efforts needed to diagnose and treat the patient.A 79-year-old man with a 1-month history of progressive dyspnea and exercise intolerance was found to have severe pulmonic valve stenosis and was referred to our institution for balloon valvuloplasty. Prior medical history included coronary artery disease, hypertension and chronic kidney disease.Additional file 1: Movie S1. Movie of Fig. Additional file 2: Movie S2. Movie of Fig. Additional file 3: Movie S3. Movie of Fig. ).At the referring institution, the physical exam was notable for a III/VI systolic murmur best appreciated in the left upper sternal border. An electrocardiogram (EKG) demonstrated sinus rhythm with a right bundle branch block and a chest x-ray was normal. Transthoracic echocardiogram (TTE) was reported as demonstrating severe pulmonic stenosis with a peak gradient of 100 mmHg and peak velocity of 5 m/s associated with right ventricular hypertrophy, severe tricuspid regurgitation and severe right atrial dilatation  revealing flow obstruction at the level of the pulmonic valve. (MP4 3061 kb)). Contrast-enhanced computed tomographic (CT) angiogram and gadolinium-enhanced cardiac magnetic resonance imaging (MRI) were obtained to better characterize the obstructive mass.The patient was taken to the catheterization lab for planned balloon valvuloplasty but the procedure was canceled after angiography revealed an obstructive mass in the right ventricular outflow tract (RVOT) of unclear etiology extending into the main pulmonary artery .Given the CT and MRI findings, the mass was presumed to be a primary cardiac tumor and decision was made to proceed with surgical resection. A preoperative transesophageal echocardiogram (TEE) corroborated CT and MRI findings  that showed a fungating mass involving the pulmonary annulus and MPA with extension into the RVOT Fig. . The tumPostoperatively, a TTE demonstrated normal pulmonary valve function and his dyspnea resolved. He was then referred for chemotherapy with pazopanib, a tyrosine kinase inhibitor, but was lost to follow up.The vast majority of cases of pulmonic stenosis in children and adults are due to congenital heart disease. Acquired pulmonic stenosis is rare with carcinoid syndrome, rheumatic fever and infective endocarditis accounting for the majority of cases . Very raThe majority of cardiac tumors are malignant and metastases of extracardiac malignancies . The incHere, we report a case of a malignant intimal sarcoma infiltrating the pulmonic valve, a very rare cause of adult-onset severe pulmonary stenosis and otherwise unexplained progressive exertional dyspnea. The patient in question was initially referred to our institution for balloon valvuloplasty – the treatment modality of choice for symptomatic, congenitally-acquired pulmonic stenosis. However, it is highly atypical for congenitally-acquired pulmonic stenosis to present late in life with symptoms. Therefore, the presentation of adult-onset symptomatic pulmonic stenosis should prompt a nuanced diagnostic workup to identify the correct diagnosis and optimal choice of treatment.Intimal sarcoma was first described in 1923 by Moritz Mandelstamm . Such tuIt has previously been reported that intimal sarcomas have a female predominance. However, a more recent study has shown an equal sex distribution with an average age of disease onset of 49.3 years (range 13-81 years) . By the Establishing the diagnosis of intimal sarcoma is challenging. Pulmonary artery intimal sarcomas often present with cough, dyspnea and chest pain associated with radiological features suggestive of a thrombus or obstructive mass in the pulmonary artery . The mosThe current diagnostic gold-standard is tissue sampling and immunohistochemical analysis. Intimal sarcomas can radiographically mimic thrombus and drastically alter clinical decision making. Therefore, preoperative, multimodality imaging is of paramount importance. Doppler echocardiography is the screening tool of choice and should be considered in all patients with suspected intracardiac masses as it allows for identification and characterization of the mass based on potential hemodynamic consequences . TransthOther imaging modalities that are useful in diagnosing intimal sarcoma include CT, cardiac MRI and positron emission tomography (PET) scans. On CT, intimal sarcomas are more likely to have a heterogeneous appearance with smooth, contiguous areas of spread, often expanding beyond the vessel wall, in contrast to thrombus . On MRI,Radical surgical resection remains the only definitive mode of treatment. Without surgery the mean survival rate is 1.5 months and with surgery the chance of recurrence and spread remains high . In certIn summary, in patients presenting with symptomatic, adult-onset pulmonic stenosis with radiographic features of an obstruction in the pulmonary artery or RVOT, intimal sarcoma should be a consideration on the differential diagnosis. Early diagnosis is crucial as this disease is rapidly progressive and has a poor prognosis.


Cholecystocolic fistula, a rare complication of long‐standing gallstone disease, is a diagnostic challenge owing to nonspecific clinical presentation and lack of accurate preprocedural diagnostic modalities. In case of incidental discovery of the fistula during the surgical procedure, excision of the fistula with repair of the colonic defect is imperative. Biliary enteric fistulas are the most common kind of internal biliary fistulas, of which cholecystocolic fistulas are the second most common type 6.3–26.5%) 6.5% 2, 3We present a case of a middle‐aged female, who was found to have cholecystocolic fistula intraoperatively while being operated laparoscopically for cholelithiasis.A 52‐year‐old hypertensive female patient presented to the outpatient department of a university hospital with a history of intermittent right upper quadrant abdominal pain for 4 years which had been increasing in severity for the past 1 month. This was not associated with fever, vomiting, or jaundice. She did not give any history of weight loss, and her bowel habit was also normal. She had undergone emergency appendectomy 1 year back for acute appendicitis. On examination, there was no icterus and she was afebrile. Examination of the abdomen did not reveal tenderness, and there was no guarding, rigidity, or rebound tenderness.3 with 75% neutrophils, 21% lymphocytes, and 3% eosinophils; and a platelet count of 109,000/mm3. Liver function test was also normal . Plain abdominal radiograph revealed normal findings. Abdominal ultrasonography revealed a calculus measuring approximately 17.2 mm within the lumen of the gallbladder. A provisional diagnosis of symptomatic cholelithiasis was made.The hemogram revealed a hemoglobin level of 10.8 g% with packed cell volume of 33.8%; a white cell count of 5750/mmThe patient was planned for laparoscopic cholecystectomy. During laparoscopy, a fistulous tract was evident between the fundus of the gallbladder and the transverse colon. Hence, the initial laparoscopic approach for cholecystectomy was converted to open via a right subcostal incision. The cholecystocolic fistula was excised along with primary repair of colonic defect. The Calot's triangle was dissected, and the gallbladder was separated off the gallbladder fossa. The cystic artery and the cystic duct were isolated, ligated, and cut. A 2 cm × 2 cm large calculus was noted in the fundus along with two smaller calculi within the gallbladder lumen Figs , 2, 3.The patient's hospital stay was uneventful, and she was discharged without any complications on the third postoperative day. Histopathological examination of the specimen revealed lympho‐plasmacytic infiltrates in the lamina propria and fibrosis in the subserosa, features suggestive of chronic cholecystitis.Between July 2015 to February 2017, 686 patients underwent cholecystectomy in our department, with only one patient being diagnosed with a cholecystocolic fistula. Here, we describe this case of cholecystocolic fistula as a rare, yet, important complication of gallstone disease. The vague and variable clinical presentations and the lack of highly sensitive preoperative diagnostic tools make it difficult to clinically suspect the presence of cholecystocolic fistula and hence pose a significant diagnostic dilemma.Biliary enteric fistulas have an incidence of 0.9% of biliary tract surgeries for nonmalignant causes Savvidou in 2009 proposed a triad of pneumobilia, chronic diarrhea, and vitamin K malabsorption to be pathognomonic for cholecystocolic fistula Owing to a wide array of nonspecific symptoms and inefficient diagnostic modalities, cholecystocolic fistula has a low preoperative diagnosis rate <10%) 0% 1. AccCholecystectomy with closure of fistula has been considered as the standard treatment for the management of cholecystocolic fistula and can be reproduced laparoscopically in uncomplicated cases. Although laparoscopic approach may decrease the length of hospital stay, but its association with higher conversion rates (55%) and longer operating time may be a cause of concern in elderly patients with coexisting comorbidities which are present in 45% of the patients In the presented case, the patient was initially diagnosed to have symptomatic cholelithiasis in isolation. The clinical presentation and preoperative investigations did not suggest the presence of cholecystocolic fistula. However, during laparoscopic cholecystectomy, the operating surgeons visualized a fistula connecting the fundus of the gallbladder and the transverse colon. Failure to detect such fistulas during operation can be devastating due to risk of division of fistula and colonic perforation. In situations like these, when there is an incidental evidence of fistula during surgical procedure, the fistulous tract should be obliterated. The obliteration of the fistula removes the theoretical risk of cholangitis that can occur because of colonic bacterial translocation through the tract into the biliary system. Moreover, laparoscopic procedure should be converted to open if there is difficulty in accessing the fistula site, as in our case.Cholecystocolic fistula is an uncommon complication of cholelithiasis. Even though the clinical symptoms and signs are nonspecific and there are no diagnostic modalities specific enough to make a diagnosis preoperatively, clinicians should be aware of its possibility in patients with long‐standing cholelithiasis and chronic cholecystitis. Once the fistula is detected intraoperatively, it is imperative to excise the fistula, either by laparoscopic or by open approach, whichever feasible.The authors declare that they have no competing interests.VA: involved in conception and design, acquisition of data, and analysis and interpretation of data; drafting the article; and final approval of the version to be published. UJ: involved in conception and design, acquisition of data, and analysis and interpretation of data; drafting the article; and final approval of the version to be published. SM: involved in conception and design; critical revision of the article; and final approval of the version to be published.


Introduction. A patent urachus is a rare congenital or acquired pathology, which can lead to complications later in life. We describe a case of urachal cystitis as the etiology of small bowel obstruction in an adult without prior intra-abdominal surgery. Case Report. A 64-year-old male presented to the acute care surgery team with a 5-day history of right lower quadrant abdominal pain, distention, nausea, and vomiting. He had a two-month history of urinary retention and his past medical history was significant for benign prostate hyperplasia. On exam, he had evidence of small bowel obstruction. Computed tomography revealed high-grade small bowel obstruction secondary to presumed ruptured appendicitis. In the operating room, an infected urachal cyst was identified with adhesions to the proximal ileum. After lysis of adhesions and resection of the cyst, the patient was subsequently discharged without further issues. Conclusion. Although rare, urachal pathology should be considered in the differential diagnosis when evaluating a patient with small bowel obstruction without prior intraabdominal surgery, hernia, or malignancy. Surgical evaluation for small bowel obstruction by an acute care surgical team is common. Etiologies include, but are not limited to, adhesions secondary to prior intra-abdominal operations, hernias, and malignancy. However, urachal pathology can also lead to inflammation, adhesions, and mechanical small bowel obstruction.Numerous studies have described the management of urachal pathology –5. Howev Escherichia coli.A 64-year-old male presented to the emergency department with a 5-day history of right lower quadrant abdominal pain and distention. He had nausea, vomiting, obstipation, and anorexia. He denied fevers and chills. His past medical history was significant for benign prostate hyperplasia and a two-month history of urinary retention for which he had been followed up by the urology service. He denied previous abdominal surgeries. Examination revealed a distended tympanic abdomen with bilateral lower abdominal quadrant tenderness without rebound or guarding. Laboratory values revealed a white blood cell count of 15,100 cells/mcL with 89% neutrophilia. A urinalysis contained 182 white blood cells, 3+ leukocytes, and 4+ bacteria with a subsequent urine culture growingA computed tomography (CT) scan was performed which demonstrated fat stranding in the right inferior abdominal cavity with an adjacent fluid collection, distended small bowel loops with fecalization, and a clear transition point at the proximal ileum. The preliminary radiologic interpretation was that of an intra-abdominal abscess secondary to a ruptured appendicitis with associated high-grade small bowel obstruction. Following the insertion of a nasogastric tube and the administration of antibiotics, the patient was taken to the operating room. Prior to incision, the CT scan was reexamined and a fluid collection with surrounding fat stranding was noted extending from the bladder to the umbilicus with a transition point at the phlegmon . Moreove Escherichia coli. The patient was discharged on postoperative day 9 following an uncomplicated course in hospital.Upon entry into the peritoneal cavity, a 4 × 5 centimeter cystic mass was encountered inferiorly and to the right of the umbilicus which was adherent and in continuity with the bladder . The proUrachal pathology has been described in the literature for a century. The categorical description with regard to epidemiology and diagnostic modalities has only recently been described. In the developing fetus, the bladder descends into the pelvis and the apical aspect of the urachus transforms into a fibromuscular strand between the transversalis fascia anteriorly and peritoneum posteriorly called the space of Retzius. Normal vestigial structures are between 3 and 10 cm in length in adults and symptomatic pathology involves dilatation of the urachus . The an umbil a vesicoUrachal pathology may have similar presentations as incarcerated umbilical hernia, acute appendicitis, Meckel's diverticulitis, or peritonitis secondary to bowel perforation. Initial diagnosis of urachal pathology is challenging. For example, a recent report described a young male without medical problems or surgical history who presented with periumbilical pain after heavy lifting. A preliminary diagnosis of umbilical hernia was made. Surgical evaluation confirmed the presence of urachal cyst . IntrapeInfection of urachal cysts is rare beyond the 5th decade of life. Most frequently, the infection occurs in infancy. Patients may present with pain, periumbilical erythema, and leukocytosis. The space of Retzius, which contains the urachal pathology, is extraperitoneal and management options include incision and drainage of the preperitoneal infection with packing and subsequent excision of the cyst [Urachal remnants progressing to malignancy are rare, compromising less than 0.01 percent of cancers. Case reports have described the progression of disease into adenocarcinoma, which occurs in the 5th to 7th decade of life, and sarcoma, which occurs in adults prior to the 5th decade , 7. AdenDiagnostic modalities are limited in adults. CT has been used to identify adjacent pathology and the extent of the disease but CT has limitations. Namely, fat stranding can mask the true underlying pathology and not allow identification of the space of Retzius. Urachal cystitis may also appear as an intraabdominal phlegmon, as with our case . The utiAlthough uncommon, an infected urachal cyst should be considered in the differential diagnosis when evaluating an adult with small bowel obstruction without previous abdominal surgeries and a clear transition point near the anteroinferior peritoneal wall. In children, ultrasound should be used to diagnose urachal pathology. Adults benefit from both an ultrasound and a CT scan to rule out malignant transformation. In the case of urachal cystitis in an adult causing small bowel obstruction, the surgical management should include the standard management of small bowel obstruction with excision of the urachal remnant to exclude malignancy.


We report a case of adenomyosis which developed from a hypoplastic uterus and leiomyoma in a patient with MRKH syndrome. A 45-year-old Malay female with primary amenorrhoea and primary infertility presented with abdominal mass and abdominal pain. She is phenotypically female, has well developed secondary sexual characteristics, and has normal female external genitalia with shallow vagina dimple. Transabdominal ultrasonography showed a homogenous adnexal mass of 10 × 8 cm, uterus sized 5 × 4 cm, and normal kidneys. A complex mass of right adnexa was demonstrated by CT scan. Exploratory laparotomy showed torsion of right adnexal mass and rudimentary uterus with fibroid but no endometrial tissue and blind end with absent cervix. The normal right ovary and tube were not visualized. The left fallopian tube and ovary were normal. It is also complicated by vaginal agenesis. Removal of right adnexal mass and rudimentary uterus was done with preservation of left ovary. The histologic diagnosis was uterine adenomyosis and leiomyoma arising from the right adnexa, possibly from the broad ligament. Mullerian agenesis, a congenital malformation of the genital tract, is a common cause of primary amenorrhea, second only to gonadal dysgenesis . It affeA 45-year-old Malay female, with primary amenorrhoea and primary infertility for 11 years, presented with abdominal mass and abdominal pain. She had sought treatment for her primary amenorrhoea when she was 16 years old, with no further investigation after then. She got married at the age of 34 years. There was no complaint of difficulty during sexual intercourse with her partner. Investigations were done for primary infertility after one year of marriage and diagnostic laparoscopy was offered but patient refused.She presented with abdominal mass for one year, which gradually increased in size and associated with intermittent pain. There was no bowel or bladder compressive symptoms.She is phenotypically female, with normal intelligence and average height. No hirsutism or acne was noted. Examination of the head and neck did not reveal a webbed neck or any abnormal facies. Thyroid was not enlarged. There were no gross abnormalities of the extremities such as polydactyly, syndactyly, or absence of digit. Chest and heart examinations were normal. There was no complaint of galactorrhoea.On abdominal examination, a nontender, fixed suprapubic mass with measurement of 15 by 15 cm was palpable with regular margin and firm consistency. There were no ascites or hepatosplenomegaly. The breasts and pubic hair were in Tanner stage 4 with normal female external genitalia. Vagina examination revealed shallow vaginal canal with length of 2 cm and cervix was not palpable.Transabdominal ultrasonography showed a homogenous adnexal mass of 10 × 8 cm. The uterus was visualized measuring about 5 × 4 cm. The kidneys were in normal in site, size, and position. MRI revealed a complex mass of the right adnexal measuring 8.8 × 13.8 × 15.2 cm as shown in Figures Gonadotropins level were normal: Follicle stimulating hormone (FSH) was 5.5 IU/L and luteinizing hormone (LH) was 5.1 IU/L. Serum level of CA-125 was 226 U/mL. Provisional diagnosis of MRKH syndrome associated with pelvic mass (leiomyoma or ovarian tumour) was made and exploratory laparotomy was offered.Intraoperatively, torsion of right adnexal mass of 15 × 13 × 13 cm was found, freely mobile, together with enlarged left horn of the uterus measuring 5 × 5 cm which has no endometrial tissue, blind end with no cervix Figures .The patient was offered for neovaginoplasty, but she refused. Postoperative recovery was uneventful.Histopathological examination was reported as leiomyoma arising from the right adnexae and structure was possibly broad ligament. While the enlarged left rudimentary uterus showed adenomyosis which involved part of the uterus, right ovary and right fallopian tube showed haemorrhagic necrosis possibly secondary to torsion.MRKH syndrome is a rare disorder described as aplasia or hypoplasia of uterus and upper two-thirds of vagina due to early arrest in development of mullerian duct. Women with this syndrome have normal 46 XX karyotype, secondary sex characters, ovarian functions, and underdeveloped vagina . Renal, Here, we report a patient of MRKH syndrome with a large leiomyoma originating from the broad ligament and adenomyosis from the rudimentary uterus. Leiomyomas of uterus are oestrogen-dependent tumours. Although mullerian ducts are primarily endodermal in origin, some smooth muscle cells may exist at their proximal ends, which may be the origin of leiomyomas. However, the exact etiopathogenesis of leiomyoma from the rudimentary uterus in MRKH syndrome is not known. Parikh stated that fibroids and adenomyosis rarely develop in the rudimentary nonfunctioning uterus . The firConventionally uterine adenomyosis always represents a downgrowth from the basal layer of the endometrium, which means that adenomyosis arises through direct invasion of the uterine mucosa into the uterine musculature . But thiWomen with MRKH syndrome who present with abdominal mass and pain, endometriotic ovarian cysts, adenomyosis, or leiomyoma of mullerian remnant should be considered for diagnosis. Ultrasonography is the first modality to evaluate intra-abdominal masses and genitourinary system. CT and MRI are more accurate modalities to delineate the intra-abdominal masses before planning for surgery. Complete removal of the masses with the uterine remnant by either laparotomy or laparoscopy is recommended.


Abdominal wall invasion by cancerous cells arising from the colon with an overlying secondary infection that presents as an abdominal wall abscess has been encountered previously, but such a symptom is rarely the first presentation of colon cancer. There are very few cases reported in the literature.  In this case report, we present a case of a 66-year-old male presenting with abdominal wall abscess that was refractory to treatment. The patient later was found to have an abdominal wall invasion by an underlying colonic carcinoma.  The purpose of this review is to set forth the proper approach when encountering such cases and emphasize on the significance of keeping a high index of suspicion. We also highlight the need for utilizing proper diagnostic imaging modalities prior to invasive intervention. Carcinoma of the colon has the ability to mimic any abdominal disease with a wide spectrum of presentations. Direct invasion of transverse colon adenocarcinoma into the abdominal wall is rarely encountered. We hereby report a case of transverse colon tumor presented as an abscess infiltrating the abdominal wall.Because of the infrequency of this condition, our purpose with this review will set forth the proper approach in such cases to spread the awareness and improve the outcome.Our patient is a 66-year-old Eritrean gentleman, who presented to our emergency department with severe epigastric pain and a history of a growing abdominal wall mass. On systematic review, he reported anorexia and weight loss, with no history of alteration in bowel habits. The patient had no significant past medical history apart from this presentation.Ten days prior to his presentation to our institution, he underwent an incision and drainage procedure of an abdominal wall abscess at an outside institution. The patient was discharged with outpatient dressing protocol and oral antibiotics.On examination, the patient was thin and cachectic, with a large tender warm swelling occupying the supraumbilical and epigastric regions. It measured about 10 × 15 cm in greatest dimension. There were two ulcerations on the surface of the swelling draining purulent discharge corresponding to the incisions done previously . There wµL , and carcinoembryonic antigen (CEA) level of 12.99 ng/ml . Coagulation profile and liver function tests were within normal ranges. Wound culture showed mixed bacterial growth of Escherichia coli and Klebsiella pneumoniae.Laboratory results revealed a hemoglobin level of 5.7 g/dl , white blood count level of 13.3 K/The patient was admitted for blood transfusion, intravenous hydration, and IV antibiotics while being worked up for the cause of this abdominal wall mass.Computed tomography of the abdomen and pelvis revealed a large soft tissue heterogeneous mass in the upper abdomen (measuring 9 × 10 × 10 cm). The mass was causing displacement of the stomach with no obstruction. It was inseparable from part of the small bowel, extending to the adjacent muscles and penetrating the abdominal wall Figures . HoweverUpper and lower gastrointestinal endoscopies were done. The upper scope was normal, and the lower scope was advanced up to the transverse colon but failed to advance beyond due to external compression causing complete luminal collapse.Only gastric fold biopsy was taken, which revealed chronic superficial gastritis with no evidence of activity or malignancy.The patient underwent exploratory laparotomy through a midline incision in an elliptical fashion to include the affected abdominal wall part with the specimen; upon exploration, a malignant-looking mass was found to be adherent to the greater curvature of the stomach and the transverse colon. An extended right hemicolectomy with primary ileocolic anastomosis along with omentectomy, partial gastrectomy, and complete en bloc resection of the abdominal wall including the abscess area was performed . There wThe resulting defect in the fascia was large, 20 cm in its maximum dimension. The fascia was approximated after undermining. Abdominal wall reconstruction was successfully carried out by placing a double-layer synthetic mesh (Vicryl) in a tension-free manner, and the skin was closed over it. The patient had an uneventful recovery.Postoperative histopathological examination revealed a transverse colon moderately differentiated adenocarcinoma with direct invasion to the abdominal wall and stomach. All surgical margins were free of disease, and fifteen lymph nodes were retrieved and were found to be negative for malignancy. The pathological staging was . The final stage was Stage IIC according to American Joint Committee on Cancer (AJCC) staging. Follow-up CT scan was done on day 5, which showed subcutaneous midline anterior abdominal wall fluid collection with multiple air pockets with a tiny contrast focus noted at the inferior part representing enterocutaneous fistula. The follow-up CEA level was 3.45 ng/ml. The patient was scheduled for chemotherapy cycles with the oncologist. The patient received 6 cycles of chemotherapy (capecitabine 1500 mg tablet BID and Xelox). He is being followed up and free of recurrence after almost 19 months.Locally advanced colorectal cancers, a subgroup of colorectal tumors that invade adjacent organs without distant metastases, account for 5%–22% of all colorectal cancers . LocallyWhen encountering such a case, early diagnosis, appropriate drainage, and definitive management may reduce patient morbidity and mortality rates especially if the patient was in poor condition in which elimination of the source of sepsis may be lifesaving . ConfirmPatients presented with atypical abdominal wall abscess should be further evaluated by imaging modalities. Abdominal computed tomography (CT) is a very valuable tool and the key in making the diagnosis and planning for surgery. Computed tomographic colonography (CTC) provides comprehensive examination for preoperative evaluation of patients with suspicious lesions or with colorectal cancer. Sali et al.  describeEn bloc resection is the treatment of choice in the majority of such cases, given the fact that R0 resection  , 9 with Little is known about the outcome of multivisceral resection for colorectal cancer. Complete, microscopic negative margin resection is a critical predictor factor for long-term survival. In a prospective study conducted by Lehnert et al., 201 patients  underwent en bloc resection for locally advanced tumors . After mThe role of chemotherapy and radiation holds promise in facilitating curative resection and improving postresection survival in locally advanced colorectal cancer.The percentage of developing peritoneal metastasis (PM) after complete resection of colorectal cancer is 10% of all patients . PatientIn the light of these promising results, phase III studies were initiated to highlight the role of second-look surgery and administration of prophylactic HIPEC. A multicentric randomized controlled trial being run by Elias and his colleagues (ProphyloCHIP)  is compaLocally advanced colorectal cancer may require an intraoperative decision for en bloc resection of surrounding organs or structures to achieve complete tumor removal. Long-term survival after surgery becomes achievable with all efforts being made to reach complete resection. The prevention of a disease process has always been superior to the treatment of the same disease; early PM detection and treatment at an earlier stage prolong the survival.In summary, locally advanced colon cancer still poses challenges when it comes to achieving the best therapeutic approach. In those presenting with perforation, a high index of suspicion early on helps early identification of underlying malignancy in otherwise previously not known patients. A multimodal approach helps optimize the patient's treatment and ultimately survival.


Myxoinflammatory fibroblastic sarcoma is a rare sarcoma which typically presents in the extremities and is treated by definitive surgery. In recurrent disease, the reported utilization of radiotherapy is increasing, and more modern techniques such as intensity‐modulated radiotherapy may be improving long‐term outcomes. Myxoinflammatory fibroblastic sarcoma (MIFS) is a new and abnormal growth of mesenchymal tissue, typically involving the hands or feet, and can be either benign or malignant On MRI imaging, most lesions demonstrate low signal intensity on T1‐weighted images and high intensity on T2‐weighted images. Postcontrast enhancement shows a wider spectrum of variability from relatively diffuse enhancement to more subtle linear and nodular peripheral enhancement, which often corresponds to areas of osseous involvement An institutional and database review, with median follow‐up >2 years, demonstrated a rate of local recurrence of 22%, with a median time to recurrence of 15 months Here, we present a case of recurrent MIFS in the lower left extremity, with a biopsy‐proven recurrence at the proximal surgical margin, 2 years after his initial definitive surgical treatment. The patient's primary complaint at the time of recurrence was a changing skin lesion near his prior surgical incision site with associated tenderness.A 74‐year‐old male patient with a history of a previously diagnosed myxoinflammatory fibroblastic sarcoma of the left lower extremity treated with definitive surgery presented <2 years later for the development a new tender area of nodularity distal to his previous surgical incision site. The patient's past medical history was also significant for early stage nonsmall cell cancer approximately 20 years prior, which was treated surgically, as well as localized prostate cancer treated with radical prostatectomy.The patient had initially presented with a mass on the right anterior‐medial shin, which at the time measured approximately 4.5 cm. He subsequently underwent an excisional biopsy which revealed low‐grade myxoinflammatory fibroblastic sarcoma. One month later, the patient underwent a wide local excision and negative margins were achieved. The patient then underwent skin graft placement and close observation with no adjuvant therapy.Fourteen months later, the patient noted the development of a tender nodule on the anterior/inferior edge of his prior surgical scar. The patient underwent wide local excision with pathological evaluation showing recurrent myxoinflammatory fibroblastic sarcoma measuring 2.5 cm in size, with extension to the deep margin and a close 1 mm anterior margin. A metastatic workup including CT scans of the chest, abdomen, and pelvis revealed no evidence for metastatic progression of the tumor. An MRI scan 1 month following surgery revealed an “enhancing subcutaneous nodule on the lateral lower leg at the proximal surgical margin consistent with residual recurrent tumor”  Fig. . MicroscOccurrences of myxoinflammatory fibroblastic sarcoma have been detailed in literature mostly through individual case reports and institutional case series. An institutional case series of five patients along with review of the literature in 2013 identified 138 cases following a MEDLINE literature review of cases from 1997 to 2012. This analytical review from the Rizzoli Orthopedic Institute highlighted various characteristics of MIFS. They identified pertinent clinic‐pathological data for these patients when present; however, many of the individual patient details were not available. Their data showed that the median age of patients was 45 years (34–56 years), with slightly more cases reported in males 55% (76/138 cases) versus 45% (62/138 cases) in females. The median tumor size reported was 3 cm (2–5 cm) Additionally, although MIFS has traditionally been overemphasized as being present in the distal extremities, the originally descriptive “acral” term for the tumor appears to be highly negligent of other common sites (hands and fingers) α1‐ACT, α1‐AT, CD95 and CD117 may also be high for myxoinflammatory fibroblastic sarcoma Immunohistochemical studies showed that when testing for vimentin was performed, it was strongly positive in all lesions. Tumors often demonstrated focal positivity for CD68 (84%) and CD34 57 %). Positivity for smooth muscle actin (SMA), S‐100 protein, activin receptor‐like kinase 1 (ALK‐1), and keratin was less common (6–16 %). No cases showed positive staining for CD30, leukocyte common antigen (LCA), desmin, epithelial membrane antigen (EMA), HMB45, or melan‐A. Although less frequently utilized, immunoreactivity rates for 7 %. PosiLiterature suggests that the most common methods of treatment are surgery, including both local excision and amputation, with the latter being cited as the “only predictive factor of clear margins” Local recurrence is the primary problem in cases of MIFS posttreatment. One recent database review population of 138 cases showed a local recurrence rate of 22% alongside a five year relapse‐free survive (RFS) probability of 67% Another survey of all published cases of this disease reported a crude local recurrence rate of 31.3%; however, the majority of these patients were treated with surgery alone In our case, the decision to proceed with radiotherapy was based primarily on the presence of the patient's two previous recurrences following surgical excision without adjuvant therapy. The morbidity related to radiotherapy treatment in the distal extremity is low and should be well tolerated with the utilization of an IMRT technique. Our patient's multiple recurrent MIFS has shown he is at risk for additional recurrence, which as suggested by the MGH data can be decreased with the usage of preoperative radiation therapy.The rarity of this disease and the incomplete nature of case reports and studies regarding the development of MIFS tumors complicate the development of definitive conclusions regarding the best methods of treatment for this disease as well as the potential for local recurrences and metastases. There are suggestions that radiotherapy may have a role in improving local control, especially in cases involving positive surgical margins, and potentially in recurrent disease Case reports detailing the existence of myxoinflammatory fibroblastic sarcoma currently remain limited. Those cases have been predominately treated with a definitive surgical approach; however, the usage of radiotherapy is also increasing in the setting of difficult surgical excisions or the high likelihood of local recurrence. Case reports analyzing occurrences of MIFS detail a range of target areas throughout the body, but the disease does notably show a predilection for the hands and feet. The limited number of reported cases and a lack of available data for many of the treatment plans and criteria for diagnoses of MIFS make it difficult to draw definitive conclusions regarding the best methods for detection and treatment of the disease. The use of FISH and immunohistological staining can help in making proper diagnoses of such abnormal cells in rarely seen tumors. Nonetheless, a greater amount of data on as many aspects of this illness in a multitude of patients is necessary to further proper diagnosis and treatment of MIFS.NJ: involved in conception or design of the work, data collection, drafting the article, critical revision of the article, and final approval of the version to be published. DHM: involved in conception or design of the work, data collection, drafting the article, critical revision of the article, and final approval of the version to be published. WS: involved in conception or design of the work, data collection, drafting the article, critical revision of the article, and final approval of the version to be published. SA: involved in drafting the article, critical revision of the article, and final approval of the version to be published. CES: involved in drafting the article, critical revision of the article, and final approval of the version to be published. CC: involved drafting the article, critical revision of the article, and final approval of the version to be published. BCM: involved in conception or design of the work, data collection, drafting the article, critical revision of the article, and final approval of the version to be published. RCM: involved in conception or design of the work, data collection, drafting the article, critical revision of the article, and final approval of the version to be published.None declared.


This case report highlights the value of prompt intervention of diagnostic laparoscopy in a patient suspects of having an acute abdomen due to an intestinal perforation, where there is a limitation of performing Contrast Enhanced Computed Tomography of abdomen. A previously healthy young adult presenting with an acute abdomen due to a spontaneous ileal perforation, without any associated risk factors is a rare clinical entity in a developing country. Therefore, entertaining an early diagnosis will possibly prevent a fatal consequence.A male patient, 29 years old, recently diagnosed as a young hypertensive without any associated factors, currently on antihypertensive treatment, was admitted to our hospital presenting with an acute severe abdominal pain. During initial assessment, the patient was febrile (101 °F), ill looking, tachycardic (pulse rate 121 bpm) with rapid shallow breathing. Abdominal examination reviled diffuse guarding and rigidity, more severe on right iliac fossa. Following history and clinical examination probable clinical diagnosis was made as an acute appendicitis with perforation. However, ultrasonography was found to have normal appendix. Contrast Enhanced Computed Tomography was not performed as a subsequent investigation because of the impairment of renal functions of this patient. Though, non-contrast CT would have been ascertained more diagnostic yield, given the critically ill status of this patient we decided to perform urgent diagnostic laparoscopy. It reviled pus in several abdominal cavities and dense adhesions. Therefore, the procedure was converted to a laparotomy and found to have an ileal perforation with diffuse peritoneal contamination. Diseased ileal segment was resected and anastomosed. Followed by peritoneal lavage.Ileal perforation due to diverticular disease in a healthy young adult is rare. This case report highlights the importance of considering this clinical entity as a differential diagnosis, the value of early diagnostic laparoscopy, especially in clinical settings with limitations to CT scan, since late diagnosis can give rise to fatal outcome. The causes of Ileal perforation are many. According to literature the commonest cause is spontaneous ileal perforation . Other cTwenty nine year old male patient with persistent elevated blood pressure who was 2 weeks ago newly diagnosed of having non progressive renal disease with elevated creatinine levels. The patient presented to the surgical ward complaining of right sided lower abdominal pain with two to three episodes during last 5 days after his initial medical diagnosis.He has been recently well until his renal disease was diagnosed. No significant surgical history and no medical co-morbidities other than renal disease, no significant family history of renal and gastrointestinal disease, no immunocompromised state no recent trauma. He was put on low dose steroids for 2 weeks. And his hematological, radiological and biochemical investigations had not shown any features of malignancy during his initial diagnosis of renal disease 2 weeks ago.3, with 94.6% of Neutrophils, 2.9% of Lymphocytes, 0.0% of Eosinophils, 2.5% of Monocytes, 0.0% of Basophils. His Initial hemoglobin was 11 g/dl and Platelet count was 226,000/mm3. The provisional working clinical diagnosis was suspected of him having a perforated appendix. However, ultrasound scan of the abdomen did not show any evidence of inflamed appendix since the ultrasonic outer diameter of the appendix was not exceeding more than 6 mm. Except pelvic, right iliac fossa, right para colic gutter fluid collection. The multidisciplinary discussion concluded that the patient need to undergo a diagnostic laparoscopy since the CECT is restricted due to his non-progressive renal disease and hypercreatininemia. Diagnostic laparoscopy was performed with sub umbilical approach, with Open Hassan Technique with 10 mm trocha with 2.5 l of Carbon Dioxide insufflation with 12 mmHg of intra-abdominal pressure. 10 mm, 30 degree side view scope was used. During laparoscopy, diffused adhesions with intestinal content and pus was noted in the pelvis, right iliac fossa, left iliac fossa, and right paracolic gutter. Appendix macroscopically found not inflamed. Rest of the laparoscopic peritoneal survey found normal. Due to difficult anatomical visualization laparoscopy was converted to a lower midline laparotomy and small bowel survey was done, ileal perforation was noted 25 cm proximal to the ilio-colic valve. Rest of the peritoneal survey was found normal. No diverticular disease was found in rest of the gastro intestinal tract. Thorough peritoneal washing was done with copious amount of 0.9% warm saline. Ileum was resected, distal and proximally 2 cm away from the perforated site and side to side anastomosis was established by using 60GIA Boston Scientific Stapler  with a pelvic drain in situ. Patient was in intensive care unit with supportive therapy for 3 days and had an uneventful recovery. And discharged on fifth post-operative day and presently in the surgical clinic follow up. Surgically resected specimen was sent for histological analysis. Specimen was a piece of bowel measuring 15 mm × 10 mm × 5 mm. The entire specimen has been sampled. Microscopy reviled sections of small intestine displaying a normal crypt villous architecture with no evidence of villous flattening. There was no evidence of significant inflammation within the lamina propria. The mucosa-muscularispropria contains a diverticulum surrounded by extensive acute and chronic inflammation leading to the serosa of the bowel. Hence denoting the presence of diverticulum inflammation and perforation. There is no evidence of a neoplasm or presence of inflammatory bowel disease.On clinical examination, the patient was febrile (101 °F), ill looking, tachycardic (pulse rate 121 bpm) with rapid shallow breathing. Abdominal examination reviled diffuse guarding and rigidity, more severe on right iliac fossa. It was found he was having acute abdomen with sepsis. Subsequent hematological and biochemical investigations showed inflammatory process. Initial full blood count reviled, white blood cell count of 23,050/mmLiterature projects the prevalence of small intestinal diverticular disease is 0.06–1.3% . This caWe would like to suggest performing diagnostic laparoscopy for suspected intestinal perforation where CECT is not available may results in early diagnosis of intestinal perforation, hence avoid fatality. And also, it is worth to notice that thorough peritoneal washing opens doors to patients with pus and intestinal content in peritoneum to have side to side intestinal anastomosis with no postoperative complications.


Neurogenic tumors of the tracheobronchial tree are extremely rare and include neurofibroma and schwannoma. We report a case of primary recurrent tracheal schwannoma causing obstructive airway symptoms.A 60-year-old man presented with obstructive airway symptoms due to recurrent tracheal schwannoma. Due the recurrence, size of the tumor and low surgical risk, the patient was treated with tracheal resection.Primary endotracheal neurogenic tumors are extremely rare, but one should consider them in the differential diagnosis of persistent upper airway symptoms. While endoscopic therapies recur nearly a quarter of the time, surgical resections do not have any recorded recurrences. Primary tracheal tumors are rare. Together, malignant squamous cell and adenoid cystic carcinoma compose around 75% of the tumors. The other quarter of the tumors is composed of multiple histological subtypes that include benign, intermediate, and malignant tumors . NeurogeA 60-year-old man with history of type II diabetes mellitus, hypertension, ischemic heart disease, clear cell renal carcinoma (RCC), and recent low grade mucinous neoplasm of the appendix was referred from the urology clinic for evaluation of a scattered subcentimeter intraparenchymal pulmonary nodules found incidentally on follow up for his RCC. A bronchoscopy was performed by another service which revealed an incidental finding of a small posterior upper tracheal lesion. The mass was a less than two centimeter, mobile, irregular vascular tumor protruding from the posterior wall of the trachea and was three centimeters distal to the vocal cords causing partial obstruction. The lesion was excised using endotracheal laser resection. The histology showed primary tracheal schwannoma with positive resection margins. The intraparenchymal nodules were all less than 5 mm and follow up surveillance with low dose computer tomography was recommended. In November 2016 the patient developed a dry cough with occasional wheezes and his follow-up CT scan showed his tracheal tumor had recurred with extratracheal extension Fig . Given hThe macroscopic pathological examination showed a smooth dumbbell lesion originating from the posterior wall of the trachea. The microscopic examination illustrated a spindle cell neoplasm with well-differentiated Schwann cells. Histochemically, it had features consistent with cellular schwannoma: composed of predominantly Antoni A areas, positive for S100 protein expression diffusely, and the epithelial membrane antigen showed peripheral staining. There were no early or late post-operative complications and no recurrence of the tumor after a year follow-up. His follow-up is ongoing.Primary tracheal neurogenic tumors are extremely rare. These tumors include mainly the benign peripheral nerve sheath tumors: neurofibroma and schwannoma , 4 and tTracheal schwannoma was first reported in 1951 . They arKasahara et al.  proposedTypically, most of the dumbbell shaped tumors of the trachea are malignant lesions with transmural extension of the mucosal lesion. However, this rule is not applicable in schwannoma because the lesion that is originating in the wall of the trachea and can be compressed by the cartilaginous rings either intraluminally or to the surrounding tissue of the trachea . This paIn the published literature that describes this rare disease there are 4 successive prominent case reports with review of the literature in which the newer review includes the older reported cases , 8. ThesIn the study that reviewed the literature between 1950 and 2013, only 51 cases of primary tracheal schwannoma were identified in the English literature . In addiThe clinical manifestations of intraluminal schwannomas of the trachea depend on the site, size, and the extent of obstruction produced by the tumor . They caTracheal schwannoma is a disease of adults with female gender predilection –6, 8. ItThe definitive diagnosis of primary tracheal schwannoma is usually made by tracheobronchoscopy with tissue biopsy taking in consideration all precautions that are needed in suspected upper airway obstruction. Additionally, multislice computerized tomography is used to delineate tumor size, site, and extratracheal extension –6. OtherTracheal schwannomas can be treated through multiple modalities: primary tracheal resection or endoscopic treatment including laser with or without a CO2, electrocautery snaring, argon plasma coagulation, cryotherapy, endoscopic excision, and microdebridement . The choThe prognosis for patients with schawnnomas that are either removed surgically or by endoscopic treatment methods is excellent .Primary endotracheal neurogenic tumors are extremely rare, but one should consider them in the differential diagnosis of persistent upper airway symptoms. To avoid recurrence, it is preferable to offer tracheal resection to low risk patients with sessile tumors or with extratracheal extension.


Her general physical examination revealed pallor. Abdomen showed mild epigastric fullness. Hemoglobin was 6.7 g/dl. Leucocyte count, liver and kidney function tests were within normal limits. Ultrasonography of the abdomen and pelvis revealed a 4.4x3.0x2.7 cm well defined isoechoeic solid mass within bowel lumen possibly in the second part of the duodenum. A contrasted tomography of the abdomen and pelvis A revealeUpper gastrointestinal endoscopy with endoscopic ultrasound EUS, B showed Intraoperatively , an apprBrunner glands are branched acinotubular glands located mainly in the duodenal bulb, proximal duodenum, and, rarely in the distal duodenum and proximal jejunum. They secrete an alkaline fluid which protects the duodenal epithelium from acid chyme of the stomachHelicobacter pylori infection, and hyper acidic environment in duodenum have also been suggested though none proven so farHow Brunner's gland hamartoma grows is unclear. Repeated mucosal damages activate mucosal repair, facilitating proliferation accompanied by surface gastric foveolar metaplasia. Mechanical stimuli, ,It is often an incidental finding during esophagogastroduodenoscopy or imaging studiesThe lesion must be differentiated from adenoma, GIST, lipoma, neurogenic tumor, aberrant pancreatic tissue and cystic dystrophy of the duodenal wall,Endoscopically, Brunner's gland hyperplasia appears as submucosal nodules in the first or second portion of the duodenum. Endoscopic ultrasound shows a heterogeneous, hypoechoic mass in the submucosal layerThe abnormal proliferation of Brunner glands are classified as type 1, diffuse nodular hyperplasia with multiple sessile projections throughout the duodenum; type 2, circumscribed nodular hyperplasia with sessile projections limited to the duodenal bulb; and type 3, glandular adenoma with polypoid tumor-like projections. Hyperplasia of Brunner glands greater than 1 cm is a Brunner gland adenomaThree to four case reports of the approximately 150 cases reported in literature have shown cellular atypia and malignany. However, as far as treatment is considered, endoscopic resection is also an accepted treatment choice owing to a negligible riskTreatment options can include endoscopic or surgical resection. The benign nature, and the lack of significant symptoms makes endoscopic management the preferred initial treatment. However, if endoscopic interventions fail or if there is a diagnostic dilemma, or for large lesions, or those in whom a malignancy is suspected surgical resection may be necessary


The physical examination showed violaceous petechial purpuric patches, coalescing by area, ulcerated nodular lesions extended to both lower limbs, with presence of necrosis in center of lesions (Vasculitis is an inflammatory disease of blood vessels characterized by the alteration or destruction of the vessel wall. A 55 year’s old woman, followed for diabetes and hypertension, presented to our consultation complaining of generalized pruritic lesions, without fever arthritis or any other systemic manifestations. The patient reported the concept of taking Oxicam; Brexin lesions Figure 1A lesions Figure 1B


Objective: Pilomatrixomas are benign neoplasms originating from thecells of hair follicles. They typically present as a slowly enlarging, solitary masson hair-bearing areas of the head and neck. While a common childhood lesion,pilomatrixomas are unusual in infancy. Our objective is to present an atypicalpilomatrixoma located on the midline nasion of an 11-month-old as such a lesion andits management has not been previously described. Methods: Despitepreoperative diagnostic imaging, including computed tomography and magnetic resonanceimaging, the diagnosis was not made until examination by pathology after completesurgical excision. We also completed a thorough review of the literature pertainingto pilomatrixomas, which is presented in a concise fashion. Results: Ourpatient's clinical presentation did not correlate with traditional descriptionsin the literature, skewing preoperative diagnosis. However, surgical management wasultimately appropriate and effective. To date, the patient has not demonstratedevidence of recurrence. Conclusion: We believe that this is the firstsuch reported presentation of a pilomatrixoma. Given its incidence, we encouragereaders to consider this diagnosis when evaluating similar pediatric skin lesions ofthe head and neck. Complete surgical excision is the definitive treatment. They typically present as a slowly enlarging, solitary mass, most commonlyon the hair-bearing areas of the head and neck.1,The differential diagnosis for an expanding, midline mass of the infant nasion includesdermoid or epidermoid cyst, glioma, encephalocele, or vascular anomaly.5A previously healthy, 11-month-old child developed a solid mass of the nasion. It beganas a subtle swelling and rapidly expanded within 3 months, causing significantdeformation of the child's face . ThechiOn examination, the mass was located directly between the orbits and measuredapproximately 17 mm in diameter. It appeared pink in color and did not transilluminate.It was nontender to palpation and had a rubbery texture. The remainder of theexamination was unremarkable and the patient demonstrated no neurologic deficits.The patient underwent surgical removal of the mass through a transverse, ellipticalincision. The patient is doing well after 6 months of follow-up.Preoperative workup included computed tomography (CT) and magnetic resonance imaging(MRI) of the head. The CT scan demonstrated a soft tissue mass of mixed attenuationventral to the nasal bone. Small portions of the mass demonstrated increasedattenuation, consistent with calcification, surrounding a central portion with lowattenuation. The mass did not appear to arise from the bone and did not demonstrateextension into the calvarial vault A and2B.Surgical pathology revealed a pilomatrixoma. The lesion was well-demarcated, composedof solid sheets of basaloid cells with bland, round nuclei. Islands of “ghostcells” with abundant eosinophilic cytoplasm devoid of nuclei were presentcentrally, arising as abrupt keratinization from the surrounding basaloid cells.There was no evidence of significant nuclear atypia or mitotic activity, andcalcification was not present .,4-6,Pilomatrixoma, formerly referred to by the eponym calcifying epitheliomas of Malherbe,were first described in 1880 by Malherbe and Chenantais.2These tumors typically present as asymptomatic, slow-growing, blue-colored, subcutaneousor intradermal, firm nodules.Given their cells of origin, pilomatrixoma have a predisposition toward hear-bearingareas, particularly of the head and neck region. Age at presentation typically displaysa bimodal pattern with peaks seen in the second and sixth decades of life.-16-The etiopathogenesis of pilomatrixomas remains unknown, although investigations havedemonstrated an association with genetic mutations in β-catenin and similar tumorshave been induced by the polyomavirus.13,10,25,In our patient, the pilomatrixoma was rapidly growing, pink-colored, and located alongthe midline of her nasion. This unique presentation obscured the diagnosis, which is notuncommon for pilomatrixoma.4A rapidly expanding mass over the midline of the nasion in an infant typically suggestsa differential diagnosis of dermoid or epidermoid cyst, nasal encephalocele or glioma,or vascular tumor or malformation.-Dermoid cysts are the most common congenital midline mass, resulting from failure ofneuroectodermal structures to regress during embryologic development. They are linedwith keratinized squamous epithelium and contain mesodermal adnexal structures. They canpresent as a pit, fistula, or noncompressible mass, commonly along the midline, anywherefrom the glabella to the columella, by 2 to 3 years of age.29-34,34,Encephaloceles, meningoceles, and meningoencephaloceles are rare, extracranialherniations of brain, meninges, or both caused by a failure of the surface ectoderm toseparate from the neuroectoderm during development. Nasal encephaloceles, which includefrontoethmoidal and basal encephaloceles, represent approximately 15% of encephaloceles.While they may be due to structural weakness or arrested growth of the frontal andethmoidal bones, hyperthermia, viral infections, exposure to teratogens, or in uterofolic acid deficiency, the exact etiology remains unclear.33-Imaging modalities such as ultrasonography, CT, or MRI can aid in the diagnosis ofpilomatrixomas. In one retrospective review comparing pilomatrixomas with othersubcutaneous growths, Choo et al39On CT scan, pilomatrixomas typically appear as well-defined, heterogeneous, subcutaneousmasses with calcific foci, microcalcifications, or complete calcification. They areisodense with surrounding tissue prior to contrast and demonstrate mild to moderateenhancement with contrast. On magnetic resonance image, pilomatrixoma demonstratesinternal reticulations, patchy areas of increased signal intensity, and rim enhancementwith gadolinium-enhanced T1-weighted and T2-weighted imaging. They are isodense withsurrounding tissue on T1-weighted imaging alone.,10,43,45-Pilomatrixomas are composed of a thin layer of peripherally located basaloid cells andcentrally located, clusters of anucleated cells with eosinophilic cytoplasm, also knownas ghost or shadow cells, initially described in 1944 by Highman and Ogden.42,48-43,53-Complete surgical excision is the most commonly described treatment of pilomatrixoma,regardless of tumor location.2We believe that pilomatrixomas should be included in the differential diagnosis of headand neck masses of infants and children, even in the setting of rapid growth. Treatmentis surgical excision with a very low recurrence rate. Preoperative imaging with CT, MRI,or ultrasonography each has some value, but the diagnosis may not be clear untilpathologic analysis.


The association of visual agnosia and prosopagnosia with cerebral metastasis isvery rare. The presence of symmetric and bilateral cerebral metastases ofmelanoma is also uncommon.We report the case of a 34 year-old man who wasadmitted to hospital with seizures and a three-month history of headache, withblurred vision during the past month. A previous history of melanoma resectionwas obtained. CT of the skull showed bilateral heterogeneous hypodense lesionsin the occipito-temporal regions, with a ring pattern of contrast enhancement.Surgical resection of both metastatic lesions was performed after which thepatient developed visual agnosia and prosopagnosia. On follow-up, he showedpartial recovery of visual agnosia, while prosopagnosia was still evident. Therelevance of this case is the rare presentation of metastatic malignant melanomaaffecting homologous occipito-temporal areas associated with prosopagnosia andassociative visual agnosia. It isassociated with bilateral lesions in the fusiform gyrus, although unilateral lesionsinvolving the right fusiform gyrus have also been described1.Ischemic lesions are the most frequent causes, but focal atrophy, congenital disordersand tumors can also be associated with prosopagnosia6. Associationwith prosopagnosia has previously been described in only one patient7.Brain metastases are the most frequently encountered intracranial tumors. Malignantmelanoma is the third most frequently encountered histologic type of brain metastasis.Occipital lobe lesions represent 5.5% of brain metastasisA 34 year-old man, a professional cook, with an educational level of four years,presented a clinical history of headache, nausea and vomiting in the past threemonths. He also complained of a visual disorder described as a “reading difficulty”in the last month.The patient was admitted to the emergency room because of a tonic-clonic seizure theday before. On examination, the patient was confused and somnolent, but arousable,with reactive pupils and no motor deficits.The magnetic resonance imaging (MRI) showed bilateral occipito-temporal lesionssuggestive of brain metastasis. These lesions, involved the medial and inferioroccipital gyrus bilaterally, the left fusiform and lingual gyrus and part of theright fusiform gyrus . Eight ySubsequently, he was submitted to a neurosurgical procedure involving totalmetastasis resection through occipital craniectomy. A ZEISS 588 microscope was usedto access both lesions. Following surgery, the patient was admitted to the criticalcare unit.After surgery, the patient had no motor, sensory or coordination deficits, butpresented associative visual agnosia for colors, objects, faces and letters.Upon hospital discharge, he underwent whole-head radiotherapy with 30 Gy, followed bychemotherapy using dacarbazine. On follow-up the MRI was repeated, showing no signsof residual brain metastasis .The patient was re-evaluated at the outpatient unit 30 days after surgery. Hecomplained of difficulties in recognizing faces.On neurological examination, he scored 21 out of 30 points on the Mini Mental StateExamination (MMSE). No motor, sensory or coordination deficits were recorded. Theexamination of the cranial nerves was unremarkable. Visual recognition deficits werestill evident, albeit improved since surgery. Neuropsychological testing threemonths after surgery confirmed visual recognition deficits, more markedly for facesand colors .The patient died nine months after surgery due to multiple metastases .1.The pattern of distribution of the lesions involving, bilaterally and almostsymmetrically, the medial and inferior occipital gyrus, the left fusiform andlingual gyrus and part of the right fusiform gyrus is unusual, especially for brainmetastasis. These areas play a critical role in visual recognition of objects,faces, colors and letters and are known as the “what system” of the central visualprocessingDeficits presented soon after surgery were more obvious, probably due to brainswelling, surgical manipulation and brain resection, characterizing a clinicalpicture of associative visual agnosia. The patient underwent neuropsychologicaltesting approximately three months postoperatively  and 2 wh3. Right fusiform gyrus lesions arealso described in association to prosopagnosia9. Degenerative,vascular, traumatic and congenital lesions are possible etiologies1, but a metastatic lesion has beendescribed in one case8.Prosopagnosia was initially associated with bilateral occipito-temporal lesions, mostof them being ischemic4.Achromatopsy is also associated with occipito-temporal lesions, mainly on the rightside. In the majority of cases it has a favorable outcome, except when the lesion ismore posteriorly located, the case in our patient10.In this patient, the right fusiform gyrus involvement was partial, but the medial andinferior occipital gyri were also involved. This pattern of anatomical distributionof the lesions probably disrupted the visual processing network for facerecognition, as described by RossionThe relevance of the present case is justified not only because of the rarity ofprosopagnosia due to brain metastasis, but also to the relative preservation of theright fusiform gyrus, indicating the importance of other areas in the visual processrelated to face recognition.


A rare case of cerebral schistosomiasis is reported from Guangzhou, which is a non-endemic region.A 70-year-old female with a half-month history of schistosomiasis presented to a nonendemic region for treatment. Brain computed tomography (CT) and MRI revealed a lesion in the left occipital lobe; other clinical testing was not remarkable. The diagnosis was an intracranial occupying lesion in the left occipital lobe. After the removal of the brain lesion via cranial surgery, it was noticed that the woman came from an endemic region of schistosomiasis. The discovery of eggs in the brain lesion and a positive ELISA result led to a final diagnosis of cerebral schistosomiasis.Although studies on the treatment of cerebral schistosomiasis exist, few reports have focused on the diagnosis of this illness in nonendemic settings. In this case, the exposure history of the patient was not taken into account at the beginning of treatment. This experience indicates the need for physicians to consider disease epidemiology in relation to patient history before conducting clinical interventions.Schistosoma japonicum, S. haematobium, and S. mansoni 2016006).9/L to 0.2×109/L . The patient had no history of epilepsy, infectious disease, or wounds due to surgery, and she lived in a schistosomiasis-endemic region. Cerebral MRI revealed a lesion in the top left of the occipital lobe with mottled nodule linear enhancement in the surrounding area. The primary diagnosis of this case before surgery was a brain lesion in the left occipital region of the brain.A 70-year-old woman who lived in Jianli county, an endemic region for schistosomiasis in China, experienced a continuous headache at the top of the left occipital lobe beginning a half-month before presentation. She went to the county hospital for treatment, and the symptoms eased after the intervention. A week before presentation, the patient began to exhibit disorderly speech, her contralateral limbs became weak, and she became unable to see clearly out of her right eye, so she returned to the doctor. CT and MRI scans of her head showed an occupied lesion in the left occipital region of the brain , and sheCranial microsurgery was performed to remove the brain lesion. The hard-textured nidus was yellow in color, with a size of 3 cm by 4 cm by 6 cm and obvious edema in the surrounding area, and its barrier was not distinctive from the surrounding tissue. The lesion was removed, and supportive care was provided. The patient’s condition was stable after the surgery. The incision recovered well, but the patient’s clinical symptoms did not improve significantly compared with her preoperation status. Inspection of the CT images showed low-density edema in the temporoparietal occipital lobe and a clear border with the surrounding tissue. Dehydration therapy was provided, but the edema peripheral to the nidus remained exacerbated. Because the patient was from a schistosomiasis-endemic region and the frozen section suggested chronic granulomatous inflammation, it was suspected that the illness was caused by cerebral schistosomiasis.Schistosoma eggs  . NeverthSchistosoma exposure was gathered, it was neglected because the clinicians did not know the disease well.In the diagnosis of disease, it is important to fully understand the epidemiological exposure, especially for cases from areas outside the treatment location. In the present case, the disease was treated as a brain tumor before surgery; although information about Nonendemic diseases should be considered when clinically diagnosing infectious diseases because of the increased movement of the population.Focusing on both exposure history and clinical detection can optimize the accuracy of diagnosis.In the present case, if the epidemiology of exposure had been considered from the beginning, the treatment scheme would have been optimized, and noninvasive treatment would have been considered before invasive brain surgery was performed.


Pelvic masses are a common gynecologic problem, and majority of them are diagnosed as ovarian tumors finally. Sometimes, it is hard to distinguish the origin of these pelvic masses. The following case is a solitary neurofibroma arising from the right-side obturator nerve, which was impressed as a right-side ovarian tumor initially. We reported this case, and also performed a PRISMA-driven systematic review to summary the similar cases in the literature. This review includes image, molecular and pathological findings and outcome of neurofibroma.A 33-year-old woman with a regular menstrual period denied any symptoms or signs. During her physical check-up, image examination revealed a right-side heterogeneous pelvic mass; it was suggestive of a complex of right-side ovarian tumor. A provisional diagnosis of retroperitoneal pelvic mass, probably a benign ovarian tumor, was made.Excision of the right-side pelvic mass was performed. We sent the specimens for frozen pathology, which indicated neurofibroma and lipomatous tumor and that the possibility of liposarcoma cannot be excluded. A segment of the obturator nerve was attached to the tumor and was severed. A right-side obturator nerve tear during tumor excision was observed, and a neurosurgeon was consulted for obturator nerve grafting and repair. The patient complained of mild weakness and paresthesia affecting the right leg, and we consulted a rehabilitation doctor for neuron injury. The patient’s recovery was uneventful, and she was discharged eight days after the drain was removed. Further rehabilitation treatment was arranged.A neurofibroma is an uncommon pelvic retroperitoneal tumor, and it can be misdiagnosed as an adnexal mass. To our knowledge, this is a rare case of a solitary neurofibroma arising from the obturator nerve. It usually does not have any neurological deficit. We present this case to demonstrate that pelvic neurofibroma can be mistaken for an adnexal mass. This fact should be borne in mind during the diagnosis process. A neurofibroma is a benign soft tissue tumor arising from Schwann cells. Neurofibromas have been classically associated with neurofibromatosis type I . They are found in diverse anatomical locations but seldom in the retroperitoneal location [A 33-year-old woman  with a regular menstrual period denied any symptoms or signs such as abdominal pain, dysmenorrhea, or menorrhagia. During a routine physical examination, ultrasonography revealed two right-side adnexal masses. One measuring 3.7 cm × 3.0 cm was suggestive of a right-side chocolate cyst. The other one measured 6.9 cm × 4.1 cm with vascularity on color-flow Doppler study. A computed tomography scan revealed a right-side heterogeneous pelvic mass posterior to the urinary bladder pushing the uterus to the left side  reviewed the relevance of all titles and abstracts identified from the computerized database. Full articles were further assessed when the abstracts appeared to meet the inclusion criteria. The reviewed data were obtained and entered onto an ad hoc standardized data entry form by each reviewer. We compared the inclusion data for the origin (continent/country), year of publication, case report text and discussion, length of recruitment period, and source of information.poor) to 9 (excellent) [The quality of observational studies  was scored in accordance with the Newcastle–Ottawa Quality Assessment Scale, which ranges from 1 (cellent) . BecauseOur search yielded 20 citations. After reviewing the title and abstract and reviewing the entire text, 12 were discarded as they did not meet the criteria proposed. In total, eight papers were identified for review, as illustrated in the PRISMA flow diagram Fig. . The clin = 2) or surgical exploratory total or subtotal tumor excision (n = 6). The prognosis in most cases (n = 7) was uneventful without neurological deficit but one was under physical therapy; it improved after 7 months of surgery. Computed tomography, magnetic resonance imaging, and ultrasound are screening imaging tools, but diagnosis depends on pathologic reports and immunochemistry staining. Genetic analysis of four citations showed no neurofibromatosis gene, and the other was not mentioned. Immunochemistry staining of four cases showed positive S-100, and that of two cases showed negative S-100.Of these eight citations, the gender was female in seven cases and unknown in thirty-eight cases. Age varied from young to old. Tumor location was focused on the retroperitoneal space, presacral space, and pelvic cavity, and symptoms were dependent on the location of organic compression. Surgical intervention was included in laparoscopic-assisted tumor excision (The lifetime risk is approximately 5%–10% for women undergoing surgery for a suspected ovarian neoplasm . An adneNeurofibromatosis is hereditary, and the clinical presentation could vary in the bones, nervous system, eyes, skin, gastrointestinal tract, and other body parts . It is cPatients with neurofibroma usually do not have any neurological symptoms . These tIf a case has no cutaneous neurofibromatosis, diagnosis of pelvic neurofibroma is made only on histology of the excised specimen . When a Complete surgical resection is the only treatment for these tumors . The neuKIT gene in a 22-year-old man with solitary neurofibroma on the left flank [The exact pathogenesis of solitary neurofibroma remains unclear and genetic studies of neurofibromas in the literature are scarce. Systemic review of genetic analysis of solitary neurofibroma was also analyzed Table . Beert eft flank . Sugiyamft flank . SolitarA solitary retroperitoneal neurofibroma is rare, and it can be misdiagnosed as an adnexal mass. A neurofibroma can be associated with NF-1; however, a solitary pelvic neurofibroma probably arises de novo without other organ involvement. It usually does not have any neurological deficit. Inadequately localized pain is the most common symptom, and the other clinical symptoms depend on the tumor location. Histology of the excised tumor specimen is the only diagnostic tool. Computed tomography could facilitate preoperative diagnosis. Complete surgical resection is the only treatment for such tumors—it is preferred because it prevents local recurrence and malignant transformation. We present this case to demonstrate that pelvic neurofibroma can be mistaken for an adnexal mass. This fact should be borne in mind during the diagnosis process.