Neuroblastoma (NB) is the most commonly occurring soft-tissue malignancy of childhood. Surgery plays an important role in multidisciplinary treatment and its principal aim is a local control of the disease, respecting the integrity of the surrounding structures. There is no unanimous consensus on the best surgical technique, and the operative approach largely depends on the anatomical location and the extension of the mass. To have a complete overview of the different type of treatment, we made a review of the literature from the last twenty years of all the surgical approaches applied for NBs resection, accordingly to the anatomical site. Neuroblastoma (NB) is the most commonly occurring soft-tissue malignancy of childhood and the third most common pediatric solid malignancy after central nervous system tumors. Tumors’ treatment must always pass through a multidisciplinary approach, in which surgery is almost constantly involved. However, when facing complex neoplastic masses, it might be difficult to define the surgeon’s course of action, carefully bearing in mind the balance between risks and benefits.At the moment there is no unanimous consensus neither on the best surgical technique and the extension of surgical resection or the right surgery timing for this disease, as it depends on the location and nature of the mass. In literature there is an ongoing debate on surgical resection and its impact on overall outcome. The main goal of surgery in patients with NB would be a most complete resection of the mass (achieving >90% resection), respecting its integrity, and avoiding excessive invasiveness and damages to the surrounding organs and tissues. The assessment of operability must take into account the feasibility of complete resection and the risk of injury to related structures; individual case discussion should lead to define the best surgical approach.In the case of high-risk NB, multiple studies have tried to evaluate the correlation between degree of resection and outcome, in term of overall survival, through variables such as metastatic response, impact of known biological risk factors  and evaluation of Image Defined Risk Factors (IDRFs) at diagnosis and/or time of surgery. As a result no correlation between surgical resection and metastatic response or residual metastatic disease has been found .IDRFs are useful indicators for predicting surgical risk and extent of primary resection. Anyhow, new reports suggest that not all IDRFs have the same value and utility during the planning of NB surgery. Intraspinal tumor extension, trachea compression, and main artery encasement may have a stronger influence on surgical outcomes and event-free survival ,2.Another aspect being discussed is the optimal timing for surgical resection in high-risk NB, which has not been well defined and is usually based on individual expertise of oncologists and surgeons. Studies show that surgery is generally feasible in the early cycles of induction chemotherapy (second or third cycle), but the impact of pre-operative treatment on operative complexity and survival remains unclear .Current treatment protocols for NB consist of a combination of intensive multi-agent induction chemotherapy, surgery, radiation, myeloablative consolidation therapy with stem cell rescue and transplantation, 13-cis retinoic acid and immunotherapy . This woWe retrospectively reviewed the literature on NBs of the last twenty years (2000–2020). A Medline research was made and the main NBs localization  were cross-matched with five different terms to capture all the existing evidence on NBs surgery. These terms were: surgery, surgical approach, surgical technique, surgical treatment, minimally invasive surgery. The yielded articles were selected based on Title and Abstract. Selection criteria were: English written articles, specified NBs site and presence of the operative technique description. The selected articles were analyzed and the different surgical approaches, depending on the tumor localization, were summarized.Thoracic neuroblastomas account for up to 15% of all neuroblastomas and are frequently associated with a better outcome compared to abdominal NBs .Cervical NBs, with no extension to the thorax, can be removed using a cervical approach with a transverse skin incision, just above the clavicle. One the other hand, two main approaches are described in cases of mass’ extension to the thoracic inlet: the trans manubrial osteo muscular-sparing technique and the trap-door-approach (TDA) .In the trans manubrial osteo muscular-sparing technique, widespread by Grunenwald, the incision extends from the thyroid cartilage, downward along the anterior margin of the sternocleidomastoid muscle, to the manubrium and the upper sternum. It is then prolonged with an anterior thoracotomy at the level of the second rib ,8. This The trap-door approach (TDA) is characterized by a supraclavicular incision, followed by a partial median sternotomy and associated with a transverse incision on the third or fourth intercostal space. This approach provides a good exposure of the operatory field, allowing an easy access to the neurovascular structures and a sub-adventitial dissection, when vascular encasement is present ,12. DiffA recent new approach has been proposed for the resection of cervicothoracic neuroblastomas, named Cervico-Parasternal Thoracotomy. It is characterized by an incision made along the anterior margin of the sternocleidomastoid muscle until its sternal insertion, and then vertically following the ipsilateral parasternal line. The major pectoralis muscle is detached, and the clavicle and the ribs are disarticulated from their sternal insertions. This technique allows for good exposure of the posterior costovertebral space starting from the retro-clavicular space, permitting an accurate isolation of the major subclavian blood vessels and the brachial plexus roots in order to completely expose and safely resect the mass. This approach has been applied in a limited number of patients and further follow-up is needed .When referring to thoracic NBs, the main traditional approach is posterolateral thoracotomy, which provides good access to the mediastinum A. DisadvThoracoscopic surgery is well established as the preferred approach for many diseases involving the chest but continues to be controversial for thoracic pediatric malignancy . MinimalTechnical challenges of MIS for thoracic tumors are relevant. The use of single lung ventilation is generally recommended; however, its realization can be difficult in small children and infants . Large sIn the case of spinal cord infiltration or tumors located very close to the vessels, it is important to have a low threshold of conversion to open approach. On the other hand, thoracic neuroblastoma has a better prognosis than extra-thoracic tumors, so that incomplete resection of the mass (more than 90%) is acceptable and visual magnification of the spinal foramina afforded by thoracoscopy allows for better control of the intercostal arteries and easy access to the thoracic paravertebral sympathetic chain, especially to the inframediastinal space ,26,27. WThe development of smaller surgical instruments and the improvement of surgical techniques has helped to achieve better results for complex thoracoscopic procedures .The potential advantages for the thoracoscopic approach B are: beIn children with cancer, these advantages—in particular the cosmetic outcome—take secondary priority because the goal is to achieve a complete resection of the neoplastic mass respecting the oncological rules. In this regard, one peculiar disadvantage of thoracoscopic surgery is the inability for the surgeon to directly handle the tumor; in fact, the tactile sensation, especially for highly infiltrative masses, can help surgeons to define safe tissue from the tumor itself . AnotherThe most common complications are similar to thoracotomy, including chylothorax commonly linked to the location of intrathoracic neurogenic tumors , rather than to the type of surgical resection.Recent data suggest that port site recurrences are extremely rare and should not be a deterrent to the use of MIS . A resumAdrenal glands represent the main localization of abdominal NBs. In the pediatric population, most of the adrenal tumors are malignant and NBs cover up to the 85% of all the adrenal masses . HistoriWith the advent of laparoscopy a growing interest in a minimally invasive technique was reported and, since its first use description by Gagner in 1992 , it becaThe main concerns on its use are referred to the risk of incomplete resection, especially for large lesions or high-risk tumors, and the necessity of a quite long learning curve. Despite no clear guidelines on MIS, some selection criteria have been proposed, such as absence of major vascular structures encasement or IDFRs and tumor confined to the organ of origin (INSS stage 1 or 2) . AlthougInitially, with laparoscopy, a transperitoneal approach B was perReferring to the lateral laparoscopic adrenalectomy, Catellani et al  describeRobot-assisted adrenalectomy has been reported for NB surgery . CharactReferring to MIS, another point of discussion is the correlation between tissue CO2 exposure during pneumoperitoneum and tumor dissemination. Several studies have highlighted how hypoxemia and a lower pH could improve angiogenesis and Myc (dedifferentiating factor and negative prognostic marker) over-expression in NBs cells . On the Adrenal NBs are more likely to be unilateral and the recommended treatment is always total adrenalectomy. In cases of bilateral tumor, a rare entity covering 2% of all childhood NBs, an open adrenal sparing surgery has been described with good outcome . This teWhile laparoscopic resection for adrenal NBs is widely performed and reported in the literature, studies on abdominal NB resection are poorly represented. In these tumors the resection of the primary mass and the lymph nodes highly correlates with a proper intra-operative visualization of the para-aortic and retroperitoneal structures .At the time of surgical resection most abdominal NB are deeply connected with the surrounding structures and the surgical approach must enable the surgeon to display all the major vessels and noble structures of the abdominal cavity. For this reason an open approach is widely preferred.In the case of spinal infiltration of the mass a sub-specialty surgical team might be required.Direct invasion of the renal parenchyma is detected in 11 to 14% of patients and the renal vasculature is encased or narrowed in 32 to 45% of patients. Kidney-sparing surgery is widely preferred in NB surgical resection, as long as gross total resection is feasible . In a reRecent studies reveal that vessel tumor infiltration usually does not go beyond the tunaca adventitia; based on this data Kiely  propose A laparoscopic approach is still debated for abdominal NB, as it comes with some procedure-related technical challenges and risks, with tumor dissemination and port-site recurrence above all. Pre-operative IDRFs play an important role towards the operational technique choice; IDFRs-negative tumors are eligible for MIS.Pelvic NB is a rare entity, covering 2 to 5% of all pediatric NB, but its surgical treatment can be challenging due to closeness of the primary mass to noble nervous structures, leading to potentially invalidating sequelae, and to a high risk of bladder or colon intra-operative damage. Prevalence of neurovascular complications after pelvic NB resection ranges between 15 to 35%. Neurologic impairment includes complete or partial cauda equine syndrome, neuropathic bladder, nerve palsy, leg weakness and long-term fecal and urinary incontinence. The standard approach for pelvic lesions is a lower median laparotomic incision, associated with neurosurgical decompression in cases of spinal involvement. Neuromuscular stimulation is usually intra-operatively required. The impact of IDRFs on the outcome of pelvic NB has been evaluated and the presence of one or more of these risk factors seems to relate with perioperative complications, local recurrence and worse oncological outcome .Alternative surgical approaches common to other pelvic diseases  or congenital anomalies  has been described, such as retro-pubic, trans-perineal and anterior trans pubic; no major differences are reported between these techniques in terms of outcome. In recent years a new approach for pelvic lesions removal has been described see .While oncological surgery is moving toward a minimally invasive approach, some tumors may require a more invasive treatment to obtain complete exposure and control of the mass, in particular when it involves more than one anatomical compartment or when tumors are localized in deep anatomical spaces and/or in case of bilateral involvement. These conditions are not manageable by a traditional approach and may require different or combined incisions, especially when it is not possible to minimize the size of the tumor with neo-adjuvant chemotherapy. In current literature there is a paucity of indications for such lesions, and consequently the choice of surgical treatment is mainly based on the surgeon’s skills, habits and preferences. Recently, new surgical approaches have been proposed that could result in a wider all-round view of the surgical area and a radical and riskless resection. Two of the latest surgical techniques proposed are the Thoracophrenolaparotomic approach (TPL) in thoraco-abdominal tumors and the Complete Posterior Sagittal Anorectal Mobilization (PSAM) in pelvic-perineal tumors. These approaches have proved to be safe and well accepted in infants and children, with no added morbidity, and providing a better prognosis.rectus abdominis muscle beyond the umbilical transverse line. The procedure is characterized by thoracotomy, in which the periosteum-sparing partial resection of rib can is fundamental to provide a wide exposition and guarantee a regrowth of the rib, laparotomy and radial incision of the diaphragm along the posterior peripheral margin. This technique provides an excellent and complete vision of the mass, allowing a macroscopic radical tumor resection, without major complications (TPL is a well described technique in the surgical treatment of severe scoliosis in the pediatric field and of tumor’s excision in adult oncology. In literature, there are only two reports that describe the application of this surgical approach for thoraco-abdominal NBs’ treatment, proving its efficacy for gross total resection of these tumors. In this technique, the incision is made following the 10th rib, starting posteriorly from the inferior margin of the scapula and proceeding obliquely downward on the lateral margin of the ications  63]..rectus aThe PSAM technique follows the same principles of the Posterior Sagittal AnoRectoPlasty described by deVries and Peña , and rouSurgery plays an important role in the multidisciplinary treatment of pediatric oncologic patients, where a complete and safe resection still represents a surgical challenge.Referring to NBs, it is still difficult to define the gold standard for surgical treatment. The operational approach largely depends on surgeon’s expertise and confidence with a technique. What can be highlighted from this review is that no proposed treatment seems to be significantly more effective than others, according to the anatomical localization of the tumor. No significant differences on complications or survival rate can be found, although some new surgical techniques provide a better exposure of the operative field and determine functional and aesthetic outcome differences.In the current literature several studies comparing traditional open surgery and MIS can be found; cosmetic and post-operative pain advantages of a mini-invasive approach are well defined, even in the pediatric field. Regardless of surgical innovation, defined guidelines on MIS usage in oncologic patients are lacking and more comparative studies between the existing approaches for same-site NBs would be necessary. The existing evidence does not provide enough data to determine the best clinical practice for NBs, and more large, randomized clinical trials would be necessary to safely expand MIS usage and establish a standardized protocol for these tumors’ treatment, accordingly to the anatomical region involved in the disease. A multidisciplinary approach to these patients remains the key-point to obtain the higher survival rates, along with the best quality of life. Surgery’s main goal is to provide a complete excision of the masses, always considering the right balance between risks and benefits.


Intrauterine midgut volvulus is a very rare, life-threatening condition, and prenatal diagnosis is difficult. In this article, we present a case of midgut volvulus followed by a pre-diagnosis of antenatal jejunal atresia.A 1-day-old Turkish male baby, who was followed with a diagnosis of antenatal jejunal atresia, with a birth weight of 3600 g, delivered by cesarean section at 38 weeks of gestation from a 19-year-old mother in her fourth pregnancy, was taken to the newborn intensive care unit. The patient underwent surgery on the postnatal first day with a preliminary diagnosis of jejunal atresia. It was observed that the small intestine was rotated two full cycles from the mesenteric root. Bowel blood circulation was good. Volvulus was untwisted. There was malrotation. Ladd's procedure was performed. The baby was discharged on the seventh postoperative day with full oral feeding. The patient is still in the first postoperative year and follow-up has been uneventful.Intrauterine midgut volvulus has been associated with high mortality in the literature. Differential diagnosis of midgut volvulus in patients with antenatal intestinal obstruction, close prenatal follow-up, appropriate delivery and timing of surgical intervention may significantly reduce morbidity and mortality. Small bowel volvulus occurs when bowel loops become twisted around the mesenteric artery or its branches. Midgut volvulus is common in infancy but is an extremely rare life-threatening condition during fetal development –3. The tIn this article, we present a case of midgut volvulus that was followed up with a pre-diagnosis of antenatal jejunal atresia starting from the antenatal period. This report is aimed at increasing awareness regarding patients with a diagnosis of fetal bowel dilatation, because it is a very rare condition, and timely intervention could be life-saving.A 19-year-old Turkish mother in her fourth pregnancy was admitted to our institute with an ultrasound report suggestive of dilated small bowel loops at 24 weeks of gestation, which was followed up in the department of maternal fetal medicine with a pre-diagnosis of fetal bowel obstruction. The mother’ s previous obstetrical history was uneventful. There was no relationship between the parents. Repeat ultrasonography revealed a segmental distended bowel, with preserved motility and vascularization. There was no evidence of fetal anemia, and the amniotic fluid index was within the normal range. Jejunal atresia was considered as the first differential diagnosis in the fetus.At 38 weeks of gestation, the mother underwent a planned cesarean section due to a history of previous cesarian section. A Turkish male child weighing 3600 g was delivered, with APGAR scores of 8 and 10 at 1 and 5 minutes, and pulse, blood pressure and temperature within normal ranges. The baby was immediately transferred to the intensive care unit under pediatric surgery. An infant feeding tube was secured in place. Bilious drainage from a nasogastric catheter was detected. On physical examination, the patient was alive and active. The abdomen was soft and had minimal distention. Neurological examination was normal. Septic findings were not observed in the patient. Laboratory values of the patient were within the normal range. An initial complete blood count revealed no anemia or leukocytosis, with hemoglobin of 15.2 g/dL, platelet clumping with a normal count  and white blood count of 16,200/uL. There was no meconium output in the follow-up. In radiological evaluation, there was no distal gas passage on the abdominal X-ray, and air–fluid levels suggested proximal obstruction  of intestinal atresia, one case (3.85%) of small intestine volvulus and one case (3.85%) of malrotation [Although the abovementioned ultrasonographic findings for volvulus have been described, most of the patients are followed up as a diagnosis of fetal bowel dilatation without making a specific diagnosis. A retrospective study by Huang rotation . In the It is extremely difficult to predict the time of volvulus and prognosis of the affected fetus owing to a wide range of presentation, from fetal demise to survivor with good outcome. Fortunately, although the case we presented healed with a good result, there are many cases in the literature of fetal demise due to intrauterine volvulus , 13. CurPrenatal suspicion and/or diagnosis of intestinal volvulus is essential for newborn outcome, given the association with high mortality in the literature. Although the presented case had good results, differential diagnosis of midgut volvulus in patients with antenatal intestinal obstruction, close prenatal follow-up, and appropriate delivery and timing of surgical intervention may significantly reduce morbidity and mortality.


Intraosseous lipoma is a very rare lesion, and the jaw is its least common bone location. Fibrolipoma is a microscopic variant of lipoma which is characterized by a significant fibrous component intermixed with lobules of fat cells. Intraosseous fibrolipoma of the jaw is a rare lesion, and to the best of our knowledge, only two cases have been reported from 1948 in English literature. This paper presents a 39-year-old man with a chief complaint of tooth displacement in the anterior region of the mandible. Radiographic evaluation revealed a unilocular radiolucent lesion with sclerotic borders located between the left lateral incisor and canine. Histopathologic evaluation after an excisional biopsy confirmed the diagnosis of intraosseous fibrolipoma. We also reviewed the literature on this rare lesion. Intraosseous lipoma (IOL) is the rarest benign primary bone neoplasm and accounts for about 0.1% of all bone tumors. Its commonest location is the metaphysis of the long bones and the calcaneus . IOLs ofThere are few reports of IOL in the jaw, and the cause of this lesion is not known , 3–8. ItA 39-year-old man with a chief complaint of tooth displacement in the mandibular left lateral incisor and canine area was referred to a private dental clinic  in November 2019. There was neither a history of medical problems nor trauma. Extraoral examination was within normal limits and the intraoral examination revealed no expansion or inflammation. The displaced teeth were vital. Cone-beam computed tomography (CBCT) revealed an approximately 2 cm, unilocular radiolucent lesion with sclerotic borders located between the mandibular left lateral incisor and canine which causes root divergence of the involved teeth . There wLateral periodontal cyst, odontogenic keratocyst, and central giant cell granuloma were considered as differential diagnoses. To make a final diagnosis, an excisional biopsy was performed under local anesthesia in the same month. The gross of the specimen showed a well-defined, solid, yellow lesion with soft consistency . Microscth decade of life. The mandible was more afflicted than the maxilla (86.66%). All maxillary cases were in the posterior region; moreover, there is a posterior predilection for mandibular lesions  have been reported since 1948. IOLs of the jaws affect both genders equally, and it occurs most often in the 6th decade of life. The majority of cases are asymptomatic, although swelling, pain, paresthesia, and root divergence may be encountered.


Canalicular adenoma (CA) is a rare, unique benign salivary gland neoplasm, which usually involves the minor salivary glands of the upper lip, buccal mucosa and palate. It is usually seen in middle-aged or older individuals, has a female predilection, and commonly presents as a painless, slow-growing, non-ulcerated nodule or swelling. Its treatment involves surgical excision or enucleation. This case report describes a case of CA of the ventrum of the tongue diagnosed in a 41-year-old male patient, which could possibly be the first reported case of this lesion involving the tongue. The term 'Canalicular Adenoma' (CA) was first used by Bauer WH and Bauer JD in 1953 . Based oA 41-year-old male patient reported to the out-patient department of our institution in 2019 with a complaint of swelling on the ventral surface of tongue since the last one month. The patient gave a history of a motor-vehicular accident with trauma to tongue around 45 days back. Eight (8) days later patient noticed a swelling on the ventrum of the tongue. The swelling was initially soft in consistency and became firm gradually. There was mild discomfort however, there was no difficulty in speaking or swallowing. The medical history, family history and social history were non-contributory. Intra-oral examination revealed a single, well-circumscribed, oval-shaped nodular swelling measuring approximately 1.0 x 0.8 x 0.7cm on the ventral surface of tongue on the left side of frenulum linguae. Overlying mucosa appeared normal, mildly translucent, with no visible pulsations. There was mild deviation of frenulum linguae to the right side . On palpUltrasonography (USG) examination revealed a hypoechoic, well defined, benign appearing lesion with smooth margins present within the substance of the tongue. There was no internal vascularity seen, even with low flow settings . HamartoCanalicular adenoma was historically, “considered to be part of the spectrum of morphologic changes seen in basal cell adenoma. However, it is now thought to be a separate entity due to its distinctive clinical, morphologic, immunohistochemical (IHC), and ultrastructural characteristics” . The exaClinically, CA lesions are characterized by a well circumscribed, small (0.4-2cm in largest dimension), non-ulcerated, non-tender swelling or nodule that can be firm or fluctuant ,11. The Canalicular adenoma most commonly occurs on the upper lip, followed by the buccal mucosa and palate with no cases reported on the tongue. However, as seen in the present case, despite its rarity, CA can also be considered in the differential diagnosis of swellings of the tongue. While surgical excision is the treatment of choice, some lesions have a tendency to be multifocal, in which case early diagnosis is vital in its management.


We present a 76-year old man with a two year history of Gleason 9 prostate cancer (PCa) presenting with penile pain, erythema, and a fungating mass on the glans. Imaging at initial PCa diagnosis revealed confined disease. His prostate cancer was previously treated with radiation and androgen deprivation therapy (ADT) with initial laboratory response via prostate specific antigen (PSA) levels, however his PSA began to rise six months following cessation of ADT. Shared decision making resulted in partial penectomy for symptomatic management. Computed tomography (CT) and bone scan performed after surgery were not definitive for metastatic disease. •Prostatic adenocarcinoma metastasis to the penis is a rare occurrence.•Presentation can mimic that of squamous cell carcinoma.•Treatment is often focused on improving quality of life. In addition, few cases are reported in the literature, with a poor prognosis of death within 6 months of diagnosis.2A 76-year old man presented with a four month history of penile pain and erythema to the urology department. Symptom progression over the preceding months included burning with urination and difficulty retracting foreskin. Initial treatment with a two-week course of nystatin-triamcinolone cream was unsuccessful. Physical exam demonstrated a two-centimeter large fungating mass on the ventral surface of the distal shaft, which appeared to originate from the glans. Digital rectal exam revealed an enlarged, firm, and nodular prostate. The remainder of the physical exam was within normal limits. There was no palpable lymphadenopathy, no focal spinal tenderness, and a normal neurological exam without focal or gross motor weakness. Given the suspicious features of the mass for SCC, particularly the fungating and superficial nature, a discussion with the patient was made regarding management options including biopsy for definitive diagnosis versus partial penectomy. The patient opted for surgical treatment and tolerated surgery well. Pathology following treatment demonstrated Gleason 9 prostate cancer. CT scan of the pelvis was performed following penectomy to assess treatment response, and demonstrated a stable sclerotic lesion on the iliac bone with potential sclerosis inferior to this known lesion and no lymphadenopathy. Bone scan at this time demonstrated no definitive evidence of metastatic disease.Past medical history is significant for Gleason 9 prostate adenocarcinoma diagnosed two years prior. Workup at the time included magnetic resonance imaging (MRI) of the prostate which demonstrated a Prostate Imaging Reporting & Data System (PI-RADS) 5 lesion, mildly enlarged pelvic lymph nodes, and a small sclerotic focus of the left iliac bone. Bone scan did not demonstrate evidence of osseous metastatic disease, and CT scan of the chest was normal. Given benign bone scan and following discussion with hematology oncology, it was believed the iliac lesion did not represent metastatic disease. An informed discussion was made with the patient involving treatment modalities, and the decision was ultimately made to pursue combination intensity-modulated radiation therapy and ADT with leuprolide acetate. The patient tolerated treatment well and demonstrated a decrease in PSA over the following two years. Following completion of ADT, PSA levels began increasing over the following year, prompting resumption of hormonal therapy. At this time the patient began experiencing his present penile pain and urinary symptoms.3Metastatic cancer to the penis is a rare occurrence, making it difficult to establish prevalence. Cherian et al. published a review detailing site-specific etiologies of penile metastases, and found that 34 % of these cases originated from the prostate, with bladder cancer metastases as the next highest cause at 30 %.4Penile metastases are rare, with poor prognosis. Squamous cell carcinoma is the most common malignancy of the penis, and should be on the differential. Biopsy is gold standard for diagnosis and helps delineate management. For prostate cancer, combination radiation and hormonal therapy and penectomy are viable treatment options. A values-based and informed approach with the patient is crucial to determining the most appropriate treatment modality, as management will often be aimed at improving quality of life.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.None.


A history of gastrectomy is associated with an increased incidence of gallstones requiring surgery. Endoscopic retrograde cholangiopancreatography is challenging for patients who undergo total or Billroth II gastrectomy. Laparoscopic common bile duct exploration (LCBDE) has been attempted in such cases. Herein, we report a case of choledocholithiasis in which a stone formed around a migrated Hem-o-lok clip.A 67-year-old man was admitted to the hospital for acute right upper abdominal pain. He had a history of 2 open gastric cancer surgeries in the previous seven years and had undergone LCBDE 12 months prior to this admission. Postoperative examination revealed recurrence of bile duct stones.The patient underwent repeat LCBDE plus primary closure with an evaluation of abdominal adhesion. A stone had formed around a Hem-o-lok clip in the common bile duct was removed.The patient had an uneventful recovery with no stone recurrence or movement of the remaining Hem-o-lok clips after a 1-year follow-up.LCBDE with primary closure should be carefully considered in patients with certain gallstone diseases after complicated upper abdominal surgery.Postoperative clip migration is a rare complication; hence care must be taken in placing the clip appropriately to ensure that it is not too close to the common bile duct. This treatment not only demands high technology but also requires a 2-stage approach and can lead to both ERCP- and laparoscopy-related complications. Laparoscopic common bile duct exploration (LCBDE) is a valuable and cost-effective method for treating gallstones and choledocholithiasis (CCL) using a single-stage approach.,6 Primary closure is preferred to avoid T-tube-related complications. A history of gastrectomy poses a significant challenge because of extensive adhesions and the altered gastrointestinal anatomy, which may increase the risk of organ injury and technical difficulty. Therefore, surgical common bile duct (CBD) exploration can be performed as the last choice.Patients with a history of gastrectomy have an increased incidence of gallstones and gallbladder morbidity requiring surgery.The Hem-o-lok clip is used during laparoscopic surgery as a substitute ligation material and it is considered inert, nonconductive, and compatible with computed tomography (CT) and magnetic resonance imaging. Since its introduction, it has been widely used and is currently considered safe. However, we noticed that the use of Hem-o-lok clips has led to various complications. Although these complications are infrequent, some may be fatal and should be taken into consideration. One potential complication is the migration of the clip into the CBD, resulting in stone formation. Herein, we report a case of Hem-o-lok clip migration into the CBD after multiple upper abdominal surgeries. The reporting of this study conforms to the CARE guidelines.2,9 The duodenal papilla could not be identified using gastrointestinal endoscopy.A 67-year-old man was admitted to our hospital with a 12-hour history of acute right upper abdominal pain. The patient had undergone Billroth II gastrectomy in June 2012 to treat stage IIIB gastric adenocarcinoma (T4aN2M0) with 6 courses of adjuvant chemotherapy. Close follow-up, including gastric endoscopy, revealed cardia cancer in March 2017. The patient then underwent total gastrectomy. Emergency percutaneous transhepatic gallbladder drainage had been performed for acute obstructive suppurative cholangitis 17 months prior to this admission . One additional trocar (12.5 mm) was positioned in the para-xiphoid region, and 2 5-mm ports were placed in the right hypochondrium. The adhesion was then carefully dissected from the right to the midline after separating the duodenum from the liver, and the CBD and clips were exposed. Fine-needle aspiration confirmed the CBD. The stone had formed around a Hem-o-lok clip, which served as the core of the stone extracted by choledochoscopy. The normal ampullary sphincter was assured with no stone residue, and the CBD incision was intermittently sutured with 5–0 polydioxanone  in cases without severe infections. In the present case, no residue stone in the CBD was found during the T tube cholangiography 3 months after LCBDE, however, a 6-month follow-up CT showed a CBD stone. The stone was found to form around a Hem-o-lok clip during the bile duct re-exploration. Therefore, we hypothesized that the Hem-o-lok clip may have been the factor that induced stone recurrence. Several different foreign bodies, including clips and sutures, have been implicated in providing a nidus for stone formation in the biliary tree. Hem-o-lok clip migrated into the CDB with subsequent stone formation.Recurrence of CCL is usually associated with cholestasis, abnormal biliary dynamics, and CBD infection. In our case, however, the time of clip migration was three to 6 months. Most patients present with typical symptoms of primary CCLs. However, the exact pathophysiology remains unknown. Many factors, such as inadequate clip placement, a high number of clips, bile leakage, sterile inflammation, and local necrosis, contribute to clip migration. We did not find a T-tube fistula during the re-exploration of the CBD. After removing the T-tube, slight bile leakage might have occurred, inducing migration of the clip into the CBD. Moreover, we found that the clip was clinging to the CBD and provoked a chronic rejection response mechanism, leading to fistula formation around the clip and extending into the CBD. The routine use of nonabsorbable clips is safe and effective, and alternatives can further reduce the risk. The clips should be accurately placed and should not be too close to the CBD. Some surgeons advocate harmonic scalpel dissection of the cystic artery and duct instead of using clips.,23 The use of absorbable clips is another option. One absorbable clip can replicate the outcomes obtained using metal clips. Many authors recommend the use of absorbable sutures,27 or silk sutures for cystic duct ligation.Postoperative clip migration is a rare but well-established complication of LC. The clip may migrate at any time, but the median time is 2 years after LC. In most cases, only a single ERCP attempt is required for successful clearance. Biliary strictures and huge stones are essential factors that may contribute to the failure of ERCP. However, when ERCP fails or in patients with a history of gastrectomy, LCBDE can serve as an alternative for safe and efficient stone extraction. Open surgery is the final treatment choice.Stones associated with clip migration after LC are often extracted using ERCP, with a high success rate.4Although LCBDE with primary closure can be performed successfully for certain patients with CCL who have a history of gastrectomy and LCBDE, careful case evaluation and selection are necessary. The Hem-o-lok clip should be placed appropriately to ensure that it is not too close to the CBD. Absorbable clips or sutures can be used as alternatives for ligation.www.editage.com) for English language editing.We would like to thank Editage (CJ contributed to the data analysis and interpretation and drafting of the manuscript. MW, SL, and GW contributed to the data collection and analysis. XL and GW contributed to the manuscript's data interpretation and critical revision for important intellectual content. All authors have read and approved the manuscript.Conceptualization: Chao Jiang.Data curation: Xueyan Liu, Shuxuan Li.Formal analysis: Guangzhen Wu.Supervision: Guangyi Wang, Meng Wang.Writing – original draft: Chao Jiang.Writing – review & editing: Guangyi Wang, Meng Wang.


This study reports the clinical case of a 42-year-old patient with ulcerated lesions who was followed up by general practitioners with the diagnosis of recurrent cellulitis. However, when referred to the Dermatology division a diagnosis of Behçet's syndrome was established based on clinical criteria. Although there are defined clinical criteria for this syndrome, sometimes its diagnosis can be challenging, due to lack of knowledge of the disease and extremely heterogeneous clinical phenotype. The authors highlight the potential difficulties in establishing the diagnosis considering the multiple clinical findings during the investigation process, contributing to the risk of increased morbidity and mortality. This is a case report of a male patient, 42 years old, with ulcerated lesions on the lower limbs for 12 months. He had been treated in the primary health care services as a case of recurrent cellulitis. Due to therapeutic failure, after cycles of antibiotics and low doses of corticosteroids, he was referred for evaluation at the authors’ Dermatology Unit. The initial clinical examination revealed papulopustular, purpuric and ulcerative necrotic lesions predominantly located on the lower limbs . The diaa)Granulomatosis with polyangiitisb)Endocarditisc)Behçet's syndromed)eosinophilic granulomatosis with polyangiitisBased on the most recent international criteria, the diagnosis of BS was established.The initial and most common characteristics are recurrent oral and genital mucosal ulcerations, which are commonly painful and multiple, with well-defined edges, resolving with punched out scars. Pustular, purpuric, ulcerated lesions, erythema nodosum-like, and migratory thrombophlebitis have been described.Misdiagnoses have been associated with insufficient collection of semiological data and the tendency that some professionals have towards a greater appreciation of technology (laboratory and imaging tests). In this case, no specific complementary exam contributed to the diagnosis, since it is entirely based on clinical criteria, with the exception of the pathergy test.The treatment aims at symptom remission, not being curative.8In the case reported here, despite the exuberance of the cutaneous lesions, there were no lesions on the oral mucosa, which may have influenced the delay in the diagnosis. Considering BS in the presence of ulcerated lesions in the lower limbs, especially if associated with genital and/or oral lesions, is crucial for specific conduct to be adopted, reducing unnecessary treatments and the negative impact on the patients’ quality of life.None declared.Lissiê Lunardi Sbroglio: Design and planning of the study; drafting and editing of the manuscript; critical review of the literature.Karin Milleni de Araújo: Critical review of the literature; critical review of the manuscript.Bianca Passos Leite dos Santos: Critical review of the literature; intellectual participation in propaedeutic and/or therapeutic conduct of the studied case.Alexandre Carlos Gripp: Approval of the final version of the manuscript; critical review of the manuscript.None declared.


Diaphragmatic hernia is primarily congenital in origin and has potentially devastating pulmonary complications. Acquired diaphragmatic hernia as a complication of hydatid disease remains a rare clinical entity. Retroperitoneal hydatidosis, in particular is an exceptionally rare cause behind a similar presentation. This paper aims to present the first case of acquired diaphragmatic hernia likely caused by eroding retroperitoneal hydatid cysts and provide a succinct literature review regarding the causative association between hydatid disease and diaphragmatic defects.A 71-year-old Saudi man, with a history of hydatid disease involving several areas including the retroperitoneum, presented with multiple episodes of shortness of breath and abdominal pain of 10 months’ duration. Computed tomography scans of the chest and abdomen demonstrated the presence of a large diaphragmatic defect, with herniation of bowel loops into the chest cavity. Initially, the patient underwent a diagnostic laparoscopy which was then converted to a posterolateral thoracotomy to repair the defect.The ability of hydatid disease to involve several body organs makes diagnosis and management of resultant complications a challenge in some cases, like ours. Knowledge about a reported rare complication could enable early detection and management to avoid serious complications, including abdominal viscera incarceration and strangulation. Diaphragmatic hernia (DH) is a transdiaphragmatic protrusion of abdominal viscera into the thoracic cavity through a diaphragmatic defect. It is primarily congenital in origin and has potentially devastating pulmonary complications. Anatomically, it is classified into three types: Bochdalek, Morgagni and esophageal hiatal hernias. Although Bochdalek hernia is the most common type among neonates, adult onset is extremely rare, with less than 100 cases reported in the literature . AlthougA 71-year-old Saudi male patient with a 10-year history of hydatid disease involving the right kidney, retroperitoneum and right inguinal subcutaneous tissue, treated years earlier by a course of albendazole 400 mg daily for 2 months followed by partial nephrectomy, presented with multiple episodes of sudden attacks of shortness of breath and dull abdominal pain for the past 10 months. The attacks were severe enough to require multiple emergency room visits and admissions. The patient did not recall any significant history of trauma or lung infection. There was no history of chronic cough or chronic constipation. He had a significant past medical history of chronic kidney disease, diabetes mellitus, hypertension, renal stones and ischemic heart disease, for which he had undergone percutaneous coronary intervention 2 years earlier, and was started on antiplatelet therapy. The patient had also experienced several thrombotic events affecting his lower limbs in the form of “trash feet,” which were managed at that time without complications.Abdominal examination was unremarkable except for a painless, soft swelling over the right inguinal region. Additionally, his routine blood tests and hydatid titer were within normal limits. Chest X-ray Fig.  showed aTen years earlier, magnetic resonance imaging and CT of the abdomen were performed in an outside hospital and demonstrated that the diaphragm was intact. There was also a larger retroperitoneal multiloculated lesion that abuts the crus of the right hemidiaphragm as well as its dome, notably at the posteromedial aspect. A smaller similar lesion was seen within the right kidney, as illustrated in Fig. Based on his clinical situation, the decision was made to repair his DH, hopefully through a laparoscopic approach.The operation started as a diagnostic laparoscopy where major portions of the small bowel, omental fat, and ascending and transverse colon were found to be partially herniating through two diaphragmatic defects, located posteromedially. The defects were separated from each other by a delicate septum with a total defect size of about 10 × 15 cm, and neither had a hernia sac, as shown in Fig. Currently, 2 years postoperatively, the patient is symptom-free, with significant improvement in terms of his original complaints.Echinococcus granulosus. The disease is endemic in several countries of the Middle East, including Saudi Arabia, and is responsible for 1–3 million disability-adjusted life-years annually [Hydatid disease (HD), or echinococcosis, is a zoonotic disease caused mainly by the parasitic organism annually .The fluid-filled hydatid cysts have the ability to infect several body organs; however, the liver and lungs are the most common sites of involvement, with frequency of 70% and 20%, respectively . The retInterestingly, 34 cases were found in the English literature reporting this causative potential of hydatid disease, none of which was retroperitoneal in position or a consequence of spontaneous erosion, highlighting the uniqueness of the present case –12. Tablet al., which showed an incidence of 0.17% [The rarity of adult Bochdalek hernia was demonstrated in a retrospective study by Mullins of 0.17% . The majIt is not uncommon for ADH to remain clinically silent for years. In contrast to congenital DH, adult-onset herniations usually manifest as gastrointestinal symptoms rather than pulmonary symptoms. Abdominal pain was reported in 62% of cases and therefore considered the most frequent complaint . Other pWith respect to diagnostic modality, chest X-ray may demonstrate the presence of visceral herniation with the air-fluid appearance and/or contralateral deviation of the mediastinum; thus it is the initial test to perform and could be diagnostic in many cases such as ours. However, CT scan is the modality of choice to detect and visualize the hernia defect and its contents .et al. that reported a higher mortality rate with the thoracic than the abdominal approach [In the past, an operative approach was typically employed based on the chronicity of the condition, as it was believed that the release of adhesions of hernial content in the thorax would be difficult via transabdominal incision and safer via a transthoracic approach. Nevertheless, recently published experience in using the abdominal approach has shown its feasibility and safety, as demonstrated in a retrospective study by Payne approach . Additioapproach .et al. reported a successful repair of DH through laparotomy in 88% of their series [In fact, most emergency cases that require surgical intervention are done through an abdominal incision . Kishorer series .et al. reviewed a total of 36 cases of DH that were repaired laparoscopically, with no reported recurrence (average follow-up was 15.1 months) [With the advancements in minimally invasive techniques, laparoscopic repair has been tried and proven to be a legitimate option for DH repair. Although shorter hospital stay and faster recovery are reported advantages of the laparoscopic technique, concerns regarding visceral injuries and recurrence rates were initially present. Liao  months) . Technic months) .et al., with only 11% requiring mesh placement [There are not enough data on which to base a recommendation regarding methods of repair; while most reported cases used the primary suturing technique, 40% used mesh alone or in combination with suture repair . Primarylacement .Hydatid disease continues to be a significant public health issue in several countries, including Saudi Arabia. The cysts’ ability to involve any site of the body makes diagnosis and management of resultant complications a challenge in some cases. ADH as a complication of hydatid disease remains a rare clinical entity. Retroperitoneal hydatidosis, in particular, is an exceptionally rare cause behind a similar presentation. To the best of authors' knowledge, this is the first reported case of ADH likely caused by retroperitoneal hydatid cysts. Knowledge about such existing causation would enable early detection and management to avoid serious complications. A multidisciplinary, individualized approach is recommended when managing similar cases to facilitate the provision of comprehensive care.


Intracranial lipomas are one of the rarest brain lesions. It is thought to form due to abnormal persistence and differentiation of the meninx. Here we report a unique case of a five-year-old male child with no known chronic medical illnesses and with no history of previous surgeries or allergic problems. He was brought to the pediatric emergency department after having episodes of focal seizures, which lasted only two minutes. On arrival to the emergency department, the child had no neurological deficits or any form of distress. A detailed neurological examination was conducted, and it was normal. Brain CT was requested according to the departmental policy, which showed a well-defined oval shape homogenous fat density in the midline along the falx cerebri at the vertex level, likely representing interhemispheric lipoma. Intracranial lipomas are rare and usually asymptomatic lesions that are formed of adipose tissue. The tumor is usually diagnosed as an incidental finding on CT or MRI scans as patients are usually asymptomatic. However, if symptomatic, the most common presentation of this tumor is seizures. The management is usually conservative, and surgical intervention is not usually recommended. Intracranial lipomas are rare growths that represent less than 0.1% of all brain tumors . MagnetiA five-year-old male patient with no underlying medical or surgical problem was brought to the pediatric emergency department because of a single focal seizure which happened 2 hours prior to arrival in the emergency department. The seizure started while he was lying in his father's arms. He suddenly started snoring, his eyes rolled upward, his right upper and lower limbs started jerking heavily, and he was having frothy secretion from his mouth. The episode lasted for 2 minutes and was followed by a period of unresponsiveness for 1 minute after which the child woke up and was responsive. On arrival to the pediatric emergency department, He was not distressed. His vital signs were stable, and he was afebrile. On examination, there were no neurological deficits, but examination of the head revealed a soft central mass with normal skin and no hair on it. The neurologist on-call was consulted, who recommended performing a plain CT of the head as part of the workup for the focal seizure. The CT of the head revealed well-defined oval-shaped homogenous fat density (-111 Hounsfield units [HU]) seen in the midline along the falx cerebri at the level of the vertex. It measured 2.5 x 1.5 x 4 cm in maximum AP x TR x CC [anteroposterior x transverse x craniocaudal] dimensions, likely representing interhemispheric lipoma. No significant mass effect is seen, as shown in Figure Intracranial lipomas are rare malformations that form due to the abnormal persistence of meninx primitiva, which is the mesenchymal tissue that the meninges arise from and differentiate into adipose tissue. These lipomas are very rare, most commonly idiopathic in origin, and located in the interhemispheric fissure ,5.The presenting symptoms for patients with these lipomas are dependent on the location of the tumors intracranially and how they affect the brain. These symptoms may include headaches, seizures, or vertigo, but most commonly the patients are asymptomatic, and these tumors are found as an incidental finding . Our patIntracranial lipomas in the interhemispheric region associated with subcutaneous components are extremely rare, with a handful of cases being reported in the literature ,6-9. TheBoth MRIs and CTs serve as diagnostic tools for intracranial lipomas . MRI canOne of the main limitations to this study is the deficiency in imaging as neither an MRI nor a contrast CT was performed. Nevertheless, the plain CT scan performed as part of a complex seizure workup in the emergency department was sufficiently diagnostic.The majority of symptomatic intracranial lipomas are managed medically due to the complexity of surgical intervention considering the passage of nerves and blood vessels through the tumor . FurtherIntracranial lipomas are rare and usually asymptomatic lesions formed of adipose tissue. The tumor is usually diagnosed through incidental findings in CT or MRI scans as patients are usually asymptomatic. However, if symptomatic, the most common presentation is seizures. Management is usually medical through symptomatic treatment, and surgical intervention is not recommended.


Brooke–Spiegler Syndrome (BSS) is a rare autosomal dominant familial disorder resulting in dermatologic neoplasms of copious nodular appendages. Here, we report a case of Familial Cylindromatosis (FC), a subtype of BSS, in a patient with the largest cylindroma of 7.4 × 5.6 × 3.8 cm on the scalp. The patient had undiagnosed cylindromas growing for 36 years at presentation; however, he did not seek out healthcare evaluation. Excision and pathologic investigation of three large masses from different body sites determined a shared phenotype of cylindromas. Subsequent evaluation of the patient's son separately, after primary patient excision, confirmed cylindroma development as well. The pathologic evidence of cylindromas in the patient with a new history of family incidence confirmed the diagnosis of the FC variant of BSS. Brooke–Spiegler Syndrome (BSS), aptly named after its first descriptors in the late 1800s, is a rare autosomal dominant familial disorder with an unknown incidence and prevalence, resulting in dermatologic neoplasms of copious nodular appendages .The FC and MFT subtypes are associated with CYLD gene mutations on chromosome 16q12-913 [Creating an effective treatment plan with careful follow-up is imperative as malignant transformation occurs in 5–10% of patients with BSS [A 54-year-old male presented to the office with several subcutaneous nodular masses ranging in size on the scalp, groin, and back. The patient reports he had these nodules at age 18, but they have slowly grown over the years. The largest nodules were selected for surgical excision from each region. The nodules removed included a scalp lesion (7.4 × 5.6 × 3.8 cm) , right gBrooke–Spiegler Syndrome is associated with a mutation of CYLD, a tumor suppressor gene. The gene codes for a deubiquitinating enzyme by removing the lysine 63-linked polyubiquitin chain from substrates. Subsequently, it impedes the NF-kB and c-Jun N-terminal kinase pathways . The majCylindromas are usually benign slow-growing tumors presenting as red or pink dermal nodules with arborizing telangiectasias . HistoloEvaluation and successful diagnosis is important as to rule out other syndromic pathologies and possible malignant potential. Syndromic considerations for a differential diagnosis included neurofibromatosis, basal cell nevus syndrome, toxic-exposure-related incidence, and tuberous sclerosis. The differential diagnosis of a particular lesion should include benign lesions such as those shared in the abovementioned syndromic disease presentation; however, due to size and uniqueness in the removed lesions, malignant cylindromas were to be considered.Due to this condition's rarity, treatment modalities vary. Usually, surgical interventions, such as electro cryosurgery, laser surgery, and radiosurgery, have all been utilized . BesidesWe report this case to add to the incidence report of this rare variant of the rare syndrome. Moreover, we also want to highlight that our patient had cylindromas beyond his head and neck area including significantly large cylindromas in the upper back and groin. The largest cylindroma on the head measured at 7.4 × 5.6 × 3.8 cm over the period of 36 years. The unique presentation of multiple large nodules on the head and extending to other areas of the body may be secondary to socioeconomic challenges. Being in a rural area of the United States, the patient elected to delay healthcare evaluation. The concern with regards to this delay in evaluation could have allowed for lesions to grow further and possible malignant transformation, adding to the uniqueness of this case.


Primary non-Hodgkin lymphoma arising from the spine is exceedingly rare. Spinal cord compression can be the first presentation of a patient with primary spinal non-Hodgkin lymphoma. Due to its rarity and vague clinical presentation, the diagnosis can be confused with tuberculosis of the spine, a more common disease in this country. We present a case of primary thoracic spine B-cell lymphoma in a 45-year-old lady who presented with spinal cord compression. This case highlights the importance of obtaining histopathological samples for examination and the treating physician should be vigilant on this rare cause of spinal cord compression. Treatment can be initiated promptly once the diagnosis is established as primary spinal non-Hodgkin lymphoma carries a dire prognosis. Malignant lymphoma is a type of malignancy derived from the lymphoid tissue, and it normally presents as lymphadenopathy or a solid tumor ,2. CompaIn a country where tuberculosis is endemic, tuberculosis is the first diagnosis that comes to a physician’s mind when he encounters a young patient presenting with unexplained spinal cord compression ,8. CouplA 45-year-old lady with no known medical illness presented with progressive bilateral lower limb weakness and numbness for five months. Symptoms started insidiously and gradually worsened prior to presentation. There was associated occasional shortness of breath as well as bladder and bowel incontinence one week prior to presentation. There was no neck or back pain. She had loss of appetite and loss of weight of non-specific duration. She had no fever, night pain, abnormal neck, breast, or abdominal swelling. She denied history of trauma or falls.Clinically, she was bed-bound and appeared cachexic. Spine examination revealed mild tenderness at the mid-thoracic spine with no step deformity. Neurologically, both of her lower limbs had motor deficit with power of Medical Research Council (MRC) grade 0 and absent sensation from T5 downwards. The muscle tone was hypertonic and lower limb reflexes were brisk. Her anal tone was also lax with loss of perianal sensation. Otherwise, her upper limb neurology was normal. There was no palpable breast lump, thyroid nodule, or mass per abdomen. There was no enlarged lymph node at the cervical, axillary, or inguinal area. Lung examination revealed reduced air entry at the right side.9/L) with lymphocyte of 13.8%. The erythrocyte sedimentation rate (ESR) was 24 mm/h with C-reactive protein level of <0.05 mg/dL and the serum lactate dehydrogenase (LDH) level was 297 U/L. Other blood parameters such as renal profile and liver function test were normal. Mantoux test was equivocal, and the sputum acid-fast bacilli test was negative. Plain chest radiographs showed right pleural effusion until mid-zone. No abnormality detected on plain radiographs of the thoracolumbar spine  is an endemic disease in Malaysia. It is estimated that 10% of the disease in Malaysia are extra-pulmonary TB and 4% of pulmonary TB patients have extra-pulmonary involvement . Also knIn our patient, the onset of the symptoms was insidious and progressive. Clinically, there was no sign to suggest malignancy. Coupled with MR images that showed intraspinal extradural mass with vertebral body involvement and multiple lesions which enhanced post-contrast, a provisional diagnosis of TB spine was made despite an equivocal Mantoux test. As the patient had a strong aversion towards surgery initially, we started a trial of anti-TB chemotherapy but to no avail. However, excision of the extradural lesion was successfully performed and histopathological examination of the mass finally revealed primary B cell lymphoma of the spine as the true culprit in this patient.Primary non-Hodgkin lymphoma of the spine is a rare condition. In fact, a review of the literature reveals only case reports and case series, highlighting the rarity of this entity . In contIn terms of radiological investigations, plain radiographs of the spine are usually non-specific and often tend to underestimate the extent of disease. MR imaging is the radiological examination of choice as it is non-invasive and it can clearly delineate the extension of lesion and help in the planning of surgical intervention. Spinal NHL can present as an iso- or hypo-intense lesion on T1-weighted images, hyperintense on T2-weighted images with a homogenous enhancement post-gadolinium administration . In thisThe gold standard in the diagnosis of spinal NHL is the histopathological examination (HPE). Biopsy can be obtained at the time of operative intervention or done as a separate procedure, either percutaneous or open. In cases where there is no indication for open surgery, CT-guided biopsy is certainly a viable alternative, especially if the lesion is in an extradural location.Despite the advancement of chemo- and radiotherapies in managing patients with malignancy, primary spinal NHL seems to have an unfavorable prognosis . The medThe chemotherapy of choice is the CHOP regime . CHOP isThe goals of initial spinal surgery are usually to prevent further bone destruction and compression, to assist weight-bearing, to obtain pain relief and a better quality of life. But the ever-present dilemma in these cases is the fact that patients with malignant tumors are often elderly, debilitated, or systemically ill from their malignant diseases. Often, extensive operative procedures like laminectomy and posterior instrumentation carry more risks than benefits in this group of patients. In this patient, we have performed a decompressive laminectomy to alleviate the spinal cord compression, during which we are also able to excise the brownish caseous extradural mass for histopathological examination.In a conclusion, the diagnosis of primary NHL of the thoracolumbar spine is often missed or delayed due to a lack of specific findings and the presence of confusing similarities with other diseases. Even though the main form of treatment is chemotherapy and/or radiotherapy in cases of spinal lymphoma, surgery may still be indicated in patients who present with neurological symptoms. More importantly, HPE should be obtained to guide our treatment plans and for prognostication purposes. With regard to HPE, the soft tissue component of the lesion is preferred over bone, as inadequate tumor cells in biopsies taken from lytic areas of medullary infiltration have been reported.


Lymphatic malformation or cystic lymphangioma is a benign tumour of the lymphatic vessels. It is more commonly reported among children and has polymorphic clinical presentations. The diagnosis is based on imaging but requires histological confirmation. The treatment of choice is surgical excision for the abdominal and symptomatic localization.We report the case of a 30-year-old female who consulted for right iliac fossa pain mimicking an acute appendicitis. The physical examination revealed a slight tenderness in the right iliac fossa without fever or palpable mass. Though the biological screening was normal, the imaging exploration has revealed the presence of a multiloculated cyst located in the right iliac fossa at the ascending colon and measuring 15 cm. The mass matches with lymphatic malformation. Therefore, a laparoscopy was performed, and complete resection of the cystic tumor was accomplished with right hemicolectomy. The histologic exam has confirmed the diagnosis.Colonic lymphatic malformation is a rare and benign tumour, requiring a complete surgical excision to minimise any recidivism. The definitive diagnosis remains histological. A 30-year-old female with no pathological history consulted for acute pain in the right iliac fossa without fever or transit disorders. Physical examination has revealed a slight tenderness in the right iliac fossa without palpable mass. The clinical presentation suggested the diagnosis of an acute appendicitis. The biological screening was normal.Abdominal ultrasound has showed a normal appendix  without infiltration of surrounding fat neither abdominal abscess. It also has objectified a multiloculated cyst in the right iliac fossa which measures 150 × 53 mm containing a few thin septa without vascularisation in Doppler . For bet1,2The differential diagnosis includes a wide range of cystic intra-abdominal lesions, ranging from congenital duplication cyst, pancreatic pseudocyst, abdominal tuberculosis and abscess, hydatid disease, appendicular cyst, ovarian cyst, retroperitoneal cyst and malignancies such as mucinous carcinomatosis.A laparoscopy was performed, and the exploration found a cystic mass that measured 15 cm of diameter . A compl3LM are rare and benign tumours, typically arising in the axilla, head and neck regions in the paediatric population. These cystic hygromas develop rarely, in other regions.4It does not often affects the intestinal tract and most of them settle in the mesentery, omentum, mesocolon and retroperitoneum.5–7The incidence is about 0.18%. The LMs that appear in the wall of the intestine are considered even rarer and represented less than 1% of all types of lymphatic malformations.8Colonic lymphatic malformation (CLM) was first reported by Chisholm and Hillkowitz in 1932, and is a submucosal tumour covered with normal mucosa. It occurs mainly among children.9,10The specific aetiology of this tumour remains unclear. It may be due to a congenital defect of connection between the primary lymphatics spaces and the central collector system.11The symptoms are generally poor, and non-specific. The CLM in paediatric patient are usually symptomatic if compared with adults, because children have smaller cavity which might induce frequent compressive symptoms. The most common symptom is the abdominal pain which mimics acute abdomen due to intra-abdominal bleeding, acute appendicitis, volvulus and bowel obstruction, ischaemia or perforation.2The abdominal radiograph might show colonic distension, collapsed distal colon and even pneumatosis coli when complicated bowel obstruction or ischaemia was noted.Ultrasound is considered the first level of imaging investigation for a suspected mass suggestive of LM, thanks to its non-invasiveness, low cost, accessibility, and possibility of antenatal diagnosis: it grants not only the identification of the lesion and the definition of the cystic type structural characteristics, but its size also. The mass appears as a cystic liquid lesion, multilocular, thick wall without vascularisation in Doppler.12Usually, this technic needs to be integrated with CT scan or MRI in order to specify the morphology of the lesion, its components, the contrast enhancement, and the locoregional spread.12For MRI, it seems to be interesting giving its capacity to make the differential diagnosis from other cyst-like masses but also its ability to characterise the various components of the lesion in particular the fatty content.Given its availability, the CT scan is considered the golden exam for establishing a pre-operative diagnosis. The LM appears as a well-limited mass with a homogeneous content, thin partitions without significant enhancement by the liquid contrast.13The content of the cystic masse can be heterogeneous either by the fatty component which appears as negative density or by the high density in case of haemorrhage.7Definitive diagnosis remains mainly on histology. In fact, LM are classified into three types: capillary, cavernous and cystic, with the latter being the most common subtype. Macroscopically, LM present as yellow, greyish, or yellow-pink, multilocular cysts or spongy masses, containing watery/milky fluids at sectioning.14–17On histology, LM consists of enlarged irregular spaces lined by flattened, epithelial cells devoided of atypia. The stroma is often fibrocellular. The presence of lymphocyte aggregates, smooth muscle bundles and adipocytes represent uncommon features. The diagnosis might require immunohistochemistry, endothelial cells stain positive with lymphatic endothelial markers such as D2 - 40 marker and also for vascular markers including CD34, CD31, and factor VIII–related antigen.18,19Various forms of treatment have been described. A therapeutic abstention with a regular follow-up are recommended in case of accidental discovery of an asymptomatic CLM. A spontaneous regression can be obtained and it is observed in 1,6–16% of cases.9A total surgical excision is actually a first choice treatment to avoid recidivism.19A conservative approach should be performed for the adjacent organs because of the benign character of CLM.20–22For symptomatic lesions that are accessible and unresectable, the aspiration of the cyst content or the percutaneous sclerosis with sclerosing products can be effective alternatives to surgical treatment with good results.Colonic lymphatic malformation is a rare and benign tumor, requiring a complete surgical excision to minimise any recidivism.Colonic lymphatic malformation localised in the iliac fossa can be discovered in an emergency context and mimics acute appendicitis.The radiological imaging is essential for the pre-operative diagnosis of lymphatic malformation.The definitive diagnosis of lymphatic malformation is histological.


The presence of endometrial tissue outside the uterine cavity is known as endometriosis. Catamenial pneumothorax (CP) is a recurrent spontaneous pneumothorax that occurs in women of childbearing age. Thoracic endometriosis is a rare clinical entity, and CP is the most common presentation. Imaging diagnosis is based on computed tomography (CT) scans and magnetic resonance imaging (MRI), detecting blood products in endometrial deposits. We report a case of right CP in a 37-year-old woman with chest pain and dyspnea 48 hours after the onset of menstruation. The pneumothorax was drained, continuous hormonal therapy was started, and she underwent video-assisted thoracoscopic surgery (VATS), which revealed multiple diaphragmatic fenestrations and a solitary nodular thickening in the diaphragmatic pleura . After pleurodesis, multiple CP recurred, and later underwent a total hysterectomy. CP is the most common form of thoracic endometriosis and should be suspected in women of childbearing age. The presence of endometrial tissue outside the uterine cavity is known as endometriosis and affects approximately 5%-10% of women of childbearing age. Although this ectopic tissue  is more common at the pelvic level - ovaries, uterosacral ligaments, pouch of Douglas and broad ligaments - it can occasionally arise outside the pelvic cavity . Thoracic endometriosis is a rare clinical entity  and cataWe report the case of a non-smoker 37-year-old woman, admitted to the Emergency Room (ER) with chest pain, moderate dyspnea and irritating cough with 48 hours of evolution. The symptoms started days before menstruation and the duration was about four to five days, coinciding with the duration of the hemorrhagic period, decreasing or disappearing with the end of the menstruation. She reported other similar episodes of gradual and repetitive worsening during menstruation, starting in adolescence. Two years before the first observation in our ER, the patient underwent computed tomography (CT) scan of the chest, reported as normal. She denied weight loss or other relevant medical findings. Regarding the gynecological history, there was a pregnancy with a eutocic birth six years previous, and no history of documented pelvic endometriosis. Physical examination revealed decreased breath sounds in the right hemithorax. Blood analysis was unaltered and chest x-ray Figure  and CT sCP is rare. It occurs during the menstrual period and is due to lung collapse. It is considered secondary to endometriosis in the pleural cavity and causes one-third of spontaneous pneumothoraces in women of childbearing age ,2. AlthoIn young women with pneumothorax during menstruation, CP should always be suspected. Delay in treatment usually leads to recurrence and worsening. It is necessary to carefully observe and remove the pleural lesions  and surgically repair the diaphragmatic fenestrations. The start of hormonal therapy is also recommended, as it seems to help maintain the results achieved with surgery. Rarely, due to the failure of less invasive therapeutic strategies, total hysterectomy is the only solution to resolve the clinical condition. It is important to highlight the importance of a multidisciplinary team - internal medicine, pulmonology, cardiothoracic surgery and gynecology - in conducting this case, each case, in search of success.


Appendicular agenesis is a rare condition that accounts for 1 of every 100,000 exploratory laparotomies, usually in clinical suspicion of appendiceal inflammatory processes with higher incidence in adults.We present a case of a 19-year-old female with appendicular agenesis who underwent exploratory laparoscopy in the context of appendiceal inflammatory process.Vermiform appendix agenesis is a challenging diagnosis made in most cases as an intraoperatively finding. Systematic revision of abdominal cavity should be performed after ruling out other causes of acute abdomen. No implications have been described in patients with appendix abnormalities. •Appendicular agenesis is a rare entity, there isn't clinical features that could increase the clinical suspicion.•Intraoperative diagnosis is relatively frequent, and systematic revision of the cavity must be performed.•Apparently, no clinical implications of appendicular agenesis are present. She had no fever or dyspnea. Gynecologic examination did not show signs that suggest pelvic inflammatory disease . White blood cell count reveals leukocytosis (17.370 μ/L), with neutrophilia (88%). Pregnancy tests were performed with negative results. Also, C reactive protein was analyzed and reports a negative value. Due to symptoms previously described, a urine test was ordered, with no signs of infection.Initial hydration and observation were performed. Appendicitis Inflammatory Response (AIR) Score was calculated (7 points). Due to intermediate risk, based on clinical findings, and worseness of clinical status and acute abdomen, surgical approach was considered with a suspected diagnosis of acute appendicitis. A Laparoscopic approach was performed. Told fascia was released on the ascending colon, identifiying the cecum and ilioceccum valve, following the taenias and its confluence we examined the entire colon, with no visualization or identification of the appendix. All surgical causes of acute abdomen were ruled out, pelvic cavity was revised, identifying signs of inflammatory pelvic disease. In furtherance of a proper revision a Rockey-Davis approach was performed, in order to exteriorize the cecum and ileum with a systematic review of the cavity. However, no appendix was found . ContrasSurgical time was 120 min, no intraoperative bleeding was documented. In-hospital stay was 2 days. Gynecologic consultation was required in order to define treatment for inflammatory pelvic disease. Outpatient consultation after 2 weeks did not show any complication. No postoperative complications were documented after 30 days of follow up. His controls have been uneventful upto 3 months.3Abnormalities of the vermiform appendix are rare, with an incidence that arounds 0.001% .In terms of embryology, vermiform appendix development starts at the 8th week .Embryological abnormalities of the vermiform appendix have been also documented. Collins in 1951 Failure in the appendix development according to Hei et al., could be attributed to an intrauterine vascular accident, and in some cases is associated with intestinal atresia 4Vermiform appendix agenesis diagnosis could be performed as an intraoperative finding, and systematic revision of the cavity should be done after rule out other causes of acute abdomen. Apparently, no implications were described in patients with appendix abnormalities.Not commissioned, externally peer-reviewed.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval of institutional committee was made previous publication.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Felipe GironNone.Felipe Giron, MD, MSc: Make substantial contributions to conception and design, acquisition of data, analysis and interpretation of data.Carlos Rey, MD: Participate in drafting the article and revising it critically for important intellectual content.Lina Marcela Rodriguez, MD: Participate in drafting the article and revising it critically for important intellectual content.Danny Conde, MD: Participate in drafting the article and revising it critically for important intellectual content.David Venegas, MD: Participate in drafting the article and revising critically for important intellectual content.Alberto Arango, MD: Give final approval of the version to be submitted and any revised version.Authors do not declare any conflict of interest.


Pigmented epithelioid melanocytoma (PEM) is a sporadic type of pigmented melanocytic tumor with uncertain malignant potential. PEM arises as a solitary neoplasm that predominantly occurs spontaneously in otherwise healthy patients. Due to its rarity, a gold standard treatment regimen does not exist; however, symptomatic cases should be managed with radiotherapy and surgery.A 28-year-old Thai female presented with a sudden onset of back pain and weakness of the lower extremities during the postpartum period. Magnetic resonance imaging demonstrated abnormal soft tissue formation from T4 to T7; it extended to the vertebral bodies, left neural foramina, and posterior columns of T6 and T7. The patient underwent complete tumor debulking, decompressive laminectomy from T4 to T8, and posterior instrumentation from T3 to T10. The histopathology and immunohistochemistry suggested PEM. The patient fully resolved back pain after surgery. Nevertheless, as the patient re-presented with a neurological deficit a few months after the operative intervention, it was decided to perform a surgical resection via an en bloc vertebrectomy. At the one-year follow-up, although the patient reported continued improvement of her back pain, there was no motor power improvement.Spinal cord compression due to PEM is uncommon, especially in adults. Early diagnosis and treatment provide a good prognosis and help to regain lost neurological functions. Complete tumor removal and decompression of the spinal cord must be considered as a treatment strategy. Perioperative radiotherapy and chemotherapy have also been highlighted as treatment modalities for spinal tumors. With our reported case, early operative intervention coupled with radiotherapy produced satisfying outcomes. Pigmented epithelioid melanocytoma is a sporadic, pigmented melanocytic tumor having an uncertain malignant potential. The term “pigmented epithelioid melanocytoma” (PEM) was coined by Zembowicz et al. in 2004. The morphological spectrum of the condition comprises animal-type melanoma and low-grade epithelioid blue nevus of the carney complex . AlthougPEM most commonly occurs in children, adolescents, and young adults. The most common occurrence site is the extremities 40.3%) ; the oth% ; the oA 28-year-old Thai female (G3P1A1) without any previous medical illness presented with sudden-onset severe pain in the upper back and weakness of her lower limbs. The previous day, she had been admitted to the hospital for normal vaginal delivery. Immediately after the birth, the patient developed sudden-onset upper back pain. Within a few hours of delivery, she developed progressive weakness of her legs and urinary incontinence. On examination, she had a visible kyphotic deformity around the upper thoracic spine and marked tenderness on palpation at the midthoracic level. A neurological examination revealed the motor power of her legs to be grade II/V on all of the right side and grade I/V on the left side, except at L2, which showed grade II/V. The pinprick sensation was impaired below T7 level in both legs. Although the patient also had a loose sphincter tone, there was the presence of both anal wink and deep anal pressure. No clonus was detected. Based on the American Spinal Injury Association (ASIA) impairment scale, she was classified as having an incomplete spinal cord injury (ASIA B).Magnetic resonance imaging (MRI) of the entire spine revealed abnormal bone marrow signal intensity at T6 and T7, with adjacent paravertebral soft tissue formation from the T4 to the T7 levels. The lesion appeared with heterogeneous high-signal intensity on T1WI but with heterogenous low-signal intensity on T2WI/STIR. There was also an enhancement involving the vertebral bodies, left neural foramina, and posterior columns of T6 and T7. Additionally, a severe compression fracture at the T6 level and a mild compression fracture at the T7 level were observed. Furthermore, multiple nodules scattered throughout both lungs were visible, suggestive of lung metastases. The imaging findings are described in Fig. She was brought to operating room within 6 h after the occurrence of symptoms. Subperiosteal paraspinal muscle dissection was performed, after which partial tumor debulking at the T6 and T7 levels was done. Pedicular screws were then inserted from the T3 to the T10 levels—other than at the T6 and T7 levels—with the aid of the O-arm navigation system. Subsequently, complete tumor debulking was undertaken at the T6 and T7 levels. The tumor appeared as a sloppy mass containing a greenish-black secretion. A decompressive laminectomy was performed between the T4 and T8 levels, and posterior instrumentation was done between the T3 and T10 levels. Histopathological analysis of tissue samples from the T6 and T7 levels revealed heavily pigmented melanocytic lesions. They were composed of medium-to-large epithelioid cells with large vesicular nuclei, prominent macronuclei, and abundant cytoplasmic melanin pigment. The tumor demonstrated an infiltrative growth pattern at the periphery. Mitotic activity was relatively low (0–1/high power field). Psammoma bodies and adipose-like cells were not observed. Tumor necrosis averaged 20% of the tumor volume. A surrounding soft-tissue invasion and bone invasion were evident. The histopathological details are described in Fig. Immediately postoperatively, the patient’s back pain was subsided, and improvement was seen in her neurological status, with an assessment of grade C on the ASIA impairment scale. Nonetheless, upon a neurological assessment during 2 months postoperative follow-up, the motor power of both legs was grades 0/V, with grade B on the ASIA impairment scale. The pinprick sensation below the T4 level had also decreased on the right side and was absent on the left. Both clonus and the Babinski reflex were present bilaterally. The patient underwent a second operation 2 months after the first. The fourth to ninth ribs resection and resection of the residual tumor was done. Histopathological analysis revealed a residual PEM. Postoperatively, the patient’s neurological status reverted to grade C on the ASIA impairment scale. At the one-year follow-up, although the patient reported continued improvement of her back pain, there was no motor power improvement.Melanocytic tumors of the central nervous system (CNS) are exceedingly rare, solitary, low-grade, pigmented neoplasms, and they may arise anywhere along the neural axis. The term “melanocytoma” was first used in 1972 to report a heavily pigmented tumor of the foramen magnum . These tPEMs fit into the nosological category of borderline melanocytic tumors. No gender predilection has been observed, and sun exposure is not involved in the pathogenesis of PEM . The preMelanocytic lesions of the nervous system and its covering are considered to originate from leptomeningeal melanocytes, which are derivatives of the neural crest during the embryonic stage of development. Accordingly, melanocytic lesions of the central nervous system were classified by Brat et al.  as low gDiffuse melanocytosis and melanomatosis involve leptomeninges and might invade the parenchyma. They can present with signs of malignancy. Primary leptomeningeal melanomatosis is an aggressive tumor that carries a poor prognosis . MeningeThe incidence of pregnancy-related spinal tumors is about 1 in 1000 to 2000 pregnancies . They arThe atypical clinical presentations, radiographic features, and distinct histological features of specific types of spinal tumors aid in making a definitive diagnosis.Primary and metastatic tumors of the spine are often asymptomatic or have nonspecific symptoms. The symptoms depend on the location and size of the tumor, and the degree of compression of the spinal cord or nerve root. If symptomatic, pain is a crucial presenting feature; it might result from mechanical instability of the vertebral column or neural compression . Red-flaPlain radiography reveals indirect signs of a mass effect. A chest x-ray could be obtained as a part of the initial work-up. A computed tomography scan of the chest, abdomen, and pelvis could be used to stage the disease, identify metastases and lymph node involvement, and facilitate surgical planning . MRI is The histopathological features suggestive of PEM are a cellular element proliferation with epithelioid cytoplasm containing melanin pigment infiltrating the papillary dermis in blocks. In immunohistochemistry studies, PEM demonstrates positivity for Melan A, HMB-45, and S-100 , 18. PEMThe appropriate management of spinal tumors is debatable. Surgery and radiotherapy can be used simultaneously for the treatment of spinal tumors. Perioperative radiotherapy and brachytherapy have been extensively employed as management measures. However, both the optimal radiotherapy dosage and the method to combine surgery with radiotherapy to obtain the best outcomes are still being debated. Rades et al.  suggesteLocal administration of chemotherapy could be an option for eradication of residual tumor cells after excision. Systemic chemotherapy is not used for spinal tumors because of the potential for side effects caused by the treatment strategy. Local administration of paclitaxel has shown efficacious therapeutic effects; it additionally has a radio-sensitizing property that aids local tumor control. However, chemotherapy or other therapeutic strategies has not led to benefit in the case of PEM .If a tumor occurs in the spinal region, the surgical goal is to completely resect the tumor and decompress the spinal cord. The main surgical procedures are percutaneous vertebroplasty, debulking surgery, piecemeal resection, and total en bloc spondylectomy. Tumor related nerve compression can be relieved by using piecemeal resection and debulking surgery. Total en bloc spondylectomy involves removing an entire vertebral body and posterior elements to achieve tumor resection with negative margins. Evidence from the literature also indicates that gross total resection is another treatment option for central nervous system tumors . There iLong-term clinical follow-up of a patient is necessary after surgical resection and adjuvant therapy to monitor the recurrence of the tumor and determine the outcomes. With PEM, the published long-term follow-up studies do not report any adverse outcomes in cases with metastasis to the sentinel lymph nodes . MetastaIn summary, this case highlights a rare case of PEM of the spine causing incomplete cord injury from a compression fracture.PEM is an extremely rare form of pigmented melanocytic tumor. It has an uncertain malignant potential, and it predominantly occurs spontaneously in healthy patients. The rarity of the tumor creates difficulties in establishing a diagnosis. MRI is the modality of choice for patients with suspicion of spinal cord compression resulting from the tumor. Complete tumor removal and decompression of the spinal cord must be considered as part of the treatment strategy. Perioperative radiotherapy and chemotherapy have also been highlighted as modalities of treatment for spinal tumors. With our reported case, early operative intervention combined with radiotherapy produced satisfying outcomes.


Posterior tibialis tendon (PTT) dislocation is an extremely rare yet significant finding in cases with recalcitrant pain over the medial malleolus, usually as a consequence of trauma. The diagnosis is frequently delayed, as the patient’s initial clinical presentation generally resembles benign musculoskeletal pathology of the ankle joint. Herein, we report the case of a female patient diagnosed with PTT dislocation after four weeks of conservative management for an ankle sprain. Surgical intervention, including retromalleolar groove-deepening and repair of flexor retinaculum with intraosseous suture anchors, proved to be successful after a mean follow-up of 12 months. A thorough literature review was conducted regarding the aforementioned injury, concluding that PTT dislocation-in spite of its rarity-should be included in the differential diagnosis of patients with importunate pain on medial malleolus after an ankle injury. Dislocation of a posterior tibialis tendon (PTT) represents an exceptionally rare entity in the annals of orthopedics, with only a few cases reported hitherto in the literature . The vasΑ 60-year-old female housewife presented to the emergency department complaining of acute pain at the medial malleolus of the right ankle. The mechanism of injury was vague as the patient described that the pain suddenly started as she bent over to lift a heavy box with her knees extended. She also mentioned a “snap” sensation at the time of injury, followed by an inability to bear weight.During the physical examination, moderate edema, ecchymosis, and tenderness were noted over the medial malleolus with a full range of ankle motion. Plain radiographs  were normal. The patient was diagnosed with an acute sprain of the deltoid ligament and was managed conservatively with a non-weight bearing air cast, early functional rehabilitation, and nonsteroidal anti-inflammatory drugs.Four weeks later, clinical reassessment revealed swelling subsidence, but the patient referred to a persistent pain over the medial aspect of her ankle that impeded full-weight bearing and the return to everyday activities. A more detailed clinical examination unveiled a cord-like structure over the medial malleolus translating forwards and backward, with passive dorsiflexion and plantarflexion of the ankle. Computed Tomography (CT) did not showcase any bone participation, although a more flattened retromalleolar groove was depicted Figure . MagnetiMRI demonstrated the transposition of PTT over the medial malleolus, anteromedial to the retromalleolar sulcus Figure , with exThe patient was admitted to the Orthopedic clinic, and the surgery was carried out on the first-day post-admission. Under epidural anesthesia, with the patient placed supine on the operating table, a pneumatic tourniquet was applied around the upper thigh. The affected right foot was held in external rotation by an assistant. A 7.5 cm curvilinear incision was performed along the posterior border of the medial malleolus, followed by careful blunt dissection of subcutaneous tissue. The flexor retinaculum appeared intact Figure . PTT wasEarly postoperative physical examination of the patient did not reveal any sensory/motor deficit or vascular compromise. A CT scan was conducted showcasing the newly formed retromalleolar groove Figure . The patPTT dislocation was first described in Belgian literature by Martius in 1874 .PTT is the most superficial structure of the tarsal tunnel. The flexor retinaculum, extending from the medial malleolus to the calcaneal tubercle, along with the concavity of the retromalleolar groove, is the main anatomic structure that holds the PTT and flexor tendons within the retromalleolar groove, preventing them from bowstringing. Soler et al. conducted an anatomic study on 25 dried cadaver shinbones and described that the retromalleolar groove can vary in width and depth, meaning that a shallower retromalleolar groove could make the luxation of PTT easier . In our Typically, the preferred mechanism of injury is a twisting of the ankle, pronation-external rotation, or forced dorsiflexion, although non-traumatic cases of spontaneous PTT dislocation have been reported, as well ,8. Two tThe diagnosis of PTT dislocation is mainly clinical; however, in an acute setting, the diagnosis can be delayed as the history and clinical presentation of the patient can mimic an acute ankle sprain . OuzouniTreatment choices include conservative or surgical management. Up to date, literature acknowledges that the surgical approach is most effective to restore the dislocation ,12-14. APTT dislocation is a rare yet important finding in a patient presenting with trauma and swelling of the medial malleolus. Due to regional edema, PTT can be impalpable in an emergency setting and is usually considered as an ankle sprain leading to unsuccessful conservative treatment. The fact that the injury is not tackled in the acute phase can generate chronic conditions, recurrent dislocations, acquired flatfoot, or even tendon ruptures. Persistent pain on the medial malleolus should make the physician consider PTT dislocation as part of the differential diagnosis. A dynamic ultrasound, MRI, or CT will confirm the diagnosis. Treatment is mainly surgical, restoring the PTT to its anatomical position. In our case, PTT dislocation was attributed to a hypoplasia of the retromalleolar groove in combination with a sudden contraction of the tendon in a fully extended limb. Our treatment regimen aimed to deepen the retromalleolar groove and restore a competent flexor retinaculum, leading to an optimal functional outcome for the patient.