In the workup of a pediatric patient with pericarditis we found evidence of a pseudo-aneurysm of the left ventricle, which is a rare complication of purulent pericarditis.Staphylococcus aureus. The exact mechanisms of this rare complication remain unknown.We present a case of a six-year-old girl who was diagnosed with pericarditis and a fistula between the pericardial and the intra-luminal space of the left ventricle of the heart. She was successfully treated with antibiotics and cardio-thoracic surgery. We found 23 published cases (21 with follow-up) of infectious pseudo-aneurysm of the heart, of which 19 underwent surgery, 5 had fatal outcome, and 2 who refused surgery survived. The majority of cases were associated with Staphylococcus aureus infection. Because of risk of rupture, surgical intervention is advised.A pseudo-aneurysm of the left ventricle is a rare and not well understood complication of a purulent pericarditis most commonly caused by  Since the widespread use of antibiotics, purulent pericarditis became a relatively uncommon disease. In the workup of a pediatric patient with pericarditis we found evidence of a pseudo-aneurysm of the left ventricle, which is a rare complication of purulent pericarditis. We hereby describe our case and the available literature.A literature search was performed on Medline using the following key words: pseudo-aneurysm, pericarditis, pancarditis, perimyocarditis. No filters were used to avoid missing relevant review articles and case reports. Also, the references of the relevant case reports and review articles were hand searched, to identify additional cases.Staphylococcus aureus. After 1 month she was transferred to our center under the suspicion of pericarditis, because of persistent fever and cardiomegaly on the chest X-ray. Echocardiography revealed pericardial effusion, located mostly behind the left ventricular (LV) posterior wall .High doses of intravenous cefotaxime and flucloxacillin, already started in the referring hospital, were continued. She developed arthritis of the left knee and right elbow which were both aspirated but with negative cultures. Two weeks after admission her clinical condition did not improve with persistent leukocytosis and high C-reactive protein levels. A pericardial abscess with ongoing bacteremia was suspected and surgical intervention was scheduled.A median sternotomy was performed, leaving the pleural space closed. The patient was placed on extracorporeal circulation using standard bicaval cannulation. The operation was performed on a beating heart. On opening of the pericardium multiple small abscesses and adhesions were identified and removed, as were thick vegetations on the left ventricular posterior wall. The fistula in the LV myocardium connecting the LV lumen with an abscess on the posterior-lateral wall of the LV was found and closed with prolene sutures with felt see Fig. . The perStaphylococcus aureus osteomyelitis. The pericarditis and pseudo-aneurysm were effectively treated with antibiotics, surgical drainage of the pericardium and closure of the fistula.We report a pediatric case of left ventricle pseudo-aneurysm as a complication of purulent pericarditis secondary to a Staphylococcus aureus was the most common causative microorganism occurring in 52% of cases, excluding MRSA. Mycobacterium Tuberculosis was reported in three patients. The most common location of the pseudo-aneurysm was at the posterior and/or lateral wall of the left ventricle. Echocardiography was the most frequently used imaging tool to obtain diagnosis. Nineteen patients underwent an operation because of the risk of rupture or ongoing infection. Four patients died post-operatively, including one 18-year-old male and three adult patients. The causes of death in these four cases were profuse bleeding because of a serious coagulopathy postoperatively, further deterioration because of the widespread infection despite surgery, persistent hypotension postoperatively and the inability to repair the LV pseudo-aneurysm (LVPA) with eventually rupturing of the LVPA. The outcomes in the other cases that underwent surgery were uneventful and all these patients recovered fully. It is intriguing that in the two of the three reported cases of patients that refused surgical treatment no rupture occurred during follow-up [A left ventricular pseudo-aneurysm is a rare complication of a bacterial pericarditis. Our literature search revealed a total of 23 cases, including 12 children, with outcome reported in 21 cases , it is likely that there is publication bias, which asks for caution in interpreting the overall outcome.Staphylococcus aureus infection. Because of risk of rupture, surgical intervention is advised, although there are two reported cases that survived without surgery.In summary, this is a case of a 6-year-old girl with pseudo-aneurysm of the left ventricle as a complication of purulent pericarditis secondary to osteomyelitis, with good recovery after antibiotics and cardiac surgery. A pseudo-aneurysm of the left ventricle is a rare and not well understood complication of a purulent pericarditis most commonly caused by


Neuroendocrine tumors (NET) of the colon and sigmoid colon are uncommon compared to colorectal adenocarcinoma. Few reports have been made of NET of the colon and sigmoid colon that presents with peritonitis and large bowel obstruction.Here, we report two cases of NET of the colon and sigmoid colon, which were diagnosed and treated at our institution. In our first case, a 66-year-old man with a history of abdominal distension was diagnosed with NET via histopathology of the sigmoid colon. The second case involved a 45-year-old woman with the chief complaints of abdominal distention and inability to defecate; specimen histopathology of the descending colon showed neuroendocrine carcinoma features. Clinical outcome was very poor in our patients: eight months after the resection, the second patient demonstrated a sign of metastasis on the liver.An uncommon case of colon and sigmoid colon carcinoma with neuroendocrine and diagnostic difficulties precludes an exact description of the initial diagnostic criteria and management. Thus, our case series offers an overview of initial symptoms, radiological and histopathological features for early diagnosis, and proper management of NET. The cliThe incidence of NETs has increased, probably due to improved diagnosis and the availability of very specific and sensitive modalities, like endoscopy, computed tomography (CT scan), magnetic resonance imaging (MRI), ultrasonography (USG), and scintigraphy .The incidence rate by age increased sixfold from 1973  to 2012  [22.1A 66-year-old man was admitted to our hospital after a previous laparotomy surgery in a tertiary hospital. Before the surgery, the patient had abdominal distension for three days and diarrhea for two weeks, which led to his admission to the hospital. The patient was diagnosed with peritonitis in the tertiary hospital. On August 13th, 2018, sigmoidectomy (Hartmann’s procedure) and primary closure of perforated caecum was performed in the tertiary hospital. The post-surgical diagnosis was peritonitis caused by perforated caecum and distal sigmoid colon tumors. The histopathology results on August 29th, 2018, showed neuroendocrine carcinoma with a near incision edge; all lymph node specimens were tumor-free .Fig. 1Hi3/ul; platelets 493,000/ul; albumin, liver function test values, and other biochemical parameters within normal limits; and carcinoembryonic antigen (CEA) tumor markers within normal levels. We operated close the stoma. The post-operative period was uneventful, with removal of a drain on postoperative day 4, and the patient was discharged on the 5th post-operative day. Patient showed no signs of recurrence during the two-year follow-up period.The patient came to our institution on November 12th, 2018, and reevaluation was conducted; abdominal ultrasound showed no sign of metastasis as well as other intra-abdominal organs within normal limits. Thoracic x-ray examination showed no sign of metastasis. The lopography result was within normal limits: the distance of the rectosigmoid colon from the distal descending colon was aproximately 9.5 cm. Laboratory tests showed hemoglobin 12.3 g/dl; white blood cell 16.0 × 102.2A 45-year-old woman came to the emergency room at our hospital with the chief complaints of abdominal distention and inability to defecate for seven days before entering the hospital on March 29th, 2018. Laboratory findings showed an elevated white blood cell count , slightly decreased hemoglobin level (9.4 mg/dL), and CEA tumor markers 43.15 ng/m (high). A 3-position abdominal X-ray was performed and showed large bowel obstruction. Left hemicolectomy was performed with end-to-end anastomosis see .Fig. 2InRemoval of a drain was performed on postoperative day 5, and the patient was discharged 8 days postoperative with a good condition. On March 23rd, 2018, prior to surgery, patient came to outpatient department in tertiary hospital with abdominal distention then an abdominal CT scan with contrast had been conducted that showed descending colon tumors . The pat3With more than 100,000 cases, NET has a higher prevalence rate than gastric and pancreatic cancer . The incData from the Surveillance, Epidemiology, and End Results (SEER) program indicated that the incidence of NET in the United States was 6.98 cases per 100,000 people in 2004 .NETs can be cancerous or benign; if NETs are malignant, the tumor has the potential to metastasize, although the tumor itself grows very slowly . SymptomWhen NET is present in the rectum, symptoms may include gastrointestinal bleeding, change in bowel habits, anorectal discomfort, and pruritus ani ,13. TherAbout 10% of patients with NETs will experience carcinoid syndrome, caused by the overproduction of serotonin or other hormones secreted by some NETs, which often presents after the cancer spreads to other body parts . Common In our cases, the first patient, a 66-year-old man, presented with a history of sigmoidectomy and primary closure of a perforated caecum. The patient had a history of non-specific abdominal symptoms, including abdominal distention for three days and diarrhea for two weeks before being admitted to hospital. The tumor was found in the sigmoid colon at the time of the surgery and was confirmed by a histopathology study as a neuroendocrine tumor . The hisPatients with suspected NETs should undergo biochemical evaluation. Traditionally, several plasma, serum, and urine markers have been evaluated as predictors of tumor progression in NETs, including 5-hydroxy indole acetic acid (5-HIAA), chromogranin A (CgA), serotonin, neuron-specific enolase (NSE), neurokinin A, E-cadherin, or neuropeptide K . CurrentElevated levels of CgA serum have been associated with poorer prognosis. CgA is sometimes used as a biochemical marker in non-functioning tumors. One meta-analysis calculated the sensitivity of CgA to range from 67%  to 73%  and its The most-commonly employed marker in patients suspected of having a carcinoid tumor is urinary 5-hydroxy indole acetic acid (5-HIAA). Serotonin is a neurotransmitter that is produced mainly in the brain but also in the bronchi and gastrointestinal tract; it is degraded in the liver, and its metabolite 5-HIAA is excreted through urine . UsuallyImaging has a vital role in locating the primary tumor, identifying the location of metastasis site(s), and assessing the response to treatment . In thisAccording to the World Health Organization (WHO)’s classification (2019), NET is determined by histopathology and biological characteristics, including grading of tumor cells, size and location of primary tumors, a proliferation of tumor cell markers, local and vascular invasion, and production of active biological substances . The claThe characteristics of the NETs in our patients were described in the histopathology report, which is summarized in The American Joint Committee on Cancer (AJCC) Manual, 8th edition, has created staging definitions according to T, N, M . The defWe classified the first patient as cT4N0M0 (stage IIIA) based on clinical characteristics and as pT4N0M0 (stage IIIA) according to the histopathology findings. Unlike the first patient, the second patient had a history of liver metastasis with ascites, gall bladder stones, and hepatomegaly, which was found in surveillance eight months after the initial surgery. We classified this patient as cT4N0M1 (stage IV).If possible, radical surgery is the standard therapy for NETs. If there is locoregional or liver metastasis, debulking surgery can be performed, with the possibility of the tumor being removed at almost 90% . It is rResection of the GI-NET must be followed by adequate regional lymph node resection  and thorough exploration of the associated synchronous primary tumors (15%–30% incidence) .In the first case, we performed Hartmann’s procedure and primary closure on the perforated caecum, because the tumor was located in the sigmoid colon. For our second patient, we performed left hemicolectomy with end-to-end anastomosis, because of the descending colon tumor. This surgical treatment was consistent with NCCN recommendations for locoregional disease—that is, bowel resection with regional lymphadenectomy.Within 3–12 months after the operation, it is necessary to perform GI-NET surveillance, which consists of history-taking and physical examination, biochemical marker examination , abdominal pelvic multiphasic CT or MRI , and chest CT with or without contrast .Both of our patients underwent surveillance within one year after the resection. The first patient underwent surveillance at three months after the resection. The surveillance included abdominal ultrasound (which showed no signs of metastasis), chest x-ray (which found no sign of metastasis), and lopography results . Our second patient underwent surveillance at eight months after the resection. The surveillance included chest x-ray , colon in loop (which showed colitis and stenosis in the lower descending colon), and whole abdominal MSCT .The prognosis for patients with NETs varies according to the stage at diagnosis, the histologic classification, and the primary site of the tumor. Tumors measuring > 2 cm with invasion of muscularis propria at the time of diagnosis has an overall poor prognosis, with 5-year survival rates of only 33–42%. The first patient was classified as stage IIIA with the following histopathology characteristics: all lymph nodes were free of tumors, high mitotic rate, and the primary site of the tumor was in the sigmoid colon. The second patient was classified as stage IV with liver metastasis, the histopathology characteristic of low mitotic rate, and the primary site being in descending colon. Both of the patients had a poor prognosis due to muscularis propria invasion and thus had the 5-year survival rates mentioned above.4Two uncommon cases of colon and sigmoid colon carcinoma with neuroendocrine features in patients with peritonitis and large bowel obstruction were described. Because of the rapid growth pattern of GI-NET, it is difficult to manage; therefore, early diagnosis, careful management, and thorough understanding of the disease are very important. Staging and classification systems for GI-NETs are likely to continue to evolve, along with further advancement of tumor-directed diagnostic and therapeutic modalities, as our understanding of GI-NET continues to grow over time. We hope that our case series can enhance the information related to GI-NETs and help clinicians better understand this disease.Nothing to declare.No funding or sponsorship.The study is exempt from ethical approval in our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not applicable – case series report.Warsinggih.Not commissioned, externally peer-reviewed.Warsinggih: Conceptualization, Methodology, Supervision. Liliyanto: Conceptualization, Methodology, Data curation, Writing - original draft, Writing - review & editing. Prihantono: Data curation, Writing - original draft, Supervision. Gusti Deasy Wilda Ariani: Visualization, Investigation. Muhammad Faruk: Software, Validation, Writing - review & editing.


A cutaneous sinus tract of dental origin is relatively uncommon and may easily be misdiagnosed because of its unusual occurrence and absence of dental symptoms. Extraoral drainage depends on the location of the affected tooth as well as on specific factors such as the virulence of the microorganism, resistance of the patient's body, and the relationship between anatomy and muscle facial attachments. An odontogenic cutaneous sinus tract is a pathologic channel that initiates in the oral cavity and exits at the cutaneous surface of the face or neck. It might resemble an ulcer, cyst, furuncle, or retracted, sunken skin . The purA healthy 17-year-old female patient presented herself to the dental hospital of the Faculty of Rabat complaining of discomfort and nonesthetic appearance of her face. The patient presented an extraoral sinus tract associated with the mental protuberance region, with an approximate size of 5 mm x 5 mm. The nodule was soft with minimal purulent discharge. During the interview, the patient reported that the sinus tract had appeared 3 months before and several treatment attempts based on antibiotics and dermatologic ointment had been made after visiting a dermatologist without any improvement . No intrA working diagnosis of an extraoral sinus tract related to a previously unknown traumatic injury to the incisors with consequent pulpal necrosis and periapical infection associated with the mandibular incisor tooth 31. Root canal treatment of tooth 31 commenced. The 31 was extirpated and dressed with a non-setting calcium hydroxide. Tooth 31 was then obturated with gutta-percha and hermetically sealed. The patient was monitored post-initial treatment at 2 months. The patient at 2 months review was concerned regarding the residual extraoral scarring affecting the mental protuberance region. For it we started the surgical procedure with the reflection of a full-thickness flap which allowed to observing that one of the fistulous tract extremities stuck to the bone around the apical region of 31. Consequently, the area was dissected to surgically remove the cord-like tract . After tCutaneous sinus tracts in the lower face is frequently described as an extraoral manifestation of pulpal-periradicular pathosis, might have other etiologies related to infectious disease such as mycobacterial infections, actinomycosis, deep fungal infections, osteomyelitis, or tumors such as pyogenic granulomas, epidermal cysts, squamous cell carcinomas, or congenital malformations such as thyroglossal duct cysts, brachial cleft cysts, and salivary gland fistulas . Like ouRadiographic findings are also important for the diagnosis and identification of affected teeth. Radiographic findings are also important for the diagnosis and identification of a carious tooth or retained roots along with the associated radiolucency periapical lesion, which may be a granuloma or a cyst . AlthougFacial lesions of dental origin are rare. This case highlights the significance of including odontogenic origins to the differential diagnosis of orofacial skin lesions. Early correct diagnosis, based on radiologic evidence of a periapical root infection, and treatment of these lesions can help prevent unnecessary and ineffective antibiotic therapy or surgical treatment, reducing the possibility of further complications.


Sarcoidosis is an inflammatory disease that affects one or multiple organs, most commonly the lungs and lymph nodes. This disease can present in a variety of ways which often makes diagnosis difficult. A 54-year-old postmenopausal African American female with a history of omental carcinomatosis of unknown origin was referred to the gynecology-oncology service at a local community hospital following a laparoscopic incarcerated hernia repair where multiple abdominal lesions suspicious of ovarian carcinomatosis were visualized. She was brought to the operating room for a diagnostic laparoscopy at which point the intra-abdominal survey revealed white tubercle-like lesions that were consistent with peritoneal tuberculosis. The lesions were excised and sent to pathology. The omentum biopsy was originally reported as adipose tissue showing focal fibrosis, focal mild acute inflammation, few cyst formation, and multiple granulomatous chronic inflammation, with multinucleated giant cells. Periodic acid-Schiff stain and acid fast bacilli stain were negative, and a diagnosis of peritoneal tuberculosis was made. The patient was started on an antituberculosis treatment regimen; however, she was not improving. The pathology slides were reexamined and revealed nonnecrotizing granulomatous inflammation consistent with sarcoidosis. The patient was immediately referred to the department of pulmonology and rheumatology, at which point she was started on corticosteroids and had an improvement in her condition. Sarcoidosis is a systemic disease of unknown etiology with a wide variety of clinical and radiological manifestations . It affeSarcoidosis affects males and females of all ages and races; however, it is most prevalent in African American, Afro-Caribbean, Swedish, and Danish individuals due to a genetic predisposition . It is rSarcoidosis is typically diagnosed in women between the ages of 20 and 40 years of age with African American women being at greatest risk . In addiDiagnosing sarcoidosis mainly depends on clinical and radiological findings as well as the pathologic evidence of noncaseating epitheloid cell granulomas with the exclusion of other granulomatous diseases . Given tA 54-year-old postmenopausal African American female, G4P3013, with a past medical history of type 2 diabetes mellitus, hypertension, hypothyroidism, and stage 5 chronic kidney disease with multiple hospitalizations for hypercalcemia as well as recurrent pleural effusions, with a history of omental carcinomatosis of unknown origin, was referred to the gynecology-oncology service at a local community hospital following a laparoscopic incarcerated hernia repair where multiple abdominal lesions suspicious of ovarian carcinomatosis were visualized. The lesions were noted throughout the abdomen including the abdominal wall, bowel, liver, and pelvis. Biopsies of the lesions taken from the omentum and abdominal wall were found to be granulomatous with chronic inflammation and multinucleated giant cells. Some granulomas were matted, and others showed foreign bodies containing crystalloid material and rare granulomatous necrosis. Periodic acid-Schiff stain and acid fast bacilli stain were negative. Although cytology did not suggest neoplasm, the patient was immediately referred to the gynecology-oncology clinic due to the suspicion of an ovarian neoplasm.On presentation to gynecology-oncology clinic, the patient offered no gynecological complaints but endorsed nonspecific symptoms. She complained of anorexia and accompanied weight loss. Hospital records confirmed a fifty-nine-pound weight loss over seven months. She also complained of a chronic cough with scant-sputum production. She denied abdominal pain, abdominal cramping, vaginal bleeding, abdominal bloating, nausea, vomiting, and constipation. On exam, the patient was noted to have abdominal ascites, and her CA-125 level was elevated at 57.4 U/ml, which had risen from 39.9 U/ml a month prior. Following the appointment, she was scheduled for a diagnostic laparoscopy with possible hysterectomy and bilateral salpingo-oophorectomy; however, surgery was delayed due to her being hospitalized for symptomatic hypercalcemia and recurrent pleural effusions.Once the patient was stabilized, she was taken to the operating room for diagnostic laparoscopy. Intra-abdominal survey revealed white tubercle-like lesions that were consistent with peritoneal tuberculosis. Laparoscopic scissors were used to excise a piece of the peritoneal wall containing the tubercle-like lesions. The tissue was then sent to pathology.6.The omental biopsy was originally reported as adipose tissue showing focal fibrosis, focal mild acute inflammation, few cyst formation, and multiple granulomatous chronic inflammation, with multinucleated giant cells. Periodic acid-Schiff stain and acid fast bacilli stain were negative, and a diagnosis of peritoneal tuberculosis was made. The patient was immediately started on rifampin, isoniazid, pyrazinamide, ethambutol (RIPE) therapy, supplemented with azithromycin and vitamin BAfter several weeks of RIPE therapy, the patient was not showing any signs or improvement. Adenosine deaminase level was tested in the patients' pleural fluid and found to be elevated at 28.7 U/l. She also had a quantiferon test performed which was indeterminate. Decision was made to have the pathology from the tissue sample taken during surgery reviewed. The pathology revealed nonnecrotizing granulomatous inflammation Figures  and multCorrect identification and differentiation of peritoneal sarcoidosis from ovarian carcinoma and peritoneal tuberculosis in middle-aged females continues to be a significant challenge to the medical community. According to the literature, gastrointestinal involvement of sarcoidosis is very rare, seen in approximately 1% of all cases , with saSarcoidosis has been referred to by some experts as a partial autoimmune disease , 21. GraHowever, nonspecific symptoms such as abdominal pain, bloating, and weight loss, coupled with an elevated CA-125, should raise concern for peritoneal sarcoidosis. Carbohydrate antigen or cancer antigen 125 (CA 125) is a tumor marker that is secreted by the mesothelial cells lining the peritoneal cavity as well as many other tissues of nonmesothelial origin such as tracheobronchial epithelium, epithelium of the pancreas, colon, gallbladder, stomach, kidney, breast, amniotic tissue, placenta, and cervical mucus membrane, making it a nonspecific tumor marker .Nonnecrotizing granulomas are a characteristic pathologic finding of sarcoidosis. Caseation is absent in these granulomas but occasionally fibrinoid necrosis may be seen . FibrinoAlthough an isolated occurrence of sarcoidosis in the genital system is rare, if disease does occur here, the uterus and ovaries are the most common sites affected, most often in reproductive aged women , 29. SymSerosal involvement of sarcoidosis is rarely reported, especially due to the unique manifestation of this disease . MoreoveElevated CA-125 in addition to nonspecific symptoms such as fatigue, weight loss, dry cough, fever, night sweats, and shortness of breath should raise suspicion for peritoneal sarcoidosis. Women with peritoneal sarcoidosis who are misdiagnosed as having ovarian carcinoma often undergo unnecessary debulking operations which is the treatment of choice for malignant ovarian carcinoma. Radical treatment of this neoplasm generally involves removal of the uterus, fallopian tubes, ovaries, omentum, pelvic, and retroperitoneal lymph nodes, as well as debulking for metastatic spread. Misdiagnosing peritoneal sarcoidosis as an ovarian neoplasm can thus result in increased morbidity and mortality for young women undergoing such invasive surgical interventions.


Nodular fasciitis (NF) is a type of rare and rapidly growing tumor that affects the muscular fascial layers. Due to its locally aggressive nature and rapid growth, NF can be mistaken as a malignant process on either clinical or histological grounds.A 61-year-old man was affected by rectal cancer. We performed a robotic, high-anterior resection with lymph node dissection. According to the 8th edition of Union for International Cancer Control, the diagnosis was stage I pT2N0M0. During a routine follow-up 1.5 years after the robotic surgery, a computed tomography examination revealed a tumor in the upper right abdominal wall, at the site of the surgical port, that measured 45 mm. Magnetic resonance imaging indicated a hypo-intensive mass within the right straight muscle of the abdomen. Port site recurrence following the robotic surgery for rectal cancer was suspected, and an ultrasound-guided fine-needle aspiration was performed; it revealed a low-grade myofibroblastic tumor or benign neoplasm, but was inconclusive. We performed an excision of the lesion, and histopathology confirmed NF, seen as a solid, nodular, spindle-cell lesion. The patient was postoperatively followed for more than 1 year without any sign of recurrence of either cancer or NF.NF is histologically benign, but local recurrence frequently occurs. We encountered a patient with NF at the port site after robotic surgery for rectal cancer. Nodular fasciitis (NF), described for the first time by Konwaler et al. , is a tyA 61-year-old man was affected by rectal cancer and underwent a robotic, high-anterior resection with lymph node dissection. Histopathologically, well-differentiated adenocarcinoma was suggested. The pathological stage was evaluated as I (pT2N0M0) according to the 8th edition of the Union for International Cancer Control. He presented with a 1-month history of a growing mass in his right abdomen, at the surgical port site, 1.5 years after the robotic surgery. This mass was asymptomatic and non-tender. When first noticed 1 month prior to his complaint, the mass lesion was soft and mobile. He had a medical history of an appendectomy for appendicitis and a procedure for inflammation of the paranasal sinuses. There were no overlying skin changes, the swelling was firm, and the mass was not tethered to the overlying skin. An abdominal CT examination revealed a tumor in the upper right abdominal wall, at the surgical port site, that measured 45 mm  was performed. The examination revealed this lesion as either a low-grade myofibroblastic tumor or a benign neoplasm, but was inconclusive.The patient decided to undergo surgery to excise the lesion. Through laparoscopic surgery and a pedicled flap at the right fascia lata, the defect was covered with mesh to create an artificial fascia from the intraperitoneal side Fig. . The patThe resected tumor measured 40 × 35 × 30 mm. It was dark red with an unclear border , sharply demarcated , with myxoid stroma, and have scant lymphocytic infiltrate with erythrocytes . FurtherWe encountered a patient with NF at the port site after a robotic surgery for rectal cancer. A port site recurrence was suspected, and a resection was performed. NF is histologically benign, but a local relapse frequently occurs.


Intracranial pseudoaneurysms (PSA) are scarcely presented in the literature. We describe the case of an intracranial PSA on the right anterior cerebral artery, which developed during the complicated surgical treatment of a ruptured right middle cerebral aneurysm. The pseudoaneurysm grew over time and was co-incidentally diagnosed 3 months after the original surgery. The PSA was successfully treated by coiling. In cases of vascular injuries during complicated brain surgery, the timely and careful radiological diagnosis of such a lesion is necessary to allow its fast and proper treatment and thus prevent the patient from potential risks. Intracranial pseudoaneurysms (PSA) are rare vascular entities which occur in cases of head trauma, vascular collagenopathies such as Marfan’s syndrome, infection, vasculitis or aneurysm rupture. Furthermore, they can be iatrogenic, developing after endoscopic surgery in the sellar area, endovascular procedures of intracranial vessels, external ventricular drain insertion or even a rare case of PSA occurrence following a transcallosal approach. Generally speaking, literature concerning PSA occurrence following aneurysm surgery is, for the most part, discreetly silent. It is certainly a rare complication of these procedures. We found only three cases of pseudoaneurysm development in association with aneurysm surgery in the current literature; all three of them were treated surgically ,2,3. On In this paper, we describe the iatrogenic development of an anterior cerebral artery (ACA) PSA which occurred during a technically difficult procedure of middle cerebral artery aneurysm clipping, as well as the successful concurrent endovascular treatment of the PSA.A 49-year-old man was admitted to his local neurological department in September of 2016 with symptoms of aphasia, aggressiveness and confusion. A computed tomography (CT) and computed tomography angiography (CTA) were performed and showed a subarachnoid hemorrhage with hemocephalus (Fisher 4) as well as an aneurysm of the right middle cerebral artery (MCA) bifurcation (M12). Due to deterioration of consciousness, the patient was sedated, intubated and transported to our neurosurgical department for further treatment. After consultation, the patient was indicated for acute surgical clipping of the aneurysm by the surgeon on duty (the first author). A standard pterional craniotomy and durotomy were performed; however, major brain edema with brain herniation through the craniotomy was present and did not allow cisternal dissection. Antiedema measures, including lumbar drainage of the cerebrospinal fluid (CSF), were unsuccessful; therefore, the surgeon decided to utilize major retraction of the frontal lobe in order to quickly gain access to the lamina terminalis, aiming to fenestrate it. Unfortunately, this maneuver resulted in arterial bleeding from this area, which was successfully controlled with Surgicel, and fenestration of the lamina terminalis was microsurgically performed. This resulted in sufficient CSF decompression and brain relaxation, which allowed the dissection of the carotid and Sylvian cisterns and resulted in the successful clipping of the ruptured aneurysm. When leaving the surgical field, the surgeon did not observe any bleeding in the anterior cerebral artery area; the original source bleeding was controlled with a Surgicel tamponade. A CT and CTA were performed on the first postoperative day A and shoPostoperatively, the patient developed severe vasospasms, which were successfully treated pharmacologically, including with a one-time pharmacological angioplasty with milrinone. On the fifth postoperative day, a final CTA was performed and demonstrated successful clipping of the ruptured aneurysm without any other vascular anomalies apart from a previously described small mirror aneurysm on the left B. On theWe decided to treat the pathologies immediately, which necessitated the insertion of a caval filter due to deep vein thrombosis. The following day, a ventriculo-peritoneal shunt  was implanted and, six days later, diagnostic angiography was performed and verified the presence of a 17 mm PSA in the distal A1 segment of the ACA A,B. The Twenty-two months later, he was readmitted with a severe headache; a CTA was performed and did not show PSA recurrence or a subarachnoid hemorrhage but identified thrombosis of the straight, right sigmoid, right transverse and partial left transverse sinuses. Anticoagulation therapy was initiated and resulted in the recanalization of all sinuses, with the exception of the right transverse sinus. Afterwards, the patient and his family elected surgical clipping of the contralateral mirror MCA aneurysm, which was performed by the original surgeon 11 months later. The final procedure was uncomplicated A,C, and Iatrogenic pseudoaneurysms can occur as rare complications of several neurosurgical procedures, including transsphenoidal surgery ,8, exterDunn et al.  describeA more recent case report is presented by Shoja et al. , who desOur department represents a medium-volume center in treating cerebral aneurysms (400 aneurysms within 8 years). This is the first time such a case has occurred, and it has led to a paradigm shift in our approach when performing the surgical clipping of a ruptured brain aneurysm in conditions of severe brain edema. We believe this will be beneficial to future patients who are treated in similar conditions. In cases of suspected injury to an arterial vessel, large or small, extreme care must be taken to visualize, control and treat the suspected lesion by means of clip or suture. Tamponade in combination with local hemostatic agents is not a sufficient treatment strategy. In cases where such treatment is not possible, an early diagnosis must be obtained after the treatment of vasospasms, as these can delay PSA formation. We prefer CTA from digital substraction angiography (DSA) in order to avoid the 1% risk of a neurological deficit associated with angiographic assessment . NonetheIn cases where the surgeon predicts severe brain edema on the basis of preoperative CT scans, the preoperative insertion of an external ventricular drain should be considered in cases with sufficient ventricle width. Insertion of a lumbar drain may not be sufficient in such cases. As a last resort, in cases of brain edema which is unresponsive to conventional antiedema therapy , an emergent external ventricular drain may be inserted from the superior part of the pterional craniotomy , via theThe occurrence of an intracranial PSA after the surgical repair of an aneurysm is a rare complication. In cases of extensive perioperative brain edema which is unresponsive to regular management , emergent external ventricular drain (EVD) implantation, rather than a direct approach to the lamina terminalis, should be attained in order to avoid vascular lesion complications. In case of any suspicion, targeted diagnostic steps such as repeated CTA are to be performed in order to confirm the development of a PSA, which would facilitate early treatment.


Osteoid osteoma (OO) is a benign osteogenic lesion, regularly noticed in young individuals. A solitary lesion most frequently appears in long bones but is extremely rare in jawbones. Pain is a distinguishing characteristic of this lesion. Herein, we report a rare case of an OO in the right maxilla of a 37-year-old male presenting as pain associated with dental implants. Clinical and radiographic features were indicative of a benign neoplasia of boney origin. An excisional biopsy and histological examination of the lesion confirmed the diagnosis of osteoid osteoma. Surgical excision was followed by immediate relief of most of the pain. His follow-up visits were documented; complete relief of symptoms with no complications was observed during the postoperative period. There was no evidence of recurrence at a two-year follow-up. Osteoid osteoma of the maxilla may present as pain related to dental implants, and careful radiographic assessment of the entire jawbone should be considered if diagnosis of dental implant pain is unclear. Solitary osteoid osteoma (OO) is a rare benign osteogenic tumor of unknown etiology. First described in 1930 by Bergstrand and later classified by Jaffe in1935 . Walia eSince the original descriptions of osteoid osteoma were first published, 31 examples of isolated osteoid osteoma arising in the jawbones have been reported in the English-language literature until September 2019 , 13–40. Hence, to acquaint our awareness in the concerned field, such case reports should be discussed. However, its occurrence in the anterior wall of the maxillary sinus wall just below the infraorbital rim is a rare entity. Here, we presented a rare case report of OO of the maxilla in a 37-year-old patient presenting as pain associated with dental implants. This case report highlights that osteoid osteoma of the maxilla may present as pain related to dental implants and careful radiographic assessment of the entire jawbone should be considered if diagnosis of dental implant pain is unclear.A 37-year-old male patient was seen at the Oral and Maxillofacial Clinic of the Dental University Hospital, King Saud University, Riyadh, Saudi Arabia. He was complaining of localized severe pain in the right maxilla. No swelling or tenderness was noted clinically. The patient had previously undergone the replacement of missing maxillary premolars and molars on the same side with dental implants, and thus, implant-related complication was suspected although the implants were loaded and functional with intact periodontium.A panoramic radiograph  and CT eOn the day of the surgery, the patient was brought to the operating theater where the surgical intervention under general anesthesia in a sterile manner was done; the lesion was approached via a transcutaneous incision of the right lower eyelid (midlid incision) after protecting the right eye by employing temporary suture tarsorrhaphy. Sharp and blunt dissection was done exposing the inferior orbital rim adequately. A small bony swelling was located on the facial aspect of the medial portion of the right inferior orbital rim just medial to the right infraorbital nerve and foramen with no violation of the foramen. The lesion was a nodule-like bony mass with central crater-like defect, brownish-red, and gritty. It measured about 3 to 4 mm in dimension and was distinct from the surrounding normal bone . The lesThe histopathologic examination of the excised specimen  revealedFrom day one postoperatively, the patient felt a great improvement in the pain intensity which became mild pain and discomfort (about 3 to 4 out of 10) according to his visual analog scale. His follow-up visits were documented regarding his pain perception including the nocturnal pain, which revealed that he is almost in pain-free status. His surgical site after two years healed nicely without noticeable scarring.Osteoid osteomas are benign skeletal tumors that are portrayed by an intracortical nidus with a variable amount of calcification, sclerosis, and bone marrow edema . Jaffe dClinically, osteoid osteomas are characterized by dull, throbbing, intermittent, local, and nocturnal pain relieved with nonsteroidal anti-inflammatory drugs such as aspirin and are associated with slight local swelling . For decRadiographically, OO is a small, radiolucent intracortical nidus, less than 1 cm in diameter, surrounded by a large, dense sclerotic zone of cortical thickening . Jaffe pThe histopathological examination of OO differs according to the site and age of the lesion. Huvos illustrated three specific evolutionary stages of modification of OO. Originally, dense osteoblasts are seen proliferating actively in a highly vascularized stroma followed by deposition of the osteoid matrix between the osteoblasts in the intermediate phase. In the mature stage, the osteoid is transformed into well-calcified, compact trabeculae of atypical bone, which is neither typically woven nor lamellar . SometimPreviously reported cases mentioned several lesions as a differential diagnosis of OO, such as ossifying fibroma, peripheral osteoma, osteoblastoma, osteosarcoma, and fibroosseous lesions. Ossifying fibroma and peripheral osteoma are usually asymptomatic, increase in size, lack nidus, and cause resorption and displacement of teeth . OssifyiIn the present case, the diagnosis of osteoid osteoma was made considering the reported symptom of gradually increasing pain , the CT radiographic appearance, and the histopathologic examination of the specimen.Studies suggested complete excision should be the treatment of choice with intact removal of the nidus. Recurrence of the lesion depends upon the complete removal of the lesion. To date, no history of malignant transformation of OO has been reported , 42. AlbWexell et al. recently reported a 7-year follow-up of a 37-year-old woman with Gardner syndrome who had multiple osteomas in both jaws with dental implant treatment with no complication. However, in that case, the patient had known long standing preexisting nonpainful multiple osteomas as part of the Gardner syndrome .Herein, we reported a case of osteoid osteoma that occurred in the right maxilla of an adult male patient. The correct diagnosis was achieved by considering clinical, radiographic, and pathological features. To avoid confusion with similar bony pathosis, the treating physician should have a clear concept and keen observation skill. Osteoid osteoma is a benign bone lesion that occurs very rarely in the jawbones. Due to the rarity of this lesion, it is essential to report these cases to increase awareness among dental surgeons worldwide. Osteoid osteoma of the maxilla may present as pain related to dental implants and careful radiographic assessment by CT or CBCT of the entire jawbone should be considered if diagnosis of dental implant pain is unclear.


Although papillary endothelial hyperplasia may occur at almost any site, one of the most common sites is the hand. It is generally regarded as a reactive vascular proliferation i.e. exuberant form of organizing thrombus. Diagnosis of Masson tumor can be challenging due to its close clinical, radiological and even histopathological resemblance to angiosarcoma. We present seven cases of Masson tumor of the hand; wanting to reveal its nature using new vascular markers and discuss the treatment options and expected outcomes, present clinical and radiological features that may aid diagnosis and also offer treatment plans. A multicenter retrospective study was performed between January 2014 and November 2019. Immunohistochemical stains of Glut1, WT1, ERG, CD31 and alpha smooth muscle actin (ASMA) were performed on each cases. We found seven cases during the examined period. 4 out of 7 cases were women. All lesions occurred in the hands. 3 out of 7 cases appeared in a previously present vascular malformation. All cases were treated with surgical excision and the diagnosis of papillary endothelial hyperplasia was made by histology. Pre-operative testing (radiograph/MRI/US/fine needle aspiration biopsy) did not suggest the diagnosis of Masson tumor; however, aspiration cytology could rule out malignancy. The proliferative endothelial cells proved to be Glut1 negative and WT1 positive and the accompanying pericytic cells were ASMA positive in all cases. Though Masson tumor is a rare vascular lesion in the hand among other vascular tumors, it should be considered in the differential diagnostics even in the case of previously existing vascular malformation. WT1 positivity of the endothelial cells and the accompanying pericytic cells raises the question whether the initially reactive endothelial proliferation may transform into a true benign vascular tumor. Masson tumor is a rare malformation of skin and subcutaneous tissues and was first described by Pierre Masson in 1923 . It presThe differential diagnosis of vascular tumors in the musculoskeletal system may be challenging because radiologists are usually able to identify only the vascular nature of the lesion, but it is difficult to differentiate IPEH from other malignant vascular neoplasms , 33. MasIn this work we present seven cases of Masson tumor of the hand; wanting to reveal its nature using new vascular markers and discuss the treatment options and expected outcomes and present clinical and radiological features that may aid diagnosis and also offer treatment plans.A multicenter retrospective study was performed at the Department of Orthopedics Semmelweis University, at the Department of Orthopedics-Traumatology of Saint John’s Hospital, at Budaörs Healthcare Center and 2nd District Municipal Health Service between January 2014 and November 2019. Patients who had undergone surgery at these institutions for soft tissue growths of the hand and wrist during this period were included. We filtered patients according to the results of the histopathological examination. Data from the patients whose histopathological diagnosis was Masson tumor will be presented.Immunohistochemical staining was performed with Bond Max™ Autostainer . Tissue sections of 3 μm thickness were cut from the blocks, followed by deparaffinization in xylene and retrieval using either the Bond Epitope Retrieval Solution 1 (pH ∼ 6) or the Bond Epitope Retrieval Solution 2 (pH ∼ 9)  at 99–100 °C for 20–30 min, and immunostained using a monoclonal mouse anti-ASMA antibody , monoclonal mouse anti-human ERG , monoclonal mouse anti-human WT1 , monoclonal mouse anti-human CD31,  and polyclonal mouse anti-human Glut1 . Sections were incubated with the primary antibody for 25 min, followed by using the peroxidase/DAB Bond Polymer Refine Detection System (Leica Microsystems) for visualization.In the above-mentioned period, histopathological diagnosis was Masson tumor in all 7 cases. Table  displayed the recurrence of the hemangioma. Surgical excision was performed . She had a good recovery , there were no complications from surgery, circulatory or sensation disturbances did not appear.26-year-old female patient had a pre-existing vascular malformation on the right hand since her childhood. Surgical excision was performed once in 2011 and proved to be hemangioma based on the histopathological report. The preoperative MRI Fig.  displayemed Fig. . She had; indicating a hemangioma. Surgical excision was performed. Histological examinations diagnosed Masson tumor.24-year-old male patient had a pre-existing hemangioma on the left hand since childhood. Pre-operative radiological workup was performed . MRI Fig. ; indicat. The histological examination diagnosed the lesion as a Masson tumor. No recurrence appeared during the 6-month follow-up period .31-year-old male patient noticed a mass growing on his left ring finger. Based on patient complaints and physical examination this was presumed to be a hemangioma. Surgical excision was performed Fig. . The hisiod Fig. .All seven tumors displayed similar histological pictures. Lesions appeared in a dilated vessel or in pre-existing hemangioma, such as in cases of No. 1 and No. 3 Fig. . A papilIPEH was originally designated as “vegetant intravascular hemangioendothelioma” by Masson and he regarded it as a true neoplasm with intermediate malignancy (applying the recent WHO nomenclature). Although it turned out very soon after the initial description that this is a benign lesion, nevertheless the debate whether it is a true neoplasm or a reactive vascular proliferation continued. However, even if many pathologists accepted the “reactive” nature of this peculiar lesion, clinically it appears as a true neoplasm, especially because of its relatively high recurrence rate.Pathogenesis of the tumor is not clear. It may appear de novo or they may form in association with or on the basis of other pre-existing vascular lesions or it can be in extravascular form which arises in a hematoma. Other investigators  have argRecently, using new vascular markers combined with vascular flow parameters , a new cConsidering the long-standing condition of Masson tumor, the relatively high recurrence rate, the appearance in preexisting vascular tumors, the Glut1 negativity and WT1 positivity and the accompanying pericytic layer and furthermore the constant positivity with different vascular markers , it seems that Masson tumor begins as a proliferative process but with time it transforms into a true benign neoplasm. It is also important to consider Masson tumor as a benign tumor because the possibility for further transformation into a malignant one cannot be excluded, however, there has been no report of this phenomenon so far.In our series, pre-operative radiological examinations were unable to establish the exact diagnosis of Masson’s tumor - even the FNAB did not point directly to this lesion. Our 7 cases also demonstrate that there are 2 major etiological factors behind the IPEH. The lesion can develop de novo (5 out of 7 cases) or on the basis of pre-existing vascular malformations . The clinical appearance can be from no symptom to a limited of range of motion. In hand surgery, it is very important to plan the appropriate surgical solution to prevent recurrence.The main problem during the differential diagnostic process is not that Masson’s tumor may be misinterpreted as a different benign malformation e.g.: hemangioma, but that due to radiological appearance and sometimes features of FNAB, it may be over-diagnosed. This may open the gate for overtreatment if it is presumed to be a malignant tumor (e.g.: angiosarcoma) , 22.Masson’s tumor usually occurs in adults aged 30–40 years and is slightly most common in women, just as hemangiomas, suggesting a hormonal factor in development of this kind of lesions , 9. FemaIn 2 of out 7 cases, the Masson tumor appeared in a previously present hemangioma. This is relatively high, but there is no exact ratio about it in the literature.All 7 cases included a palpable mass and tenderness to palpation. In 4 cases, the lesion demonstrated growth which resulted in impaired finger function. Remarkably, symptoms can enhance drastically on the hand, compared to other regions of the body, since even a small lesion may interfere with harmonious hand function due to discomfort and a limited range of motion.Marginal surgical excision is the hallmark of treatment for these lesions in the hand. Total excision would theoretically reduce the risk of recurrences. However, this may be technically difficult to perform due to location and the tumor being interwoven with the vasculature of the finger. We encountered this limitation when performing excision of expansive lesions. , 13 As aFNAB was performed in one of our cases and it did not raise the possibility of Masson tumor, but suspected hemangioma. In 2 other patients who underwent diagnostic tests  before surgery, hemangioma was suspected too. Unfortunately, neither the clinical examination, nor the FNAB could give an absolutely accurate diagnosis. The final exact diagnosis was given by postoperative histology in all 7 cases. It is difficult to plan the surgery in the absence of an accurate diagnosis, but if there is no evidence for malignancy, as it happened in our cases, the proper route can be chosen. During surgery, care should be taken of the surrounding anatomical structures; especially with digital terminal arteries because they are responsible for the blood supply of the fingers and as these may be interwoven with the vessels of the vascular tumor. Dissecting them from the vessels of the Masson tumor may be quite an intricate task.In each case, a discussion with the patient and an individual consultation must precede the operation as these are slowly increasing lesions which cause progressive symptoms over time. Most of the symptoms are increasing pain, discomfort and consequently, a limited range of motion. Once the diagnosis has been made, patients also need to be informed regarding expected outcomes and recurrence rates, the necessity of radiological follow-up or the possibility of further operations. We plan to follow our cases every 3–6 months for 1 year, and once a year for the next 3–4 years. If clinical progression is suspected, the patient is referred for further imaging studies. Patients are also advised to register for a check-up if they notice any growth or in case if new symptoms appear. According to the literature, the expected recurrence rate of these lesions is around 15%. It has been described that if IPEH arises in a pre-existing vascular lesion, the recurrence rate depends on the technical difficulties as to how someone can remove the original vascular tumor. In our series no recurrence appeared during follow-up. However, this period was not a long-term one. We expect especially that in the patients who had pre-existing vascular lesions, recurrence may appear in the subsequent years, therefore, radiological follow-up is recommended , 18, 26.Though Masson tumor is a rare vascular lesion in the hand among other vascular tumors, it should be considered in the differential diagnostics even in case of a previously existing vascular malformation. It is important to have the most conclusive preoperative diagnosis. Therefore, preoperative examinations such as radiography, MRI/ultrasound and also fine needle biopsy can be necessary to aid the diagnosis and differential diagnosis of Masson tumor or at least exclude malignancy. Depending on size, location, symptoms and rate of growth , 21, sur


Acute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed.We report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time .The IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery. Concomitant vascular resection with reconstruction is often required during liver resection for hepatobiliary tumors involving major vessels . FailureSuch intraoperative acute HV or PV obstruction requires urgent surgical repair including direct re-anastomosis, implementation of vascular grafts and removal of intravascular thrombi. However, as such surgical attempts may result in failure, other options need to be devised as this complication is life-threatening. In this report, we present two cases of successful intraoperative endovascular placement of self-expandable metallic stents (SEMSs) by interventional radiology (IVR) for critical HV or PV obstruction that occurred in the middle of liver surgery.The patient was a 58-year-old male with synchronous, multiple colonic liver metastases which had remarkably responded to chemotherapy. He had a tumor at the segments 4 to 8 (S4/8) of the liver, involving the root of the middle hepatic vein (MHV) Fig. a. The ouHere, we focused on the reconstruction of the MHV after its resection during an S4/8 partial hepatectomy and the subsequent EPRS. The distal resected stump the MHV was about 60 mm far away from the divided stump of the MHV root Fig. a. A 30-mImmediately after restarting the hepatic inflow, the remnant RAS became swollen with persistent oozing from the cut liver surface, suggesting hepatic venous congestion. Doppler ultrasonography (US) confirmed no flow inside the reconstructed MHV and a regurgitating flow in the right anterior branch and trunk of the PV. We instantly revised the anastomoses, firstly by a direct end-to-end re-anastomosis, secondly with an interposition of autogenous right external iliac vein graft (EIVG) between the stumps of the RHV and MHV, and finally by a vein graft patch repair on the EIVG–MHV anastomosis. However, all these revisions failed to restore the HV outflow. As further surgical attempts appeared to be impossible due to the fragility and small diameter of the peripheral stump of the MHV, we thought of repairing the failed reconstruction by IVR in the operating room.An urgent hepatic venogram by direct HV catheterization from the left femoral vein showed that the EIVG–MHV anastomosis had a firm stricture due to twisting, which was seen to have caused the outflow obstruction Fig. b. We plaThe postoperative course was complicated by temporary liver failure, but the patient gradually recovered and was discharged from the hospital on postoperative day 81. The placed stent had been patent for 32 months after stenting until its obstruction by recurrent tumor invasion  major HV or the PV during liver surgery, whatever the cause, is an urgent status condition that may lead to fatal hemodynamic complications, unless immediate correction is achieved. In such a situation, surgical revision may not always be successful, because the secondary procedures are generally more difficult than the first reconstruction, due to the inferior condition of the veins, altered position of the organs, exacerbated bleeding tendency and unstable systemic circulatory state. Both patients in this report suffered difficult situations in which a variety of surgical revisions resulted in failure. Under these tough circumstances, an IVR-directed, urgent endovascular placement of SEMS completely resolved these potentially fatal complications which occurred in the operating room. Furthermore, the treatment was quick, safe and highly effective, with a sufficient duration of patency, although the patients may need life-long anticoagulants to prevent in-stent thrombosis formation.The probability of such critical intraoperative vascular complications that need urgent stenting during liver surgery is unknown; there were no previous reports on this issue. In our institute, during the last 20 years between 2000 and 2019, we performed 65 hepatectomies in conjunction with HV and/or inferior vena cava (IVC) reconstruction, 114 hepatectomies with concomitant PV reconstruction, and 74 LDLTs (unpublished data). During this period, we needed an urgent intraoperative HV or PV stent placement in the middle of liver surgery in three cases  including two reported in this article. Although the probability of surgically uncorrectable vascular obstruction during liver surgery is low as shown above, we need to consult the IVR team preoperatively in cases at high risk for HV reconstruction failure. At the moment, we consider that the high-risk cases are those where the hepatic vein to be resected and reconstructed drains one or more liver sections and at the same time, a small-diameter (≤ 7 mm) and long-distance (≥ 4 cm) end-to-end anastomosis is planned.Several etiologies may underlie the perfusion problems in our cases. In Case 1, in the first and second anastomoses, although the surgical techniques, the vein diameters and liver mobilization seemed to be appropriate, the reconstruction had a significant tension. So, we next interposed a vein graft to relieve the tension, but the peripheral end of the EIVG–MHV anastomosis created a twisting. This may be because the directions of the MHV and EIVG orifices did not conform well. Then, we patched a vein graft on the anterior wall of the EIVG–MHV anastomosis to enlarge the anastomotic orifice to lessen the effect of twisting. However, this revision was also unsuccessful. Collectively, the most crucial factor influencing the perfusion failure was that we inappropriately selected the RHV as the opponent vein for the anastomosis with the MHV stump, which may have resulted in the misalignment of reconstruction. Considering the alignment problem in this case, it might have been a better practice to anastomose the stump of MHV and a newly opened hole on the IVC with a long interposed vein graft in the first place. In Case 2, the size-mismatched large-size liver graft was an important detrimental factor, because the porta hepatis of the graft was significantly deviated to the right side from the appropriate position, which may have produced an inadequate alignment of the PV reconstruction.Previous studies described the use of IVR-directed endovascular stenting for the postoperative acute or chronic stricture or obstruction of the reconstructed HV or PV –5. TheseBalloon angioplasty (BA) is another useful option for either PV or HV stenosis after LDLT and liver resection –10. In oUpon acute obstruction of PV during surgery, creation of a mesenterico-portal bypass between a mesenteric vein and the intrahepatic portal vein system is a potential method to relieve portal hypertension and restore the PV flow into the liver. For this purpose, a permanent bypass by a jumping vascular graft anastomosis  or a temAn IVR-directed, intraoperative emergency endovascular stenting with SEMS is a useful and recommended treatment option to resolve acute and potentially fatal obstruction of the HV or the PV during liver surgery, particularly after failure of other surgical corrections.


Lipomas arising from the omentum are extremely rare in adults. Omental lipomas are typically asymptomatic, but very large ones may cause nonspecific abdominal symptoms and discomfort. Rarely they can cause omental torsion and present with an acute abdomen. We report a 41-year-old female patient with a giant lipoma  who presented with mild abdominal discomfort. Workup included abdominal ultrasound (USG) and magnetic resonance imaging (MRI). Surgical resection was performed without complication. No recurrence was observed during 4-year follow-up. Although lipomas are the most common encapsulated benign mesenchymal tumors of soft tissue, omental lipomas are extremely rare. We found no case series published in the global literature. Only a few case reports have been reported in the literature, and most of these are in childhood . FurtherA 41-year-old woman was admitted to the hospital with mild abdominal pain, discomfort, and bloating on the abdomen. In recent years, the patient had mildly suffered from these symptoms. The patient did not complain of weight loss, nausea, vomiting, weakness, or anorexia, but she was worried about increasing waist circumference and some dyspeptic symptoms. Physical examination revealed a big, relatively mobile, nontender, smooth solid mass occupying almost the entire abdomen. There was no evidence of mechanical bowel obstruction. There was no history of any abnormalities of the digestive system, liver or renal failure, gynecological malignancy, or any other reason to cause abdominal ascites. All hematological and biochemical parameters were within normal range. Also, tumor markers (please be specific) were normal. A solid, well-defined mass lesion measuring approximately 40 cm in greatest diameter was reported on ultrasound (USG). On magnetic resonance imaging (MRI), T1-weighted axial and coronal MR images showed a hyperintense giant mass filling most of the abdomen and displacing the bowels. The lesion was also compressing the liver. In fat-saturated T1-weighted MR images, the signal of the mass was suppressed similarly to fat. The mass did not enhance with contrast. The lesion measured approximately 34 cm × 26 cm in size  are the preferred imaging studies for abdominal lipomas. On USG, the lipomas appear as homogenous echogenic well-bounded masses. Because USG is largely user-dependent, most surgeons need further diagnostic imaging study including CT or MRI. CT shows the specific characteristics of fat content and aids in distinguishing from the other intra-abdominal masses including leiomyosarcoma, liposarcoma, fibroma, fibrosarcoma, or hemangiopericytoma . CT alsoIn this patient, the lipoma was arising from the greater omentum and associated with the falciform ligament. It caused minimal discomfort and abdominal distention. But different unexpected clinical scenarios or acute abdominal syndrome occurred in some of the other cases. Hishiki et al. reported a case arising from the lesser omentum, presenting as an acute abdomen due to torsion . Other rSurgery is the treatment of choice for omental lipomas. Because lipomas are encapsulated and seldom infiltrate the surrounding structures, the excision technique is generally uncomplicated. However, every effort should be made for complete excision with an intact capsule to avoid recurrence. The rate of recurrence after excision is reported to be less than 5% . PreoperThis case report revealed that omental lipomas can remain silent until they reach a giant size. In these cases, surgery is the definitive treatment option, and preoperative cross-sectional imaging is critical for surgical planning.


Chondromas are benign cartilaginous tumours that rarely occur in the head and neck region. Only a limited number of cases have been reported involving the nasal septum. Here we report a case of a 55-year-old male that presented with a suspicious lesion involving his nasal septum and columella. The lesion was removed under general anesthestic using a combination of both columellar and hemitransfixion incisions. The lesion consisted of firm tan-white tissue measuring 2.5 cm. Histopathologic examination revealed a low-grade chondroid neoplasm with lobulated hyaline cartilage. No signs of ischemic change, significant pleomorphism, mitoses, or necrosis were present. This was consistent with the features of a chondroma rather than a low-grade chondrosarcoma. A chondroma should be considered in the differential diagnosis of nasal septum lesions. Surgical excision of the tumour is the preferred treatment option. Chondromas are benign cartilaginous tumours that often occur in the small bones of hands and feet. The presence of cartilaginous tumours in the head and neck region are rare . AmongstA 55-year-old male presented to the clinic with a suspicious growing lesion involving the nasal septum and columella. The lesion was firm and there was associated swelling of the distal aspect of the nasal septum. The nasal septum was severely deviated due to past untreated nasal fractures. A punch biopsy of the lesion was performed in the clinic under local anesthesia, which demonstrated fragments of necrotic cartilage and no malignancy. The lesion continued to grow in size, prompting excision under general anesthesia in the operating room. An inverted gull-wing incision was made and iris scissors were used to lift off the skin over the dorsum of the nose. The incision was then extended into a hemitransfixion incision into the nasal septum. Iris scissors were used to dissect around the lesion which encompassed bilateral lower cartilages. The excised lesion measured 2.5 x 1.5 x 1.1 cm and was sent for pathology.A ragged polypoid firm-tan white lesion resembling a cartilaginous tumour was observed upon gross examination. Histopathological examination revealed a well-circumscribed tumour composed of lobulated mature hyaline cartilage with slightly increased cellularity. The chondroid matrix was evenly distributed in a well-defined lobular pattern invested by fibrous septae Figure . The majChondromas of the nasal septum are a rare occurrence . Of those rare cases, 60% occur in patients under 50 years old, with the most common age group being early adulthood .Nasal chondromas are often defined by their firm smooth texture, lobulated appearance, and well-defined boundaries ,5. As a Malignant tumours are twice as common as benign cartilaginous tumours . TherefoA number of theories exist regarding the origin of a chondroma. This includes the cell rest theory which states that chondromas originate from embryonic cartilage that was not resorbed during endochondral ossification . AnotherDiagnosis of a nasal chondroma involves a combination of imaging and histopathological examination. CT scans are used to assess growth in the circumstance that a chondroma will appear well-circumscribed and homogenous . Multi-sSurgical excision is the treatment of choice and different approaches may be utilized depending on the aspect of the nasal septum that is affected . CartilaAlthough rare, a chondroma of the nasal septum should be considered in the differential diagnosis of a nasal septum lesion, especially with a history of nasal trauma. Macroscopic and histopathological features differentiating a chondroma from a chondrosarcoma should be identified. The treatment of choice is surgical excision, but long-term follow-up is recommended.


Hyperplastic polyp of the esophagus is a rare condition and most of the time asymptomatic. We report a case of a 69-year-old female with scleroderma who presented with worsening dysphagia, regurgitation of food, and non-cardiac chest pain. Upper endoscopy showed a nodular lesion in the distal esophagus. Biopsy of the lesion showed features of hyperplastic polyp without any metaplastic changes. She was started on anti-acid therapy and an outpatient upper endoscopy was performed which showed no residual polyp. Benign esophageal tumors are uncommon as compared to gastroesophageal reflux disease and malignant lesions. The majority of benign tumors are asymptomatic, slow growing, discovered incidentally, and have a low malignant potential, most require nothing more than diagnosis and occasional surveillance. However large benign tumors that become symptomatic require removal -3. BenigA 69-year-old female with a medical history of scleroderma was referred by her primary care physician for evaluation of worsening solid food dysphagia. She had dysphagia for many years which got worse lately and was associated with regurgitation of food, and non-cardiac chest pain. She had no problem drinking fluids. There was no associated weight loss, night sweats, nausea, vomiting or diarrhea. Physical examination was notable for diffuse skin tightening consistent with known diagnosis of scleroderma but was otherwise unremarkable. An esophagogastroduodenoscopy (EGD) was performed to investigate her symptoms which revealed a 3-cm sliding type hiatal hernia and a Schatzki’s ring. Following a careful examination of the distal esophagus and the ring, a subtle nodularity was detected Figure . The rinHyperplastic polyps of the esophagus and esophagogastric junction (EGJ) are uncommon lesions characterized by hyperplastic epithelium , with variable amount of stroma ,6. HyperIn our case, following removal of the polyp with forceps biopsy, we initiated anti-acid therapy. Follow-up endoscopy in two months was negative for polyp recurrence and the patient's symptoms significantly improved.This case has previously been presented as an abstract .Hyperplastic esophageal polyps are rare and most commonly associated with GERD. To our knowledge, we report the second case of esophageal hyperplastic polyp that was grown on Schatzki's ring. These polyps need to be observed closely. They regress with anti-acid therapy in most cases. Endoscopic mucosal resection is recommended for symptomatic polyps and those associated with Barrett esophagus.


We report the case of a six-year-old male child with progressive pain and swelling of the right shoulder for six months. On examination, there was a 7x7 cm globular, tender swelling with firm consistency over the posterolateral corner of the right shoulder. Radiographs showed an expansile lytic lesion in the acromion process of the scapula. Biopsy showed lobules of hypocellular cartilage separated by fibroconnective stroma suggestive of an enchondroma. Extended curettage and fibular bone grafting of the lesion was done. At one-year follow-up, the patient was symptom-free and had full, painless shoulder range of motion. To the best of our knowledge, there is no published record of an enchondroma of the acromion. Enchondroma is a benign cartilaginous lesion commonly found in small bones of the hands and feet . It is cA six-year-old male child presented to our orthopaedics department with the complaints of pain and swelling over the right shoulder for six months. Both pain and swelling were of insidious onset and had gradually progressed. Pain was of dull-aching type. This was not associated with radiation of the pain or any history of trauma, fever or night pains. On clinical examination, there was a globular, tender swelling, about 7x7 cm in size with firm consistency, present over the posterolateral corner of the right shoulder. Overlying skin was normal and there were no dilated veins, scar marks or sinuses. There was no local rise in temperature, lymphadenopathy, distal neurovascular deficit or any other swelling elsewhere in the body.Blood investigations showed normal counts and kidney and liver functions. Serum calcium, erythrocyte sedimentation rate, C-reactive protein, alkaline phosphatase and parathyroid hormone were normal.X-ray of the right shoulder showed an expansile lytic lesion in the acromion process of scapula with no periosteal reaction or soft tissue component. CT scan showed an expansile lytic lesion with incomplete septations and a cortical breach. MRI showed the lesion to be hypointense in T1 images and hyperintense in T2 images , aneurysmal bone cyst (ABC), giant cell tumour with secondary ABC, chondroblastoma, metastasis and rarely multiple myeloma, have been described in the literature. Our six-year-old patient with expansile lytic lesion of the acromion had differential diagnoses of SBC, ABC, and chondroblastoma. Both SBCs and ABCs present as lytic lesions, but ABCs are blood-filled cavities with septations and fluid-fluid levels on MRI scan . ChondroOur case was proved to be a solitary enchondroma on biopsy. It could be managed conservatively with serial radiographs, but an extended curettage and fibular bone grafting was done due to persistent pain and its proximal location which made it prone to a malignant change. Various other options of treatment for an acromial tumour such as en bloc excision with or without stabilisation have been described .Enchondroma represents a rare differential diagnosis of a lytic lesion of the acromion and must be kept in mind. Extended curettage and bone grafting in a symptomatic patient yields excellent clinical outcomes. A long-term and regular follow-up is required to monitor for recurrence or malignant transformation.


The occurrence in children is exceptional and only few cases have been reported in the litterature. Clinical and radiological findings mimic other benign nasosinusal pathologies; therefore, diagnosis is based on histopathology either via biopsy or following surgical excision. Here we present a rare case of pediatric inverted papilloma in a 11-year-old child and we discuss clinical, radiological, therapeutic and evolutionary features through a literature review.Inverted papilloma is a rare nasosinusal tumor that mainly occurs in adults during the 5 It is exceptional in the pediatric population and only a handful of cases have been reported in the litterature [An inverted papilloma (IP) is a rare benign tumor that counts for only 0.5-4% of all nasal neoplasms . IP occuterature . IP is kterature . We repoAn 11-year-old boy presented to our department with a 12-month history of right-sided nasal obstruction, purulent nasal discharge and posterior rhinorrhea. His medical, surgical and family history was unremarkable. He had no others rhinological symptoms; particularly no epistaxis nor olfactory disorders. Physical examination with nasal endoscopy found a large polypoid mass  filling Magnetic resonance imaging (MRI) showed an ethmoido-nasal mass extending lateraly to the maxillary sinus with a meatal enlargement and posteriorly to the nasopharynx. The lesion appeared in heteregenous signal with a cerebriform aspect and a peripheral enhancement on T1-weighted-gadolinium sequences . The diath and 6th decades of life, with a 3: 1 male predilection [Inverted papilloma represents 0.5 to 4% of polypoid lesions of the nose and paranasal sinuses. It characteristically presents in the 5IP in children occurs predominantly in males. Ages range from 6 to 15 years and arise most commonly from the maxillary sinus, nasal septum and also the middle turbinate . Our patAetiopathogenis of IP remains icompletely understood, however, some etiologic factors such as chronic rhinosinusitis, proliferation of nasal polyps, allergy, environmental pollutants, tobacco and viruses particularly the human papilloma virus (HPV) have been reported in the literature, however, no significant evidence for this theory exists . The sigImaging investigations with CT scan and MRI are necessary to analyze nasosinusal masses. In typical cases IP arise from medial wall of nasal cavity  and extent to maxillary sinus. We can observe intralesional calcifications and/or bone thinning or erosion ,7. MaxilBefore surgery, pathologic examination is essential to diagnosis. IP may coexist with an inflammatory process showing inflammatory polyps. This accounts for the false negative rates of up to 17% on biopsy reported in the literature . In our Extra-nasal approach was the “gold standard” to perform the “en bloc” resection of the tumor for about 35 years. Whereas, since the development of the endonasal endoscopic surgery, along the last years, mini-invasive techniques are more and more used. The endoscopic medial maxillectomy and its varieties became the essential way to remove IP . It provRecurrences occurs especially in cases of incomplete resection explained by a poor exposure and visualization of the tumor´s limits. They generally appear within 6 months after surgery, however, cases of IP recurrence have been reported 20 years after in the literature . The recAlthough it is exceptional, IP should be evoked as diagnosis of unilateral nasal masses in children. Failure to consider this entity may lead to inadequate treatment and risk of recurrence. Pediatric IP shows clinically, radiologically and pathologically similarities to the adult one thus the diagnosis and treatment approches seem to be the same. Since recurrences can occur after a long period of time, life-long follow-up is required.


Accounting for less than one percent of all GI tumors, gastrointestinal stromal tumors are uncommon neoplasms that arise from the intestinal cells of Cajal. They can arise anywhere along the gastrointestinal tract, but most often arise from the stomach or small bowel. Usually, they are small and present with vague symptoms such as abdominal pain and are found incidentally. They usually don't involve other structures unless they metastasize. Here, we present a case of small bowel GIST. The patient is a 72-year-old male who was seen in the clinic with symptoms of abdominal pain for 4 months along with intermittent gastrointestinal bleeding for 6 years. Imaging studies revealed a mass in the small bowel with no signs of obstruction. During surgery, a 9 cm by 9 cm small bowel mass was identified with adhesions to the appendix, omentum, and a segment of small bowel. There was also a hemoperitoneum. En bloc resection was performed with clean margins. Histopathology report showed malignant gastrointestinal stromal tumor with focal involvement of adjacent small bowel loop. •GIST's usually don't involve other structures unless they metastasize.•20–30% of GIST's involve the small bowel and exhibit an endophytic growth pattern.•GIST small bowel tumors with adjacent small bowel involvement and pseudocapsule is very rare.•Surgery is the best treatment option especially for removal of pseudocapsule without rupture to prevent seeding. GISTEstimated incidence of GIST tumors is 10–20 cases per million, with the majority of cases in patients over 50 and mean age of diagnosis being around 64 years of age . GIST tu1.1A 72-year-old male presented to the clinic with generalized abdominal pain for 4 months that was constant and dull. Patient had a history of intermittent GI bleeding for about 6 years with no known source of bleeding despite having a workup at different hospitals. Past history includes hypertension, benign prostatic hyperplasia, gastritis, and anemia. Patient had undergone colonoscopy and esophagogastroduodenoscopy about four months ago that showed no abnormalities. He subsequently underwent a computed tomography scan of abdomen that showed a lobulated mass like structure originating from a bowel anastomosis. However, the patient did not give a history of any abdominal surgery, nor did he have any scars on his abdomen to indicate any previous abdominal surgery. On reviewing the CT scan, there was a linear calcification inside the mass, which seemed to arise from the small bowel or its mesentery without evidence of bowel obstruction Due to the findings on CT scan, a diagnostic laparoscopy was planned with biopsy/resection of the mass. During diagnostic laparoscopy, there was hemoperitoneum in the pelvis and Morrison's pouch. On examination of the small bowel, the mass was located in the distal small bowel with omentum and loops of small bowel densely adhering to and covering the mass Histopathological examination of mass showed a gastrointestinal stromal tumor measuring 9.5 × 9 × 8 cm 2Gastrointestinal stromal tumors account for less than one percent of all GI tumors and have a wide array of presenting symptoms ranging from asymptomatic to bowel obstruction. Sixty to seventy percent of GIST's are found in the stomach as the primary site, with the other twenty to thirty percent found in the small bowel, and less than ten percent from elsewhere in the GI tract . They usThere is no specific diagnostic test that is very sensitive or specific for detection of GIST. A computed tomography scan, magnetic resonance imaging, upper endoscopy are some of the tests used based off of clinical suspicion with CT scans being the most effective . CT scanThere are many ways to classify GIST's and the traditional TNM staging exists but is rarely used in clinical settings due to the fact that most GIST's aren't necessarily classified into benign and malignant . AlthougLarge GIST tumors have a change of recurrence even after surgery though the rate of recurrence decreases if treated with imatinib mesylate. This case was of a rather large tumor that intraoperatively was seen to have dense adhesions to the adjacent small bowel, omentum, and appendix. These adhesions were so significant that partial omentectomy, two small bowel resections and anastomosis and appendectomy were done. There was also hemoperitoneum, which in our case seemed to be due to the size of the tumor causing hemorrhage in the tumor, thereby leading to rupture of the capsule.3Gastrointestinal stromal tumors originating from the small bowel are uncommon. Small bowel GIST with involvement of adjacent small bowel and rupture of the pseudocapsule leading to hemoperitoneum are even rare findings.High index of suspicion is warranted in patients having recurrent GI bleeding without obvious source on esophagogastroduodenoscopy and colonoscopy. Further imaging modalities including CT scan and MRI of abdomen can help in making the diagnosis.Recommended treatment of choice for small bowel GIST is en bloc surgical resection with inclusion of pseudocapsule. Radical lymphadenectomy is not routinely indicated as lymph node involvement is less than 10%. Treatment with selective tyrosine kinase inhibitor is recommended in high risk cases to reduce risk of recurrence.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.


Emergency appendectomy for acute appendicitis is the most common emergency surgical procedure performed all over the world. While amputating the appendix from the cecum, a small  stump is left behind. Below this, the suture or stapler is applied to secure the base of the appendix, which is now known as a stump. Stump appendicitis, the inflammation of appendiceal remnant after an appendectomy, is a rare phenomenon. Additionally, the incidence of adenocarcinoma in the stump of the appendix is also extremely rare and can present with the symptoms of appendicitis. Adenocarcinoma in stump appendectomy patients can present from 5-43 years after the index appendectomy surgery. The majority of patients present with symptoms similar to that of appendicitis, with right lower quadrant abdominal pain, usually diagnosed via CT scans, after which they undergo stump appendectomy. The diagnosis of adenocarcinoma is only made on the histopathology report. We engaged in a review of the relevant literature published in the English language for the last 100 years. This was conducted by reviewing Google Scholar, PubMed, and MEDLINE® databases, as well as references to all related articles. There are only six cases reported in the literature, which shows the rarity of this condition. Regarding the appropriate treatment for this rare entity, multi-disciplinary team discussions should be carried out for optimum management of the individual patients. Right hemicolectomy is the recommended procedure for all patients, and prognosis depends on the staging of the disease. Adenocarcinoma of the appendix is a rare gastrointestinal malignancy . DiagnosMethodsGoogle Scholar, PubMed, MEDLINE®, and references to all related articles were searched with the keywords mentioning stump as well as recurrent, residual, incomplete, appendicitis, adenocarcinoma, and appendectomy. More than 210 case reports were found in the literature of which 197 were in English. These articles discussed stump appendicitis after a history of appendectomy in the past; out of these, six cases of adenocarcinoma were discussed. The data was collected, and the histopathologic diagnosis of adenocarcinoma was determined to be the inclusion criteria. The major limitation was the lack of follow-up period, as it was mentioned only in one case.ResultsOnly six cases of adenocarcinoma were identified in the literature in the English language. The features of presentation, time after the first/index appendectomy, and further management of the patients are discussed in this review article. All the patients were above 60 years except for one who was 40 years old. The shortest interval after index surgery was found to range from 5-43 years. All patients underwent right hemicolectomy except for one who refused surgery. Follow-up for two years without incident was mentioned in one case.DiscussionAppendiceal primary cancers are very rare, and studies from the USA report an incidence rate of 1.2 patients per 100,000 people in a year [The peak age of primary malignant neoplasm of the appendix ranges from 55-65 years; however, malignant carcinoids affect a slightly younger population, usually in their third decade of life (mean age: 38 years). Carcinoid is by far the most common type of tumor of the appendix; it is followed by mucinous cystadenocarcinoma, adenocarcinoma, lymphosarcoma, paraganglioma, and granular-cell tumors, which all account for an overall incidence of 10-20% .Adenocarcinoma of the appendix is a rare disease, which accounts for 0.5% of all gastrointestinal cancers, and has been found in only 0.08% in appendices removed for disease, incidentally, or at autopsy . The firThe diagnosis cannot be determined until laparotomy/laparoscopy or pathological evaluation of the appendectomy specimen is performed. The recommended treatment modality for appendiceal adenocarcinoma is oncologic right hemicolectomy as the condition is only diagnosed after histopathological examination of the specimen of the appendix . An uncoSince the recognition of both pathologies of malignancy in the appendix and reoperation of symptomatic stump appendicitis are two different entities, only six cases of combined pathologies were identified in the literature in English Table . All patLimitationsWe could include only a few numbers of cases, as the condition is very uncommon, and only English language reports were considered. Moreover, the follow-up period was mentioned in only one case.Stump appendicitis is a rare presentation after an appendectomy, and it might be related to inflammation or malignancy. Adenocarcinoma of the stump, despite its rarity, must be considered in the differential diagnosis for patients with post-appendectomy right lower abdominal pain, especially in those who are of older age. Diagnosis is usually made by CT abdomen, and surgery should be offered in all cases of appendicitis as part of the management for diagnosis or treatment and for decreasing the risk of malignancy. A consultation involving a multi-disciplinary team should be considered for the optimum management of patients, which usually involves procedures like CT abdomen and chest with tumor markers, followed by right hemicolectomy whenever there is adenocarcinoma in the stump of an appendix.