Ovine laryngeal chondritis is a rare entity of sheep in the USA, Great Britain, New Zealand and Iceland, but has not been reported in Germany so far. Here, two German cases are reported.Fusobacterium necrophorum and Streptococcus ovis were isolated from the laryngeal lesion in one animal.Two rams showed severe and progressive signs of dyspnea. Endoscopically, a severe bilateral swelling of the larynx was identified in both rams. Due to poor prognosis and progression of clinical signs one ram was euthanized, while the other ram died overnight. In both cases, a necrosuppurative laryngitis and chondritis of arytenoid cartilages was found at necropsy. This is the first report of ovine laryngeal chondritis in continental Europe. This entity should be considered a differential diagnosis for upper airway disease in sheep. Pasteurella multocida, Mannheimia haemolytica or Histophilus somni ). The hematocrit was within normal range in both cases.Endoscopically, a severe bilateral symmetric swelling of the larynx with obstruction of the laryngeal cavity was observed in the first ram Fig. a. For inSimilar to the first case, a swelling of the larynx was suspected in the second ram leading to an immediate treatment with 20 mg dexamethasone  intravenously. Despite this treatment the condition of the ram worsened. To prevent suffocation, a tracheotomy was performed and a tube was inserted into the trachea. After breathing was ensured the upper airways were examined endoscopically. This revealed a narrowed glottis caused by swelling of the mucous membranes of the right arytenoid cartilage Fig. b. 20 mg Both rams were necropsied at the Department of Pathology. Macroscopically, the larynx of case 1 showed a severe diffuse symmetric edematous swelling that caused a nearly complete obstruction of the laryngeal cavity. Bilaterally, the mucosa over the arytenoid cartilages had dark brown ulcers, 0.5 cm in diameter. These defects extended into the cartilage. Bilaterally within the arytenoid cartilages, a 0.5 × 1 × 1 cm sized cavitation filled with yellowish, viscous, opaque material was present. Similar exudate covered the surface of the mucosal lesions  reaction were performed using standard staining protocols . Alcian Histologically, the arytenoid cartilages of both rams showed morphologically similar lesions but of varying severity. Case 1 presented bilateral cavitations within the arytenoid cartilages Fig. a, which Histochemically, the loss of arytenoid cartilage was confirmed by Alcian blue, Masson–Goldner and Safranin O stains. Intralesionally, the arytenoid cartilages revealed a decreased stainability by Alcian blue and Safranin O Fig. b. In conAt the inner surface of the cavitation and within the surrounding arytenoid cartilage abundant PAS positive, Gram-negative filamentous bacteria, arranged in chains were found Fig. c. The AzAdditional histological findings in case 1 include a moderate suppurative bronchopneumonia partly with abscess formation in the right cranial and medial pulmonary lobes, a mild sinus histiocytosis in the pulmonary lymph nodes and a mild multifocal meningeal melanosis.Additionally, in case 2, an ulcerated squamous papilloma was found on the forehead as an incidental finding., Fusobacterium necrophorum, Porphyromonas sp. and Streptococcus ovis were isolated in large number from the laryngeal lesions of case 1. In addition, Clostridium septicum was isolated in moderate number in this sample.Samples of the laryngeal lesions were submitted to the Institute of Microbiology to examine bacterial involvement by bacterial culture. Samples were processed and grown bacteria were differentiated up to species level regarding routine protocols. MicrobiologicallyMicrobiologically, no bacterial growth was evident within laryngeal tissue in case 2. However, a negative impact of the antibiotic pre-treatment on bacterial growth has to be taken into account.rima glottidis [F. necrophorum, Bacteroides spp., Trueperella pyogenes, Streptococcus spp., Pasteurella spp. and Escherichia coli has been reported [The examination of the two rams revealed a chronic laryngitis with necrosis of the arytenoid cartilages and ulceration of the overlying mucosa. Laryngeal chondritis is a rare entity of sheep that has been reported in Great Britain , New Zealottidis . The dislottidis  and signlottidis . Microbireported , 10–12. Fusobacterium necrophorum alone is not able to pass through intact mucosa; therefore a primary traumatization of affected tissue is being considered as an initiating event [The pathogenesis of the condition remains unknown. ng event , 8, 11. ng event , 8, 12. ng event . Additiong event , 8, 12. ng event , 13, 14.Odocoileus virginianus) [F. necrophorum [. In racing horses these lesions are detected in arytenoid chondropathy [Mycobacterium tuberculosis or Corynebacterium diphtheriae induced lesions are discussed [Laryngeal lesions, comparable to those described in sheep, have been reported in calves , camelidinianus) , thorouginianus)  and humainianus) . In calvrophorum . In racidropathy . In bothdropathy . In humaiscussed , 20.Ovine laryngeal chondritis is associated with a poor prognosis. Therapy with antibiotics and corticosteroids can cure the disease in very early stages, but often fails , 7, 8. IDifferential diagnoses include swellings of lymph nodes (for example due to pseudotuberculosis), foreign bodies, ovine pulmonary adenocarcinoma or Maedi . To prevIn conclusion, albeit being a rare disease, laryngeal chondritis should be considered as a differential diagnosis in sheep with upper airway disease, also in mainland Europe.


Mesonephric-like adenocarcinoma (MLA) from ovary is a very rare tumor which derives from mesonephric duct remnant of the female genital tract. Only six cases have been reported so far in the English literature.A 29-year-old female patient was referred to the local hospital with a 20-day history of abdominal discomfort.Pelvic ultrasound examination revealed a solid and cystic mass measuring 10 cm in diameter in the right adnexal area and a cystic mass measuring 5 cm in the left adnexal area. Postoperative pathology in the local hospital revealed suspected malignancy of the right ovary, and she was then transferred to our institution for definite diagnosis. The tumor mass was finally diagnosed as a primary MLA arising from the right ovary by histological and immunohistochemical examination in our institution.The patient underwent laparoscopic right adnexectomy and removal of left ovarian cyst in the local institution. Then, she underwent a complete staging surgery including a total hysterectomy, left adnexectomy, pelvic plus para-aortic lymphadenectomy, and omentectomy in our hospital. In addition, she received four cycles of combination chemotherapy with carboplatin plus paclitaxel.There is no evidence of recurrence with 13 months of follow-up till now, and we are still following-up this patient.MLA is an extremely uncommon malignancy with difficult diagnosis, unclear treatment and poor prognosis. Familiarizing with the clinical features and optimal management of this rare tumor may increase awareness of the disease among clinicians and pathologists, thus avoiding the misdiagnosis and mistreatment. Mesonephric adenocarcinomas have only rarely been reported to arise in the uterine corpus, but never been reported in the ovary. It was reported that adenocarcinomas of endometrium and ovary shared morphologic, immuonphenotypic, and molecular features with mesonephric adenocarcinoma, but were lack of association with mesonepheric remnants or hyperplasia.,3 Hence, mesonephric-like adenocarcinomas (MLAs) are recently suggested to describe these neoplasms that occur in uterine corpus and ovary. Due to the rareness of the disease, there are only six case reports including ten cases of ovarian MLA in the English literature up to now. The optimal treatment of ovarian MLA, especially the effective chemotherapy regimen after surgery remains unclear. The diagnosis is pathologically confused due to its diverse morphological patterns that could be mistaken for benign mesonephric remnants or other malignant neoplasms. Here, we report a very rare case of ovarian MLA, and discuss the clinical characteristics, pathological diagnosis and treatment of this tumor.Mesonephric adenocarcinoma (MNAC) of the female genital tract is an infrequent non–human papilloma virus-related neoplasm, which is considered to originate from the embryonal remnant of mesonephric duct .2The patient has provided informed consent for publication of the case.A 29-year-old female patient presented to the local hospital with a 20-day history of abdominal discomfort. A transvaginal ultrasound revealed that a solid-cystic mass measuring 10 cm in diameter in the right adnexal area and a cystic mass measuring 5 cm in the left adnexal area. Exploratory laparoscopy was performed, and a 10 cm ovarian solid and cystic tumor with ruptured capsule in the right ovary and a 5 cm ovarian cyst of the left ovary were found during surgery. Then, she underwent laparoscopic right adnexectomy and left ovarian cystectomy. Postoperative pathological results in the local hospital demonstrated the right ovarian tumor was suspected to be a kind of neuroendocrine neoplasm and the left ovarian cyst was benign, hence she was transferred to our institution and pathologic specimens were sent to the pathology department of our hospital. Pathological finding revealed the histologic pattern of tumor was glandular, and some of the glands contained luminal eosinophilic material  and paclitaxel (175 mg/m2) 3 weeks after the second surgery. There is no evidence of recurrence with 13 months of follow-up till now. We are still following-up this patient.The patient was discharged 7 days after surgery without any immediate postoperative complications. In accordance with ovarian cancer staging system of the International Federation of Gynecology and Obstetrics , the patient's disease was staged as IC2 (the tumor limited to the right ovary with capsule ruptured before the first surgery). Medical oncology was consulted, and additional chemotherapy was recommended. The patient received adjuvant chemotherapy with four cycles of carboplatin  and deep in the cervical stroma in the lateral walls. Hence, mesonephric adenocarcinomas in the female genital tract occur most commonly in the cervix and vagina, and less frequently in upper female genital tract.Mesonephric adenocarcinoma (MNAC) is a very rare malignant tumor in female genital tract. It is thought to be derived from remnant of the regressed Wolffian duct . During embryonic development, the females have two sets of paired primitive reproductive ducts: the paramesonephric (Müllerian) and the mesonephric (Wolffian) ducts. In the embryologic females, Mullerian ducts become female reproductive ducts, while the mesonephric ducts degenerate. MLAs are recently recommended to describe these neoplasms. It was argued whether these cases occurred in the ovaries or uterine body essentially represent mesonephric carcinoma or endometrioid carcinoma that were similar to MNAC, and they suggested these neoplasms could be designated MLAs unless the histogenesis of these tumors is firmly established.,4,7,8Mesonephric adenocarcinomas have only rarely been reported to arise in the uterine corpus, but never been reported in the ovary. Adenocarcinomas of ovary, which sharing morphologic, immunophenotypic, and molecular features with mesonephric adenocarcinoma, but lacking association with mesonephric remnants or hyperplasia have been reported.,7,9 MLAs lack mucinous and squamous differentiation and may also show morphology reminiscent of the corded and hyalinized variant of endometrioid carcinoma.,9 Immunohistochemically, MLAs frequently exhibit positive staining for calretinin, GATA-3, and CD10 , and almost all of them are positive for TTF-1 and negative for PR/ER. Moreover, the wild-type p53 could also be expressed in MLA.,9 Molecularly, MLA, similar to MNAC, is characterized by activating KRAS mutations, but lack of PTEN mutation/deletion or microsatellite instability and gain of chromosomes 1q. PIK3CA mutations, which have never been found in mesonephric adenocarcinoma, were identified in nearly half of MLAs.,10,11Morphologically, both MLA and MNAC could reveal different growth patterns including retiform, papillary, tubular, sex cord, glandular, glomeruloid, spindled, sieve-like, and solid architectures in various combinations, even in the same neoplasms.There were only six case reports including 10 cases of MLA arising in the ovary in the English literature up to now  or/and MRI (Magnetic Resonance Imaging) and PET/CT (Positron Emission Tomography-Computed Tomography), are required when a routine abdominal ultrasound examination reveals a mass in the adnexal region. Blood tumor marker test may detect an elevation of CA125 in patient with ovarian MLA. Therefore, preoperative diagnosis of ovarian MLA is extremely difficult and definite diagnosis mostly depends on postoperative pathology and immunohistochemistry. The differential diagnosis of MLA should include endometrioid adenocarcinoma, and serous adenocarcinoma. Endometrioid adenocarcinoma is characterized by squamous, mucinous, or ciliated differentiation and presence of precursor lesion , and expression of ER and PR but it is negative for GATA-3 immunohistochemically. Serous carcinomas have high-grade nuclear atypia, pronounced pleomorphism, and are associated with abnormal p53 staining and typically strong and diffuse p16 staining. Serous neoplasms are immunoreactive for WT1 (Wilms’tumour 1) and negative for GATA-3, whereas MLA will exhibit the opposite staining pattern. These evidences suggest that combination chemotherapy with carboplatin plus paclitaxel may be the effective chemotherapy regimen to treat MLA like other ovarian cancer, and could be recommended as a first-line chemotherapy regimen.The pathogenesis of these tumors, which have been termed as “mesonephric-like adenocarcinomas” is unknown. Hence, for pathologists it has been debated whether these represent endometrioid adenocarcinomas that closely mimic mesonephric adenocarcinoma or mesonephric adenocarcinomas that occur in the ovary/endometrium. However, it is not so important whether the rare disease should be diagnosed as ovarian MNAC or MLA for the gynecologic clinicians, because the treatment for these neoplasms, which the gynecologic oncologists are more concerned about, may be the same. Due to the paucity of available data related to treatment of the rare disease, there is no established guideline about standard therapy of ovarian MLA. Although there is no guideline for the rare malignancy disease, comprehensive staging surgery may be the initial choice for localized disease. A hysterectomy, bilateralsalpingo-oophorectomy, pelvic plus para-aortic lymphadenectomy and omentectomy were performed in most of the previous cases Table . In our KRAS/NRAS mutations, inhibiting the RAS/MAPK pathway could potentially be a useful method in the treatment of ovarian MLA. However, further studies will need to be conducted to better understand the clinical characteristics, optimal treatment and prognosis of MLA.We presented a case of ovarian MLA without sign of relapse or metastasis so far, which revealed a good response to combination chemotherapy with carboplatin plus paclitaxel. Due to the chemosensitivity, we think it is plausible that chemotherapy with carboplatin plus paclitaxel plays a major part in MLA. In addition, a recent study has shown the vast majority of MNAC/MLA harbor 4Mesonephric-like adenocarcinoma is an extremely rare malignant tumor in the female reproductive system, which is believed to arise from the embryonal remnants of mesonephric ducts. Preoperative diagnosis of MLA is exceeding difficult, and postoperative pathological diagnosis is challenging since MLA typically shares a mixture of morphologic patterns. Comprehensive staging surgery followed by systemic chemotherapy may be the initial choice for localized disease. Patients with ovarian MLA may be sensitive to chemotherapy drugs with carboplatin plus paclitaxel, which could be recommended as a first-line chemotherapy regimen. Further studies will need to determine the exact role of chemotherapy and select better therapeutic schedule.Conceptualization: Qiuhe Chen, Chuan Xie.Data curation: Qiuhe Chen, Yangmei Shen, Chuan Xie.Formal analysis: Qiuhe Chen.Investigation: Qiuhe Chen, Chuan Xie.Methodology: Yangmei Shen, Chuan Xie.Software: Qiuhe Chen, Chuan Xie.Supervision: Qiuhe Chen, Chuan Xie.Writing – original draft: Qiuhe Chen, Chuan Xie.Writing – review & editing: Qiuhe Chen, Chuan Xie.


Internal hernia is a relatively uncommon condition and is a rare type of intestinal obstruction. Paraduodenal hernia is considered the most common type of internal hernias. The rare prevalence and the variable symptoms make the clinical diagnosis of paraduodenal hernia a diagnostic challenge. We present the case of a 26-year-old male patient presented with a seven-day history of generalized intermittent crampy abdominal pain accompanied by nausea and multiple episodes of vomiting. He was otherwise healthy and had no history of previous abdominal operations. Computed tomography scan of the abdomen demonstrated sac-like clustered small bowel loops noted in the left upper quadrant, in the anterior pararenal space, consistent with the diagnosis of left paraduodenal hernia. Laparoscopic surgery for the repair of the hernia was planned but it was converted to open surgery due to technical difficulties. The patient tolerated the procedure without complications, and he was asymptomatic in the follow-up visit. This case sheds light on the importance of considering the diagnosis of left paraduodenal hernia in patients with recurrent abdominal pain, particularly among those who have not undergone abdominal surgery previously. Internal hernia is an abnormal protrusion of abdominal viscera  through a defect, which may be congenital or acquired, within the peritoneum or mesentery. Internal hernia is a relatively uncommon condition accounting for less than 1% of the abdominal hernias, and it is a rare cause of intestinal obstructions . Herein,A 26-year-old male patient presented to the emergency department with a seven-day history of generalized intermittent crampy abdominal pain. The pain was accompanied by nausea and multiple episodes of vomiting. The pain worsened after meals. His last bowel motion was three days before the presentation; however, he continued to pass flatus. He had multiple similar episodes of this pain over the last two months that resolved spontaneously. He was otherwise healthy and had no history of previous abdominal operations.On examination, she was in pain and her vital signs were as follows: pulse rate as 90 bpm, blood pressure of 121/76 mmHg, and respiratory rate of 20 bpm, and she was afebrile. Abdominal examination revealed a distended abdomen, with no tenderness or guarding. There was hyperactive bowel sounds all over the abdomen. No palpable masses or organomegaly and no external hernias were noted. The digital rectal examination was unremarkable.Laboratory studies showed hemoglobin of 13 g/dL, white blood cell count of 8,000/mL shift, and platelet count of 144,000/mL. Serum electrolytes, urea, creatinine, and liver function tests were all within normal limits. The chest X-ray did not reveal any abnormalities with no free air under the diaphragm. CT scan of the abdomen was performed . It arises from the fossa of Landzert, which is present in 2% of the population, through a defect in the left portion of the transverse mesocolon causing retroperitoneal retrocolic herniation of small intestine . The fossa of Landzert is located to the left of the fourth part of the duodenum, posterior to the inferior mesenteric vein and ascending branch of a left colic artery, where they form the free edge of hernia, and directly below the posterior parietal peritoneum .The rare prevalence and the variable symptoms make the clinical diagnosis of paraduodenal hernia a diagnostic challenge. The clinical presentation is entirely non-specific. It ranges from being completely asymptomatic and found incidentally during surgery or autopsy to acute intestinal obstruction seen in 50% cases with the risk of gangrene and perforation ,7. Such The first case of paraduodenal hernia that had a correct preoperative diagnosis was made by Kummer in 1921 by the barium study . CurrentOnce diagnosed, the surgical treatment of paraduodenal hernia is indicated because the lifetime risk of incarceration or strangulation is over 50% with a mortality risk of 20%-50% . The samThe surgical treatment of the paraduodenal hernia may be carried out by the conventional open approach or minimally invasive laparoscopic approach. In our case, because of the dense adhesion, it was converted to open surgery.The diagnosis of internal hernia should be taken into consideration in patients with recurrent abdominal pain, particularly among those who have not undergone abdominal surgery previously.


The splenic artery aneurysm (SAA) is rare clinical entity which is the third most common intra-abdominal aneurysm. Pancreatic neuroendocrine tumors (pNETs) are rare malignancies which comprise less than 2% of all pancreatic tumors. Non-functioning pancreatic neuroendocrine tumors set forth up to 90% of all PNETs. Sixty-seven-year-old female presented to our polyclinic with increasing pain in the left upper quadrant in the previous three months. A computed tomographic angiography revealed 13x13x12 cm sized regular bounded aneurysmatic expansion of medium part of splenic artery. In addition there was a 8x7 mm sized hypoecoic lesion in the distal pancreatic tissue. Distal pancreatectomy, splenic aneurysm resection and splenectomy was performed. Pathological results revealed that there was a 12 cm sized giant true splenic aneurysm and 0.7 cm sized neuroendocrine tumor in the pancreatic tissue. This manuscript is presentation of surgical approach to a case with coexistence of these two rare conditions. SAA is very rare, but has been diagnosed more often with the development of imaging possibilities. Because the risk of rupture, SAA is one of the most dangerous treatable surgical diseases and with mortality in the range of 10 to 40%.A 67-year-old multiparous  female presented to our polyclinic with increasing pain in the left upper quadrant in the previous three months. She had no history of hypertension, trauma, aneurysm, or pancreatitis. In physical examination, she had a swelling in her left upper quadrant. All laboratory tests were within the normal range. A computed tomographic angiography revealed 13x13x12 cm sized regular bounded aneurysmatic expansion of medium part of splenic artery. In addition there was an 8x7 mm sized hypoecoic lesion in the distal pancreatic tissue . Plasma SAAs are a rare entity commonly diagnosed incidentally. The true incidence of SAA is not clear, studies of autopsies, angiography findings showed rates between 0.01% and 10.4%, respectively. Most SAA are located in the distal portion of the artery, close to splenic hilum.4Portal hypertension, cirrhosis and liver transplantation are also associated with SAA. Less common etiologies are alpha 1-antitrypsin deficiency, inflammatory and infectious disorders. Arteriosclerosis is probably a secondary process occurring from primary degeneration of the media. Pseudoaneurysms are caused by pancreatitis, trauma and may also be iatrogenic.5There is no documented algorithm regarding the approach of treating SAA based on prospective randomized trials; treatment is planned on a case by case basis. It seems to attempt transcatheter embolization or endovascular techniques in patients with serious co-morbidities and favorable vascular anatomy. If this fails, laparoscopic treatment should be the next option.6Pancreatic neuroendocrine neoplasms (pNENs), originating from diffuse neuroendocrine cells. It’s include well differentiated pancreatic neuroendocrine tumors (pNETs) and neuroendocrine carcinomas (pNECs). pNENs comprise only 1% to 2% of all pancreatic neoplasms and about 7–9% of all gastroenteropancreaticneuroendocrine tumors (GapNETs).7Depending on the hormone produced, different clinical manifestations arise. Conversely most pNEN’s are asymptomatic due to lack of hormone secretion. As a result, the majority of patients are diagnosed at an advanced stage and they produce either non-specific symptoms or mass-related symptoms, the latter depending on the location and size of the lesion.8Diagnostic point of pNEN is laboratory tests which confirm the oversecretion of the specific pancreatic hormone should be performed . Chromogranin A (CgA), pancreatic polypeptide (PP), and pancreastatin has a diagnostic and prognostic role for both functioning and non-functioning tumors.8Various imaging modalities including computed tomography (CT), magnetic resonance imaging (MRI), somatostatin receptor scintigraphy (OctreoScan®), positron emission tomography (PET), endoscopic ultrasonography (EUS), and selective angiography.9Surgical resection with regional lymph node dissection is curative treatment option and is recommended to all patients with early-stage well-differentiated pNENs. Advanced cases are incurable and systemic therapies form the mainstay. Somatostatin analogues are effective for controlling the hormone-excess state in functional pNENs.10The coexistence of giant splenic artery aneurysm and non-functioning pancreatic neuroendocrine tumor is very rare. We believe that a detailed radiological examination is very important for detecting accompanying anatomic abnormalities when surgical intervention is planned.OY & AM: Conceived, designed & editing of manuscript. and Omer Yalkin is responsible and accountable for the accuracy or integrity of the work.MY: Did data collection and manuscript writing.FA: Did review and final approval of manuscript.


The evaluation of regional/sentinel lymph nodes (LN) plays an important prognostic role and assists the clinical decision making in canine cancer patients; thus, surgeons are frequently asked to perform regional/sentinel lymphadenectomies together with management of the primary tumor sites, even when these are non-palpable and/or normal size LN. Several techniques have been described to localized regional/sentinel LN in a pre-surgical setting. The wire-guided localization is commonly used to localize non-palpable breast masses in women, with the aim to reduce surgical dissection and excision of unnecessary tissue and to reduce surgical time. This study describes the use of an ultrasound-guided hook-wire localization method to facilitate intraoperative localization of non-palpable superficial inguinal LN. The results of the present study suggest that this method is safe and effective and may allow a high rate of successful superficial inguinal LN excisions in dogs.The evaluation of loco-regional lymph nodes (LN) plays an important prognostic role and assists the clinical decision making in canine cancer patients. Excision of non-palpable LN can be challenging. The aim of the study was to evaluate surgical time, successful excision rate and surgical complications associated with the use of an ultrasound-guided hook-wire (UGHW) LN localization method for non-palpable superficial inguinal LN (SILN) in dogs. Dogs that presented for excision of non-palpable SILN, performed with the aid of an UGHW placement, were enrolled. Information including signalment, SILN width, UGHW placement and surgical procedure time, hook-wire position, successful excision and intra- and post-operative complications were reviewed. Seventeen dogs were enrolled. Median LN width was 3 mm (range 2–11). Median time of preoperative UGHW placement and surgical LN excision was 8 min and 15 min, respectively. Successful SILN excision was achieved in all cases. Two minor intra-operative (hook migration and wire fragmentation) and one minor post-operative complications (seroma) were observed. No major intraoperative or post-operative complications occurred. The UGHW LN localization method is safe and effective and may allow a high rate of successful SILN excisions in dogs. This method has the potential to facilitate LN excision for other superficial LN locations. The status of loco-regional lymph nodes (LN) in dogs with malignancies plays a pivotal role in clinical decision making ,2, and tNowadays, surgeons are more frequently asked to remove one or more non-palpable LN to better characterize malignancies such as head cancers, cutaneous mast cell tumor and oral melanoma ,2,6. BilIn dogs, superficial inguinal lymph nodes (SILN) are located deep to the inguinal mammary gland in females and at approximatively the level of the bulbus glandis in males . A singlIn a previous study SILN have been easily identified with sonography in forty-seven 96%) of 50 dogs, highlighting the potential role of ultrasound in the pre-operative localization of SILNs [6% of 50 Wire-guided localization is a method commonly used to locate non-palpable breast masses in women . The wirThe aim of the study was to describe the clinical application of a UGHW LN localization method for the excision of non-palpable SILN in dogs and to report the successful excision rate and surgical complications associated with this technique.Dogs affected by different tumor histotypes presented at two referral hospitals for diagnostic or therapeutic lymphadenectomy of superficial inguinal lymph node with the aid of UGHW placement between August 2019 and May 2020 were enrolled. This study was approved by the University of Pisa animal welfare and research ethics committees (48/2019) and the University of Liverpool Veterinary School Research Ethics Committee (VREC932). Dogs were eligible for inclusion if the SILN to be excised was deemed non-palpable. Every LN was excised via a dedicated surgical approach and lymphadenectomy was performed by five different surgeons . Information retrieved from the records included breed, age, sex and sexual status, body condition score (body condition score (BCS), range 1–9), body weight, primary tumor histotype, LN width, time of UGHW placement, surgical procedure, lymphadenectomy time, total surgical and anesthetic time, hook-wire position, results of histopathological examination of the excised LN, and intra- and post-operative complications. The position of the hook was considered perinodal, if the hook tip was less than 5 mm far from the node, or intranodal if the tip of the hook was within the LN. When the hook dislodged or was found far from the node, or was not to be found it was considered out of the node. Intra- and post-operative complications were classified as major if they required further surgical or medical treatment to resolve , and as minor if they required no treatment to resolve. Minor intra-operative complications included also hook dislodgement and hook-wire fragmentation. Dogs were clinically re-checked seven and 14 days after surgery and dogs with a minimum follow up of less than fourteen days were excluded. All dogs underwent a physical examination and blood test analysis before the procedure was performed and written informed consent was taken beforehand from all the owners.For all cases, a 20 G × 7 cm single or double hook non-repositionable needle for mammary nodules localization  was used to localize the SILN .After premedication and clipping of the surgical sites, dogs were positioned in dorsal recumbency and the surgical sites were aseptically prepared. Preoperative ultrasound was performed by a board-certified diagnostic imager, imaging resident or experienced ultrasonographer. As previously reported, the SILN were located using a linear ultrasound probe using a ventral approach  . When ulThe wire protruding from the operative field was trimmed approximately 2–5 cm from the skin insertion site and the area was covered with a sterile drape. The dogs were then transferred to the presurgical room for induction and then to the operating room with careful patient positioning to prevent dislodgment of the hook-wire. An alcohol-based solution was repeated over the surgical field prior to surgery. To avoid accidental dislodgment of the hook-wire, lymphadenectomy was performed before excision of the primary tumor or any other concomitant procedure.A two to 4 cm skin incision was made in the inguinal region at entry site of the wire, avoiding any excessive manipulation or damage to the hook-wire. A combination of blunt and sharp dissection was used following the direction of the wire until the LN was located. Once the LN was isolated from the surrounding tissue, vessels of the lymph node hilus were ligated or cauterized to prevent hemorrhage. The LN was removed, and the surgical site was closed routinely.Data were collected in a .xlsx  format file and analyzed with descriptive statistics. Continuous variables were presented as median and range, whereas categorical and ordinal variables were presented as absolute and relative frequency.Seventeen dogs for a total of 23 lymphadenectomies met the inclusion criteria. Breeds included crossbreed (five), Labrador retriever (three), pug (two), American Staffordshire (one), boxer (one), Cocker Spaniel (one), Entlebucher Mountain dog (one), golden retriever (one), Jack Russell terrier (one), Staffordshire bull terrier (one). There were nine male (five neutered) dogs and eight female (five neutered) dogs with a median age of 98 months (range 37–178). Body weight ranged from 6.8 to 56 kg (median 26.8). One (6%) dog had a BCS of four, three (18%) dogs had a BCS of five and six (35%) dogs had a BCS of six. Five (29%) and two (12%) dogs had a BCS of seven and eight, respectively. The most common primary tumor was cutaneous or subcutaneous mast cell tumor , followed by soft tissue sarcoma . These were most frequently located on hindlimbs , followed by trunk , prepuce , scrotum  and vulva . Superficial inguinal lymphadenectomy was performed in association with excision of the primary tumor in 14 (82%) cases. Nine cases (53%) had concurrent excision of other LNs; splenectomy was performed in two (12%) cases, and orchiectomy and thyroidectomy were performed in one (6%) case each. Median LN width was 3 mm (range 2–11). In fourteen (82%) dogs, the LN width was measured by ultrasound, in three (18%) by computed tomography. A single SILN was identified in the majority of dogs , and three SILN were identified on the same side in one dog. Median time for preoperative UGHW placement was 8 min (range 5–20) for each LN. Median lymphadenectomy time was 15 min (range 4–40). The hook-wire was placed perinodally in eighteen (78%) cases, intranodally in three (13%) cases, and out of the node in two (9%) cases. The UGHW allowed the localization of twenty-one (91%) of 23 SILN. In two (9%) cases, surgical dissection was started following the hook-wire, but a traditional lymphadenectomy was eventually performed. In particular, in one case, the hook was dislodged by wire traction during surgical dissection, whereas in another case, the hook-wire fragmented during surgical dissection and could not be retrieved despite the aid of intraoperative radiography. In these cases, surgical time  was longer compared to the rest of the population. SILN excision was successful in all the cases. During the follow up period , only one dog (6%) developed a self-limiting seroma at the lymphadenectomy site two days after surgery. This latter dog belonged to the twenty-one dogs that had a successful LN localization. No major intra- or post-operative complications were observed. The wire fragmentation that happened in dog n.17 resulted in no late complication 108 days after surgery. Histopathological evaluation of the SILN revealed no neoplastic cells in 10 (43%) LNs, whereas metastases were diagnosed in the remaining 13 (57%) LNs. Data are summarized in Surgeons are more frequently asked to remove lymph nodes for diagnostic and therapeutic purposes, whether these are enlarged or normal size, even if these are not palpable and/or resulted non metastatic at the cytological examination ,6. In thAs previously reported in healthy dogs, normal size SILN were considered palpable only in two (4%) of 50 cases, with a mean height and width of 3 mm and 6 mm , respectThe preoperative ultrasound time, including visualization of the LN, cytological sampling (when indicated) and hook-wire placement observed in the present study was similar to the time of UGHW localization of impalpable breast nodules reported in women . The timOnly two intra-operative and one minor short-term post-operative complications occurred. The dislodgment of the hook in one case, and the fragmentation of the wire in the other did not affect LN excision which was successful in all dogs. Surgical time for SILN excision in these two cases (20 and 40 min) was longer than the median time for SILN excision. Hook-wire dislodgement and fragmentation are two of the most frequent complications associated with the procedure . RecentlIn people, infection rate has been reported to range from 0 to 1% in patients where the guide wire was placed the day before the surgery and in patients that were moved from the radiological room (where the wire-guided was placed) to the operating room ,21. SincIn twenty-one of 23 SILN, the hook-wire was placed either peri- or intranodally and the placement seemed not to influence node localization. In the two cases where dislodgement occurred, the hook-wire guided the surgeon to the target LN which was located immediately dorsal to the tip of the hook and the SILN was excised without extending the surgical dissection. Unfortunately a direct comparison with wire-guided lymphadenectomy in people is not possible, however, the successful rate of non-palpable breast and pulmonary lesion excision with the aid of preoperative wire-guided localization is higher than 95% in people, confirming that it is of great help for surgeons in the majority of cases ,15,22,23Fifty-seven percent of the LN were diagnosed as metastatic, resulting in tumor stage migration from solitary tumor masses to locoregional disease. As previously reported, this highlights the superior accuracy of histology versus cytological evaluation and the important contribution of surgery to the tumor staging work-up ,2,6. TheThis study revealed that the UGHW localization method is associated with a high success rate for the excision of non-palpable SILN in dogs. The UGHW placement is an easy procedure, comparable to an ultrasound-guided fine-needle aspiration with the needs of an ultrasonographer and a second operator that will deploy the hook from the introducer needle.The fact that LN excision using UGHW localization was performed by five surgeons with different levels of experience, suggests that this procedure may be easily replicated. We would also point out that planning with the surgeon the preferred location where the wire should enter the skin may result in a smaller skin incision, less extensive dissection, and faster node identification and excision.The present study has some limitations: no control group was included in the study design, making any direct comparison with traditional LN excision not possible. Dogs were followed for a minimum of fourteen days; no long-term complications were evaluated, therefore, it is possible that late onset complications have been missed. The number of dogs included in this study was too small to statistically evaluate any relationship between variables.In conclusion, the present study showed a high successful rate of SILN excision using a UGHW localization method. The UGHW localization method has shown to be a fast and easy method to perform. The UGHW placements and the SILN excisions were associated with infrequent and minor complications making the procedure suitable for further prospective and larger case-control studies to confirm our findings.


Juvenile ossifying fibroma (JOF) is a controversial and uncommon lesion that has been distinguished from the larger group of ossifying fibromas because of distinct clinical features and some morphological peculiarities. Furthermore, JOF shows an aggressive biological behavior that has led researchers to consider it a benign neoplasm, resulting in its differential diagnosis with important benign and malignant bone neoplasms.This study describes a case of synchronous presentation of JOF in the mandible and maxilla of a young patient. In addition, the literature was reviewed to identify clinical-pathologic features and possible factors that could help establish the correct diagnosis. A 26-year-old male patient presented simultaneously a lesion affecting the body, angle and ramus of the left mandible and another lesion in the left maxilla. Both lesions were well delimited and radiolucent, being unilocular in the maxilla and multilocular in the mandible. The mandibular lesion was partially resected and the maxillary lesion was submitted to curettage. The diagnosis was JOF.A delay in seeking medical care and a late diagnosis can have serious consequences for the postoperative functional and esthetic outcome. Much care should be taken during establishment of this diagnosis since an equivocal diagnosis can have serious consequences for the patient in terms of treatment.After 1 year, the patient shows no signs or symptoms of recurrence of the lesions and was referred for reconstructive surgery of the mandible. An early and correct diagnosis is necessary to permit the best therapeutic management. Clinical, radiographic and microscopic features are discussed, highlighting the main criteria used for its differential diagnosis.2A 26-year-old black male patient with 2-year history of a painless swelling involving the left mandibular body. No reports of drug use, underlying diseases or harmful habits. Family history without relevant associated information. Extraoral clinical examination showed an asymmetry in the left lower third of the face A. IntraoHistopathologic analysis of the two lesions revealed characteristics of JTOF. 3Sixteen cases of synchronous manifestation of conventional ossifying fibroma are reported in the literature Although JOF is a benign neoplasm, it can manifest as an aggressive lesion because of its rapid growth, expansion of cortical bones and possible displacement of adjacent structures, leading to the suspicion of a malignant neoplasm in some cases JPOF, commonly found in the craniofacial skeleton, can affect the frontal, orbital and zygomatic bones and paranasal sinuses of young people and adults between 16 and 33 years of age. On the other hand, JTOF is a purely gnathic lesion that preferentially affects the maxilla of children aged 8 to 12 years The radiographic and imaging features of the present case agree with those commonly reported in the literature The clinical and imaging findings of the mandibular tumor and the rarity of JOF led to the diagnostic hypotheses of ameloblastoma, followed by KOT and myxoma. The maxillary lesion did not cause swelling or cortical bone expansion and was discovered during radiography for diagnosis of the mandibular lesion. Its radiographic appearance was suggestive of KOT. The detection of hyperdense foci in computed tomography also suggests the calcifying odontogenic cyst (COC).The criteria available in the present case were sufficient for the diagnosis of JTOF. The lesion was characterized by intensely cellularized fibrous connective tissue associated with the presence of mineralized tissue at different stages of maturation and calcification that appeared as irregular trabeculae, some of them lined by osteoblasts The initial microscopic diagnosis of myxoma obtained by incisional biopsy of the mandibular lesion highlights the importance of a careful differential diagnosis. Clinical, radiographic and histopathologic findings should always be correlated since lesions with a different etiopathogenesis, behavior and prognosis can exhibit clinical and pathologic similarities. In the present case, the material collected during the incisional biopsy may have corresponded exactly to the myxoid areas found in JOF, resulting in the diagnosis consistent with myxoma.The differential diagnosis of JOF includes fibrous dysplasia, COD, conventional ossifying fibroma, and even low-grade osteosarcoma JOF have been distinguished from the large group of conventional ossifying fibroma based on the age of the patient, the site affected, and biological behavior The greater cellularity and the presence of myxomatous foci and abundant osteoid material favored the diagnosis of JOF in the present study. A useful intraoperative finding that helps distinguish conventional ossifying fibroma and JOF from COD is the fact that ossifying fibromas can be separated easily from the adjacent normal bone tissue The therapeutic approach to treating JOF must consider the aggressiveness, size and potential of recurrence (30% to 58%) of this tumor. Consequently, surgical resection with safety margins seems to be the preferential treatment Recurrence of JOF is related to the difficulty in performing an adequate resection due to the location of the borders of the tumor and its infiltrative nature. It would therefore be more prudent to determine the therapeutic approach based on the location, extent and biological behavior of the tumor This study reported the synchronous presentation of a rare lesion. The aggressive biological behavior of this lesion indicates the need for an early diagnosis so that the best therapy can be instituted for the patients, preferentially conservative treatments that do not compromise function or esthetics. In the case reported a extension lesion in the mandibular body, a fact justifying the hemimandibulectomy performed. The maxillary lesion that measured approximately 5 cm and in view of the diagnostic hypothesis, a more conservative approach of surgical curettage was adopted. After 1 year, the patient shows no signs or symptoms of recurrence of the lesions and was referred for reconstructive surgery of the mandible. Despite radical treatment, the patient was well accepted with the prospect of future mandibular reconstruction.Based on the literature review, we recognize that, despite major diagnostic difficulty, some clinical and pathologic features favor the diagnosis of JOF. Thus, the knowledge and combination of clinical, radiographic and histopathologic features of JOF are extremely important for its accurate diagnosis. The presente work has been reported in line with the SCARE 2018 criteria We declare no conflict of interest.This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectores.Ethical approval exempted by our institution.Written informed conset was obtained from patient. A copy of a signed document stating this is avaliable for review by the Editor-in-Chief of this journal on request.Vildeman Almeida Júnior: performed sugery, manuscript writing, revision and submission.Joaquim Dultra: performed sugery and manuscript writing.Paloma Cerqueira: manuscript writing and revision.Tarcísio Fernandes: performed sugery and manuscript writing.Flávia Xavier: manuscript writing, revision and histopathologic analysis.Jean dos Santos: manuscript writing, revision and histopathologic analysis.Águida Henriques: histopathologic analysis, manuscript writing, revision and submission.NA.Vildeman Almeida Júnior.Águida Henriques.Not commissioned, externally peer-reviewed.


The stomach has many incoming vessels and is resistant to ischemia due to the rich microvascular network within its submucosal layer. Although reports of gastric remnant necrosis after gastrectomy have been rare, mortality rates remain substantially high when present. A double elementary diet (W-ED) tube, which can be used for both enteral feeding and gastrointestinal tract decompression, has been developed for anastomotic leakage and postoperative nutritional management after upper gastrointestinal surgery. The current report presents a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment with a W-ED tube.A 73-year-old male was referred to our hospital for an additional resection after endoscopic submucosal dissection (ESD) for gastric cancer. Endoscopic findings showed an ESD scar on the posterior wall of the upper portion of the stomach, while computed tomography (CT) showed no obvious regional lymph node enlargement and distant metastases. The patient subsequently underwent laparoscopic proximal gastrectomy and esophagogastrostomy but developed candidemia on postoperative day 7. On postoperative day 14, endoscopy revealed gastric ischemic changes around the anastomotic site, suggesting that the patient’s candidemia developed due to gastric necrosis. His vital signs remained normal, while the gastric remnant ischemia was localized. Given that surgery in the presence of candidemia was considered extremely risky, conservative treatment was elected. A W-ED tube was placed nasally, after which enteral feeding was initiated along with gastrointestinal tract decompression. Although the patient subsequently developed anastomotic leakage due to gastric remnant necrosis, local control was achieved and conservative treatment was continued. On postoperative day 52, healing of the gastric remnant necrosis and anastomotic leakage was confirmed, after which the patient started drinking water. Although balloon dilation was required due to anastomotic stenosis, the patient was able to resume oral intake and was discharged on postoperative day 88.Herein, we present our experience with a case of gastric remnant necrosis after proximal gastrectomy, wherein conservative management was achieved using a W-ED tube. In cases involving high operative risk, the management should be mindful of gastric remnant necrosis as a post-gastrectomy complication. The stomach has numerous incoming vessels and is resistant to ischemia due to the rich microvascular network in its submucosal region , 2. AlthA 73-year-old man underwent endoscopy for follow-up after endoscopic submucosal dissection (ESD), with findings showing a new lesion on the posterior wall of the upper portion of the gastric body. Although additional ESD had been performed, the pathology report revealed indistinct margins and an unknown depth. The submucosa was highly fibrotic, which made it difficult to dissect the submucosa and cause tears in the tumor, making it difficult to assess the margins and depth. The patient requested additional excision and was referred to our department. Pathological findings of the ESD specimen were as follows: tub1, 18 * 10 mm, pTX, INFa, pUL0, Ly0, V0. Endoscopy showed an ESD scar on the posterior wall of the upper gastric body, while computed tomography (CT) revealed no obvious regional lymph node enlargement or distant metastasis.The patient was on medication for hypertension and hyperlipidemia; had undergone vascular replacement for an abdominal aortic aneurysm, vascular replacement surgery for an abdominal aortic aneurysm, and surgery to bypass the right common femoral artery and popliteal artery for atherosclerosis obliterans; and had been placed on aspirin and ethylicosapentate. It was a high-risk case and we also explained to him an option of follow-up, but since he wanted an additional resection, we planned proximal gastrectomy.After admission, preoperative heparinization was started, followed by laparoscopic proximal gastrectomy, D1 + lymph node dissection, and esophagogastrostomy. Gastrectomy was performed at the line leaving approximately 1/2 of the stomach and preserved the right gastric artery and right gastroepiploic artery. Esophagogastrostomy was performed by anastomosing the anterior gastric wall and the posterior esophageal wall using a linear stapling device, while the common foramen was closed by hand-sewn suturing. The surgery was completed in 6 h and 48 min with a total blood loss of 299 mL and no blood transfusion. Abdominal drainage tubes were placed anterior to the anastomosis and under the left diaphragm.On postoperative day (POD) 3, however, the patient developed a fever of 39 °C, with unremarkable abdominal symptoms and drainage fluid characteristics, as well as high C-reactive protein at 19 mg/dL, for which antimicrobial medication was started. Although no abdominal symptoms or drainage fluid abnormalities had been noted thereafter, the patient underwent an oral contrast study and CT on POD 8 due to his persistent febrile status Fig. a and b, On the same day, a W-ED tube , which allows for simultaneous enteral feeding and gastrointestinal tract decompression, was placed nasally Fig. , and entRegarding nutritional status, the patient had a preoperative serum albumin level of 4.1 g/dL. During the course of the treatment, his lowest serum albumin level was 1.7 g/dL, which gradually recovered with enteral nutritional management and increased to 2.9 g/dL prior to discharge. The patient had a preoperative weight and body mass index of 73 kg and 25.6, respectively, and a body composition showing 46.2 kg of muscle mass, 24.2 kg of body fat, and 33.2% body fat percentage. However, upon discharge from the hospital, his weight decreased to 65.0 kg and BMI to 22.8, with 45.6 kg of muscle mass, 16.8 kg of body fat, and 25.8% body fat percentage, although his muscle mass was relatively well maintained through enteral nutritional management and rehabilitation.Pathological findings of the resected specimen showed no tumor remnants and no lymph node metastasis. Follow-up endoscopy after discharge showed that the diameter of the anastomosis was maintained Fig. c and d.The present case involving gastric remnant necrosis after proximal gastrectomy had been successfully managed through conservative treatment with a W-ED tube. The stomach has been considered resistant to ischemia given its numerous inflowing vessels and rich microvascular network in the submucosal layer , 2. ConsIn recent years, ICG fluorescence has been used to assess blood flow in the gastrointestinal tract. It has reportedly been used for evaluation of residual gastric blood flow in pancreatic resection after gastrectomy –16. It hGastric remnant necrosis can be diagnosed through CT and endoscopy, although reports have suggested that endoscopy is the more helpful for the early diagnosis of ischemic changes in the gastric wall . The timGastric remnant necrosis in the current case had been managed through conservative treatment using a W-ED tube. Previous reports have often employed surgical treatment for gastric remnant necrosis , 7, whicThe usefulness of the W-ED tube for postoperative nutritional management after abdominal surgery has been reported . This paHerein, we present our experience with a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment using a W-ED tube, which allows for both enteral feeding and gastrointestinal tract decompression. In cases of high operative risk, the management should be mindful of gastric remnant necrosis as a post-gastrectomy complication.


Bronchogenic cysts are commonly located in the middle mediastinal compartment as fluid‐filled cysts and thymoma is one of the most common neoplasms in the anterior mediastinum in adult cases. For two cases of asymptomatic, incidentally discovered anterior mediastinal soft tissue mass in adults, we planned to perform complete thymectomy with minimally invasive techniques based on the guidelines of International Thymic Malignancy Interest Group. Their pathological finding revealed cystic lesions lined by ciliated epithelium and this supported the diagnosis of bronchogenic cyst rather than thymic neoplasm. We report the two cases of resected bronchogenic cysts which were in the unusual location of anterior mediastinum with uncommon radiological feature. We present two cases of surgically resected bronchogenic cysts in the anterior mediastinum mimicking thymoma. Primary mediastinal masses are heterogeneous and have their own predilections for a specific compartment. Masses that are usually located in the anterior compartment of mediastinum are thymoma, germ cell tumours, or lymphoma, and thymoma is one of the most common neoplasm in adult cases . On the Bronchogenic cyst is mostly found in the middle mediastinal compartment as a well‐circumscribed, fluid‐filled lesion on computed tomography (CT) scan. However, it can be misdiagnosed as other types of mediastinal mass if it is discovered in unusual location with uncommon radiological characteristics .We report two cases of surgically treated bronchogenic cyst which were located in the anterior mediastinum with soft tissue density on CT scan.A 64‐year‐old male patient with previous history of hypercholesterolaemia presented to our outpatient clinic due to incidentally discovered mass in the anterior mediastinum on chest CT for routine check‐up. He did not complain of myasthenic symptoms or chest pain and his chest radiography showed no significant abnormality. Contrast‐enhanced CT scan showed a 1.4 × 1.8 × 2.6 cm sized, well‐defined mass with homogeneous attenuation (Hounsfield units (HU) of 42) Fig. . The radA 44‐year‐old female patient was referred for evaluation of incidentally discovered anterior mediastinal mass from health check‐up centre. Her medical history was unremarkable except previous uterine myomectomy and she did not complain of any symptoms related to myasthenia gravis. There were no significant abnormalities on physical examination or in the laboratory tests. Contrast‐enhanced chest CT scan revealed an anterior mediastinal mass measuring 2.2 × 2.0 × 3.6 cm with soft tissue attenuation (HU of 60) Fig. . ThoracoBronchogenic cysts are congenital anomaly derived from abnormal germination of the embryonic foregut during the first 16 weeks of gestation  and finaIntrathymic or anterior mediastinal bronchogenic cysts are extremely rare , 8 and TCardinale et al.  suggesteAs long as surgery of thymoma is concerned, the International Thymic Malignancy Interest Group (ITMIG) recommended that patients should undergo a complete thymectomy including mass itself, surrounding thymus, and mediastinal fat even though they did not have myasthenia gravis . AccordiIn summary, this study presented two cases of resected anterior mediastinal bronchogenic cyst using minimally invasive techniques. Surgical resection with the intention of complete thymectomy is recommended for accurate pathological diagnosis and curative treatment.Appropriate written informed consent was obtained for publication of this case report and accompanying images.


In this report, we describe a patient with myoepithelial hamartoma, which is regarded as synonymous with adenomyosis and heterotopic pancreas. Endoscopy revealed a submucosal tumor in the antrum of the stomach. Subsequently, distal gastrectomy with Roux-en-Y reconstruction was performed. Histological findings of adenomyomatous lesion and heterotopic pancreatic tissue were observed in this lesion. The distribution of OCT4, which is a pluripotency marker, varied in each part. Submucosal tumors of the stomach are rare, with the exception of gastrointestinal stromal tumors and lymphomas. Myoepithelial hamartoma (MEH) was described in 5 cases for the first time by Magnus–Alsleben in 1903 –5. HistoWe report the case of a patient who presented with abdominal pain and MEH and discuss the association between adenomyoma and heterotopic pancreas.A 39-year-old woman visited the previous hospital with a chief complaint of abdominal pain that lasted for a week. She had no history of gastrointestinal diseases. Subsequently, she underwent esophagogastroduodenoscopy, which revealed a submucosal tumor in the gastric antrum and a duodenal ulcer scar. Computed tomographic scanning showed wall thickening of the gastric antrum, after which the patient was referred to our hospital for further investigation and treatment. Esophagogastroduodenoscopy at our hospital revealed a pedunculated mass resembling a submucosal tumor in the antrum of the stomach . EndoscoThe lesion was located in the gastric antrum and duodenum and was 3.7 cm long . The resWe reported the presence of an MEH with various histological features. MEH is synonymous with adenomyosis and ectopic pancreas. In this case, there were two histological components: “adenomyosis,” in which only the ductal structure that expanded to the smooth muscle bundle was seen and “heterotopic pancreas,” ducts, and acini. Although different names have been given due to the differences in histological findings, we essentially have the same two types of lesions; both components appear in the same lesion in this case.In this study, OCT4-positive cells were not found in the adenomyosis part; they were found in the part showing a more organoid structure. OCT4 is a pluripotency marker –11, suggThere is a theory that heterotopic pancreas is a stray pancreatic tissue during embryonic development –14; howeNeoplastic lesions arising from ectopic pancreatic tissue have been reported , 17, mosMucosal incision-assisted biopsy (MIAB) is powerful method for the diagnosis of subepithelial lesions , 21; we To our knowledge, no studies have reported the distribution of OCT4 in such tumors; however, analysis of cases is needed to explain the tumor genesis. Since there are many mysteries about the development of MEH, further examination is needed with regard to it.


The management of a congenital hepatic cyst is typically conservative with periodic monitoring by ultrasound, especially for large cysts. Most hepatic cysts resolve spontaneously, surgical intervention with aspiration, sclerotherapy, or excision being indicated only for cases in which there is hemorrhage, torsion, a progressive increase in size, or imaging characteristics that lead to diagnostic uncertainty.Like congenital hepatic cysts, liver abscess is uncommon in the pediatric population. However, it is a serious infectious disease that is responsible for hospital admissions and even deaths worldwide. Although most abscesses are caused by bacterial infection, cases of infection by protozoa (amebiasis) or fungi (candidiasis) can occur. The diagnosis of liver abscess is usually made on the basis of clinical and laboratory data, together with the presence of focal liver lesions showing characteristics consistent with an abscess. The standard treatment is antibiotic therapy, with or without percutaneous drainage. Most patients with liver abscess have a favorable evolution, although death from liver abscess occurs in most case series studies,2.In the pediatric population, liver neoplasms can be malignant or benign. The most common malignant liver neoplasm is a metastasis. Primary liver malignant neoplasms account for a small proportion of solid tumors that occur in the pediatric population; hepatoblastoma and hepatocellular carcinoma are the most common such neoplasms, together accounting for approximately two thirds of all primary malignant pediatric liver neoplasms,6.The most common primary malignant liver tumor in the pediatric population is hepatoblastoma, the cells of which resemble those of the embryonic liver. Most cases appear in the first two years of life, and there are few cases that are congenital or are diagnosed after the age of five years. A slight predominance of occurrence in boys has been reported. The typical presentation is of an abdominal mass, together with anemia and vomiting, in a child under three years of age. Serum levels of alpha-fetoprotein (AFP) are high in most cases, and the staging is based on the location of the tumor, which directly correlates with patient survival. Complete surgical resection continues to be the standard treatment for hepatoblastoma, either as the initial treatment or after neoadjuvant chemotherapyHepatocellular carcinoma is a less common liver malignancy than is hepatoblastoma, accounting for approximately one quarter of pediatric liver neoplasms, and its incidence peaks during two periods of life: between 0 and 4 years; and between 10 and 14 years. Predisposing conditions include liver fibrosis/cirrhosis secondary to metabolic liver disease, viral hepatitis, extrahepatic biliary atresia, total parenteral nutrition, and chemotherapy-induced fibrosis.,7.Serum AFP is elevated in approximately half of all cases of hepatocellular carcinoma. Metastases usually occur in the lung and lymph nodes. The staging system is similar to that used in hepatoblastoma. More than 70% of these tumors are considered unresectable at the time of presentation, and, unlike hepatoblastomas, hepatocellular carcinomas do not usually respond well to chemotherapy. In most cases, the only potentially curative treatment options are complete surgical resection and transplantation. Recently developed therapeutic strategies include chemoembolization, intra-arterial chemotherapy, and intraoperative cryotherapy. The overall survival rate is low, and pediatric patients with initially resectable disease have a much better prognosis than do those with locally advanced or metastatic disease,2.Other primary malignant tumors of the liver include undifferentiated sarcoma, rhabdomyosarcoma of the biliary tract, angiosarcoma, and rhabdoid tumors, the most common benign liver tumors are hemangiomas, hamartomas, and focal nodular hyperplasia (FNH).In the pediatric population, approximately one third of primary liver neoplasms are benign. As demonstrated in previous studies,8.Hemangiomas are the most common benign liver tumors in the pediatric population, typically occurring in fetuses, neonates, or infants ≤ 6 months of age. They feature endothelial cells lining the vascular spaces and range from small masses, identified as incidental findings, to large cavernous hemangiomas that are distinguished by large vascular spaces and low cellularity. The natural history of a hemangioma is spontaneous regression within the first two years of life; however, treatment may be necessary when there are symptoms or complications such as heart failure,8,9.Mesenchymal hamartomas are uncommon benign pediatric liver tumors. They are observed mainly in children under two years of age, and some authors consider them developmental abnormalities rather than neoplasms. Like other hamartomas, mesenchymal hamartomas of the liver are disorganized lesions that are usually cystic and contain varying amounts of soft tissue. They typically arise during the first few months of life, after which they stabilize, continue to grow, or regress. Mesenchymal hamartomas are generally asymptomatic and have a good prognosis; the treatment options are resection and observation,8.Hepatic adenoma and FNH are rarely diagnosed in childhood. Both are benign lesions, are associated with a high estrogen environment, and occur predominantly in adolescent girls. Hepatic adenomas are associated with the use of oral contraceptives. Signs and symptoms may be absent or are nonspecific, the latter including abdominal pain and a liver mass. FNH has no malignant potential, is generally asymptomatic, and can be monitored by serial ultrasound whereas symptomatic or rapidly growing lesions can be treated by resection or embolization. Larger hepatic adenomas can be treated with complete surgical excision, because they present a low risk of rupture or hemorrhage,2,6,8,10.Most pediatric patients with focal liver masses are investigated because they present with abdominal pain or abnormal physical examination findings, such as an abdominal mass or abdominal distension. The diagnosis of a pediatric liver tumor is based on the clinical characteristics, serum AFP level, patient age, and imaging characteristics. Ultrasound is the initial imaging modality of choice, because it does not emit ionizing radiation and does not require sedation, as well as because it can detect, characterize, and provide information on the extent of focal liver lesions presented a variety of pediatric focal liver lesions, which can have a hyperechoic aspect on ultrasound. They can result from trauma or fatty liver disease; they can also be congenital or neoplastic  lesions. Color Doppler ultrasound can suggest the vascular nature of a tumor, such as infantile hemangioma and FNH.In a pictorial essay published in the previous issue of Radiologia Brasileira, Rocha et al.. If a contrasted multiphase study is indicated, MRI can be considered. Although MRI does not expose patients to radiation, sedation is generally required for younger patients. Despite all these resources, there are many cases in which only biopsy findings can provide the definitive diagnosis of a liver mass identified in childhood.Although a liver mass can sometimes present a characteristic appearance on ultrasound, subsequent CT or MRI scans are often performed for better characterization, precise evaluation of the extent of the mass, and detection of any associated metastatic disease in cases of a malignant liver neoplasm. When CT is used, the radiation risks can be minimized with the dose reduction techniques outlined in the guidelines published by the Image GentlyIn conclusion, knowledge of the pathological spectrum, epidemiological characteristics, and imaging aspects of liver lesions in the pediatric population is essential. Such knowledge guides radiologists in assessing and providing appropriate treatment to pediatric patients with focal liver lesions, thus minimizing the risks of the investigation.


The complications induced by mesh, such as foreign body reaction, deep-seated infection, mesh migration and perforation into viscera, have been reported sporadically. Colon erosion and penetration by laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair mesh can possibly cause perforation of the colon with acute abdomen.A 100-year-old male, who underwent 4 years ago TAPP repair of left inguinal, presented to the emergency department with acute abdomen due to chronic mesh penetration into the sigmoid colon, the migrating mesh generated a free wall perforation with generalized fecal peritonitis.Tailoring the mesh, appropriate suture placement and adherence to principles of antisepsis during hernia repair surgery are crucial in avoiding longterm mesh-related complications.TAPP is a safe procedure for treat groin hernias, unless, mesh complications like foreign body reaction, deep-seated infection, mesh migration and perforation. The tension-free method with mesh as a muscle reinforcement technique is regarded as an important part of inguinal hernia repair since it reduces the hernia recurrence rate. With the introduction of laparoscopic inguinal hernioplasty the superficial infection rate has decreased dramatically (less than 2 %) .Chronic pain and surgical site infection associated with prosthetic mesh are well-known complications, which mainly occur in the early postoperative period. However, serious complications, such as mesh migration, erosion and perforation of adjacent organs, are rarely reported and may present symptoms at different time intervals after inguinal hernia repair ,6.Colon erosion and penetration by laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair mesh can possibly cause perforation of the colon with acute abdomen. We report the first case of chronic mesh penetration into the sigmoid colon, where the migrating mesh generated a free wall perforation wiht generalized fecal peritonitis in a centenary patient . This wo2A 100-year-old male patient, presented to the emergency department with a 4-day history of abdominal pain, mainly localized in the left quadrants, associated with anorexia and impaired mental status. No nausea nor vomiting were present. The patient only had as previous abdominal surgery in his medical history a TAPP repair of left inguinal hernia 4 years previously with a light weight mesh of polyester. The patient was hemodynamically stable and apyretic. The abdomen was distended, showing generalized tenderness, with physical signs of peritoneal irritation. Laboratory investigation was abnormal with acidosis and elevated lactate. Abdominal CT scan confirmed the presence neumoperitoneum with a strange body into de left colon lumen. These CT features raised suspicion of an area of colon perforation . Laparos3Acute abdominal pain  is a common presenting complaint among older patients. Approximately one fourth of patients who present to the emergency department are older than 50 years. Older patients tend to present later in the course of their illness and have more nonspecific symptoms. In addition, a broader differential diagnosis must be considered in older patients with abdominal pain that can make an accurate diagnosis more difficult, like in our case with a centenary patient ,7,9,10.Incidence rates for mesh erosion, migration and perforation of adjacent organs such colon sigmoid remain unknown. Depending on the different positional relationship of migrating mesh with visceral organs, clinical manifestations vary significantly and may present from 1 to 20 years after inguinal hernia repair. The intestine and urinary bladder were involved in most cases of mesh migration reported from 2003 to 2017. A relatively rare case of a migrated mesh in the retroperitoneal region mimicking a cystic adnexal mass was also documented previously .Lower abdominal pain and mild tenderness were described in the majority of cases, while weight loss, anorexia, symptoms of bowel obstruction, palpable abdominal mass were merely referred to by a few reports. In our case, the male patient complained of severe abdominal pain plus peritoneal irritation signs and acidosis with elevated lactate, simulating a mesenteric ischemia which led to diagnosis delay .Typical signs caused by mesenteric ischemia or peritonitis were almost absent on the computed tomography (CT) but this image showed neumoperitoneum as a sign for gastrointestinal perforation. In previously reported cases, migrating mesh plugs were neglected or misdiagnosed as a poorly defined mass, an intra-abdominal neoplasm or sigmoid diverticulosis based on radiological investigations .Incomplete peritoneal repair, inadequate fixation or inappropriate amount of implantation space are possible reasons accounting for mesh migrating into intraabdominal viscera, occasionally followed by fistulas formation or mechanical bowel obstruction. In addition, the sharp edges of prosthetic mesh or tackers could injure the viscera serosal layer, initiating the intraabdominal inflammatory process and subsequent mesh erosion. The bowel injury incidence rate ranged between 0.4 % and 5.6 % in previous studies .In our case, the patient presented in the acute phase of a chronic process due to the folling factors: (1) The foreign body reaction to mesh enables gradual movement of the mesh through the anatomic planes in the abdominal cavity; (2) the mesh can be encapsulated by the omentum during its migration and create a channel into hollow organs along with inflammatory reaction and peristaltic bowel movement; (3) Gram-positive cocci are generally responsible for superficial wound infection and can further trigger the deeper infection. Bacterial biofilm can develop over the mesh due to chronic contamination by staphylococcus species, which results in painless mesh migration through the tissue and (4) Prosthetic mesh material decreases the formation of the mesothelial cell layer in peritoneal repaired defects, predisposing the irregular surface of mesh to be surrounded by scar tissue, all 4 processes failed when the mesh cross the entire wall of the colon, introduce into the lumen and generate a free perforation .The exact etiology of the complication encountered in our patient remains unclear. During the initial surgery, the mesh should be sutured to the abdominal wall wiht non absorbable tackers, and then the peritoneum can be reconstructed with interrupted tackers to cover the mesh plug. When both of these sutures are insecure, the mesh would migrate into the peritoneal cavity and erode into the sigmoid colon. Al Subaie et al. presumed that the pressure necrosis resulting from the physical contact between the mesh and the colon lead to fistula formation and consequently to mesh migration into the colon. D’Amore et al. found that 5 of 7 patients (2 involving cecum and 5 involving left colonic after plug repair) suffered from diverticular disease and thought that diverticular inflammation might induce the plug to erode into the colon .Morbidity and mortality among older patients with abdominal pain are high; evaluation and management often requires admission to the hospital and surgical consultation. In retrospective studies, more than one half of older patients presenting to the emergency department with acute abdominal pain required hospital admission, and 20–33 percent required immediate surgery, like in our case. Surgical intervention occurs twice as often in older patients when compared with a younger population. Overall mortality rates from retrospective series vary from 2 to 13 percent. In a retrospective study of 380 older patients with acute abdominal pain, the presence of free air on plain film radiographs or CT, leukocytosis with a high neutrophilic band count, and age older than 84 years were associated with an increased risk of death, like in our case ,23,24.Moorman and Price believed that lack of fixation of mesh predisposes to its migration. D’Amore et al. considered that other technical details, such as to avoid the excision of the sac, identify and repair any hole in the peritoneal sac, use preshaped devices, and choose the proper size and light material, could reduce the incidence of this complication. To treat and prevent further erosion of migrating mesh and preserve the function of affected viscera, total removal of the mesh via laparoscopy or laparotomy is advised in clinical practice, along with either partial or entire resection of the organ, like in our case with extraction of the mesh plus enbloc sigmoidectomy. Meanwhile, the possible wound sinus or enteric fistulas linked to the mesh should be completely eradicated by excision in combination with medication therapy . Regardless of the type of mesh repair (open or laparoscopic), meticulous care for correct placement and reliable suture is necessary to avoid complications. Suturing the mesh to the surrounding fascia is a critical step during the operation. Tailoring the mesh, appropriate suture placement and adherence to principles of antisepsis during hernia repair surgery are crucial in avoiding longterm mesh-related complications .4TAPP is a safe procedure for treat groin hernias, unless, mesh complications like foreign body reaction, deep-seated infection, mesh migration and perforation into viscera can occur even 20 years later of the procedure with no defined incidence. We recommend do not forget this possible mesh associated issues in a patient with previous TAPP procedure and a foreign body into the lumen of the colon in the abdominal CT.Nothing to declare.The study is exempt from ethnical approval in our institution.Written informed consent was obtained from the patient for publication of this case report.Dr. Fajardo, Dr Diaz and Dr Cabrera: Evaluation and post-operative managementof the case along with surgical assistance.Dr. Fajardo, Dr Diaz and Dr Cabrera: Performed the surgical technique.Dr. Pedraza, Dr Cabrera: Assisted the surgical procedure.N/A.Mauricio Pedraza Ciro.Not commissioned, externally peer-reviewed.Nothing to declare.


Left ventricular false tendons are cord like structures that traverse the left ventricular cavity. They are found in approximately half of the human hearts examined at autopsy and have no clinical or prognostic significance. They have been well described and usually pose no diagnostic dilemma. We present the first case of a partially ruptured false tendon mimicking mural vegetation in an 80-year-old male with extended-spectrum beta-lactamase Escherichia coli bacteremia. Left ventricular false tendons (LVFTs) are distinct fibromuscular structures that are extensions of the innermost myocardial layer of the left ventricle and may vary in size and dimension . They arWe present a case of an 80-year-old male with a past history of hypertension, heart failure with reduced ejection fraction, type 2 diabetes mellitus, dyslipidemia, and acute coronary syndrome status post percutaneous coronary intervention with non-drug eluting stent placement in 2019. He presented with a three-day history of subjective fever associated with multiple episodes of non-bloody emesis and intermittent right-sided lower abdominal pain with radiation to the ipsilateral back. No additional complaints were elicited on the initial presentation. No flank tenderness was appreciated on physical examination.The patient was febrile to 103.1° F with an elevated white blood count (WBC) of 14,600 per microliter. He was hemodynamically stable and started on empiric broad-spectrum antibiotics. CT abdomen was significant for mild perinephric stranding but negative for calculi. Urine and blood cultures on admission were positive for extended spectrum beta-lactamases (ESBL) Escherichia coli and he was transitioned to meropenem given the sensitivity profile. The hospital course was complicated by a transient episode of dyspnea, which responded to diuretics. An electrocardiogram done at that time showed sinus rhythm with non-specific ST-T-wave abnormalities unchanged from prior. Transthoracic echocardiogram (TTE) was done because of the change in clinical status that showed an ejection fraction of 25-30% with severely decreased global left ventricular systolic function with aneurysmal anterior and anteroseptal walls unchanged from prior TTE. However, there was a new finding of a mobile echodensity Figure  attachedGiven the history of ESBL bacteremia, a transesophageal echocardiogram (TEE) was performed to further characterize the echodensity and to rule out infective endocarditis. It showed a linear mobile hyperechoic opacity with sharp borders, not characteristic of endocarditis Figure .The location of the linear density, when compared to prior echocardiograms, was consistent with a partially ruptured false tendon (Figure Although LVFTs have been a well-established echocardiographic finding widely reported in the literature, in almost all reported cases, they remain attached as they traverse the interventricular septum and left ventricular free wall or papillary muscles without any connection to mitral valve leaflets . In onlyAs mentioned earlier, even though LVFTs are a benign finding and are readily seen on echocardiograms, partially ruptured LVFTs may resemble vegetation or thrombus, resulting in unnecessary therapies including anticoagulation or extended antibiotics. It is hard to distinguish between a partially ruptured LVFT and vegetation on a transthoracic echocardiogram; our case demonstrates the importance of comparing current studies with prior studies, which provide additional clues and help make a more informed diagnosis. It is also important to use additional tests in cases where a clear diagnosis cannot be made on TTE. A TEE has increased sensitivity compared to TTE and can help characterize the opacities better. Adequate description and characterization of echodensity on echocardiogram with commentary on tissue texture and attachment site may help differentiate between different structures .LVFT are cord-like structures that cross the left ventricular cavity and serve no prognostic significance. Our case report illustrates a very rare entity of an idiopathic primary partial rupture of LVFT and the importance of a systematic approach in coming to a correct diagnosis. We urge other researchers to pay close attention to the aforementioned finding, given its subtlety.


Case Report. A 75-year-old male underwent a laparoscopic cholecystectomy with an incidental diagnosis of adenocarcinoma in situ (TisN0M0 according to AJCC 8th edition). The operative report mentioned that the removal of the gallbladder was difficult due to the inflammatory process, and the gallbladder was accidentally opened during the operation. It was not clear from the operative report whether an extraction bag was utilized to remove the specimen, but the histopathological study confirmed an open gallbladder. He presented 11 years later with an asymptomatic heterogeneous complex cystic mass involving the anterior rectus abdominis muscle. Colonoscopy showed synchronous tumors in the descending and sigmoid colon with pathology confirming adenocarcinoma. The patient underwent an elective laparotomy with resection of the anterior abdominal wall mass, left hemicolectomy, and sigmoidectomy. The histopathological results of the abdominal mass  were described as metastasis of adenocarcinoma of biliary origin. Discussion. Port site recurrences are rare complications following laparoscopic surgery when malignancy is unsuspected. Possible factors related to local implantation include direct seeding of spilled bile or tumor cells into the wound or shedding of tumor cells due to pneumoperitoneum-induced loss of the peritoneal barrier at the trocar site. In the absence of distant metastasis, treatment should include wide port site excision with malignancy-free surgical margins.  Abdominal wall masses are a common finding in clinical practice. A high percentage of these masses are malignant. We present the case of a patient operated for a gallbladder adenocarcinoma, who consulted eleven years later for a malignant mass of the abdominal wall in synchrony with two adenocarcinomas of the left colon and sigmoid.  Abdominal wall metastasis from gallbladder carcinoma is rare, and its synchronous presentation with a malignant neoplasm of the colon is exceptional. This is the first report of a patient with abdominal wall metastasis from a gallbladder adenocarcinoma operated eleven years ago that debuted synchronously with two adenocarcinomas of the left colon and sigma. Abdominal wall masses are a common finding in clinical practice and up to 42.2% can be malignant . The patWe present the first report of a patient with a metastatic mass in the abdominal wall from a gallbladder adenocarcinoma operated on eleven years earlier by laparoscopic cholecystectomy, who presented with a synchronous sigmoid and descending colon adenocarcinoma.Laparoscopic cholecystectomy is the standard operation for symptomatic cholelithiasis and other benign gallbladder diseases , 3. The Moreover, the association between gallbladder polyps and adenomatous colon polyps is well known and will be discussed.A 75-year-old Caucasian male presented in September 2019 with a long-term asymptomatic mass (for approximately the last 3 years) that had increased in recent years .The patient had a medical history of laparoscopic cholecystectomy for cholelithiasis in 2008. The pathological study indicated a chronic cholecystitis with an incidental diagnosis of adenocarcinoma in situ over a 12 mm adenomatous polyp located at the bottom. The operative report mentioned that the removal of the gallbladder was difficult due to the inflammatory process, and the gallbladder was accidentally opened during the operation. It was not clear from the operative report whether an extraction bag was utilized to remove the specimen, but the histopathological study confirmed an open gallbladder. The patient did not undergo any adjuvant therapies, and there was no postoperative follow-up medical history.The current physical examination revealed a mass effect in the mesogastrium of stony consistency, painless to palpation and no signs of peritonitis. An abdominal contrast-enhanced computed tomography (CT) scan was performed . A heterGiven the presence of mucin and the history of adenocarcinoma in situ of a gallbladder polyp, a gastroscopy and a colonoscopy were performed. The colonoscopy showed tumors in the descending colon and sigma with biopsies from both sites confirming adenocarcinoma.The patient underwent an elective laparotomy. We found an amorphous, well-defined mass that involved the skin, subcutaneous fat, the rectus muscle, and the posterior sheath of the rectus without affecting the peritoneum or the abdominal organs . En blocThe histopathological results were described as metastasis of adenocarcinoma of biliary origin , CDX2 , MUC1, MUC5AC, MUC2 , EMA, CA19. 9, CEA , CD10 , beta-catenin; negative for CA125, PAX8, PSA, TTF1, S100, estrogen and progesterone receptors, CD34, inhibition) without affecting surgical margins. The histological study of the colon revealed an adenocarcinoma in sigma T3N0M0 (according to the eighth edition of the AJCC) while the left colon showed an adenocarcinoma in situ (TisN0M0) . The patDuring the follow-up (18 months), the patient has not presented evidence of recurrence, wound infection, or mesh rejection. The follow-up schedule based on an abdominal contrast-enhanced computed tomography scan and analytical blood test with tumor markers (CEA and CA 19.9) was every 6 months.Abdominal wall masses are a frequent finding in clinical practice and cover a large number of pathologies. Abdominal masses are traditionally classified as benign tumors, malignant tumors, or tumor-like lesions such as hernias or abscesses of the abdominal wall . AccordiThe patient's clinical history and personal history play a very important role in the diagnostic suspicion of abdominal masses. It is well known that benign lesions tend to grow slowly, with a long time of evolution. On the other hand, malignant lesions tend to have a more aggressive course with a faster growth of the tumor mass. In our patient, the antecedent of interest was the accidental finding of an adenocarcinoma in situ of the gallbladder. Eleven years later, the patient consulted for a tumor in the abdominal wall that had progressively grown after gallbladder surgery and was not causing symptoms. Despite the long time since the gallbladder surgery, the patient started to notice the abdominal wall mass 3 years ago. Since then, it grew slowly, with minimal local discomfort. Given the long time of development of the tumor, the probability that the mass was secondary to gallbladder adenocarcinoma was initially low. However, the surgical wound of the umbilical port was engulfed by the tumor mass.In relation to imaging tests, ultrasound is usually a good imaging technique for the initial diagnosis because it is cheap and not harmful to the patient. Furthermore, most abdominal masses are superficial and therefore accessible by ultrasound . HoweverHowever, some abdominal wall masses remain undetermined due to the heterogeneous spectrum of disease and the limited capability of imaging tests . While iWith the previous results, we reviewed the anatomopathological report of the gallbladder and the histological preparations . The patTherefore, assuming the diagnosis of secondary metastasis to gallbladder adenocarcinoma and taking into account its location in the mesogastrium, the initial suspicion was implantation at the site of the laparoscopic port. There are two hypotheses about the main factors that may intervene in the mechanism of recurrence of the abdominal wall at the site of the port: one is the systemic progression of the malignancy and the other is local implantation at the port site . In favoPossible factors related to local implantation include direct seeding of spilled bile or tumor cell in the wound or detachment of the tumor cell due to loss of the peritoneal barrier at the trocar site and induced by the pneumoperitoneum in the peritoneal cavity , 14. TheWound or port metastasis is a rare but recognized complication in patients undergoing laparoscopic surgery when a malignancy is diagnosed or not suspected . Port siThe average time of recurrence at the port site after cholecystectomy reported in the literature is 7 months , 17. RecHowever, since laparoscopic surgery is currently fully implemented, port metastasis can be reduced by meticulous surgical resection to avoid cell or bile leakage . In addiTreatment will depend on the presence of disseminated disease. In the absence of distant metastasis, treatment should include wide port site excision with malignancy-free surgical margins (R0 resection) and exploration of the peritoneal cavity to exclude peritoneal metastasis 14). However, it is not clear whether the presence of wound or port site metastases can be considered a risk factor for peritoneal spread of disease . However. AlthougThe prognosis in patients who have developed wound or port site metastases for gallbladder carcinoma is unclear . There aFurthermore, despite recent advances in diagnostic imaging, initial imaging studies often do not reveal a diagnosis of gallbladder cancer . The cliThe decision to undergo additional treatment in patients with an incidental diagnosis of gallbladder carcinoma should be based on a pathological examination of the resected gallbladder. Previous reports have indicated that simple cholecystectomy and observation is appropriate for patients with pTis or pT1a disease (AJCC 8th ed.) . CholecyOn the other hand, some studies seem to indicate that the risk of incisional metastasis is higher after laparoscopic cholecystectomy , 21. TheFinally, the association between gallbladder polyps and adenomatous colon polyps is well known. Several studies suggest that the presence of polyps in the gallbladder is associated with an increased incidence of colorectal adenomas, which in turn can develop into colorectal cancer , 25. In Gallbladder polyps and colorectal neoplasia share several risk factors that could explain their association, such as male gender, age, and metabolic syndrome, including obesity, insulin resistance, and lipid profile abnormalities , 26. In However, these studies do not differentiate between cholesterol polyps or adenomatous polyps of the gallbladder. Cholesterol polyps are benign and are the most common , 27. HowTherefore, we must be consistent with this possible association and additional screening tests such as CT scan or colonoscopy could be justified if polyps are found in the gallbladder. However, more studies are needed to determine this.Metastasis in the abdominal wall of a gallbladder carcinoma operated 11 years ago is rare. Its synchronous presentation with two malignant neoplasms of the colon is exceptional and has not been described before. Its treatment is mainly surgical. Its prognosis depends on the tumor stage of the colon and negative surgical margins after resection of the metastasis.Finally, the association of gallbladder and adenomatous polyps in the colon is well known. Therefore, this association can be taken into account for early detection studies by colonoscopy.


The urachal sinus is a vestigial remnant that ensues in the aftermath of incomplete obliteration of the embryonic urachus. Urachal sinuses often remain asymptomatic, being discovered incidentally in instances where they are complicated with a superimposed infection or abscess. Due to their rare occurrence in adults, urachal sinuses are rarely included in the list of differential diagnosis surrounding umbilical pain in adult patients. We hereby delineate a unique case of a urachal sinus in a 26-year-old male patient. Due to the presence of an abscess in a hirsute male, a presumptive diagnosis of an umbilical pilonidal sinus was suspected. However, further diagnostic workup divulged an unequivocal diagnosis of a urachal sinus complicated by an abscess formation. The urachus is a vestigial tubular structure that connects the umbilicus with the urinary bladder during the fetal life and subsequently involutes after fibrosis . In rareWe elucidate an interesting case of a 26-year-old male with no comorbidities who presented to our department with a complaint of purulent discharge from the umbilicus. The purulent umbilical discharge was accompanied by intermittent umbilical pain for the past month. Pertinently, the patient also reported a history of burning micturition of recent onset. Physical examination of the umbilicus, along with the abdomen, revealed a hirsute male with a deep, erythematous umbilicus with a purulent discharge. Coupled together, the physical examination and the patient’s presenting history alluded towards a presumptive diagnosis of an umbilical pilonidal sinus (UPS), which commonly presents in a hirsute male with a deep umbilicus. However, owing to recent urinary complaints, a urachal communication was suspected. A subsequent urinalysis was unremarkable. To ascertain the underlying pathology, an MRI scan of the abdomen and pelvis was conducted. MRI was considered the imaging modality of choice because MRI, in addition to elucidating the underlying urachal anomaly, also shows the extent of the infection and the potential involvement of the adjacent organs. The MRI scan divulged a mild peripheral wall enhancement below the umbilicus. Pertinently, there was no communication with the bladder observed. Furthermore, the MRI scan revealed a fluid-containing cystic lesion measuring 17 x 18 x 23 mm, insinuating a diagnosis of a urachal sinus  at the wound site; aspiration of the seroma was thus performed, and the seroma subsequently abated within the three following days. The patient continues to thrive without any additional complications. Pathologies evoking the involvement of a urachus remain exceedingly rare. Persistence of a urachal sinus is a rare clinicopathological entity that boasts a meagre prevalence of one in 5,000 live births and usually presents in male children . Since uA perusal and evaluation of the published medical literature reveals that cases of infected urachal sinuses can manifest with a vague constellation of clinical symptoms, including umbilical discharge, erythema, lower abdominal pain, fever, and burning micturition ,7. In a A multitude of studies purport the notion that multimodal imaging techniques remain pivotal in aptly construing a diagnosis of an infected urachal sinus in the adult population ,7. AlthoIn our case, considering the eventual diagnosis of a urachal sinus, an omphalectomy with complete resection of the urachal remnant and the entire remnant tract was deemed apt. Omphalectomy therefore remains the treatment of choice since conservative incision and drainage of the abscess may lead to recurrence of the abscess in the tract. Furthermore, the tract can serve as a nidus for future infections. In accordance with this notion, surgical literature vouches for surgical excision as the preferred treatment modality ,7,9. AppInfected urachal sinuses are an exceedingly rare clinicopathological entity. Their presence in hirsute adult males can often mimic umbilical pilonidal abscesses, obscuring a timely diagnosis. Imaging modalities, such as MRI, play a pivotal role in yielding a timely and accurate diagnosis. Due to the risk of future infections, complete surgical resection of the entire tract remains the preferred treatment modality.