Bezoars, characterized by undigested or partially digested foreign bodies in the gastrointestinal (GI) tract, are a rare condition associated with significant complications. We present a case of a 31-year-old woman who sought medical attention due to weight loss, diarrhea, and anorectal pain. Upon investigation, she was diagnosed with fecal impaction caused by a rectal sunflower seed bezoar. The patient had a history of regular sunflower seed consumption, suggesting a potential association with the development of the bezoar. Fecal impaction resulting from the bezoar led to chronic constipation, contributing to the patient's weight loss and anorectal discomfort. Imaging studies, including abdominal X-rays or computed tomography (CT) scans, played a crucial role in confirming the diagnosis by identifying the presence of the bezoar within the rectum. Management involved a multidisciplinary approach, with gastroenterologists and colorectal surgeons. A flexible endoscope was utilized to visualize and remove the sunflower seed bezoar under direct vision, providing immediate relief from the symptoms. This case emphasizes the importance of considering bezoars as a potential cause of GI symptoms, even in young and otherwise healthy individuals. Although rectal bezoars are relatively rare, they can lead to significant morbidity. Therefore, it is essential to include them in the differential diagnosis of patients presenting with fecal impaction, anorectal pain, and associated symptoms. Prompt diagnosis, appropriate imaging, and early intervention are crucial for the successful management and prevention of potential complications and the improvement of patient outcomes. A bezoar is a solid mass formed by the accumulation of indigestible or poorly digestible substances within the gastrointestinal (GI) tract, commonly found in the stomach and small intestine . DiffereBezoars typically develop in individuals with certain risk factors, such as mental retardation, psychiatric disorders like trichotillomania (compulsive hair-pulling) or trichotillophagia (compulsive hair-eating), inadequate chewing, abnormal gastric emptying (as seen in diabetes mellitus or mixed connective tissue disorders), and altered GI anatomy resulting from procedures like gastric bypass or partial gastrectomy accompanied by vagotomy .In many cases, bezoars are asymptomatic and are incidentally discovered during endoscopic procedures performed for unrelated reasons. However, as they migrate downward through the GI tract with peristalsis, bezoars can become more symptomatic. The symptoms associated with bezoars can vary depending on their location and the presence of complications, such as gastric outlet obstruction, GI bleeding due to ulceration, ileus, perforation, and intussusception . GastricIn mild to moderate cases of bezoars, medical treatment with enzymatic agents like cellulase or dark soda is typically attempted as the initial approach. However, more severe or refractory cases may require interventions such as manual disimpaction, endoscopic removal, or surgery . In thisA 31-year-old woman with no significant past medical history presented to the clinic with severe watery diarrhea, along with a weight loss of 20 pounds over a span of four weeks. She complained of anorectal pain and exhibited a perianal rash. The onset of diarrhea coincided with the initiation of stool softeners four weeks prior, which she had started taking for constipation. The patient denied any previous episodes of diarrhea or constipation, and there were no reports of fever, nausea, vomiting, recent travel, sick contacts, or anal intercourse. On physical examination, the patient appeared unremarkable, except for a heart rate of 128 beats per minute. The perianal area exhibited an erythematous, superficial rash, along with dried sloughed-off external hemorrhoids. Due to severe anorectal tenderness, the digital rectal examination was not performed. Laboratory data and stool studies yielded unremarkable results, except for iron deficiency anemia. To further investigate the condition, a computed tomography (CT) scan of the abdomen and pelvis was conducted, revealing fecal impaction and the presence of hyperdense material within the rectosigmoid colon, as observed in Figure Upon obtaining a detailed history from the patient, it was revealed that she had been consuming a large quantity of sunflower seeds. Consequently, a colonoscopy was performed under general anesthesia. The colonoscopy revealed the presence of a large phytobezoar consisting of undigested seeds, accompanied by multiple superficial ulcerations and edematous, friable mucosa in the surrounding area, indicative of fecal impaction Figure , 2B.The sigmoid colon and the rest of the colon appeared normal. During the procedure, successful manual disimpaction was achieved, leading to rapid alleviation of pain and discomfort Figure .Subsequently, the patient was discharged with instructions to follow a high-fiber diet and refrain from consuming sunflower seeds.The presented case highlights the association between excessive sunflower seed consumption and the development of a rectal phytobezoar, leading to fecal impaction. In patients with a history of constipation or signs of obstruction, the possibility of overflow diarrhea should be considered as part of the differential diagnosis, particularly in the presence of increased abdominal distension. The patient experienced significant symptoms, including severe watery diarrhea, substantial weight loss, anorectal pain, and the presence of a perianal rash. Prompt identification and intervention, in the form of manual disimpaction during colonoscopy, resulted in the rapid resolution of symptoms. The patient was advised to modify her dietary habits by incorporating a high-fiber diet and avoiding further sunflower seed consumption. Bezoars are relatively rare GI tract disorders that often remain silent and asymptomatic, particularly in individuals with predisposing factors. The stomach is the most common location for bezoar formation, followed by the small intestine. In this case, we present a rare occurrence of a sunflower seed bezoar in the rectum, leading to fecal impaction, rectal ulcers, and anorectal pain in a young woman without any identifiable precipitating factors. It is noteworthy that our patient experienced severe diarrhea and significant weight loss following the use of a stool softener for constipation.Bezoars are relatively uncommon, with an average of 2.5 cases per year reported in high-volume patient centers . While sCT imaging plays a crucial role in both identifying impacted bezoars and excluding other potential etiologies, such as rectal cancer or obstruction. Following successful bezoar evacuation, a complete colonoscopy is recommended to assess for possible strictures and colon ulcers. While small rectal bezoars may pass spontaneously or with the aid of enemas, symptomatic large rectal bezoars require manual rectal disimpaction under general anesthesia. Surgical intervention is indicated when conservative management, including manual or endoscopic disimpaction, fails or when complications such as perforation are present . AdditioBezoars are a rare condition that may be unfamiliar to many physicians; however, maintaining a high index of suspicion in patients with predisposing factors and GI symptoms is crucial for diagnosis. A rectal sunflower seed bezoar is an exceedingly rare entity that presents with constipation, anorectal pain, and rectal bleeding. Accurate diagnosis relies on meticulous history-taking and digital rectal examination, complemented by CT abdomen and colonoscopy in selected cases. Long-term management following bezoar detection necessitates addressing underlying risk factors to minimize the likelihood of recurrence.


Ossified intramuscular hematomas (OIH) are an exceptionally rare condition that may be mistaken for alternative calcified intramuscular pathologies, such as myositis ossificans. Exceedingly few cases of OIHs have been reported to date, with no cases yet to be reported in the paraspinal muscles.Here, we report on a patient who presented with a chronic back pain and swelling in the setting of trauma 15 years prior. Radiographic workup revealed a calcified mass in the erector spinae muscles. The lesion was surgically excised, and histologic examination confirmed the presence of an OIH. The patient did well postoperatively.An OIH is a poorly understood pathology. Although benign, these lesions can cause significant morbidity, and surgical excision is a reasonable and safe treatment option. OIHs may be distinguished from related calcified intramuscular pathologies based on key clinical features and distinct histopathology. Clinically, they are characterized by a history of remote trauma and, on histopathology, by compact, mature bone in the setting of an old, organizing hematoma. Despite this, similarities with other calcified intramuscular pathologies persist, and further study is warranted to better understand and classify these lesions. An ossified intramuscular hematoma (OIH) is a rare condition. It is exceedingly rare in the paraspinal muscles with no reported cases to date. Such lesions can likely be traced back to an intramuscular bleed emanating from local vasculature , 2. In gThe pathophysiology of an ossified or calcified intramuscular hematoma remains poorly understood . OssificClinically, ossified or calcified intramuscular hematomas present as deep-seated masses that enlarge at variable rates and may be discovered as many as 30 years following the initial injury , 8. If tThe work-up for these lesions spans 3 dimensions—clinical, radiologic and histologic. One should begin with a careful history with a particular focus on a history of prior trauma. Physical examination is essential and should be completed to evaluate for any subtle or salient signs of neurologic deficits or mechanical limitations. Palpation at the site of pain will often reveal focal swelling and a mass-like lesion . FollowiWhen evaluating an intramuscular calcification, it is important to maintain a broad differential. In particular, OIH may be mistaken for alternative calcified intramuscular pathologies. For example, without histologic examination, it is reported that an ossified hematoma may be incorrectly diagnosed as myositis ossificans (MO) . MO is aHere, we report on a unique case of an ossified intramuscular hematoma in the erector spinae muscles that was discovered in a patient who presented with chronic back pain and a history of remote trauma. We present a review of the literature on this topic and highlight key findings that may help to differentiate these lesions from similar pathologies reported in the literature. Finally, we will also identify areas of future study to aid in advancing our understanding of ossified intramuscular hematomas.A 29-year-old female presented with chronic back pain and swelling and a history of back trauma 15 years prior. On examination, there was an increase in pain with flexion. Laboratory workup was unremarkable. MRI followed by CT imaging demonstrated an ossified lesion within the erector spinae muscle on the left side, spanning from the level of T12 to L2 , 2. Due Here, we present a case of an OIH within the erector spinae muscles of the thoracolumbar region, confirmed with pathologic examination. To our knowledge, this is the first report of an ossified intramuscular hematoma in the paraspinal muscles. Calcified intramuscular hematomas in muscles groups of the extremities have been reported in the literature, although rarely—limited to one case report and one case series , 8. In 2Prior to this report, the only additional reports of calcified intramuscular hematomas are limited to a case series published in 1997 . Here, fIt is important to emphasize that these lesions maintain some resemblance to additional calcified intramuscular pathologies reported in the literature. For example, Mentzel and colleagues reported that their histopathologic findings were similar, if not identical, to what had been reported in cases of calcific myonecrosis . CalcifiFurther, as previously mentioned, an OIH can be mistaken for MO . MO is aIn regard to treatment, there are no formal recommendations. However, similar to MO, it can be assumed that either conservative or surgical management is appropriate depending on clinical context . For lesLooking to the future, additional work is needed to characterize these lesions in order to better understand their natural history, histologic and radiologic features, and pathophysiology. Foremost, all calcified and ossified intramuscular hematomas reported thus far have been excised due to symptomatic progression, and we have been unable to determine natural history—for example, whether these lesions have the capacity to self-resolve without intervention. Surveillance of more benign lesions that would have been confirmed with biopsy will be key to elucidating natural progression. Further, among cases reported, there remains variation in radiographic and histologic findings alongside apparent similarities with alternative pathologies—for example, calcific myonecrosis and MO. As a result, a more broad, unifying condition is possible, and further reports of OIH will be needed to better classify these similar pathologies. Finally, the process of calcification and subsequent ossification in the setting of an intramuscular hematoma remains poorly understood. With reports of additional cases, continued histopathologic study may contribute to our understanding of the ossification process.The occurrence of an OIH is rare in the literature, and here we report the first case of an OIH within the paraspinal muscles, specifically the left erector spinae muscles of the thoracolumbar region. The patient was symptomatic due to location and size of the lesion and successfully treated with resection of the mass. She did well postoperatively without complications.There are few prior reports of calcified intramuscular hematomas, limited to one case report and one case series. The clinical, radiographic, and histopathologic findings among these lesions maintain important features in common. For example, a history of remote trauma, a calcified mass on radiographic workup, and evidence of an old, organizing hematoma with calcification or ossification on histopathology. However, commonalities between these cases and alternative calcified intramuscular pathologies reported in the literature persist, and further study may be needed to definitively classify calcified intramuscular pathologies.


Sarcomas are rare tumors arising from a variety of mesenchymal tissues which are even rarer in head and neck region amounting 1% only of the 5% of sarcomas. About 80% of head and neck sarcomas originate in soft tissue while the remaining 20% arise from bone . One among the commonly presenting variants of sarcomas in head and neck that our patient was diagnosed with is Low grade myofibroblastic sarcoma (LGMS). These even though uncommon have a predilection for head and neck region particularly the tongue . LGMS was reclassified as a distinct entity by the WHO classification of soft tissue tumors in 2002 . Oncological resection is the mainstay of treatment. In case of bulky tumor, resection and reconstruction would be challenging. We report a recurrent LGMS of 15-year-old girl who presented with a ginormous soft tissue swelling in her left neck region which made her day-to-day activities strenuous and made her non ambulatory and the line of treatment executed in order to get her back on feet, healthy & free of the debilitating tumor. A young adolescent girl presented to us with complaints of gradually increasing painful swelling with ulcer and bleeding from tumor surface in her left neck region which made her daily activities close to impossible with the amount of strain it caused along with restricting her movement and making her non ambulatory in spite of taking both surgical and medical line of treatment for the same over a course of 3 years.The first presentation of the swelling was reported way before the patient presented to us. First history of swelling in the same region was three years ago, for which she underwent excision at other hospital. Patient quickly encountered symptoms of local recurrence in the following months and underwent another surgery in 2018, wherein excision of the swelling was done & remained symptom free post that for a brief period only as she displayed symptoms of local recurrence yet again in the year 2020.The previous excision biopsy reported to be low grade myofibroblastic sarcoma. In view of small size and recurrent nature, she was started on metronomic chemotherapy and planned for reassessment. However, in view of COVID-19 pandemic, she defaulted and presented with bulky tumor. She has received hemostatic radiotherapy and palliative chemotherapy just prior to our consultation.She was bedridden in view of bulky tumor. On examination of the left cervical region, a 23 × 25 cm well defined fixed swelling with bleeding ulcer was noted with erythema in the surrounding skin Fig. a, b. TheOn investigation, MRI of neck Fig.  showed 2Following meticulous planning, the patient was planned for semi-emergency surgery in view of tumor bleeding following blood transfusion and optimization. The possibilities of R2 resection near external auditory canal, facial nerve paresis/palsy and ligation of left IJV was kept in mind and explained to parents. The first step of surgery was to dissect the carotid sheath. Left common carotid artery was dissected and freed. The external carotid artery was ligated. The dissection continued towards skull base by safeguarding internal carotid artery. Left IJV was ligated superiorly and inferiorly after getting control near skull base and supraclavicular fossa respectively. The posterior dissection started with adequate tumor free margin. The last part of surgery was at external auditory canal and mastoid area. We could not identify Facial nerve trunk separately from the tumor in view of large tumor size and previous surgery scar, which made dissection was difficult. Gross total resection was done and remaining soft tissue at middle ear area was completely removed by piece meal technique. Fig. a, b. TheOn postoperative day 3, she had sudden onset of massive bleeding at drain. She was taken to emergency operation room. On exploration, there was bleeding from lateral wall of carotid artery, which was repaired using 5–0 prolene sutures. Again after 2 days, she had one more episode of massive bleeding and was taken to emergency OR. This time, left common carotid artery was ligated. Postoperatively, Left tarsorrhaphy was done and facial muscle physiotherapy was started in view of facial nerve palsy. There were no neurological symptoms related to left carotid ligation and was discharged after 1 week.The final histopathology reported to be Low grade Myofibroblastic Sarcoma which showed spindle shaped cells in a sheet like and fascicular pattern with indistinct borders Fig. a, b.Fig.The patient thereafter received adjuvant radiotherapy and remains disease free at 24 months allowing her to carry out her daily activities which were compromised earlier due to the disease.LGMS is a malignant tumor of myofibroblastic origin occurring at submucosal and subcutaneous locations. These generally affect middle aged patients with an average age of 40 years but can affect any age group and has a male predominance . LMGS haA study by Yamada et al. , reporteEven though there’s no validated treatment protocol for this tumor and the local aggressive presentation, bleeding and the history of multiple local recurrences of this tumor in our patient may have been intimidating for the surgeon’s knife at first, we went ahead with the wide local excision of the tumor followed by adjuvant radiotherapy.Owing to the rarity of LGMS, the optimal treatment is still unclear. Like other soft-tissue sarcomas, LGMS is primarily treated with surgical excision . For patThe combination of surgical excision along with adjuvant radiotherapy instead of treating it only with palliative chemotherapy and radiotherapy improves not only the quality of life, but also ensures a better disease-free survival rate and keeps the recurrence at bay.To conclude, combination of wide excision and plastic reconstruction followed by adjuvant radiotherapy provide best possible disease-free survival and better quality of life in a patient with recurrent, giant Myofibroblastic Sarcoma of Neck.


Biphenotypic sinonasal sarcoma (BSNS) is a rare malignant tumour of the upper nasal cavity and ethmoid sinuses that presents predominantly in middle aged female patients and show a characteristic infiltrative and hypercellular proliferation of spindle cells that demonstrate a specific immunoreactivity. We present three cases with BSNS that had different presenting complaints, either sinonasal or orbital problems, underwent endoscopic surgical treatment and/or radiotherapy and have been disease free on long follow up. A systematic review of all published cases was performed to identify all BSNS cases known at present. BSNS requires prompt and correct diagnosis with accurate surgical resection as well as consideration of radiotherapy. Our three cases confirm the findings of the literature and support that BSNS is an aggressive but treatable malignant disease of the sinonasal tract. There is a wide variety of sinonasal tumours with multiple presentations, phenotypes and symptoms. Sinonasal malignancies are a diagnostic and therapeutic challenge due to histologic diversity and proximity to vital structures like the orbit, skull base, brain and cranial nerves. Biphenotypic sinonasal sarcoma (BSNS) is one of the rarest and slow growing soft tissue sarcomas that has been only described in the last decade . The morA thorough systematic review of the literature was conducted by two electronic databases Medline/Pubmed (1946–December 2022) and Embase databases (1947–December 2022) using the Ovid research tool. The research terms used were “biphenotypic”and “sinonasal” and “sinus” and “nasal” and “sarcoma” creating the MeSH terms respectively. A systematic review flowchart was created and followed to ensure coherence. Only 52 results were identified with the research terms described and abstract assessment led to inclusion of 27 articles that were either case reports or reviews of the existing literature. Studies or case reports that had doubtful results or did not confirm BSNS diagnosis were excluded from the search. Non English language articles were excluded from the search. Table We present a 52 year old lady that suffered with exophthalmos symptoms and was initially assessed by ophthalmology specialists. During her investigation process, she underwent a CT scan of her orbits and sinuses that revealed an ossified hard tumour extending from the sinonasal tract until the cribriform plate and into the orbit, pressing the rectus medialis and the orbital fat causing exophthalmos Fig. a, b. OffΑ 30-year old lady who presented with pressure symptoms of her orbit resulting in bulb protrusion without any other complaints. She underwent a CT scan of her orbits and sinuses that revealed a tumour in the maxillary sinus with orbital floor destruction and intraorbital extension Fig. a. PrimarThe third case is summarised in a 47 year old lady who presented with severe recurrent headaches as her main concern. She underwent a CT scan of her paranasal sinuses that revealed a mass extending in the middle meatus involving the orbit and the anterior skull base Fig. a. PrimarSinonasal tract tumours are neoplasms that affect mostly the sinuses, internal nasal cavities, orbits, skull base and in some cases can have intracranial extension. Common presenting symptoms are nasal obstruction, epistaxis, facial pressure or pain, smell impairment, as well as neurological or ophthalmic complaints due to the tumour’s extension , 26. In Biphenotypic sinonasal sarcomas were firstly discovered by Lewis et al. in 2012 , who desBSNS histopathological analysis reveals a spindle cell carcinoma that infiltrates the surrounding tissues including the nasal bones . It is mHowever, the important finding that determined the diagnosis was smooth muscle actin (SMA) and S100 positivity with EMA and CD34 negativity during the immunohistochemical analysis , 24. NorAX3-FOXO1, PAX3-MAML1, PAX3-MAML2, PAX3-NCOA1, PAX3-NCOA2 and PAX7-MAML3 are also observed. To make differential diagnosis more challenging, most of the above combinations exist in various sinonasal sarcomas such as the PAX3-FOXO1 and PAX3-NCOA1 that exist in rhabdomyosarcomas. However, the pathognomonic finding of PAX3-MAML3 fusion transcript is an adjunct towards BSNS diagnosis [Interestingly, it emerges from the literature that different combinations lead to various presentations of BSNS with characteristic tumour site or extension or even affecting the recurrent rates. In order to achieve such results though, more cases with genetic testing are required to gain safe and reliable information on how genetics affect clinical variations  [In terms of genetic analysis, PAX3 and MAML3 are genes involved in BSNS and their mutations may lead to different presentations of the disease or even different sinonasal mesenchymal tumours . MAML3 iiagnosis , 34. Intiations  . UnfortuRegarding treatment modalities, all cases in the literature were treated with surgical excision either endoscopic or open using craniotomy or lateral rhinotomy as an access point with or without adjuvant radiotherapy with some cases receiving chemotherapy as well Table . RecurreBiphenotypic sinonasal sarcomas are uncommon low-grade spindle cell carcinomas in the sinonasal tract that demonstrate positive myogenic and neural differentiation. The clinical importance of these tumours is summarised to their common symptoms in association with the non-specific radiological findings but their high local recurrence rates that makes the early diagnosis and full treatment critical. Additional radiotherapy should always be a consideration but individualised treatment according to clinicopathological features of the tumour is key. Treatment with radiotherapy is individualised and is supported by concrete criteria based on location of the tumour, intraoperative surgical margins, histopathological features and general condition of the patient. It is therefore crucial for the multidisciplinary team that consists of the ENT surgeon, radiologist and primarily pathologist as well as oncologist, to be aware of this sinonasal entity to correctly diagnose BSNS, avoid misdiagnosis and treat effectively and successfully the disease.


Here, we present a case series of four patients diagnosed with acute ischaemic stroke due to occlusion of the artery of Percheron (AOP), a rare stroke variant, observed in a single emergency centre within a three-month period. AOP occlusion is characterized by bilateral thalamic infarction with or without involvement of the mesencephalon. The presenting symptoms are diverse and not specific, but commonly include disturbance of consciousness, memory impairment, and vertical gaze palsy. In addition, due to the location of the infarction, imaging recognition is challenging and AOP occlusion often remains undiagnosed. This paper emphasizes the necessity of early recognition and appropriate management of AOP occlusion to significantly impact patient outcomes. Moreover, we argue that the condition might be more common than previously thought and that misdiagnosis or delay in diagnosis may lead to inappropriate treatment and potential failure to apply thrombolysis within the required timeframe. Even with the advancement of diagnostic and treatment options, acute ischaemic stroke (AIS) treatment is still based on prompt and correct clinical diagnosis. Compared to the anterior circulation, clinical presentation of AIS in the posterior circulation is much more diverse . In thisThe data about AOP prevalence are not well known. According to the post mortem examinations, AOP is present in approximately 10% of the adult population . HoweverHere, we describe four cases of AOP occlusion that were diagnosed in a single Neurology Emergency Department (NED) of a University Medical Centre within three months between March and June 2023, A 70-year-old male with a history of alcoholism and homelessness presented to the Internal Medicine Emergency Department (IMED) due to instability while biking. Electrocardiogram (ECG) showed a known atrial fibrillation (AF) with tachycardia (146/min), and he had elevated blood ethanol levels . He received saline infusion and was dismissed. The next day he was found in a local store, hypoglycaemic and somnolent with Glasgow Coma Scale (GCS) 7. At the IMED, his ECG once again showed AF with tachycardia (114/min). He had elevated ethanol blood levels  and mild hyponatremia (130 mmol/L). As the somnolence persisted until the next morning, a head computer tomography (CT) scan was performed, which showed chronic vascular leukopathy and two hypodensities in the right thalamus and right corona radiata. He was transferred to the NED, where he was somnolent and severely dysarthric with GCS 9. A repeated head CT showed hypodensities in bilateral medial thalami that extended to the anterior mesencephalon A, upper,A 74-year-old male with previous history of cognitive decline presented to the ED due to one week of general weakness. He was febrile (38.3 °C), tachycardic (103/min), and had mild infiltrative lesions on chest x-ray. Antibiotic treatment was started due to suspected pneumonia. Two days later, he was brought to IMED due to impaired consciousness, GCS 7. A head CT showed only older lacunar ischaemic lesions in the right thalamus, right putamen, and left internal capsule B, upper.A 73-year-old female was brought to the NED due to acute disturbance of consciousness, GCS 7. She was only reacting to painful stimuli without lateralization. Her ECG revealed an AF with normocardia. Blood work was unremarkable, but chest x-ray showed bilateral pleural effusion and atelectasis without inflammation. Head CT did not show any acute or subacute ischaemic areas C, upper;An 81-year-old male presented to the NED due to disturbance of consciousness. His symptoms began the previous evening with transient diplopia and gait instability. Next morning at NED (9 h after first presentation), he was somnolent, first reacting only to painful stimuli but later also to verbal command. ECG was normal. Head CT showed only older ischaemic lesions in occipital and parietal cortex and right lateral thalamus D, upper.In addition to the four presented cases, we conducted a search of head CT and MRI radiological reports from scans performed within the last 5 years (between 22 July 2018 and 22 July 2023) searching for the mention of AOP occlusion. We identified just six more patients with AOP occlusion that were treated at University Medical Centre Ljubljana (UMCL) in the preceding five years. Single cases were recognized in years 2018, 2020, and 2021, and three in 2022. In 2018, we treated 1 patient with AOP occlusion out of 1121 patients with AIS (1/1121 = 0.09%), as was the case in 2020 (1/1003 = 0.10%) and in 2021 (1/981 = 0.10%). In 2022, there were 3 cases with AOP occlusion out of 1056 treated AIS patients (3/993 = 0.30%). The estimated prevalence for the first half of year 2023 was 1.53%.In this paper, we presented four patients with AOP occlusion that were treated at our UMCL over a short course of three months. The patients had variable outcomes, highlighting the need for increased awareness and understanding of this condition. Misdiagnosis or delay in diagnosis can lead to missing the time window for the thrombolysis and inappropriate treatment. Through these cases, we aimed to emphasize that early recognition and appropriate management of AOP occlusion can significantly impact patient outcomes.Recognition of acute AOP occlusion is a clinical challenge. Non-specific symptoms can be explained by the different roles of the thalamus. The thalamus is a bilateral structure located between the brainstem and the telencephalon which plays an important part not just in relaying  but alsoVariability of the clinical presentation is also a consequence of variable arterial supply of the paramedian thalamic area. In 1973, Gerard Percheron described four variants , ®, San Mateo, CA, USA), VIZ CTP , e-Mismatch  or syngo.via , have the potential to improve diagnostic accuracy, they are still dependent on the position of the window. Whole-brain CTp can overcome that issue, but so far, it is also not widely available [In addition to variable clinical presentation, acute AOP occlusion also presents an imaging challenge. Similar to our case series, Flowers et al.  reportedvailable .Taken together, our cases as well as data from the literature suggest that a higher vigilance among neurologists, internal medicine physicians, and radiologists is necessary to recognize and appropriately treat these patients. Delayed diagnosis leads to missing the time window for thrombolysis and, thus, to possible worse outcomes. In our case series, only one patient (case 4) received thrombolytic treatment; however, his outcome was nonetheless poor. Of note, this patient received thrombolytic treatment several hours after initial symptom onset on the basis of DWI-FLAIR mismatch . The iniHere, we report four patients with AOP infarction seen within three months at a single UMC. The short time in which the cases presented highlights the possibility that AOP infarctions are more common than previously thought and the condition might be overlooked as the patients with disturbance of consciousness are not necessarily first referred to the Neurology Clinics. Additionally, as observed in all four cases, acute CT imaging can be unremarkable and targeted CTp or MRI should be used. Consequently, AOP infarction is diagnosed only by the follow-up CT or MRI when the changes are already irreversible or not at all.


Esotracheal fistula is a rare malformation represented by a thin ascending channel between the esophagus and the posterior surface of the trachea. Diagnosis is sometimes difficult due to the atypical character of the symptomatology. Diagnosis is made by a gastro-duodenal oesophageal transit (TOGD) and the treatment is surgical.We report a case of isolated congenital esotracheal fistula collected in the pediatric visceral and urogenital surgery department at the Mohammed VI University Hospital Center in Oujda, Morocco, previously not discovered, and its surgical treatment as well as an updated literature review of this entity. Isolated esotracheal fistula (ETF), without esophageal atresia, called H or N fistula is a rare congenital malformation, it represents approximately four percent of all esotracheal malformations. Early diagnosis of this condition is crucial for a better prognosis, even though it can be challenging to diagnose at times, and the treatment is surgical ,2. We prThis was a nine-month-old infant, who has received all recommended vaccinations to date. The history of the disease dates back to birth with recurrent choking episodes and bronchoalveolitis treated repeatedly with pain relief medication, antibiotics, and antitussives without improvement. The child was referred to pediatrics for suspected gastroesophageal reflux. Radiological studies are front chest X-ray with an esophagogastroduodenal transit (TOGD) was performed showing an isolated ETF Figure .Upon admission, the infant was conscious and tonic, with delayed growth and slight abdominal distension. Respiratory system examination, snoring sounds, and bilateral rales were noted, and the chest X-ray was unremarkable Figure .The infant underwent a preoperative bronchoscopy, revealing the fistula and its cervical location. A right transverse cervical incision was made, allowing for the resection of the fistula, suture of the esophagus tear, and trachea with muscular interposition Figure .The postoperative course was marked by the onset of respiratory distress on day 10 after oral feeding was started Figure .Clinical examination revealed a reddish cervical swelling with crepitation at the site of the cervical incision scar. Radiological testing showed a cervical emphysema bubble with a defect in the right lateral wall of the esophagus at the level of the first thoracic vertebra (D1), supplying a cervical-mediastinal abscess collection, and no identification of an ETF tract Figure .Fistula repermeation was observed, leading to the decision to redo the surgery. Intraoperative exploration revealed a purulent collection in contact with the esophagus with an occluded esophageal and tracheal fistula. Closure of the esophageal defect, drainage, and gastrostomy for feeding were performed.The second post-op course was uneventful, with feeding via gastrostomy without incident. At two months postoperatively, the follow-up TOGD showed no fistula, and oral feeding was started Figure .At the four-month postoperative follow-up, the infant was found to be normal, with appropriate weight, no respiratory signs, and the gastrostomy spontaneously closed.The H-type fistula embryologically represents the least severe form of laryngotracheoesophageal clefts. Its incidence is estimated to be between one in 50,000 and one in 80,000 live births. It is the result of incomplete development of the tracheoesophageal septum between the fourth and eighth week of gestation. Genetic, environmental, and teratogenic factors are believed to play a role -4.Associated malformations are common and similar to those observed with esophageal atresia, and sometimes are part of the VACTERL syndrome. The site of the fistula is usually cervical, and it connects the esophagus and trachea in an ascending pathway from back to front, with a short caliber of a few millimeters ,2,5.The pathognomonic clinical signs consist of a triad that includes coughing during feeding, abdominal distention, and recurrent pneumonia. This triad is rarely completely described. Only coughing and choking while drinking are consistently observed. The diagnosis is made in 80% of cases before the age of one year, but it can be challenging and delayed. The differential diagnosis is made with other causes of recurrent lung infection, such as gastroesophageal reflux, cystic fibrosis, bronchial dilation, intra-bronchial foreign body, and laryngeal cleft ,2,4,6.The definitive diagnosis relies on direct visualization of the fistula by contrast radiography. A kinetic study by cineradiography is currently the most recommended ,3,4. RepCurrently, the complementary technique that is unanimous is tracheoscopy, which some authors couple with esophagoscopy. During this exam, methylene blue can be injected into the esophagus to see if it appears in the trachea. Finally, endoscopy allows for catheterization of the fistula, which will guide the surgical procedure -4,6,8.The treatment of H-type fistulas is surgical. The cervical approach is always preferable for fistulas located above D2. The thoracic approach is reserved for those close to the carina ,2.Preoperative catheterization of the fistula under tracheoscopy makes its identification easy and allows for minimal dissection, some authors propose muscle-aponeurotic interpositions between the esophagus and trachea, such as pleural tissue, sternocleidomastoid muscle, thyroid muscle, thymic tissue, rectus abdominis muscle, and pericardium -4,6,9-12Postoperative morbidity can be significant, including usually transient recurrent laryngeal nerve palsy, tracheomalacia, atelectasis, fistula recurrence, and, most notably, digestive problems such as gastroesophageal reflux, motility disorders, and esophageal stenosis ,2,4,7.Fistula recurrence is a rare but serious complication. It is more likely a missed fistula during the initial surgery. Catheterization of the fistula by tracheoscopy and muscle interposition plasty can reduce this risk ,9,10,12.Esophageal tracheal fistula is a rare malformation. The diagnosis should be considered in the presence of respiratory symptoms occurring during feeding, particularly in the neonatal period. If clinical evidence suggests this abnormality, complementary investigations should confirm it and may need to be repeated. Bronchoscopy can provide initial assistance with the diagnosis and prepare for surgical intervention.


Tension pneumoperitoneum is a vapid presentation of pneumoperitoneum, which generally refers to free air in the abdomen and can mimic abdominal compartment syndrome. A diastatic perforation in the abdomen refers to a perforation of the cecum due to a distal obstruction in the colon, manifesting as a closed-loop syndrome. We present a 46-year-old male diagnosed with obstructed left inguinal hernia who underwent hernioplasty. Postoperatively, the patient had progressive abdominal distention and abdominal pain. An abdominal x-ray and computed tomography of the abdomen showed massive air in the abdomen. The patient was diagnosed to have tension pneumoperitoneum. Needle decompression of the abdomen was done, and the patient underwent an emergency laparotomy. Intraoperatively, we found a large cecal perforation and a large amount of pneumoperitoneum. The patient underwent limited resection and ileostomy and ascending mucus fistula. Postoperatively, the patient had an uneventful course and was discharged. Tension pneumoperitoneum is an uncommon, life-threatening form of abdominal compartment syndrome that generates intra-abdominal pressures high enough to compromise vascular flow and cause systemic homeostatic destabilization . It has A 46-year-old male presented with abdominal distension, abdominal pain, and obstipation for four days. The patient also gives a history of the irreducibility of the left inguinal hernia for four days, which was present for the last 10 years. The patient did not have similar complaints in the past. The patient was conscious and oriented, with a pulse rate of 106 beats per minute and blood pressure of 140/90 mm of Hg. Abdominal examination showed a distended abdomen without any tenderness. Bowel loops were palpable. Left inguinal examination showed the presence of an irreducible left inguinal hernia without significant local tenderness.All routine blood investigations, including renal function tests and renal function tests, were done and were normal except for the mild leucocytosis. Abdominal x-ray showed significantly dilated large and small bowel loops Figure .The patient was diagnosed with obstructed inguinal hernia and was taken up for immediate surgical exploration. Inguinal exploration was done, and it was found to contain a sigmoid colon. There was no evidence of strangulation of the bowel. Hence, the bowel was reduced, and a left inguinal hernioplasty was done.The patient complained of abdominal pain and progressive distension on a second postoperative day. The patient had multiple fever spikes. There was no history of decreased urine output or dyspnea. The patient had a pulse rate of 120 beats/min, a respiratory rate of 20 cycles per minute, and a blood pressure of 100/80 mm of Hg. Abdominal examination showed a distended and diffusely tender abdomen with rigidity. Abdominal x-rays showed massive air under the diaphragm (Figure CT of the abdomen showed a massive pneumoperitoneum with significant fat stranding along the right iliac fossa Figure .The patient was taken up for immediate exploratory laparotomy. Intraoperatively, we found 200 ml fecopurulent fluid and a 3 cm x 2 cm perforation in the posterior wall of the cecum with necrotic margins with inflamed cecum and distal ileum. Limited resection of the cecum and distal ileum with covering ileostomy and distal ascending colon mucus fistula was done Figure .The postoperative period was uneventful, and he was discharged after one week.Perforation of an over-distended, disease-free cecum due to an obstructing lesion in the distal colon is called diastatic perforation. The pathophysiology associated with this phenomenon obeys the Laplace law, which causes the circumference of the gut to increase by three times in comparison to the diameter . This leRegarding pathophysiology, diastatic perforations are theorized to occur by two main mechanisms. Malignant causes lead to direct perforation resulting from tumor necrosis, and benign ones usually form a closed-loop obstruction from a competent ileocecal valve. Cecal perforations are primarily found on the anterior longitudinal axis with sharp uninflamed margins, with other common sites being hepatic flexure, splenic flexure, and the descending colon . ClinicaMost cases of such colorectal perforations usually present with classical clinical signs with radiological imaging showing characteristically air under the diaphragm. In suspicious sealed-off perforations, CT abdomen will demonstrate collection, significant fat stranding, or mass formation. Symptoms and signs are outright, which makes the diagnosis evident and easy to tackle. However, in our case, the developing symptoms of closed-loop syndrome from the obstructed hernia and the initial absence of a florid picture of perforation led to a delayed diagnosis. Risk factors heralding the progression from ischemia to a frank perforation, as would have been in our case, depending on a cecal diameter of more than 9 cm, a long-standing dilatation, and an intraluminal pressure of more than 80 mm of Hg tethered by a predisposing closed loop syndrome .Tension pneumoperitoneum is a rare form of abdominal compartment syndrome. It occurs due to the entrapment of a large amount of intraperitoneal air within the abdomen, which increases abdominal pressure. Patients may develop decreased venous return, tachypnoea, bradycardia, decreased urine output, and mesenteric ischemia. Tension pneumoperitoneum as presenting symptom of a diastatic perforation has never been reported in medical literature as per our research. In contrast, most have been seen to be secondary to hollow viscus perforation. Usually, with frank peritonitis and shock-like features, the patient's course is too short for free air to collect inside the abdomen and create significant tension. The most commonly reported causes of tension pneumoperitoneum include complications from gastrointestinal endoscopies, trauma, improper intubation, and scuba diving . In addiPatients usually present with an overtly distended abdomen in refractory shock due to cardiorespiratory collapse, florid acute kidney injury, hypotension, and tachycardia. Prompt diagnosis in the form of an abdominal x-ray showing the saddle sign or centralization of the bowel, or in cases of doubt, contrast-enhanced CT helps clinch the diagnosis. In our case, an abdominal x-ray and a plain abdomen CT sufficed in establishing the diagnosis.Tension pneumoperitoneum is a surgical emergency with emergency laparotomy as the best and definitive treatment modality. If the patient is too unstable for the definitive procedure or anesthetic induction, temporary measures with needle decompression or intra-abdominal drain placement can help mitigate the hemodynamic instability and ventilatory impedance. However, it is also associated with its own risk as a stealing phenomenon . In our Although reported, the combination of tension pneumoperitoneum and a hollow viscus perforation is a rare presentation due to florid clinical signs before its development. In addition, tension pneumoperitoneum in a case of diastatic perforation was never reported, which makes the diagnosis difficult. As tension pneumoperitoneum has lethal outcomes, clinicians should be aware of such scenarios. Patients who have been diagnosed to have tension pneumoperitoneum need urgent surgical intervention.


Camptodactyly is a relatively rare hand deformity presenting as the proximal interphalangeal joint’s nontraumatic and progressive flexion contracture. Most cases are limited to the fifth finger. The severity and type of camptodactyly should be considered to optimize treatment. Since many structures at the finger base can be involved in the pathogenesis of the deformity, surgical treatment for this particular type of deformity is challenging. This paper aims to bring insight into camptodactyly’s pathogenesis and treatment options. We discuss the indication and pitfalls of surgical treatment options for particular camptodactyly types and present a case of a fourteen-year-old boy who was admitted to our department with proximal interphalangeal joint flexion contracture of the left fifth digit. Camptodactyly is a nontraumatic and progressive flexion deformity that most commonly affects the proximal interphalangeal joint (PIPJ) of the fifth finger and may or may not include the other fingers, while the first finger is always spared ,2,3,4. IThe primary cause of camptodactyly is still discussed ,8,9. AbnFrom a clinical point of view, Siegert et al.  divided Type I (infantile) is the most typical form. The little finger is most often affected, and cosmetic complaints are more common than functional impairments.Type II (adolescent) occurs predominantly in females between the ages of seven to eleven years. Clinically, it resembles type I, with subtle initiation and progressive evolvement.Type III (syndromic) camptodactyly is present from the time of birth. It usually affects multiple fingers; bilateral deformities with severe fixed contractures are constant. Syndromic camptodactyly causes more discomfort than infantile and adolescent types.(gemmae membrorum) and is finished by the 8th week. The upper limb emerges as an outgrowth of the somatic lateral plate mesoderm and somatic mesoderm between the 9th and 10th somite in the presumptive upper limb-forming field [, essential for limb development in the proximo-distal axis. The limb patterning occurs in two other axes, namely the anteroposterior originating from the zone of polarizing activity and the dorsoventral axis. Each depends on a specific gene expression sequence. The proximo–distal, anterior–posterior, and dorso–ventral axes are predominantly controlled by the fibroblast growth factor, sonic hedgehog, and Wnt signaling pathway, respectively [(lamina manus) formation/differentiation failures in an unspecified axis. The exact mechanisms behind dorsoventral and digit-specific ligament/tendon formation have been long under-researched. A gene encoding proteoglycan 4 (PRG4 gene) has been thought of as the candidate gene responsible for this flexion-contraction disorder, but a more in-depth analysis providing deeper insights into the pathogenesis of this condition has been lacking [PRG4 gene mutations, leading to the development of camptodactyly-arthropathy-coxa vara-pericarditis (CACP) syndrome. In the most recent 2023 paper, Bağrul et al. [PRG4 mutation can be behind the condition. The pathogenesis of CACP syndrome has been linked to the defective PRG4 product called lubricin, found in the synovial fluid, cartilage surface, and tendons, which, besides its lubricating function, is also responsible for cell growth regulation. To make the issue even more complicated, some authors estimate that camptodactyly occurs as a feature within more than 50 different conditions [From the embryological perspective, limb development is a highly complex and tightly orchestrated process which starts around Day 26 (4th week) after fertilization as limb buds ng field . The groectively ,16. The ectively . The con lacking . In recel et al.  corroborHistorically, conservative treatment has been the first choice of camptodactyly management ,21,22,23It is generally accepted that surgery should be reserved for failed cases of nonoperative management, where a fixed 60-degree flexion contracture of PIPJ has been reached ,9,24,25.A fourteen-year-old boy was admitted to the outpatient clinic with PIPJ flexion contracture of the left fifth digit. There was no history of hand injury. The X-ray showed 60° flexion PIPJ contracture without bone changes .Clinically, the 60° extension deficit of PIPJ was nonreducible during passive manipulation. There was no deficit in PIPJ flexion, distal interphalangeal, and metacarpophalangeal joint motion. No sign of other hand deformity was present. The diagnosis of the established, rigid form of simple adolescent camptodactyly was set. Due to the extent of the deformity and unsuccessful nonoperative management, our patient was indicated for surgical treatment.A transverse incision was made in the distal palmar crease. The flexor digitorum superficialis (FDS) was located in low-quality tissue and released as distal as possible by flexing the digit . BecauseThe aim was to release any tethered structures, lateral bands, and lumbrical insertion. After releasing all structures, a full extension was reached by gentle passive manipulation . The skiThe pathogenesis of camptodactyly is not clear ,8,9. AltThe problem with camptodactyly management is that several types and forms of presentation exist, which means there is no single model for effective treatment. Generally, flexion deformities of less than 30 degrees do not interfere with daily life. On the other hand, more than 60 degrees contractures diminish function and require surgical treatment. Almeida et al. , in theiThe approach to deformities between 30 to 60 degrees differs. Many studies have demonstrated success with conservative management ,22,23. UIn our fixed, established adolescent camptodactyly case, a simple release of FDS was not enough to reach full contracture correction. A full extension was achieved after the abnormal lumbrical insertion, and the lateral bands were released, followed by gentle passive manipulation. Although we consider the pathology of FDS as the most common in camptodactyly pathogenesis, addressing any other abnormalities is crucial. These include abnormal lumbrical origin and insertion, volar skin deficits, secondary changes, such as adhesions of the dorsal apparatus and lateral bands, a deficient dorsal central slip extensor mechanism, volar plate contracture, and tightness of the collateral ligaments. This notion agrees with the findings of the retrospective multi-centre study of 59 surgically treated patients presented by Corain et al. . They coIn cases of syndromic camptodactyly, a distinctive view of the surgical treatment occurs. A one-stage extension shortening osteotomy of the proximal phalanx has shown promising results. The Korean authors considered the extension osteotomy a straightforward and effective technique for improving finger function through the indirect lengthening of volar structures without the flexor tendon lengthening. The authors highlighted the suitability of this simple procedure for surgery on multiple fingers in patients with syndromic camptodactyly .Camptodactyly remains a puzzling condition. Although its embryological background and exact etiopathogenesis are poorly understood, the conservative and surgical approaches yield favorable results. Our case report demonstrated that a full correction could be achieved when an appropriate surgical procedure is chosen. However, the main pitfall is the heterogeneity of its presentation, preventing the routine application of a single best surgical model.


Transdiaphragmatic intercostal hernia is a rare disease. It is usually caused by trauma and is rarely caused by coughing. Although a few cases of intercostal hernia induced by coughing have been reported, our case of a non traumatic acquired acute transdiaphragmatic intercostal and abdominal hernia induced by coughing is very rare. A 77-year-old woman presented with sudden-onset left lower chest pain after an episode of violent coughing. She had risk factors for intercostal hernia, including obesity, chronic obstructive pulmonary disease, oral steroid use, and diabetes mellitus. Computed tomography showed herniation of the lung and intra-abdominal organs into the thoracic and abdominal wall through a ruptured diaphragm, as well as the intercostal and abdominal muscles. Surgery was completed with interrupted sutures to close the defects after the reduction of the herniated organs. Our experience suggests that careful examinations, including the assessment of risk factors and computed tomography imaging, were essential for establishing an accurate diagnosis, and that the repair of a ruptured diaphragm with simple interrupted sutures without any prosthetic materials seems to be feasible in selected patients with a transdiaphragmatic intercostal hernia. Dear Sir,Recently, an unusual case of transdiaphragmatic intercostal hernia (TDIH) with delayed onset and history of blunt trauma incurred in a high-speed motor vehicle accident has been reported . TDIH is9/L) and serum creatine phosphokinase . CT showed herniation of the basal portion of the lower lobe of the left lung and intra-abdominal organs, including the stomach, left colon, and mesenteric fat, into the thoracic and abdominal walls through the ruptured diaphragm, as well as the abdominal and ninth intercostal muscles (Fig. A 77-year-old obese woman with a history of long-term steroid use for asthma and diabetes mellitus presented with sudden-onset left lower chest pain after an episode of violent coughing. She had no history of blunt trauma to the chest or abdomen. Physical examination revealed soft tissue bulging on the left lower chest wall. The chest wall exhibited ecchymosis. The laboratory results showed increased levels of white blood cells (11.80, 4.0–10.0 × 10TDIH is commonly caused by trauma involving motor vehicle accidents, and it may be diagnosed during admission to the emergency department . MohandaAlthough a few cases of cough-induced intercostal hernia have been reported –7, our cThere are several surgical options for the treatment of TDIH including primary closure, using mesh, and closure with prosthetic or autologous material . In acutIn summary, we encountered a rare case of an extensive transdiaphragmatic intercostal and abdominal hernia without a trauma history to the thoracoabdominal wall, with the sudden onset of symptoms after an episode of violent coughing. Through our experience, we would like to emphasize that careful examinations, including suspicion based on symptom history, the assessment of risk factors, physical examination, and CT imaging, are essential for establishing an accurate diagnosis of spontaneous TDIH and that the repair of a ruptured diaphragm with simple interrupted sutures without any prosthetic materials seems to be feasible in selected patients with a TDIH.


Retained products of conception (RPOC) are frequently associated with previous cesarean section (C-section), abortion, and intrauterine operations, which may affect subsequent pregnancies. A 38-year-old female had a history of C-section and two abortions. After the second abortion, she underwent evacuation of RPOC and was treated with uterine artery embolization (UAE) and hysteroscopic resection. She became pregnant again and vaginally delivered an infant at full term. After delivery, RPOC was suspected on magnetic resonance imaging (MRI), but the patient was discharged for follow-up. She was rehospitalized with a diagnosis of infection and a placental remnant. Antibiotics did not improve the infection; therefore, she underwent a total hysterectomy. After the operation, signs of infection rapidly improved. The pathological diagnosis was placenta accreta. This case was considered a high-risk group for RPOC. In such rare and complicated cases, it is important to consider the possibility of recurrent RPOC and provide sufficient explanations before delivery for subsequent intensive management. Retained products of conception (RPOC) depict a condition where pregnancy tissues, such as chorionic tissues, remain in the uterine cavity after delivery or abortion. They represent causes of postpartum hemorrhage and intrauterine infection, occurring in 1% of all deliveries , but varA 38-year-old female with a history of C-section owing to cephalopelvic disproportion had two miscarriages in one year, five years after the C-section. The first miscarriage occurred at seven weeks of gestation, for which she underwent suction curettage. The second one was a spontaneous miscarriage at eight weeks of gestation, which resulted in her visiting our emergency room because of massive bleeding. Ultrasonography revealed placental remnants with abundant blood flow in the uterus; magnetic resonance imaging (MRI) to consider the treatment also revealed a tissue mass size, 20×16×27 mm) in the uterine cavity, and RPOC was diagnosed  on day 2 postpartum was 4.8 g/dL, she needed a blood transfusion. MRI examination on the third day of puerperium helped diagnose retained placenta owing to placenta accreta rather than placenta percreta  and fever persisted. PAS, the cause of RPOC in this case, is a condition in which the villi invade the uterine myometrium, and part or all of the placentae adheres to the uterine wall, thereby preventing normal placental separation after delivery. The prevalence of PAS has been increasing yearly and is currently reported to be between 0.13% and 0.18% . Miller Conversely, hysteroscopic surgery is an endoscopy-guided surgical procedure, which facilitates the excision of the remnant locally while arresting the bleeding by electrocoagulation. The amount of intraoperative bleeding is also minimal in hysteroscopic surgery; however, the rate of intrauterine adhesion after surgery is 7%-10%, which is lower than that in intrauterine curettage ,7. BasedAlthough the treatment of choice should be considered according to the request of the patient, UAE is performed prophylactically at our hospital if RPOC with abundant blood flow is suspected on MRI or ultrasonography, and hysteroscopic surgery is performed after blocking the blood flow. In the present case, although the long diameter of the mass was small, about 2 cm, there was significant vascularity in the RPOC. Radiologists were consulted, and UAE and hysteroscopy were performed. The patient had a history of cesarean section and intrauterine procedures and was at risk for placental abnormalities and recurrent RPOC. We explained these potential complications and allowed her to conceive after RPOC treatment. Fortunately, she delivered the infant vaginally after treatment, but because this was the second RPOC and was complicated by an adherent placenta and bacteremia, we had to opt for a total hysterectomy. Considering the invasive nature of the procedure, laparoscopic surgery should have been chosen. However, since the patient was in the process of uterine restoration and intra-abdominal infection was suspected, we suggested that an abdominal total hysterectomy would be a better treatment. While the intrauterine procedure is an effective treatment for RPOC and can protect the possibility of pregnancy, it can also pose various risks to subsequent pregnancies. Therefore, in selecting and agreeing on a treatment for RPOC, it is imperative to present the expected complications in subsequent pregnancies.Despite the good progress of pregnancy after RPOC, it increases the complications from remnants of the placenta during the third stage of labor. In our hospital, we sometimes combine UAE and hysteroscopy for RPOC. Recently, hysteroscopy has been reported in most cases, and UAE is regarded as a safe and effective procedure to control blood flow. However, UAE might affect the endometrium in the future. Therefore, the advantages and disadvantages of treatment options should be considered. Investigating vascularity with color Doppler and undergoing UAE for cases of massive bleeding are crucial. In the case of various risk factors of pregnancy and deliveries, such as this case, we reconsider methods of examinations and timing of policy decisions and would like to make use of this experience in future cases.


Lymphocytic esophagitis (LyE) is a rare diagnosis made on esophageal biopsy whose pathogenesis is poorly understood. Since its appearance in the literature 15 years ago, it still remains an enigma due to its low prevalence. In this case report, a 71-year-old male presented with an episode of acute dysphagia due to food impaction. Urgent endoscopy was performed to fragment the food bolus. Repeat endoscopy showed a stricture, and lymphocytic esophagitis was found on esophageal biopsy. A proton pump inhibitor (PPI) was initiated with symptomatic improvement. With its increasing prevalence, lymphocytic esophagitis should be on the differential for causes of dysphagia. Esophagitis is a common disorder with many different etiologies, including reflux; infectious; eosinophilic; and, most recently, lymphocytic types. Lymphocytic esophagitis (LyE) is an emerging, yet not well understood, condition that shares certain features with gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) . All thrHelicobacter pylori testing was negative. No stricture was noted in the esophagus. Repeat EGD was performed eight weeks later, and a distal esophageal stricture was noted and was dilated with a balloon dilator to 15 mm. Biopsies taken of the proximal and distal esophagus showed squamous mucosa with features of lymphocytic esophagitis. The patient was placed on omeprazole twice daily and reported the improvement of his symptoms and the resolution of dysphagia at one-week and six-month follow-ups. The patient reported compliance with omeprazole. One month later, a barium swallow was completed that showed no recurrence of esophageal stricture  was performed, which showed a large food bolus at the distal esophagus/gastroesophageal (GE) junction. This was fragmented and pushed distally into the stomach by Roth Net . Several ulcers were present in the lower esophagus, and biopsies taken from the gastroesophageal junction and stomach showed mild erosive gastropathy and intestinal metaplasia without dysplasia.  Figures .Lymphocytic esophagitis was first described in the literature by Rubio et al. in 2006 . In one There have been several retrospective studies on lymphocytic esophagitis, although these were of low power due to the rarity of the disorder. Of these studies, 52%-63% of those affected were females with the median age of diagnosis being 51-56 years [Lymphocytic esophagitis is distinguished by the presence of a lymphocytic infiltrate on biopsy, usually with greater than or equal to 20-40 intraepithelial lymphocytes per high-power field with only rare neutrophils or eosinophils . Other cAppearance on the endoscopy of lymphocytic esophagitis is highly variable and ranges from normal-appearing mucosa in 21%-30% of the time to anomalies such as esophagitis in 16%-33% of patients and esophageal rings in 19%-30% of patients .The pathogenesis of LyE is not well known. Some infer that the presence of lymphocytes is due to an inflammatory process . One stuIn regard to treatment, many of the modalities used in GERD have been utilized, especially proton pump inhibitors (PPIs). The treatment of lymphocytic esophagitis includes symptomatic management such as proton pump inhibitors, swallowed topical steroids, and endoscopic dilation ,10. In oThis case illustrates a case of dysphagia and food impaction with underlying lymphocytic-predominant esophageal pathology. Due to the rarity of this condition, the pathogenesis and evidence-based treatment have yet to be discovered. Increasing prevalence brings increasing recognition on esophageal biopsy, which could illicit a unique pathophysiology of lymphocytic esophagitis and therefore an optimal treatment strategy.


Gastric schwannomas (GS) are rare, slow-growing, benign subepithelial (SE) lesions of the stomach. These are difficult to differentiate preoperatively from other types of SE lesions, as the gross appearance and clinical presentation are very similar especially the gastrointestinal stromal tumors (GISTs), which are the most common SE lesions of the stomach. We present the case of a 35-year-old Asian man with a one-month history of intermittent, right, upper quadrant pain and hematemesis. Preoperatively, intravenous contrast-enhanced computer tomography scan (CECT) showed a well-circumscribed lesion in the upper abdomen closer to the stomach’s lesser curvature. Endoscopic ultrasound revealed an ulcerated subepithelial lesion and subsequent biopsy with a 22-gauge fine-needle biopsy (22G FNB) needle confirmed the diagnosis of GS. The patient underwent distal gastrectomy and a Bilroth 1 procedure. The postoperative biopsy was consistent with the initial one, therefore supporting the diagnosis of gastric schwannoma. Postoperatively, the recovery remained uneventful. Gastric schwannomas are mesenchymal tumors derived from the nerve plexus of the gastrointestinal (GI) tract; they are one of the several types of spindle cell tumors that can be encountered in the GI tract. The other spindle cell tumors include GISTs, leiomyosarcoma, inflammatory fibroid polyps, solitary fibrous tumors, and inflammatory myeloblastic tumors . Among tA 35-year-old Asian man presented in an outpatient gastroenterology clinic in April 2022 with no known comorbidities. He had a one-month history of intermittent right upper quadrant pain and hematemesis. Initial labs included a normocytic normochromic profile on a complete blood count sample with a hemoglobin of 12.8 g/dl  and a hematocrit of 38.5 % . His prothrombin time and international normalized ratio (INR) were within normal limits. However, he had a history of three units of packed red blood cell transfusions, as his hemoglobin levels had dropped to 6 g/dl one month ago.Therefore, imaging was advised and CECT abdomen was performed. It suggested a well-circumscribed, lobulated, enhancing lesion in the upper abdomen closer to the lesser curvature of the stomach and the pancreatic body Figure . EndoscoA biopsy was performed using the 22G fine-needle biopsy (FNB) needle. The microscopic examination of the resected stomach mass confirmed linear cores of spindle cells arranged in sheets with abundant collagenized stroma Figure . MoreoveSubsequently, this patient was admitted under the surgery team and underwent distal gastrectomy and the Bilroth 1 procedure. The intraoperative findings included a 4x4 cm tumor at the posterior surface of the left curvature of the stomach with no gross ascites, serosal, peritoneal, or hepatic metastasis. The postoperative time was uneventful, and the patient was discharged on the sixth postoperative day. During his follow-up after one month, he was absolutely asymptomatic. The final biopsy confirmed the diagnosis of a gastric schwannoma, as the histopathology report and immunohistochemical stains remained the same on testing.Gastrointestinal tumors are unique mesenchymal neoplasms; they display salient variations from the typical schwannomas, occurring in the soft tissues and central nervous system . FurtherGrossly, schwannomas appear as rubbery, uniform, homogenous, unencapsulated, and yellow-white to tan circular nodules . HistoloImmunohistochemically, gastric schwannomas have some common features. These include positive S100 protein and SOX 10 and negative or only locally positive CD34 and DOG-1 . All of Management includes endoscopic and surgical resection. Endoscopic resection is preferred when the lesion is small (less than 2 cm), arises from the submucosa or muscularis propria, and is located on the greater curvature or anterior wall of the stomach. Other features that favor endoscopic therapy include non-ulcerated and protuberant morphology . LesionsIn conclusion, a gastric schwannoma is a slow-paced, rare SE mesenchymal tumor of the gastrointestinal tract; its gross appearance, radiological features, and clinical presentation resemble GISTs, which makes it challenging to diagnose it preoperatively. Despite the similarity in clinical and radiological manifestations, the prognosis between the two lesions is different, as GISTs can progress to malignant lesions in some cases while schwannomas are almost always benign. Hence, it is imperative to include it in the differentials of subepithelial lesions by confirming the diagnosis with biopsy and immunohistochemical stains.


Accessory splenic tissue is a commonly encountered phenomenon in medical literature. Typically, these accessory spleens are found in close proximity to the main spleen, either in the hilum or within the surrounding ligaments. Nevertheless, it is noteworthy that they can also be located in unusual sites such as the jejunum wall, mesentery, pelvis, and, exceptionally rarely, the scrotum. The first documented case of accessory splenic tissue in the scrotum was reported by Sneath in 1913 and is associated with a rare congenital anomaly called splenogonadal fusion. This report describes an infant who presented with a scrotal mass noted by his mother and after examination, investigations, and surgical exploration, it was revealed to be splenogonadal fusion.An 8-month-old Caucasian male patient presented with a mass in the left testicle and bluish discoloration of the scrotum, which had been incidentally noticed in the previous 2 months. The general physical examination was unremarkable. Other than a palpable scrotal mass that was related to the upper pole of the testis, the rest of examination was unremarkable. Imaging revealed that this mass originated from the tail of the epididymis without infiltrating the testis and tumor markers were normal. On inguinal exploration, a reddish brown 2 × 2 cm mass was found attached to the upper pole and was completely excised without causing any harm to the testis, vessels, or epididymis. Histopathological evaluation confirmed the presence of intratesticular ectopic splenic tissue.Although uncommon, splenogonadal fusion can be included in the differential diagnosis of a testicular swelling. Accurate diagnosis allows for appropriate treatment planning which helps to avoid unnecessary radical orchiectomy, which can have a significant impact on the patient’s reproductive and psychological wellbeing. Accessory splenic tissue is a commonly encountered phenomenon in medical literature. According to Lubarsch, the presence of accessory spleens should be acknowledged as part of the normal adult anatomy due to their frequent occurrence in routine biopsies, with incidences ranging from 2% to 35% . TypicalThe first documented case of accessory splenic tissue in the scrotum was reported by Sneath in 1913 and is associated with a rare congenital anomaly called splenogonadal fusion (SGF). This anomaly involves an abnormal attachment of the spleen to a gonad . The disLe Roux and Heddle expressed the view that the latter type was merely a rare variation of an accessory spleen . They alDiagnosis typically occurs when the condition manifests as a testicular mass or is incidentally discovered during ultrasonography, orchiopexy, or inguinal hernioplasty. Having knowledge of this clinical condition can help to avoid unnecessary orchiectomies by enabling the separation and preservation of the testis while excising the lesion.While SGF typically manifests in childhood, there have been reported cases in adults. Preoperative diagnosis of this condition can be challenging due to inconclusive imaging results, leading to several reported cases being managed with radical orchiectomy. It mimics certain pathologies, making the differential diagnosis clinically relevant.Here, we present a case of SGF resembling a testicular tumor. Treatment approaches vary from no intervention required to extensive surgeries, underscoring the importance of considering the possibility of an accessory spleen, even if solely to rule out serious pathology.An 8-month-old Caucasian male patient visited the pediatric surgery outpatient department with a complaint of a mass in the left testicle and bluish discoloration of the scrotum, which had been incidentally noticed in the previous two months.The general physical examination was unremarkable. Upon local examination, a palpable mass was detected in the left scrotum, attached to the upper pole of the testis, with a normal texture. Routine blood tests, renal function tests, and liver function tests yielded normal results. Tumor marker levels [alpha-fetoprotein (αFP) and human chorionic gonadotropin (βHCG)] and lactate dehydrogenase (LDH) were within the normal range.Abdominal ultrasonography revealed normal liver, spleen, gallbladder, and kidneys. Scrotal sonography identified a well-defined hypoechoic lesion measuring approximately 2 × 1.3 cm  is a rare, benign, congenital abnormality characterized by ectopic splenic tissue found in the scrotum . The firThe diagnosis of SGF can be challenging, as it often mimics other testicular pathologies . ImagingInterestingly, some radiologists have suggested that the use of Doppler ultrasonography can possibly aid in the preoperative differentiation of SGF and testicular malignancies by identifying aberrant blood supply to the fused tissue . It is iThe surgical approach for SGF can vary depending on the location of the ectopic splenic tissue and the involvement of adjacent structures, as well as the presence of symptoms. In asymptomatic cases or those in which the size of the mass is small and unlikely to cause complications, a conservative approach with close monitoring may be appropriate. In our case, due to the size of the mass and the presence of symptoms, the patient underwent left inguinal exploration, and the mass was completely excised without causing harm to the testis, vessels, or epididymis.et al. have described a two-stage laparoscopic staged Fowler–Stephen orchiopexy and suggest it as a surgical option to be performed in cases where routine single-stage orchiopexy is not feasible [It is worth mentioning that there is no standardized approach to the surgical management of SGF due to its rarity and limited number of reported cases. Treatment decisions are often made on a case-by-case basis, taking into consideration factors such as the patient’s age, symptoms, tumor characteristics, and surgical expertise. Several studies have used an orchidopexy approach to manage SGF, and Chen feasible . The preBroadly speaking, the rarity of occurrence of SGF is a major contributing factor to the lack of awareness surrounding the case. An understanding of SGF is of utmost importance due to its potential to mimic other testicular pathologies and the implications it has on patient management. Accurate diagnosis allows for appropriate treatment planning which helps to avoid unnecessary radical orchiectomy, which can have a significant impact on the patient’s reproductive and psychological wellbeing. Continued research efforts are necessary to improve understanding of this rare condition, as well as to establish standardized diagnostic and treatment protocols.Accessory splenic tissue in the scrotum is an important consideration when evaluating testicular masses. Its presentation as an asymptomatic testicular mass can easily be misdiagnosed as malignancy, despite its normal characteristics indicating its benign nature. Preoperative laparoscopic assessment can prevent unnecessary radical orchidectomy. However, in cases where salvage is performed for cryptorchidism, surveillance is advised to detect potential future malignancies. Increased awareness of this condition facilitates prompt diagnosis, reducing the likelihood of unnecessary orchiectomies.


Osteochondroma is the most common benign bone tumor. It can be classified as isolated or multiple. While the majority of osteochondromas are asymptomatic and found incidentally, they can become symptomatic during adolescence or adulthood due to mechanical irritation, nerve compression, spinal cord compression, or vascular injury. In this article, we present a case of a 14-year-old patient who experienced spontaneous hemothorax caused by bleeding from a diaphragmatic laceration incurred by a costal exostosis on the right eighth rib. A preoperative chest CT scan revealed a bony projection from the rib and bloody effusion in the thoracic cavity, highlighting the possibility of bloody pleural effusion due to costal exostosis. It is important to note that costal osteochondromas are a rare cause of thoracic injury and can lead to laceration of the lung, diaphragm, and/or pericardium. Surgical intervention should be considered for symptomatic rib osteochondroma, and we advocate for prophylactic surgical removal of intrathoracic exostosis even in asymptomatic patients, in order to prevent potential complications. Osteochondroma is one of the most common benign bone tumors, characterized by the appearance of a bony prominence on the outer surface of the bone . AlthougA 14-year-old patient presented with a two-week history of right-sided chest pain. The home medical evaluation suggested costochondritis. Within 24 hours, the patient experienced severe chest pain accompanied by two syncopal episodes. Upon admission to the emergency room, an ultrasound and chest x-ray revealed a right pleural effusion Figure . A closeOsteochondroma is the most common benign bone tumor . Most caWhile osteochondromas are generally asymptomatic, slow-growing masses, they can become symptomatic during adolescence due to mechanical compression, injury to adjacent structures, bursitis, secondary fractures, or even malignant transformation . MalignaAccurate diagnosis relies on imaging modalities . Key feaCostal osteochondromas are rare and more commonly occur in patients with HME . They reSurgical resection is recommended in cases where osteochondromas emerge after puberty, become symptomatic, exhibit rapid growth, or show signs of malignant transformation ,8. ThoraOsteochondroma is a prevalent benign bone tumor, often presenting asymptomatically and frequently discovered incidentally due to its characteristic osseous surface projections. Costal osteochondromas are rare, representing an infrequent cause of thoracic injury that can lead to life-threatening complications, including hemothorax and pneumothorax. Diagnostic imaging techniques are essential for the initial assessment of these cases, with computed tomography (CT) being the recommended imaging modality. Surgical intervention is indicated for symptomatic or high-risk presentations, with thoracoscopy emerging as the preferred approach.


Background and objectives: An accessory navicular (AN) bone is often classified into types 1–3 according to the Veitch classification, and symptomatic type 1 patients usually receive non-surgical treatment. However, there are cases in which AN cannot be classified into one of these three types using this classification system, and the small ossicle of type 1 AN may not be the cause of foot pain. This report aimed to present a case of symptomatic type 1 AN that required surgical treatment without the excision of the small ossicle after long-term conservative treatment had failed. Case presentation: A 15-year-old girl who was diagnosed with symptomatic type 1 AN was referred to our department. Medial-side foot pain had prevented her from playing soccer well. She had been treated conservatively for type 1 AN for more than 12 months at several orthopedic clinics. Tenderness of the prominent navicular tubercle was identified, and computed tomography and magnetic resonance imaging findings suggested that the cause of her foot pain was derived from the prominent navicular tubercle not the small ossicle itself. Osteotomy of the prominent navicular tubercle with the advancement of the tibialis posterior tendon, without excision of the ossicle, was performed. At the 12-month follow-up examination, she was completely free from foot pain, and the patient-reported outcome measures were excellent. She now plays soccer at the pre-injury level. Conclusions: We report the case of a patient with symptomatic type 1 AN who underwent osteotomy of the prominent navicular tubercle with advancement of the tibialis posterior tendon, without excision of the ossicle, and who showed favorable short-term clinical outcomes. The evaluation of symptomatic patients with AN based on the Veitch classification alone may lead to inappropriate management. The small ossicle of type 1 AN was not the cause of foot pain in the present case. An accessory navicular (AN) bone is one of the most common foot accessory ossicles, with a prevalence of between 4–21% . When noHerein, we report a case of symptomatic type 1 AN (according to the Veitch classification) that required surgical treatment without excision of the small ossicle itself after long-term (>12 months) conservative treatment had failed. The patient showed short-term favorable outcomes. Informed consent was obtained from the patient and her parents for the publication of this report and any accompanying images.A 15-year-old girl was referred to our department for the assessment of left foot pain. She was diagnosed with AN, which was radiographically classified as Veitch type Ⅰ at a private orthopedic clinic .Conservative treatment including physiotherapy, medication for pain, and the application of an insole had been performed for more than one year but failed to completely remove her symptoms. She had been active in soccer, and her training experience was three years at the time of first presentation. She had tenderness at the navicular tuberosity with the exacerbation of pain while weight bearing. Plain radiographs did not show specific findings of flatfoot  or hindfoot malalignment. Computed tomography (CT) showed a small AN and prominent navicular tuberosity with a high Hounsfield unit (HU) value . A low sMagnetic resonance imaging (MRI) showed that the lesion was iso-signal in both the T1- and T2-weighted images. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot–ankle score  and visuTM, Arthrex, North Naples, FL, USA) in a “suture-bridge” fashion , and the TPT was stabilized to the navicular body using two knotless suture anchors  was allowed after four weeks following surgery. Weight bearing was gradually increased under ankle orthosis, and full weight bearing was allowed after eight weeks postoperatively. At four months after surgery, return to sports was allowed.At the 12-month follow-up examination, the AOFAS score and VAS were 100/100 and 0/10, respectively. The FAOS was as follows: symptoms, 100/100; pain, 100/100; function, daily living, 100/100; function, sports and recreational activities, 95/100; and quality of life, 100/100. Plain radiographs showed union of the bony fragment with the TPT to the navicular body . The CT We present a case with symptomatic AN that had been treated conservatively for a prolonged time in accordance with the typical approach for Veitch type 1 AN, in which surgical intervention was subsequently needed to resolve the symptoms. In addition, in this case, the excision of the small ossicle was not needed to resolve the patient’s symptoms although osteotomy of the prominent navicular tuberosity and advancement of the TPT were performed.The Veitch classification is the system most commonly used to evaluate patients with AN ,6,7,8. Tp < 0.001) [Jegal et al. reported that conservative treatment for symptomatic AN was less effective for athletes than non-athletes  . Some au< 0.001) . It was < 0.001) . Among 2In the present case, we did not remove the small ossicle itself and osteotomized the prominent part of the navicular tuberosity with the advancement of the TPT. In the present case, preoperative examinations did not detect the presence of tibialis posterior tendinitis. The tenderness to the prominent navicular bone was obvious without pain along the course of TPT Additionally, the preoperative radiographic findings did not show specific findings of the pes planus . It remains under debate whether or not the pes planus would affect the clinical outcomes following the surgical treatment of symptomatic ANs. Sun et al. recently reported that midterm surgical outcomes were not different between patients with and without flatfoot after fusion for painful type 2 ANs . On the We present a case of Veitch type 1 AN in which osteotomy of the prominent navicular tubercle with advancement of the TPT, without excision of the ossicle, was performed with favorable short-term outcomes.


Hepatoid carcinoma of the ovary (HCO) is a tumor that resembles, both histologically and cytologically, hepatocarcinoma (HCC) in a patient with a non-cirrhotic liver not involved by the disease. Hepatoid carcinoma is an extremely rare histologic subtype of ovarian cancer and should be distinguished from metastatic HCC. Here, we report the rare case of a 67-year-old woman with ovarian recurrence of HCC 12 years after first diagnosis. The patient was being followed by oncologists because she had been diagnosed with HCV-related HCC  in 2009. She had undergone surgery for enlarged left hepatectomy to the 4th hepatic segment with cholecystectomy and subsequent placement of a Kehr drain. The preoperative alpha-fetoprotein (AFP) level was 8600 ng/mL, while the postoperative value was only 2.7 ng/mL. At the first diagnosis, no other localizations of the disease, including the genital tract, were found. At the time of recurrence, however, the patient was completely asymptomatic: her liver function was within normal limits with negative blood indices, except for an increased blood dosage of AFP (467 ng/mL), and CA125, which became borderline (37.4 IU/mL). The oncologist placed an indication for a thoracic abdominal CT scan, which showed that the residual liver was free of disease, and the presence of a formation with a solid–cystic appearance and some calcifications at the left adnexal site. The radiological findings were confirmed on level II gynecological ultrasound. The patient then underwent a radical surgery of hysterectomy, bilateral oophorectomy, pelvic peritonectomy, and omentectomy by a laparotomic approach, with the sending of intraoperative extemporaneous histological examination on the annexus site of the tumor mass, obtaining RT = 0. Currently, the patient continues her gyneco-oncology follow-up simultaneously clinically, in laboratory, and instrumentally every 4 months. Our study currently represents the longest elapsed time interval between first diagnosis and disease recurrence, as evidenced by current data in the literature. This was a rather unique and difficult clinical case because of the rarity of the disease, the lack of scientific evidence, and the difficulty in differentiating the primary hepatoid phenotype of the ovary from an ovarian metastasis of HCC. Several multidisciplinary meetings for proper interpretation of clinical and anamnestic data, with the aid of immunohistochemistry (IHC) on histological slides were essential for case management.  Hepatoid adenocarcinoma is a tumor that resembles both histologically and cytologically a HCC in a patient with a non-cirrhotic liver not involved by the disease . It is, A 67-year-old woman was referred to our attention in February 2021 for evaluation of an adnexal mass. The patient, at the time, was followed by oncologists because she had a history of HCV-related hepatocellular carcinoma in 2009 . She underwent surgical procedure for a left hepatectomy enlarged to the IV hepatic segment with cholecystectomy and subsequent Kehr drainage placement. At the time of the diagnosis of HCC in the liver site, her preoperatory AFP level was 8600 ng/mL, while the post-operative value was just 2.7 ng/mL. The serology for HBV and HCV viruses was negative. No other disease’s localizations were found and the genital tract was tumor free. Investigating the patient’s medical history, we knew she had familiarity with colic neoplasia and previous surgery for benign breast lumps. Her comorbidities were not linked with the disease: she was, in fact, affected by carotid atherosclerosis, diverticular colon disease, hyperthyroidism, and gastroesophageal disease. At the time of recurrence, she was completely asymptomatic: her liver function was unaffected, and blood works were normal. The follow-up was uneventful up until October 2020, when AFP was found raised (467 ng/mL), and CA125 became borderline (37.4 UI/mL). The oncologist indicated to perform a CT scan that showed the remaining liver had no lesions whatsoever, whilst her adnexa were both enlarged, especially on the left, where the ovary was 55 × 33 × 58 mm, with a solid cystic aspect with a few calcifications  . A smallPrimary HCO is a rare, aggressive tumor that shares clinical and pathologic features with HCC and is thought to have 2 histogenic origins—i.e., superficial epithelium and germ cells, although neither of these is supported by conclusive evidence . HepatocIn our case, the story of a previous hepatocarcinoma suggested the lesions to be a recurrence. In order to resolve the numerous doubts that the evidence of medicine requires us to clarify, in addition to immunohistochemistry, an anatomical-pathological study comparing the current surgical pieces with the hepatocarcinoma removed in 2009 was necessary. It thus emerged that the two lesions were morphologically overlapping. Furthermore, molecular analyses were conducted to compare the hepatic HCC and the ovarian lesion with the same molecular fingerprint. Moreover, the liver lesion of first diagnosis (2009) was described as high-risk from the outset as it had biliary infiltration and vascular neoplastic thrombosis. Indeed, considering the rarity of such a long time to relapse, we needed more data. Molecular data could surely help the diagnosis. Among immunoprofiles, the f.e. antihepatocyte antibody is not useful to differentiate between ovarian tumors with hepatoid phenotypes, such as POHC and metastatic HCC. The CK 7+/20− profile may suggest that this favors an ovarian tumor arising from a common surface epithelium over non-mullerian tumors. Although most HCC is negative for CK 7, some works reported a rate of CK7 positivity of almost 30% for HCC and some even associated this positivity with a worse prognosis ,22,23. OHepatoid carcinomas of the ovary must be distinguished from ovarian metastasis of hepatocarcinoma. We need more scientific data to follow evidence-based medicine in this field. In this regard, it could be useful to start with implementing molecular biology and IHC to help clinicians and pathologists to distinguish these two rare conditions. Knowledge about the pathologies, however, must be improved: actually, because of their rarity, there are only few case reports or case series. For this reason, for the moment, we can assert our case is the first signaled to be an HCC relapsed after 12 years. Probably, though, we only need to learn more about this intriguing topic.